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Heart Failure

&Cardiac Arrest

Rony Yuliwansyah

Cardioloy Sub Divisionrtment Of Internal Medicine University Of Andalas - Dr M. Djamil - Padan ! In


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Internal c"ambers and valves of t"e "eart


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The Cardiac Cycle

Systole : Period of ventricular

contraction Blood ejected from heart

Diastole : Period of ventricular

relaxation

Blood llin


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Stroke Volume The amount of !lood ejected from the

heart in one !eat "verae is #$ % &$$ ml

De'ends on 'reload( contractile forceand afterload

Cardiac Output The amount of !lood ejected from the

heart in one minute Cardiac out'ut ) heart rate x stro*e

volume


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Defnitions

Chronotro'y Chane in heart rate

+notro'y Chane in contractile

force Dromotro'y Chane in conduction

velocity

Can !e 'ositive or neative


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PENGARUH SYARAF THD JANTUNG

Sim'atis: !ersifat menin*atan

a, fre*uensi denyut jantun -*ronotro'i*./

!, *uat *ontra*si jantun -inotro'i* ./

c, 'eram!atan im'uls -dromotro'i* ./


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Parasim'atis: !ersifat menuran*an

0ronotro'i* 1 +notro'i* 1

Dromotro'i* %


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M echanism s ! heart !ailure

23 systolic dysfunction 1 manycauses

3alvular heart disease

Restrictive cardiomyo'athy

Pericardial constriction 23 diastolic dysfunction

Cardiac arrhythmias


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4eart 5ailure

enition

+t is the 'atho'hysioloical 'rocess in which

the heart as a 'um' is una!le to meet

the meta!olic re6uirements of the tissue for

oxyen and su!strates des'ite the venous

return to heart is either normal or increased


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Gradin" ! Heart Failure

Coronary heart disease statistics: heart failure su''lement,( B45 7$$7( htt':88www,heartstats,or( acPrevalence data is from a 'o'ulation !ased study: Davies ;0 et al, The 2ancet 7$$&< =9>: =?%,

Definition NYHA functionalclass

Severe limitation of physical activity: dyspnoea at rest, with increased symptoms

with any level of physical activity.Class I

!ar"ed limitation of physical activity: comforta#le at rest #ut dyspnoea washin$

and dressin$, or wal"in$ from room to room.Class III

Sli$ht limitation of physical activity: dyspnoea on wal"in$ more than %&& yards oron stairs'

!oderate limitation of physical activity: dyspnoea wal"in$ less than %&& yards.

Class II (s)

Class II (m)

No limitation: ordinary physical e*ercise does not cause dyspnoea.Class I

http://www.heartstats.org/http://www.heartstats.org/


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@eneral 'athomechanisms involved in heartfailure develo'ment

Cardiac mechanical dysfunction can develo'as a conse6uence in 'reload( contractility andafterload disorders

Disorders of 'reload

↑↑ 'reload → lenth of sarcomere is more than

o'timal→

↓ strenth of contraction

↓↓ 'reload → lenth of sarcomere is well !elow the o'timal → ↓ strenth of contraction


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Characteristic features of systolic dysfunction

-systolic failure/

A ventricular dilatation

A reducin ventricular contractility -either eneralied

or localied/

A diminished ejection fraction -i,e,( that fraction ofend%diastolic !lood volume ejected from theventricle durin each systolic contraction/

A in failin hearts( the 23 end%diastolic volume -or 'ressure/ may increse as the stro*e volume

-or C/ decrease


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Characteristic features of diastolic dysfunctions

-diastolic failure/

A ventricular cavity sie is normal or small

A myocardial contractility is normal or hy'erdynamic

A ejection fraction is normal -9$E/ or su'ranormal

A ventricle is usually hy'ertro'hied

A ventricle is llin slowly in early diastole -durin the 'eriod of 'assive llin/


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Causes of heart 'um' failure

", ;FC4"G+C"2 "BGR;"2+T+FS

&, +ncreased 'ressure load

1 central -aortic stenosis( aortic coarctation,,,/

1 'eri'heral -systemic hy'ertension/

7, +ncreased volume load

- valvular reuritation1 hy'ervolemia

=, !struction to ventricular llin

% valvular stenosis

% 'ericardial restriction


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B, ;YC"RD+"2 D";"@F

&, Primary

a/ cardiomyo'athy!/ myocarditis

c/ toxicity -alcohol/

d/ meta!olic a!normalities -hy'erthyreoidism/

7, Secondary

a/ oxyen de'rivation -coronary heart disease/

!/ inHammation -increased meta!olic demands/

c/ chronic o!structive lun disease


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C, "2TFRFD C"RD+"C R4YT4;

&, ventricular Hutter and !rilation

7, extreme tachycardias

=, extreme !radycardias


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Cm m n Causes ! Heart Failure

C"D( with myocardial ischemia the'otentially most reversi!le cause of 45

4TG

+dio'athic dilated cardiomyo'athy

3alvular heart disease

Drus: alcohol( cocaine( metham'hetaminPost'artum


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#ess cm m n causes ! HeartFailureConenital heart disease +nltrative cardiomyo'athy: amyloid(

sarcoid( restrictive

5amilial4emachromotosis Thyroid disease

PheocromocytomaChronic renal disease3iral and 4+3 cardiomyo'athy


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Path$h%sil"% ! Heart Failuredue t #'SD(

,

2eft%ventricularinjury

Patholoicremodellin

• 3asoconstriction• Fndothelial

dysfunction• Renal sodium

retention

Geurohormonalactivation

"da'ted from 5onarow @C et al, Rev Cardiovasc ;ed, 7$$=< -&/:>%&I,

Coronary arterydisease

4y'ertension

Cardiomyo'athy

3alvular disease

2eft%ventriculardysfunction

Death

"rrhythmia

Pum'failure

Sym'toms:• Dys'noea• 5atiue• edema

4eart

failure


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ACU TE H EART

FAILU RE


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• AHF is defined as the rapid onset ofsymptoms and signs, secondary to abnormalcardiac function

• Cardiac dysfunction can be related tosystolic or diastolic, to abnormalities incardiac rhythm or to preload and afterloadmismatch

• It is often life threatening and requiresurgent treatment

Definition of Acute Heart Failure

#SC uideline for Acute $eart %ailure& '(()

C ! il


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Cause ! Acute Heart Failure

"cute coronary syndrome( hy'ertensivecrisis and other cardiac or non cardiac also 'reci'itate an "45,

C"D contri!utes to #$%I$ E in elderly

Cardiomyo'athy( 44D( "rrhythmia(

;yocarditis and 3alve diseases found inyoun

"45 therefore has sinicantly !ecome

the sinle most costly medical syndrome#ur $eart * '(()+',/0-01,


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+n 4os'ital mortality - #$ days/ : ?,#E

Rehos'italiation and mortality : =7(9E

& year mortality : =$E,

M rtalit% ! AHF

%onaro2 3C. 4ev Cardiovasc Med. '((1+'5suppl '6S7!S1


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+m'rove hemodynamic status to reliefsym'toms and sta!ilie oran function

Reduce Huid volume Reduced llin 'ressures of the heart

Reduce systemic vascular resistance -S3R/

+ncrease cardiac out'ut -C/ Reduce neurohormones activity

Thera$eutic Gals ! AHF

%onaro2 3C. 4ev Cardiovasc Med. '((1+'5suppl '6S7!S


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)*%"enatin and +entilatr% assist,

The rst 'riority in "45 treatment is

ade6uate cellular oxyenation to 'reventoran taret dysfunction, xyensaturation is maintained ?9%?>E !y

0ee' airway Patency

*sien su''ly < Gasal or ;as* or CP"Por non%invasive 'ositive 'ressure

ventilation -G+PP3/, 3entilator su''ort in case of res'iratory

failure


Ph l i ti i AHF


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Pharm acl"ic $tin in AHF

Diuretics Vasodilators Inotropes

Reduceuid

volume

Decreasepreload

andaterload

Augmentcontractilit

y

Vasodilate; reduce

uidvolume;

counteract

RAASS!S

Natriureticpeptides

R""S ) renin%aniotensin%aldosterone system< SGS ) sym'athetic nervous system

%onaro2 3C. 4ev Cardiovasc Med. '((1+'5suppl '6S7!S1


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A

L C

B

Congestion at rest

Yes

Yes

No

NoWarm & dry

Cold & WetCold & dry

Warm & wet

L o w p

e r f u s i o

n

a t r e s t

Sign of lo perfusion!

Narrow pulse pressure,coolextremities,sleepy, suspectfrom AC"I hypotension, lo

Na, renal orsening

Sign of congestion!

Orthopnea,elevatedJVP,edema,pulsatilehepatomegaly, ascites,rales,louder S#,$% radiation leftard, abdomino&'ugular refle(,)alsa)a square a)e

European Heart Journal of Heart Failure,!!"# $%&&'&&(

Assessment of Haemodynamic $rofile


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A

L C

B

Congestion at rest

Yes

Yes

No

NoWarm & dry

Cold & WetCold & dry

Warm & wet

L o w p

e r f u s i o

n

a t r e s t

European Heart Journal of Heart Failure,!!"# $%&&'&&(

$A*I"N* *+"A*"N* S"-"C*I.N

Diuretic3asodilato

+notro'ic drus :Do!utamine;ilrinone2evosimendan32J;F

2"D+G@


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*herapeutic /oal in AHF

Symptoms0Dyspnea and1or fatigue2Clinical sign3ody eightDiuresis.(ygenation

$C4$ 5 67 mmC. and1or SV

ClinicalHemodynamic

-aboratory

Serum electrolytes normal38N$lasma 3N$3lood glucose normali9ation .utcome

-ength of stay in IC8

Duration of hospitali9ation*ime to hospital readmissionortality

*olerability-o rate of ith dral from therapy-o incidence of ad)erse effects

#ur $eart * '(()+',/0-01,

Di ti


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Diuretics

• For achie)ing optimal )olume status ) eliminate orminimi9e congestion

• High doses of i) diuretics % times daily

• ore effecti)e ith continous i): ;&%< mg1h

• =Diuretics resistance> is a common problem

• In case of resistance!

• +estrict Na1ater inta?e and follo electrolytes

• Volume repletion in hypo)olaemia

• Increase the dose and1or Combination diuretics

#ur $eart * '(()+',/0-01,


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'asdilatrs

Gitro'russide( Gitrolycerin( Gitratefamily

Kor* !y c@;P mediated smooth muscle

relaxation % vasodilatation Decrease myocardial wor* !y afterload

and 'reload reduction

;ay cause hy'otension ;ay cause headache



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Gitrates

Got evaluated !y lare scale studies ;any studies shown their favora!le eLect

"imitation Side eLect

!itrate Resistance !itrate #olerance

Prevention +ntermittent dosin : &7 hour nitrate free

interval Fscalatin dose Concomitant use of hydralaine

#l8ayam& 9"e American *ournal of Cardioloy& '(()


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Inotropes!

• Dopamine, Dobutamine, ilrinone• Impro)e cardiac output by directly

increasing cardiac contractility

• Significant proarrhythmic effects• ay precipitate ischemia• Not recommended for routine use in AHF,

but clearly ha)e a role in specific patients



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Inotropic Doses


$


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Ra'id assessment and'rom't treatment would

result in an excellentoutcome for "45 'atients

Thank You

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