Curriculum Vitae

INDAH SUKMAWATI
EDUCATION / TRAINING
2002 - 2008 MD, Airlangga University
2010 - 2016 Cardiologist, Airlangga University
2017 Certified Single Chamber Pacemaker Implanter
2017 Interventional Cardiology Observership, Cleveland Clinic, USA
2018 Heart Failure Observership, National Heart Center Singapore

WORK EXPERIENCE:
2008 – 2016 GP at Citra Gading Medika Clinic, Surabaya
2016 – 2017 Cardiologist at National Hospital, Surabaya Clinical and Research
2017 – now Cardiologist at Siloam Hospitals Lippo Village Interest:
2018 – now Lecturer at Medical Faculty Universitas Pelita Harapan Interventional Cardiology
Heart Failure
Cardiovascular Disease in Women
PROFESSIONAL ORGANISATION :
2016 – now Member of Indonesian Heart Association
2019 – now Secretary for Woman Cardiology Working Group of Indonesia Heart Association
Diagnosis and Management of
Heart Failure in Primary Care
INDAH SUKMAWATI, MD, FIHA
Disclosure
I have no conflict of interest pertinent to this presentation
 Heart Failure – a global problem
26 Million Worldwide number of patients affected by heart failure.

1-2% Healthcare expenditure attributed to heart failure in Europe

and North America.

Heart failure patient suffering from at least 1 comorbidity:

74% more likely to increase the severity of the global status.

Ambrosy AP, Fonarow GC, Butler J, et al. J Am Coll Cardiol. 2014;63:1123-1133

Cowie MR, Anker SD, Cleland JGF, et al. Oxford PharmaGenesis. 2014, p1-60.
van Deursen VM, Urso R, Laroche C, et al. Eur J Heart Fail. 2014 Jan; 16(1):103-11
 ACEIs* ARBs* -Blockers* MRAs*
vs Placebo vs Placebo + ACEI/ARB vs. + ACEI/ARB + -blockers vs.
ACEI/ARB alone ACEI/ARB + -blockers
Reduction in relative risk of
all-cause mortality

16% 17%
(4.5% ARR; (3.0% ARR;
mean follow median follow 24%
up of 41.4 up of 33.7 (7.6% ARR;
months) months) 34% mean follow up
SOLVD4,5 (3.8% ARR; of 24 months)
CHARM-
mean follow EMPHASIS-
Alternative6
up HF1,8
of 1.3 years)
MERIT-HF7

50% of HF patients died in 5 years after diagnosis2,3

*On top of standard therapy at the time of study, except in CHARM-Alternative where patients were intolerant to ACEI.
Patient populations varied between trials and as such relative risk reductions cannot be directly compared
ACEI=angiotensin-converting-enzyme inhibitor; ARB=angiotensin receptor blocker; HF=heart failure;
ARR=absolute risk reduction; HFrEF=heart failure with reduced ejection fraction; LVEF=left
ventricular ejection fraction; MRA=mineralocorticoid receptor antagonist

1. Go et al. Circulation 2014;129:e28-e292; 2. Yancy et al. Circulation 2013;128:e240–327; 3. Levy et al. N Engl J Med 2002;347:1397–402; 4.
McMurray et al. Eur Heart J 2012;33:1787–847; 5. SOLVD Investigators. N Engl J Med 1991;325:293–302; 6. Granger et al. Lancet
2003;362:772–66; 7. MERIT-HF study group. Lancet 1999;353: 2001-7; 8. Pitt et al. N Engl J Med 1999;341:709-17
The path that led to Heart Failure
Pathophysiology
Fibrous Myocyte
scar hypertrophy

Acute
infarction Increased
interstitial
collagen

Infarct zone Spherical

thinning ventricular
and elongation dilation

Konstam MA, et al. J Am Coll Cardiol Img 2011;4:98–108

Role of General Practitioner / Primary Care Physician
▪ Primary care facility / clinic
▪ Risk factors screening and management
▪ Early detection of HF patients
▪ Timely referal to Cardiologist / HF specialist
▪ Emergency Room
▪ Triage and assessment of acute HF patients
▪ ABC’s assessment
▪ Hemodynamic assessment and prompt treatment
▪ Triggering factors detection and evaluation
▪ Intensive Cardiac Care Unit
▪ Hemodynamic monitoring and stabilization
▪ Trajectory check (not improved/worsening, stalled, improving towards target)

▪ Hospital general ward

▪ Transition to oral medications
▪ Medical optimization Education of risk factors management
▪ Pre-discharge education to patient and caregiver

Hollenberg SM, Warner Stevenson L, Ahmad T et al. J Am Coll Cardiol 2019;74:1966–2011

 Signs and symptoms to diagnose HF

Try to catch HF early before these happens

Hollenberg SM, Warner Stevenson L, Ahmad T et al. J Am Coll Cardiol 2019;74:1966–2011
Quadruple therapy of HF management

Initiation and optimization of the Four

Pillars of Heart Failure. All agents are
initiated in parallel.

This is followed by up-titration in one,

two or three steps, as required.

Additional therapies are then considered

as a final step.

Straw S, McGinlay M, Witte KK. Open Heart 2021;8:e001585. doi:10.1136/ openhrt-2021-001585

Standard HFrEF Treatment in 2020
OPTIMIZE GDMT DO NOT DELAY
Diagnose/ treat Individualize in Specific Avoid:
specific etiology populations Inertia/inaction
(that may warrant specific e.g. In AA: Hyd+ISDN is “Stable HF”
treatment) beneficial/standard
HF kills-like
RAASi
(ACEi/ARB/ARNi), cancer-if not
BB, MRA, SGLT2i optimally treated
Treat comorbidities: Time is of the essence
SGLT2i in DM, treat HTN to
SBP <130, treat iron
Shared decision with Treatment prevents and
patients’ goals improves outcomes
deficiency, sleep apnea,
depression, etc
Maddox TM, Januzzi JL Jr., Allen LA et al. J Am Coll Cardiol 2021;77:772–810
 HF medications
uptitration
de-escalation
re-assessment
re-initiation

Maddox TM, Januzzi JL Jr., Allen LA et al. J Am Coll Cardiol 2021;77:772–810

Hollenberg SM, Warner Stevenson L, Ahmad T et al. J Am Coll Cardiol 2019;74:1966–2011
Diuretic Dosing Guide

For patients receiving loop diuretics prior to

admission, the oral dose should be changed
to an intravenous dose of 1-2.5 times the
home dose

For patients naive to therapy, the lower end

of the dosing interval should be used

Hollenberg SM, Warner Stevenson L, Ahmad T et al. J Am Coll Cardiol 2019;74:1966–2011

When to refer?
Traffic light box

Refer to Cardiologist / HF Clinic

 What happens in the hospital/specialistic clinic?

HF Preceptorship NHCS, Singapore

Hollenberg SM, Warner Stevenson L, Ahmad T et al. J Am Coll Cardiol 2019;74:1966–2011
 “A journey of a thousand miles must begin with a single step.”

...Towards better Heart Failure Care...

*pictures were taken in 2018-2019 (before pandemic)
with patients/caregivers consent
Follow up care
post hospitalization/specialist care
1. Reassess clinical status
2. Review medications
3. Provide additional education
4. Address issues that may lead to worsening HF

Hollenberg SM, Warner Stevenson L, Ahmad T et al. J Am Coll Cardiol 2019;74:1966–2011

Breaking the bad news
Goals of care discussions with patient and caregiver
Manage cardiac and noncardiac symptoms
Advance care planning*
▪ Assess readiness to discuss goals of care
▪ Assess understanding of prognosis
▪ Confirm/discuss goals of care
▪ Confirm/establish surrogate decision maker
▪ Establish/reassess code status
▪ Discuss management of defibrillator when appropriate
▪ Determine need for specialist palliative care consultation

Be compassionate and empathetic

Hollenberg SM, Warner Stevenson L, Ahmad T et al. J Am Coll Cardiol 2019;74:1966–2011
Home health service
▪ Integrated, multidisciplinary care (decide the right level of care according to severity and
stability of HF and other care needs)
▪ Care plans with clear goals of care (individualise follow up in a care plan with goals, focus
care to improve quality of life, functional status and sense of security for patients)
▪ Patient education (individualise patient education and built on previous knowledge, include
family in education)
▪ Self-care management (apply Interventions to improve self-care, consider the use of alert
system to detect early symptoms of deterioration)
▪ Appropriate access to care (tele-rehabilitation, tele-monitoring, telephone follow-up)
▪ Optimize treatment (define clear strategies for uptitrations of drugs and set clear indications
for lab tests related to drug titration and deterioration)
Conclusion
▪ General practitioner / primary care physician plays an essential role in screening for CVD risk
factors to prevent established CVD which may lead to heart failure condition in time.
▪ A thorough history-taking and a meticulous physical examination are keys in detecting heart
failure patients in their earlier stage.
▪ The four pilars therapy are the current standard of treatment for heart failure. Initiation,
uptitration to optimal dose or maximally tolerated dose, de-escalation and re-initiation of HF
medications are needed to improve outcomes and to reduce hospitalisation #GDMTworks
▪ Continuity of care from primary care - specialistic care - advance care planning need to be
done in multidisciplinary approach
▪ Compassion and empathy are needed through and through when dealing with HF patients
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Thank you
For your kind attention