Arie Bachtiar Dwitaryo Bagian Kardiologi dan Kedokteran Vaskular FK. UNDIP / RS. Dr.

Kariadi Semarang

BAGAN PERBANDINGAN KEPENDUDUKAN GOLONGAN USIA LANJUT DAN BALITA DI INDONESIA

Tahun 1971 a) 1980 a) 1985 b) 1990 a) 1995 c) 2000 c) 2005 c) 2010 c) 2015 c) 2020 c) Penduduk Balita Jumlah 19,098,639 21,190,672 21,550,364 20,985,144 21,609,150 21,190,900 21,112,758 19,720,793 18,773,512 17,595,966 Persen 16.1 14.4 13.4 11.7 11.0 10.1 9.5 8.4 7.6 6.9 Penduduk Lansia Jumlah 5,306,874 7,998,543 9,440,999 11,277,557 13,600,962 15,882,827 18,283,107 19,303,967 24,446,290 29,021,128 Persen 4.5 5.5 5.8 6.3 6.9 7.6 8.2 8.4 10.0 11.4

Sumber : a) BPS Sensus Penduduk Indonesia tahun 1971, 1980 dan 1990 b) BPS Survey Antar Sensus Penduduk 1985 c) LD-FEUI, Proyeksi Penduduk Indonesia 1990 - 2020

Pertumbuhan Penduduk Lansia dan Balita Indonesia 1971 - 2020

18.0

16.0

14.0

12.0

10.0

8.0

Penduduk Balita Penduduk Lansia

6.0

4.0

2.0

0.0 1971 1980 1985 1990 1995 2000 2005 2010 2015 2020

Definition
CHF is a complex clinical syndrome caharacterized by dysfunction 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

Myocardial infarction Coronary thrombosis

Sudden death
Arrhythmia & Loss of muscle

Myocardial ischemia

Remodeling

CAD

ANG II

Ventricular dilatation

Atherosclerosis LVH

Heart failure

Risk factors (HT, LDL , DM, ect)

Endstage heart disease

The cardiovascular continuum

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

FRAMINGHAM HEART STUDY

100 90 80 70 60

Males Females

Rate per 1000

50 40 30 20 10 0

45-54

55-64

65-74

75-84

85-94

Age (yr)

Incidence of heart failure by age and sex

(Kannel & Belanger, 1981)

100

Progression Mechanism of death Sudden death 40% Worsening CHF 40% Other 20%

Patients surviving %

Further damage Excessive wall stress Neurohormonal activation Myocardial ischemia

Annual mortality 0

<5%
Asymptomatic

10%
Mild

20 to 30%
Moderate

30 to 80%
Severe

Left ventricular dysfunction and symptoms

(Massie & Shah, 1997)

Aging: The Major Risk Factor for Cardiovascular Morbidity and Mortality
STROKE STROKE

Disease

Co

tro ph y

ro

Increasing Age

normal Aging

Prevention Stage

ARTERIAL STIFFENING AND THICKENING

Ce Va ll sc Ch u an l ar ge s

At he ro sc

Clinical Practice Threshold

LV

Hy

pe

LV RESERVE

(Lakatta et al, 1994)

Increasing Age

Hy pe r

si en rt

sc h

em i

l e E ar r o ly tic Le s i ons

on

na r

yI

Cer Ischebral emia

li c Systo

V L Ma ss
e Pr e ur ss

t ys S

ic ol

Myocardial Disease

Myocyte Loss

Aging

Neurohormonal Activation

Hypertrophy Diastolic Dysfunction Ventricular Dilatation Systolic Dysfunction Vasoconstriction

Pathophysiologic responses to chronic myocardial disease and to aging

(Haidet & Cohn, 1994)

FRAMINGHAM CRITERIA FOR CONGESTIVE HEART FAILURE

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 autopsy Weight 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 Hepatomegaly Pleural effusion Decrease in vital capacity by one third from maximal value recorded Tachycardia (rate > 120 beats min)
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.

( Ho KL, et al., 1993 )

Gagal Jantung Pada Lansia

Underdiagnosed / overdiagnosed Keluhan/tanda gagal jantung sensitivitas / spesivisitas tidak begitu tinggi. karena comorbiditas dan akibat perubahan kardiovascular pada orang tua. Hidup sedentari intoleransi latihan sukar dievaluasi Keluhan atipik gagal jantung pada lansia nausea, tidak suka makan, bingung, gelisah.

Echodoppler recording of mitral inflow velocity

Velocity

Peak E velocity

Peak A velocity S2

VRT

DT

Time

Reference values to assess and classify diastolic filling

Doppler measures Normal Impaired relaxation Pseudonormalization Restrictive 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 << PVd

Abbreviations and explanation. S2 = second heart sound. E velocity = peak mitral flow velocity of early rapid ventricular filling. A velocity = peak mitral flow velocity of late ventricular filling (atrial systolic). DT = deceleration time ie. The interval from closure of aortic valve to opening of mitral valve (this parallels deceleration time). E/A = early filling/late filling of the left ventricle. PVs = pulmonary venous flow velocity in systole. PVd = pulmonary venous flow velocity in diastole.

Clinical Features of Systolic versus Diastolic Heart Failure

SYSTOLIC DYSFUNCTION DIASTOLIC DYSFUNCTION

Demographics Comorbid illnesses

Age > 60 years Male gender Prior myocardial infarction Alcoholism Valvular insufficiency Progressive shortness of breath Normotensive or hypotensive Jugular venous distension Displaced PMI* S3 gallop Q-waves, prior myocardial infarction Marked cardiomegaly

Presentation Physical examination

Electrocardiogram Chest x-ray

Age > 70 years Female gender Chronic hypertension Renal disease Obesity Aortic stenosis Acute pulmonary edema Atrial fibrillation Hypertensive Absence of jugular venous distension Sustained PMI* S4 gallop Left ventricular hypertrophy Normal or midly increased heart size

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

Non Pharmacologic
General Advice & Measure Information about simptom & Sign of HF ,MedicationUsed,Encouraged for daily & social activity. Vaccination against Influenza is adviced

Diet & Liquid&Exercise

Adequate Fluid Intake:1000-1500 cc/Day Alcohol is Strongly prohibited in Cardiomyopathy Diet: To reduced obesity,Limit salt intake

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

Angiotensin Converting Enzyme Inhibitors

Recommended as first line therapy for all stages except CI/Intoleranced Effect: Alleviate symptoms,Improved clinical status,Enhanced sense of well beeing. (Women,Elderly) Should be up-titrated to the dosages shown to be effective in large clinical trial Side Effect: cough,Angioedema CI: Pregnancy,Bilateral renal artery stenosis ,Hypotension proned to shock.

Angiotensin Receptor Antagonist

ARBs should be considered in patients who dont tolerate ACE Inhibitor and has already used to treat : Hypertension,Atherosclerotic vascular disease. ARBs can be used in Diastolic HF (More common in the elderly) ARBs + ACE Inh can be used in case of BB contraindication

Hydralazine + ISDN
Indication: Intolerance ACE/ARBs Nitrates: Angina,EdemaPulmonum,or concomitant hypertension .

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 pts regardless 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.

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

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

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.

Anti Arrhytmic Drug

Indication: Atrial Fibrilation,Ventricular Tachycardia. Class : I. Not Recommended II. BB Can Reduced Sudden Death III.Amiodarone is recommended because without clinically negative inotropic effect

Implantable Cardioverter Defibrilator

Indication: To Prevent Sudden Cardiac Death. Primary Prevention:Post MI/NonIschaemic Cardiomyopathy with LVEF<30% Secondary Prevention: History Cardiac Arrest,VT/VF.

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, uncontrolled hypertension. 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.

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.

 The general management of HF on the elderly can be applied. Education of the patient and family may play significant role in reducing hospitaliza tion and mortality. Pharmacological therapy need close observation about side effect of the drug and used simple dosing to increase compliance.

TREATMENT OF HEART FAILURE DUE TO 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)