1heart failure on the elderly

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)

1heart failure on the elderly

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