Board HF Management

OPTIMAL HEART FAILURE
MANAGEMENT
EKA GINANJAR, MD, PHD, MHA, FINASIM, FACP, FICA

SALLY AMAN NASUTION, MD, PHD, FINASIM, FACP
DIVISION OF CARDIOLOGY DEPARTMENT OF INTERNAL MEDICINE
FACULTY OF MEDICINE UNIVERSITAS INDONESIA
CIPTO MANGUNGKUSUMO NATIONAL GENERAL HOSPITAL
JAKARTA
GLOBAL PANDEMIC OF HEART FAILURE
Heart failure: preventing disease and death worldwide
GLOBAL PANDEMIC
> 26 mio people and increasing
Indonesia : > 500.000 cases
Figure 3. Proportion of the population living with heart failure in individual countries across the
Ambrosy PA et al. The Global Health and Economic Burden of Hospitalizations for Heart Failure. Lessons Learned From Hospitalized Heart Failure Registries. J Am Coll
2
4,8,9,11,42–46
globe.
Cardiol. 2014;63:1123–1133.
Data Riset Kesehatan Dasar 2013, Badan Litbangkes Kementerian Kesehatan RI dan Data Penduduk Sasaran, Pusdatin Kementerian Kesehatan RI
a
BuiHeart failure
AL, Horwich or swollen
TB, Fonarow limbs. and 54. risk profile of heart failure. Nat Rev Cardiol 2011;8:30–41.
GC. Epidemiology
Estimates based on a single centre or hospital are indicated by an H.

3
HEART FAILURE HAS A WORSE 5-YEAR PROGNOSIS
THAN A NUMBER OF COMMON CANCERS
4
CUMULATIVE ADVERSE CONSEQUENCES OF
ACUTE EPISODES (HOSPITALIZATION)
Chr
Cardiac function onic
& quality of life dec
(QoL) line
Mortality
Acute episodes
Disease progression
• WITH EACH ACUTE EVENT, MYOCARDIAL AND RENAL INJURY MAY CONTRIBUTE
TO PROGRESSIVE LV (LEFT VENTRICLE) DYSFUNCTION
• HIGH FREQUENCY OF ACUTE EVENTS + DISEASE PROGRESSION = INCREASING
RISK OF HOSPITALIZATION AND MORTALITY
Gheorghiade et al. Am J Cardiol 2005;96:11G–17G; Gheorghiade & Pang. J Am Coll Cardiol 2009;53:557–73
5
DEFINISI DAN TERMINOLOGI
Sindrom klinis yang ditandai dengan
• HFrEF
gejala khas (sesak nafas, bengkak • HFpEF
Fraksi Ejeksi
pada pergelangan kaki, dan • HFmrEF
kelelahan) dan dapat disertai dengan

tanda-tanda gagal jantung seperti • Onset baru ‘de novo’
peningkatan tekanan vena jugularis, • Kronik
Perjalanan Waktu • Kedua keadaan di atas dapat berada pada
rhonki basah pada paru, dan edema kondisi stabil atau akut (dekompensata)
perifer yang disebakan oleh
abnormalitas struktur dan/atau fungsi • Klasifikasi fungsional NYHA
jantung yang berdampak pada Berat Gejala
• Klasifikasi ACC/AHA
penurunan curah jantung dan/atau

peningkatan tekanan intrakardiak
baik saat istirahat maupun selama
beraktivitas
CARDIOVASCULAR CONTINUUM OF HEART FAILURE
Normal LV structure LV remodelling Clinical

and function and dysfunction Heart Failure
Years Years/months 7
Dzau, et al. Circulation. 2006

HF SYMPTOM SEVERITY CAN BE CLASSIFIED BY THE ACC/AHA
STAGES OR NYHA FUNCTIONAL CLASSIFICATION
ACC/AHA stages of HF NYHA functional classification
(based on structure and damage to heart) 1 (based on symptoms of physical activity)1,2
At high risk for HF, but without No limitation of physical activity.

structural heart disease. Ordinary physical activity does not
Stage A Class I
cause undue fatigue, palpitation or
No signs or symptoms of HF dyspnoea
Slight limitation of physical activity.

Developed structural heart disease
Comfortable at rest, but ordinary
Stage B strongly associated with development Class II
physical activity results in HF
of HF, but without signs or symptoms
symptoms
Marked limitation of physical activity.
Structural heart disease with prior or Comfortable at rest, but less than
Stage C Class III
current symptoms of HF ordinary activity results in HF
symptoms
Unable to carry on any physical
Advanced structural heart disease and activity without discomfort. Symptoms
Stage D marked symptoms of HF at rest, Class IV at rest can be present. If any physical
despite maximal medical therapy activity is undertaken, discomfort is
increased
ACC/AHA=AMERICAN COLLEGE OF CARDIOLOGY/AMERICAN HEART

ASSOCIATION; HF=HEART FAILURE; NYHA=NEW YORK HEART
PONIKOWSKI ET AL., EUR HEART J, 2016; 37:2129-200 YANCY ET AL., CIRCULATION, 2013; 62: E147-239
ASSOCIATION
Perbandingan Klasifikasi dan NYHA
Yancy, Clyde W., et al. "2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice
guidelines." Circulation 128.16 (2013): 1810-1852.
Stages in the development of HF and recommended therapy by stage
Yancy C W et al. Circulation. 2013;128:e240-e327

Copyright © American Heart Association, Inc. All rights reserved.
CAUSES OF HEART FAILURE
FAKTOR RISIKO PALING BANYAK YANG

MEMENGARUHI TERJADINYA GAGAL
JANTUNG :
• HIPERTENSI
• DIABETES MELLITUS
• SINDROM METABOLIK
• PENYAKIT ATEROSKLEROSIS
Atherton, John James, et al. "2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure." Eur J Heart Fail 18 (2016): 891-975.
Causes of heart failure, common modes of presentation and specific
investigations (1)
©ESC
ARVC = arrhythmogenic right ventricular cardiomyopathy; BP = blood pressure; CAD= coronary artery disease; CMP = cardiomyopathy; CMR= cardiac magnetic resonance;
ECG = electrocardiogram; GGT= gamma-glutamyl transferase; LFT = liver function test.
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
www.escardio.org/guidelines (European Heart Journal 2021 – doi:10.1093/eurheartj/ehab368)
investigations (2)
©ESC
ACE = angiotensin-converting enzyme; CMR= cardiac magnetic resonance; CK = creatinine kinase; CT = computed tomography; ECG = electrocardiogram; Echo = echocardiography;
EMB = endomyocardial biopsy; FDG = fluorodeoxyglucose; HIV = human immunodeficiency virus; h = hour; MEK =mitogen-activated protein kinase; PET = positron emission
tomography; VEGF = vascular endothelial growth factor
investigations (3)
©ESC
5-HIAA = 5-hydroxyindoleacetic acid; ANA = anti-nuclear antibody; ANCA = anti-nuclear cytoplasmic antibody; CK = creatinine kinase; CMR = cardiac magnetic resonance;
CT = computed tomography; EMB = endomyocardial biopsy TFT = thyroid function test.
SYMPTOMS AND SIGNS
• MAIN SYMPTOMS Tiredness
Shortness of breath
• BREATHLESSNESS
Pumping action of Coughing
• ORTHOPNEA
the heart grows
• PAROXYSMAL NOCTURNAL DYSPNEA weaker Fluid retention
• REDUCED EXERCISE TOLERANCE

• FATIGUE Pleural effusion
• ANKLE SWELLING
• MAIN SIGNS
• ELEVATED JUGULAR VENOUS PRESSURE
Swelling of feet,
• HEPATO-JUGULAR REFLUX ankles, abdomen
and lower back area
• THIRD HEART SOUND
• LATERALLY DISPLACED APICAL IMPULSE
• CARDIAC MURMUR
Pulmonary edema
Ponikowski et al. Eur Heart J 2016; 37(27): 2129-2200 McMurray et al. Eur
15
Symptoms and Signs
typical of Heart
Failure
Recommended diagnostic tests in all patients with suspected chronic
heart failure
Recommendations Class Level
BNP/NT-proBNPa I B
12-lead ECG I C
Transthoracic echocardiography I C
Chest radiography (X-ray) I C
Routine blood tests for comorbidities, including full blood count, urea an
electrolytes, thyroid function, fasting glucose and HbA1c, lipids, iron status (TSAT I C
and ferritin)
BNP = B-type natriuretic peptide; ECG = electrocardiogram; HbA1c = glycated haemoglobin; NT-proBNP = N-terminal pro-B-type natriuretic peptide; TSAT = transferrin saturation.
aReferences are listed in section 4.2 for this item.
©ESC
Algoritma Pendekatan Klinis
Gagal Jantung
Gagal Jantung Non-Akut

Gagal Jantung Akut
(Gagal Jantung Kronik)
CHRONIC HEART FAILURE
GAGAL JANTUNG KRONIK/NON-AKUT
The diagnostic algorithm for
heart failure
ECG = electrocardiogram; HFmrEF = heart failure with mildly reduced ejection

fraction;
HFpEF = heart failure with preserved ejection fraction; HFrEF = heart failure with
reduced ejection fraction; LVEF = left ventricular ejection fraction; NT-proBNP = N-
terminal pro-B type natriuretic peptide.
The abnormal echocardiographic findings are described in more detail in the
©ESC
respective sections onHFrEF (section 5), HFmrEF (section 7), and HFpEF (section 8).
www.escardio.org/guidelines (European Heart Journal 2021 – doi:10.1093/eurheartj/ehab368) 28
Definition of heart failure with reduced ejection fraction, mildly reduced
ejection fraction and preserved ejection fraction
Type of HF HFrEF HFmrEF HFpEF
1 Symptoms ± Signsa Symptoms ± Signsa Symptoms ± Signsa
2 LVEF ≤40% LVEF 41–49%b LVEF ≥50%
3 - - Objective evidence of cardiac structural
CRITERIA
and/or functional
abnormalities consistent with the
presence of LV diastolic
dysfunction/raised LV filling pressures,
including raised natriuretic peptidesc
HF = heart failure; HFmrEF = heart failure with mildly reduced ejection fraction; HFpEF = heart failure with preserved ejection fraction; HFrEF = heart failure with reduced ejection
fraction; LV = left ventricle; LVEF = left ventricular ejection fraction.
aSigns may not be present in the early stages of HF (especially in HFpEF) and in optimally treated patients.
bFor the diagnosis of HFmrEF, the presence of other evidence of structural heart disease (e.g. increased left atrial size, LV hypertrophy or echocardiographic measures of
impaired LV filling) makes the diagnosis more likely.

cFor the diagnosis of HFpEF, the greater the number of abnormalities present, the higher the likelihood of HFpEF.
©ESC
Therapeutic algorithm of
Class I Therapy Indications
for a patient with heart
failure with reduced
ejection fraction
ACE-I = angiotensin-converting enzyme inhibitor;

ARNI = angiotensin receptor-neprilysin inhibitor;
CRT-D = cardiac resynchronization therapy with
defibrillator; CRT-P = cardiac resynchronization
therapy with pacemaker; ICD = implantable
cardioverter-defibrillator; HFrEF = heart failure with
reduced ejection fraction; MRA = mineralocorticoid
receptor antagonist; QRS = Q, R, and S waves
(on a 12-lead electrocardiogram); SR = sinus rhythm.
aAs a replacement for ACE-I.
bWhere appropriate. Class I=green. Class IIa=Yellow.
©ESC
Strategic phenotypic overview of
the management of heart failure
with reduced ejection fraction
ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin
receptor blocker; ARNI = angiotensin receptor-neprilysin inhibitor; BB
= beta-blocker; b.p.m. = beats per minute; BTC = bridge to candidacy;
BTT = bridge to transplantation; CABG = coronary artery bypass graft;
CRT-D = cardiac resynchronization therapy with defibrillator; CRT-P =
cardiac resynchronization therapy with pacemaker; DT = destination
therapy; HF = heart failure; HFrEF = heart failure with reduced
ejection fraction; ICD = implantable cardioverter-defibrillator; ISDN =
isosorbide dinitrate; LBBB = left bundle branch block; MCS =
mechanical circulatory support; MRA = mineralocorticoid receptor
antagonist; MV = mitral valve; PVI = pulmonary vein isolation; QOL =
quality of life; SAVR = surgical aortic valve replacement; SGLT2i =
sodium-glucose co-transporter 2 inhibitor; SR = sinus rhythm; TAVI =
transcatheter aortic valve replacement; TEE = transcatheter edge to
edge. Colour code for classes of recommendation: Green for Class of
recommendation I; Yellow for Class of recommendation IIa (see Table
1 for further details on classes of recommendation).
The Figure showsmanagement options with Class I and IIa
recommendations. See the specific Tables for those with Class IIb
recommendations.
©ESC
Pharmacological treatments indicated in patients with (NYHA class II-IV)
heart failure with reduced ejection fraction (LVEF ≤40%)
Recommendations Class Level
An ACE-I is recommended for patients with HFrEF to reduce the risk of HF
I A
hospitalization and death.
A beta-blocker is recommended for patients with stable HFrEF to reduce the risk
I A
of HF hospitalization and death.
An MRA is recommended for patients with HFrEF to reduce the risk of HF
I A
hospitalization and death.
Dapagliflozin or empagliflozin are recommended for patients with HFrEF to
I A
reduce the risk of HF hospitalization and death.
Sacubitril/valsartan is recommended as a replacement for an ACE-I in patients
I B
with HFrEF to reduce the risk of HF hospitalization and death.
ACE-I = angiotensin-converting enzyme inhibitor; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; LVEF = left ventricular ejection fraction;
MRA = mineralocorticoid receptor antagonist; NYHA= New York Heart Association.
©ESC
Evidence-based doses of disease-modifying drugs in key randomized
trials in patients with heart failure with reduced ejection fraction (2)
Starting dose Target dose
Beta-blockers
Bisoprolol 1.25 mg o.d. 10 mg o.d.
Carvedilol 3.125 mg b.i.d. 25 mg b.i.d.e
Metoprolol succinate (CR/XL) 12.5–25 mg o.d. 200 mg o.d.
Nebivolold 1.25 mg o.d. 10 mg o.d.
MRA
Eplerenone 25 mg o.d. 50 mg o.d.
Spironolactone 25 mg o.d.f 50 mg o.d.
b.i.d. = bis in die (twice daily); CR = controlled release; MRA = mineralocorticoid receptor antagonist; o.d. = omne in die (once daily); XL = extended release.
dIndicates a treatment not shown to reduce CV or all-cause mortality in patients with heart failure (or shown to be non-inferior to a treatment that does).
eA maximum dose of 50 mg twice daily can be administered to patients weighing over 85 kg.
©ESC
fSpironolactone has an optional starting dose of 12.5 mg in patients where renal status or hyperkalaemia warrant caution.
SGLT2 inhibitor
Dapagliflozin 10 mg o.d. 10 mg o.d.
Empagliflozin 10 mg o.d. 10 mg o.d.
Other agents
Candesartan 4 mg o.d. 32 mg o.d.
Losartan 50 mg o.d. 150 mg o.d.
Valsartan 40 mg b.i.d. 160 mg b.i.d.
Ivabradine 5 mg b.i.d. 7.5 mg b.i.d.
Vericiguat 2.5 mg o.d. 10 mg o.d.
b.i.d. = bis in die (twice daily); o.d. = omne in die (once daily); SGLT2 = sodium-glucose co-transporter 2; t.i.d. = ter in die (three times a day.
©ESC
Other agents (continued)
Digoxin 62.5 µg o.d. 250 µg o.d.
Hydralazine/ Isosorbide dinitrate 37.5 mg t.i.d./ 20 mg t.i.d. 75 mg t.i.d./ 40 mg t.i.d.
b.i.d. = bis in die (twice daily); o.d. = omne in die (once daily); SGLT2 = sodium-glucose co-transporter 2; t.i.d. = ter in die (three times a day.
©ESC
Criteria for definition of advanced heart failure
All the following criteria must be present despite OMT:

1. Severe and persistent symptoms of heart failure [NYHA class III (advanced) or IV].
2. Severe cardiac dysfunction defined by (at least one of the following):
• LVEF (≤30%)
• Isolated RV failure (e.g., ARVC)
• Non-operable severe valve abnormalities or congenital abnormalities
• Persistently high (or increasing) BNP or NT-proBNP values and severe diastolic
dysfunction or LV structural abnormalities (according to the definitions of HFpEF)
3. Episodes of pulmonary or systemic congestion requiring high-dose i.v. diuretics (or diuretic
combinations) or episodes of low output requiring inotropes or vasoactive drugs or
malignant arrhythmias causing >1 unplanned visit or hospitalization in the last 12 months.
4. Severe impairment of exercise capacity with inability to exercise or low 6MWT (<300 m) or
pVO2 <12 mL/kg/min or <50% predicted value, estimated to be of cardiac origin.
©ESC
6MWT= 6-minute walk test; ARVC = arrhythmogenic right ventricular cardiomyopathy; BNP = B-type natriuretic peptide; HFpEF = heart failure with preserved éjection fraction; i.v. =
intravenous; LV = left ventricular; LVEF = left ventricular ejection fraction; NT-proBNP = N-terminal pro-B-type natriuretic peptide; NYHA =New York Heart Association; pVO2 = peak oxygen
consumption; RV = right ventricular.
Algorithm for the treatment of
patients with advanced heart failure
BTB = bridge to bridge; BTC=bridge to candidacy; BTD = bridge to

decision; BTR = bridge to recovery; BTT = bridge to transplantation;
CA = cardiac amyloidosis; DT = destination therapy; ESC = European Society of
Cardiology; HCM = hypertrophic cardiomyopathy; HF = heart failure;
HFA = Heart Failure Association; HT = heart transplantation;
INTERMACS = Interagency Registry for Mechanically Assisted Circulatory
Support; LVAD = left ventricular assist device; LVAD-BTC = left ventricular assist
device bridge to candidacy; LVAD-DT = left ventricular assist device destination
therapy; MCS = mechanical circulatory support.
aThis algorithm can be applied
to all patients with advanced HF defined according to the ESC/HFA criteria, with
exception of HCM, CA, arrhythmic storm, adult congenital heart disease,
refractory angina.
bRecurrent hospitalization, progressive end-organ failure, refractory congestion,
inability to perform cardiopulmonary exercise test

or peak oxygen consumption <12 mL/min/kg or <50% of expected value.
Colour code for classes of recommendation: Green for Class of recommendation
I and Yellow for Class of recommendation IIa (see Table 1 for further details on
©ESC
classes of recommendation
Triage of patients with advanced
heart failure and appropriate
timing of referral
ARNI = angiotensin receptor-neprilysin inhibitor; CRT = cardiac

resynchronization therapy; HF=heart failure; HT = heart transplantation;
ICD=implantable cardioverter-defibrillator; LT-MCS = long-term
mechanical circulatory support; LVEF=left ventricular ejection fraction;
NYHA = New York Heart Association; RASi = renin-angiotensin system
inhibitor; RV = right ventricular; SBP = systolic blood pressure;
QOL = quality of life.
aLimited life expectancy may be due by major comorbidities such as cancer,
dementia, end-stage organ dysfunction; other conditions that may impair

follow-up or worsen post-treatment prognosis include frailty, irreversible
©ESC
cognitive dysfunction, psychiatric disorder, or psychosocial issues.
ACUTE HEART FAILURE
GAGAL JANTUNG AKUT
ACUTE HEART FAILURE
• RAPID OR GRADUAL ONSET OF SYMPTOMS AND/OR SIGNS OF HF

• AHF IS A LEADING CAUSE OF HOSPITALIZATIONS IN SUBJECTS AGED > 65 YEARS, ASSOCIATED
WITH HIGH MORTALITY AND REHOSPITALIZATION RATES
• IN-HOSPITAL MORTALITY RANGES FROM 4-10%
• POST DISCHARGE 1 YEAR MORTALITY 25-30%
• > 45% DEATHS OR READMISSION RATES
AHF MANIFESTATION
• FIRST MANIFESTATION OF HF (NEW ONSET):
• HIGHER IN-HOSPITAL MORTALITY
• LOWER POST-DISCHARGE MORTALITY AND
REHOSPITALIZATION RATES
• ACUTE DECOMPENSATION OF CHRONIC (MORE
FREQUENTLY)
CLINICAL PRESENTATIONS OF ACUTE HEART FAILURE
Profil klinis pasien dengan
gagal jantung akut
berdasarkan ada/tidaknya
kongesti dan/atau hipoperfusi
Tanda/gejala kongesti à
wet vs. dry
Perfusi perifer à
cold vs. warm
Diagnostic work up of new
onset acute heart failure
ACS = acute coronary syndrome; BNP = B-type natriuretic

peptide; CT = computed tomography; HF = heart failure;
MR-proANP=mid-regional pro-atrial natriuretic peptide;
NT-proBNP = N-terminal pro-B-type natriuretic peptide;
TSH = thyroid-stimulating hormone.
aInitial laboratory exams include troponin, serum creatinine,
electrolytes, blood urea nitrogen or urea, TSH, liver function

tests as well as D-dimer and procalcitonin when pulmonary
embolism or infection are suspected, arterial blood gas analysis in
case of respiratory distress, and lactate in case of hypoperfusion.
bSpecific evaluation includes coronary angiography, in case of
suspected ACS, and CT in case of suspected pulmonary

embolism.
cRule-in values for the diagnosis of acute HF: >450 pg/mL if aged
<55 years, >900 pg/mL if aged between 55 and 75 years and
©ESC
>1800 pg/mL if aged >75 years
Management of acute decompensated
heart failure
MCS=mechanical circulatory support.

aAdequate diuretic doses to relieve congestion and close monitoring of diuresis is
©ESC
recommended (see Figure13) regardless of perfusion status.
Management of pulmonary
oedema
MCS=mechanical circulatory support; RRT= renal replacement therapy;
©ESC
SBP=systolic blood pressure.
Management of right ventricular failure
ACS=acute coronary syndrome; RV=right ventricular; RVAD=right ventricular assist device.
©ESC
aInotropes alone in case of hypoperfusion without hypotension.
Management of cardiogenic shock
ACS = acute coronary syndrome; BTT = bridge to transplantation;

MCS = mechanical circulatory support; PCI = percutaneous coronary
intervention.
aPCI in ACS, pericardiocentesis in tamponade, mitral valve surgery in papillary
muscle rupture. In case of interventricular septum rupture, MCS as BTT should

be considered.
bOther causes include acute valve regurgitation, pulmonary embolism,
©ESC
infection, acute myocarditis, arrhythmia.
Initial management of
acute heart failure
MCS = mechanical circulatory support.

aAcute mechanical cause: myocardial rupture
complicating acute coronary syndrome (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.
bSee previous slides for specific treatments according to
©ESC
different clinical presentations.
Stages of management of
patients with acute heart
failure
ICCU = intensive coronary care unit; ICU = intensive care

unit.
©ESC
Diuretic therapy
(furosemide) in acute
heart failure
i.v.=intravenous.
aThe maximal daily dose for i.v. loop diuretics is generally
considered furosemide 400–600 mg though up to 1000

mg may be considered in patients with severely impaired
kidney function.
bCombination therapy is the addition to the loop diuretic
of a diuretic with a different site of action, e.g. thiazides

or metolazone or acetazolamide.
©ESC
Diuretics
Vasodilator(nitrat)
Manajemen cairan
Inotropic
drugs
Agen Inotropik
● Digunakan pada gagal jantung dengan
hipotensi
● Inotropik dapat menyebabkan takikard dapat
memicu iskemi miokard dan aritmia à
diperlukan monitoring EKG
Vasopressor
● Digunakan pada gagal jantung dengan
hipotensi
● Contoh: NE, dopamin dosis >5µg/kg/menit
TAKE HOME MESSAGES
1. GAGAL JANTUNG MERUPAKAN SALAH SATU PENYAKIT KARDIOVASKULAR YANG
PREVALENSINYA AKAN TERUS MENINGKAT SEJALAN DENGAN PENINGKATAN KEJADIAN
SESUAI ETIOLOGI ATAU PENYAKIT DASARNYA
2. PERJALANAN AKHIR DARI HAMPIR SEMUA PENYAKIT KARDIOVASKULAR APABILA TIDAK
DILAKUKAN TATALAKSANA YANG KOMPREHENSIF
3. DIAGNOSIS DIBUAT BERDASARKAN ANAMNESIS, PEMERIKSAAN FISIK DAN PEMERIKSAAN
PENUNJANG YANG BERSIFAT NON-INVASIF MAUPUN YANG INVASIF
4. UNTUK TATALAKSANA YANG KOMPREHENSIF DIPERLUKAN DIAGNOSIS YANG
DIKLASIFIKASIKAN BERDASARKAN STATUS FUNGSIONAL, KELAINAN STRUKTURAL YANG
MENYERTAI DAN ETIOLOGI
46
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OPTIMAL HEART FAILURE

EKA GINANJAR, MD, PHD, MHA, FINASIM, FACP, FICA

Indonesia : > 500.000 cases

Estimates based on a single centre or hospital are indicated by an H.

kelelahan) dan dapat disertai dengan

penurunan curah jantung dan/atau

Normal LV structure LV remodelling Clinical

Dzau, et al. Circulation. 2006

At high risk for HF, but without No limitation of physical activity.

Slight limitation of physical activity.

ACC/AHA=AMERICAN COLLEGE OF CARDIOLOGY/AMERICAN HEART

Yancy C W et al. Circulation. 2013;128:e240-e327

FAKTOR RISIKO PALING BANYAK YANG

• REDUCED EXERCISE TOLERANCE

Gagal Jantung Non-Akut

ECG = electrocardiogram; HFmrEF = heart failure with mildly reduced ejection

impaired LV filling) makes the diagnosis more likely.

ACE-I = angiotensin-converting enzyme inhibitor;

All the following criteria must be present despite OMT:

BTB = bridge to bridge; BTC=bridge to candidacy; BTD = bridge to

inability to perform cardiopulmonary exercise test

ARNI = angiotensin receptor-neprilysin inhibitor; CRT = cardiac

dementia, end-stage organ dysfunction; other conditions that may impair

• RAPID OR GRADUAL ONSET OF SYMPTOMS AND/OR SIGNS OF HF

ACS = acute coronary syndrome; BNP = B-type natriuretic

electrolytes, blood urea nitrogen or urea, TSH, liver function

suspected ACS, and CT in case of suspected pulmonary

MCS=mechanical circulatory support.

MCS=mechanical circulatory support; RRT= renal replacement therapy;

ACS=acute coronary syndrome; RV=right ventricular; RVAD=right ventricular assist device.

ACS = acute coronary syndrome; BTT = bridge to transplantation;

muscle rupture. In case of interventricular septum rupture, MCS as BTT should

MCS = mechanical circulatory support.

complicating acute coronary syndrome (free wall rupture,

ICCU = intensive coronary care unit; ICU = intensive care

considered furosemide 400–600 mg though up to 1000

of a diuretic with a different site of action, e.g. thiazides

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