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8/4/2019 1Heart Failure on the Elderly
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Arie Bachtiar Dwitaryo
Bagian Kardiologi dan Kedokteran Vaskular
FK. UNDIP / RS. Dr. Kariadi Semarang
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Tahun Penduduk Balita Penduduk Lansia
Jumlah Persen Jumlah Persen
1971 a) 19,098,639 16.1 5,306,874 4.5
1980 a) 21,190,672 14.4 7,998,543 5.5
1985 b) 21,550,364 13.4 9,440,999 5.8
1990 a) 20,985,144 11.7 11,277,557 6.3
1995 c) 21,609,150 11.0 13,600,962 6.9
2000 c) 21,190,900 10.1 15,882,827 7.6
2005 c) 21,112,758 9.5 18,283,107 8.2
2010 c) 19,720,793 8.4 19,303,967 8.42015 c) 18,773,512 7.6 24,446,290 10.0
2020 c) 17,595,966 6.9 29,021,128 11.4
BAGAN PERBANDINGAN KEPENDUDUKAN GOLONGAN
USIA LANJUT DAN BALITA DI INDONESIA
Sumber :
a) BPS Sensus Penduduk Indonesia tahun 1971, 1980 dan 1990
b) BPS Survey Antar Sensus Penduduk 1985c) LD-FEUI, Proyeksi Penduduk Indonesia 1990 - 2020
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Pertumbuhan Penduduk Lansia dan Balita Indonesia
1971 - 2020
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
1971 1980 1985 1990 1995 2000 2005 2010 2015 2020
Penduduk
BalitaPenduduk
Lansia
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Definition
CHF is a complex clinical syndrome caharacterized bydysfunction of the left-right or both ventricles and changes
in neurohumoral regulation
This syndrome consist of :
Exercise intolerance
Disrythmia
LV-RV Dysfunction
Fluid Retention : Pretibial Edema, Ascites,
Pulmonary Edema
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Myocardial infarction
Arrhythmia &
Loss of muscle
Remodeling
Ventriculardilatation
Heart failure
Coronary thrombosis
Myocardial
ischemia
CAD
Atherosclerosis
LVH
Risk factors
(HT, LDL, DM, ect) Endstageheart disease
Sudden death
The cardiovascular continuumThe cardiovascular continuum
ANG II
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EPIDEMIOLOGY
Morbidity and Mortality rates remain high.
USA : estimated more than 2 million patient.
400.000 new patient each year.
900.000 required hospitalization.
200.000 patient die/year.
Annual mortality rate : 40-50% in NYHA Class IV
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FRAMINGHAM HEART STUDY
Incidence of heart failure by age and sex
(Kannel & Belanger, 1981)
100
90
80
70
60
50
40
30
20
10
0
45-54 55-64 65-74 75-84 85-94
Age (yr)
Rate
per
1000
Males
Females
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Mechanism of death
Sudden death 40%
Worsening CHF 40%
Other 20%
Further damage
Excessive wall stressNeurohormonal activation
Myocardial ischemia
Progression
Annual mortality
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Aging: The Major Risk Factor for
Cardiovascular Morbidity and Mortality
Aging: The Major Risk Factor for
Cardiovascular Morbidity and MortalitySTROKE STROKE
Sy
stolic
Hype
rtens
ion
LVHyp
ertro
phy
LVM
ass
Systo
licPressure
LV RESERVE
CoronaryIschemia
Vas
cula
r
CellC
hang
es
Early
Ath
eros
clerotic
Lesio
ns
Cereb
ral
Isc
hem
ia
ARTERIAL
STIFFENING
AND
THICKENING
Disease
normalAgin
g
ClinicalPractice
Threshold
Preven
tion
StageIn
cre
asingA
ge
Increa
singAge
(Lakatta et al, 1994)
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Pathophysiologic responses to chronic myocardial disease and to aging
Myocyte Loss
Systolic
Dysfunction
Myocardial Disease
Aging Neurohormonal
Activation
Hypertrophy
DiastolicDysfunction
Ventricular
Dilatation
Vasoconstriction
(Haidet & Cohn, 1994)
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Major Criteria
Paroxysmal nocturnal dyspnea
Neck vein distention
Rales
Radiographic cardiomegaly
Acute pulmonary edema
S3 gallop
Central venous pressure > 16 cm H2O
Circulation time > 25 sec
Hepatojugular reflux
Pulmonary edema, visceral congestion, or cardiomegaly at autopsyWeight loss > 4.5 kg in 5 days in response to treatment of congestive heart failure
Minor Criteria
Bilateral ankle edema
Nocturnal cough
Dyspnea on ordinary exertion
HepatomegalyPleural effusion
Decrease in vital capacity by one third from maximal value recorded
Tachycardia (rate > 120 beats min)
FRAMINGHAM CRITERIA FOR CONGESTIVE HEART FAILUREFRAMINGHAM CRITERIA FOR CONGESTIVE HEART FAILURE
( Ho KL, et al., 1993 )
The diagnosis of CHF in this study required that two major
or one major and two minor criteria be present concurrently, Minor Criteria
were acceptable only if they could not be attributed to another medical condition.
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Gagal Jantung Pada Lansia
Underdiagnosed / overdiagnosed
Keluhan/tanda gagal jantung sensitivitas / spesivisitastidak begitu tinggi.
karena comorbiditas dan akibat perubahan kardiovascular
pada orang tua.
Hidup sedentari intoleransi latihan sukar dievaluasiKeluhan atipik gagal jantung pada lansia nausea, tidak
suka makan, bingung, gelisah.
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Echodoppler recording of mitral inflow
velocity
Velocity
Peak E velocity
Peak A velocity
S2
E
A
VRT DTTime
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Reference values to assess and classify diastolic filling
E/A
DT
IVRT
Pulmonary
venous flow
1 to 2
160 to 240 ms
70 to 90 ms
PVs > PVd
< 1
> 240 ms
> 90 ms
PVs >> PVd
1 to 2
160 to 200 ms
< 90 ms
PVs ~ PVd
> 1.5
< 160 ms
< 70 ms
PVs
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Clinical Features of Systolic versus Diastolic Heart Failure
Age > 70 yearsFemale gender
Chronic hypertension
Renal disease
Obesity
Aortic stenosis
Acute pulmonary edema
Atrial fibrillation
Hypertensive
Absence of jugular venousdistension
Sustained PMI*S
4gallop
Left ventricular hypertrophy
Normal or midly increasedheart size
Age > 60 yearsMale gender
Prior myocardial infarction
Alcoholism
Valvular insufficiency
Progressive shortness of breath
Normotensive or hypotensive
Jugular venous distension
Displaced PMI*
S3 gallop
Q-waves, prior myocardialinfarction
Marked cardiomegaly
Demographics
Comorbid illnesses
Presentation
Physical examination
Electrocardiogram
Chest x-ray
SYSTOLIC DYSFUNCTION DIASTOLIC DYSFUNCTION
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Management Outline
To make sure that patient has HF
Ascertain Clinical features
Etiology of HF
NYHA Class/ Staging Concomitant disease
Estimate Prognosis
Anticipate complication Family Councelling(Exp On the Elderly pts)
Appropriate management & Monitor progress
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Non PharmacologicGeneral Advice & Measure
Information about simptom & Sign ofHF ,MedicationUsed,Encouraged for daily
& social activity.Vaccination against Influenza is adviced
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Diet & Liquid&Exercise
Adequate Fluid Intake:1000-1500 cc/Day
Alcohol is Strongly prohibited in
Cardiomyopathy
Diet: To reduced obesity,Limit salt intake
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DIURETICS
Essential for symptomatic treatment when
fluid overload is present & manifest
Short term: Reduction pulmonary
congeston,JVP,Peripheral edema,BW.
Intermediate:ImprovedSymptoms,Exercise
tolerance ,Not proven reduced morbidity
& mortality(Long term)
Use combination with ACE Inh,BB,Digoxin
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Angiotensin Converting Enzyme
Inhibitors
Recommended as first line therapy for all stagesexcept CI/Intoleranced
Effect: Alleviate symptoms,Improved clinical
status,Enhanced sense of well beeing.(Women,Elderly)
Should be up-titrated to the dosages shown to beeffective in large clinical trial
Side Effect: cough,Angioedema CI: Pregnancy,Bilateral renal artery stenosis
,Hypotension proned to shock.
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Angiotensin Receptor
Antagonist
ARBs should be considered in patientswho dont tolerate ACE Inhibitor and hasalready used to treat :
Hypertension,Atherosclerotic vasculardisease.
ARBs can be used in Diastolic HF (Morecommon in the elderly)
ARBs + ACE Inh can be used in case ofBB contraindication
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Hydralazine + ISDN
Indication: Intolerance ACE/ARBs
Nitrates: Angina,EdemaPulmonum,or
concomitant hypertension .
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Beta-Blocking Agent
Recommended for the treatment of all pts with
stable,All Stage HF already on standard
treatment,unless Contra indicated.
BB & ACE Inh should be used in Post MI ptsregardless of EF with/No HF simptom.
Bisoprolol,Metoprolol XL,Carvedilol are proven in
reductionTotalmortality,Sudden death,Death to
progression of HF. Reduced Hospitalization & Less worseningHF.
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DIGITALIS
Recommended to improve clinical status
decreased the risk of hospitalization
without an impact on survival.
Indicated in AF(Rate Controle) & Sinus
Rhytm in Persisting HF despite ACE Inh&
Diuretics
Used Low-Dose
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Aldosteron Receptor Antagonist
Recommended in Severe HF /Recurrent
Hospitalization in order to improve survival.
Recent Trial:
Eplerenone can reduced mortality from 13,6%->11,8% (I year).
Side Effect: Ginecomastia,Hiperkalemia
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Positive Inotropic Agent
Dopamin,Dobutamin,Norepinephrine:Used
for short-Term correction ofhaemodynamic
disturbances of severe episodes of
worsening HF.
Oral inotropic agent is not-recommended
because can increased mortality.
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Anti Arrhytmic Drug
Indication: Atrial Fibrilation,Ventricular
Tachycardia.
Class : I. Not Recommended
II. BB Can Reduced Sudden Death
III.Amiodarone is recommended
because withoutclinically negative inotropic effect
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Implantable Cardioverter
Defibrilator
Indication: To Prevent Sudden Cardiac
Death.
Primary Prevention:Post MI/NonIschaemic
Cardiomyopathy with LVEF
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How to Treat Diastolic Heart Failure Treat the acute episode: reduce pulmonary congestion with salt and fluid restriction,
diuretics or nitrates.
Treat any acute precipitants, eg. Arrhythmias, infection, ischaemia, uncontrolledhypertension.
Treat the underlying cause :
- lower blood pressure to 130/80 mmHg or less;
- reduce heart rate (to increase diastolic filling time) using beta blockers,
or digoxin and/or verapamil if the patient has atrial fibrillation;- maintain atrio-ventricular (A-V) synchrony (to aid late diastolic filling by
atrial systole) by sequential A-V pacing or cardioversion if patient has
atrial fibrillation;
- treat any underlying ischaemia using beta blockers and/or coronary
revascularization, etc;- promote regression of left ventricular hypertrophy (eg. By ACE
inhibition);
- correct valvular heart disease (eg. Aortic valve replacement for aortic
stenosis)
Optimize physical activity and ensure compliance with diet and medication.
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CONCLUSION
The spesific pathophysiologic that cause
clinical disordered are superimposed on
heart that are modified by aging.
Diagnosis of CV diseases is delayed
because of atypical symptoms.
The incidenced of HF doubled with each
decade of life & CHF is the leading caused
of mortality and hospitalization.
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The general management of HF on the elderlycan be applied.
Education of the patient and family may play
significant role in reducing hospitaliza tion andmortality.
Pharmacological therapy need closeobservation about side effect of the drug and
used simple dosing to increase compliance.
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TREATMENT OF HEART FAILURE DUE TO
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LEFT VENTRICULAR SYSTOLIC DYSFUNCTION
Heart Failure
Standard Treatment- Non-pharmacological Therapy
low salt diet
a void smoking
regular moderate physical
activity- Pharmacological Therapy
diuretic
ACE inhibitor
digoxin*
ACE Inhibitor Not Tolerated Consider :
hydralazine and isosorbide dinitrate Symptoms Persist
Persisting Fluid Retention
Consider : combination of oral
diuretics such as loop diuretic with : thiazine or metalazone spironolactone
Consider : Intravenous diuretic
No Fluid Retention :
Consider : digoxin hydralazine and isosorbide dinitrate
May require hospital admission and additional treatment
* Some physicians use digoxin as first line therapy for heart failure, with diuretics and ACE inhibitors, whereas others reserve its use to
those patients with atrial fibrillation or those patients whose symptoms persist (WHO 1995)