Indonesian Heart Failure and Cardiometabolic Disease Meeting 2022 ACUTE HEART FAILURE PATIENT SETTING: what should nurse concern on? HEF CARD —- Background * Gagal jantung ( Heart Failure ) : Kumpulan gejala klinis (sindroma ) akibat kelainan struktural dan atau fungsional jantung sehingga mengganggu kemampuan pengisian ventrikel dan pompa darah ke seluruh tubuh \ * Gagal Jantung Akut (Acute Heart Failure) : adalah serangan yang cepat dari tanda dan gejala gagal jantung sehingga membutuhkan terapi segera DsThe Healthcare Journey for HF patients Long-term management is crucial: HF pts are at ongoing risk of acute decompensation, hospitalization + death Approximately 25% of patients will be read hospital within 30 days after discharge # Mortality during this 30-day period can 10.10%EPIDEMIOLOGI * Gagal Jantung Akut (AHF ) merupakan penyebab utama perawatan rumah si negara - negara berkembang. + Berdasarkan data epidemiologi, secara global gagal jantung akut terjadi pada 1-; populasi orang dewasa pada negara berkembang. Angka ini meningkat menjadi 10% pada populasi yang berusia di atas 70 tahun. + Sebagian besar gagal jantung akut merupakan kasus gagal jantung akut dekompensata. Jumlah kasus gagal jantung akut de novo ditemukan hanya sebe: 1/4 hingga 1/3 dari seluruh kasus gagal jantung akut * Data epidemiologi gagal jantung akut di Indonesia menunjukkan bahwa prevalet penyakit gagal jantung di Indonesia adalah sebesar 0,3% pada orang dengan usia 215 tahun. QD oeEPIDEMIOLOGI + Angka kematian saat perawatan, sekitar 4-11%. Pasien yg diizinkan pulang dari RS : sekitar 50% akan mengalami rawat ulang, 1/3 akan meninggal dim kurun waktu 12 bulan: ----> Room for improvement + Kegagalan dalam membuat diagnosa secara akurat dan tepat waktu merupakan faktor kontributor yg penting Terlambatnya diagnosis at presentation ---> mengakibatkan lamanya masa rawat, bertambahnya angka rawat ulang dan prognosis yg buruk tioDefinition and classification of acute heart failure (AHF) based on clinical presentation at admission Rapid onset or worsening of symptoms and/or signs of heart failure OS de novo AHF Acute decompensation of chronic heart failure (ADHI+ Gagal Jantung Akut De Novo Gagal jantung akut de novo adalah gagal jantung yang terjadi tanpa adanya riwayat tanda dan gejala gagal jantung sebelumnya serta sering kali disebabkan oleh penurunan akut fungsi jantung seperti infark miokard akut, miokarditis yang parah, dan regurgitasi katup aorta. + Gagal Jantung Akut Dekompensata Merupakan gejala dekompensasi akut dari gagal jantung kronis dan didorong oleh berbagai faktor presipitasi pada pasien. Gejala yang muncul merupakan akibat dari kongesti dan retensi cairan, seperti peningkatan berat badan, dispnea akibat aktivitas, ortopnea, dan edema ekstremitasKLASIFIKASI KILLIP Pasien dengan gagal jantung akut de novo dapat diklasifikasikan berdasarkan pemeriksaan fisik menggunakan klasifikasi Killip: ‘Sumber: Mello, dkk. 2014. Validation of the Killp-Kimball Classification and Late Mortality after Acute Myocardial “Infarction. Arg Bras Cardiol Kelas Pemeriksaan Fisik |_| Tidak ada $3 dan rales, tidak ada tanda-tanda gagal jantung_| 11 Rales pada <50% lapangan paru, bunyi jantung $3, peningkatan tekanan jugular vena | Rales pada >50% lapangan paru, edema paru akut tv. | Syok Kardiogenik atau hipotensi arteri (tekanan darah sistolik <90 mmHg), tanda-tanda vasokonstriksi perifer (oliguri, sianosis, diaforesis)\ Patofisiologi Gagal Jangtung Akut eer Tey) Cot ‘Compensatory ened | Se: TOF Cee een Peeeennr ta iaet ts) ooo Asymptomatic —————_> SymptomaticPATOFISIOLOGI Gagal Jantung Akut + Patofisiologi GJA kompleks dan bervariasi, dengan banyak mekanisme patogenetik yang bersamaan + Tiga hal yang mendasari terjadinya GJA: 1.Organ jantung 2. Faktor pemicu 3. Mekanisme patologis."Normal, penyakitjontung struktura atau gagaljantung kronis| Faktor pemica perce sndrom koroner okt rtm, fel dfungal renal Taetaneme || mickaram ina ‘stor Mearchornonal petciogs. || Penurunan st Retensi natu dan || Distungsiendotel | Akiva stem fetuncop ‘olume Peningraton tein Distngs' castor |] Inurrginatakut |] ekatanmareri | Sngiotnsin Sees mio ‘NewatitaAs Vaokomsriat | aidostron Aagurgtastmizat etialacimbangen | Akiva stem Inteependenst venti! fontratitas it | sarafsimpatie ora setuncup Stes oka Redisribusi volume | infarnast Nebocoren taper Kengesth << ‘Disfungel organ Gambar 1. Patofisiclogi gagal jantung akut. Oe —Factors triggering acute heart failure Pniawské Pet al Eur Heart —_ oi:10.1083/euhearehwi28 C7 HEF Bey CARD ‘Acute coronary syndrome. Tachyarrhythmia (eg, atral ibilaion, ventricular tachycardia). Excessive rise in blood pressure. Infection (e.g, pneumonia, infective endocarditis, sepsis) Non-adherence with salud intake or medications. Bradyarrhythmia “Toxic substances (alcohol, recreational drugs). Drugs (eg. NSAIDs, corticosteroids, negative inotropic substances, cardiotoxic chemotherapeutic). Exacerbation of chronie obstructive pulmonary disease. Pulmonary embolism. ‘Surgery and perioperative complications. Increased sympathetic drive, stress-related cardiomyopathy. Metabolicthormonal derangements (eg. thyroid dysfunction, diabetic ‘ketosis, adrenal dysfunction, pregnancy and peripartum related abnormalities) (Cerebrovascular insult. ‘Acute mechanical cause: myocardial rupture complicating ACS (free wall rupture ventricular septal defect acute mitral regurgitation) chest trauma ‘or cardiac intervention, acute native or prosthetic valve incompetence secondary to endocarditis, aortic dissection or thrombosis.KLASIFIKASI GJA ADHF: perburukan gejala gagal jantun ma paru akut: sesak napas tiba-tiba ertai distress pernapasan dan penurunan rasi oksigen (< 90%), ronchee basah h dari % lapang paru, dapat disertai zing atau batuk darah Syok kardiogenik: didapati tanda klinis syok (hipoperfusi jaringan) dapat berupa Gagal j : i gal jantung kanan: sesak napas, asites, pequrunen, peer aiay ec coninbe hepatomegali, edema tungkai, serta akral dingin, kesadaran menurun, diserté tekanan jugular meningkat. dada dan sesak napas, lebih sering kare i sindrom koroner akut (NSTEMI atau STA — 4CONGESTION () CONGESTION (+) Pulmonary congestion (Orthopnoea/paroxysmal nocturnal dyspnoea Peripheral (bilateral) oedema Jugular venous dilatation Congested hepatomegaly Gut congestion, ascites Hepatojugular reflux WARM-DRY HYPOPERFUSION () WARM: _ HYPOPERFUSION (+) ‘Cold sweated extremities Oliguria Yj ae hy) Narrow pulse pressure LA Hypoperfuson i. nat synonymaus with hypotension, but often hypoperfusion is accompanied by hypotension osClinical presentations of acute heart failure = aa nt Wether ‘vey conn Snir, owner Seton ee Skee ‘Mintemenin womens ‘rem yet Sigman” fonpoamne Soran felpaet canto nat som ove Sematenate mec Secigermen Soames Soe pr neome raer scram ctype mngnamancare aia tic vl 1630 SurManajemen Gagal Jantung Akut + Tatalaksana awal adalah mengatasi gejala kongesti dan perfusi serta tentukan jenis GJA + Tujuan Manajemen GJA: + Memperbaiki keadaan klinis : menurunkan sesak dan memperbaiki kualitas hidup * Menurunkan angka kematian + Mengurangi angka perawatan berulangMORTALITAS GAGAL JANTUNG AKUT (14 HARI) ~~Sasaran Manajemen GJA Monitoring, including pulse oximetry, BP, heart rate respiratory rate, and a continuous ECG, instituted within minutes of patient, oxygen saturation <90%, non-invasive ventilation should be initiated Diagnostic workup and appropriate pharmacological and non-pharmacological treatment must be started promptly and in parallel. (CHAMPIT). which need to treated/corrected urgently, management of AHF Itis recommended to have one follow-up visit within 1 to 2 weeks after discharge, evaluated to exclude persistent signs of congestion before discharge and to optimize oral treatment. HEFUrgent phase after Cardiogenic shock and/or first medical contact respiratory failure “ 1 Recommendations Stor-trm MCS shouldbe consderedin patens with carder shock 2TR,BTD, 572 Furerindesters neue weserenof Immediate phase the as of ardogene shack orlongtem ol 60-120 min) CS or tration ABP maybe considered patents wth cardo- seni shock a2 BTR BTD, BTB inc rex mertofthe case of ardogenc hock (i mecharcal complain of ace Mi) rong fio tem MCS oe warptaion‘Wet and Cold’ patient Systolic blood pressure <90 mm Hg» Diagnostik Test mptoms and signs Aymp 9 + Fluid overload (pulmonary congestion and/or peripheral edema) + Hypoperfusion due to low cardiac output THE SENSITIVITY AND SPECIFICITY OF SYMPTOMS AND SIGNS ARE OFTEN NOT SATISFACTORY { NEED ADDITIONAL INVESTIGATIONSymptoms and signs of heart failure (Symptoms and signs of fluid congestion and hypoperfusion) * Other important but non-specific symptoms : fatigue, wheeze, abdominal bloating, anorexia, confusion and weight change * A cough productive of pink frothy sputum uncommon is relatively Ponikowski P,et al. Eur Heart J doi:10.1093/eurheart/ehw128Physical Examinations Figure 1 Failure —Additional investigation for the diagnosis of ADHF Investigation Diagnostic value Chest x-ray: . Cardiomegaly, pulmonary le vi tad congestion, pleural effusion, interstitial or alveolar edema + Normal in 20% of patients with ADHF + Can identify alternative pulmonary disease EcG + Rarely normal (high negative predictive value) Natriuretic peptides: BNP <100 pgiml or NT-proBNP <300 pg/ml. + Highly sensitive + Positive test associated with a wide variety of cardiac and non-cardiac causes Immediate echocardiography + Not used for diagnosis of ADHF Bedside thoracic ultrasound (if expertise is available): Interstitial edema and pleural effusion. Ponikowski Pet al. Eur Heart J doi:10.1093/eurhearti/ehw128 May be usefulCurrent Medical Therapy for AHF: Recommendation [toy ACC-AHA Guidelines Guidelines 2013 2016 Peenne ate 1C©) 1(B) symptoms Nees Hla (B) rae) ren ro) Ee ace IIb (B) ez fore Tt Tay Tee} IIb (B) vincent i IK) Ie) Norepinephrine IIb (B) age Pe enieeekcoeesen TeX) ea Penne easiael er lib (B) Vasopressin antagonist eG)Role of The Nurse Acute Heart Failure Hospitalization: + Respiratory failure and cardiogenic shock are the most common indications for hospitalization in heart failure patients. + Apatient's need for hospitalization marks a fundamental decline in their disease process. + Heart failure exacerbation is so common that the cost of admissions strain healthcare finances in many countries. + Reference: Akintoye &. Byasauls A. Egbe A, etal. National trends io Admission and In-Hospital Mortality of Patents With Heart Faure {Rented Sates x Sots) An Hest Sie 209 900285Kesimpulan : pee Jantung Akut adalah kondisi yang mengancam jiwa dengan berbagai macam manifestasi klinik , yang membutuhkan terapi segera. + Manajemen pra-rumah sakit adalah komponen perawatan yang penting * Keberhasilan tatalaksana GJA , ditentukan oleh : early diagnosis, clo: monitoring dan management provide by skilled Heart Failure Team.TERIMAKASIH