CHF (Congestive Heart Failure)

dr. Devi Putri Ramadani, Sp.JP, FIHA

 Klasifikasi CHF menurut NYHA
Kelas I : tidak ada simptom akibat aktivitas fisik (berjalan, naik
tangga)
Kelas II : aktivitas fisik sedikit dibatasi karena dyspnea (naik
• Class
tangga, jalanI mendaki)
: No limitation of physical activity
• Class II : Slight limitation of physical activity
Kelas III : aktivitas fisik sangat dibatasi  dyspnea (dilarang
• Class
berjalan jauhIIIdan
: Marked limitation of physical activity
naik tangga)
• Class IV : Unable to carry out physical activity without
: istirahat total  dyspnea saat istirahat (tidak dapat
Kelas IVdiscomfort
melakukan aktivitas fisik)

Klasifikasi CHF ,mnrt ACC/AHA 2001

 Stage A : Asymptomatic with no heart damage
but have risk factors for heart failure
 Stage B : Asymptomatic but have signs of
structural heart damage
 Stage C : Have symptoms and heart damage
 Stage D : Endstage disease
 Tujuan Terapi CHF
• Memperbaiki symptoms & kualitas hidup
Tx simptomatik (Diuretik)
 Me fungsi jantung (Inotropik positif,
Vasodilator)

• Me  progressifitas CHFMenghambat
adaptasi neurohormonal yg merugikan (Beta
bloker, Antagonis Angiotensin ( ACEi
&AIIRA), Antagonis Aldosteron)

• Me  resiko kematian & kebutuhan rawat inap

Faktor yg Memperberat CHF
• iskemia / infark miokard
• Diet mengandung Na berlebihan
• Intake cairan berlebihan
• Tidak patuh dalam berobat
• Arritmia
• Kondisi yg berhub dg pe  metabolisme
(kehamilan, tirotoksikosis, aktivitas fisik
berlebihan)
• Pemakaian obat yang bersifat inotropik negatif
atau retensi cairan ( mis. NSAID,
kortikosteroid)
• Alkohol
 Summary of drug treatment for CHF

Asymptomatic Mild to moderate Moderate

LV dysfunction CHF to severe CHF
ACE inhibitor Digoxin Digoxin
Beta blocker Diuretics Diuretics
ACE inhibitor ACE inhibitor
Beta blocker Beta blocker
Spironolactone
Summary of drug treatment for CHF
PHARMACOLOGIC THERAPY
Improved Decreased Prevention
Prevention Neurohumoral
Neurohumoral
symptoms mortality of CHF Control
DIURETICS yes ? ? NO
DIGOXIN yes = minimal yes

INOTROPES yes mort. ? no

Vasodil.(Nitrates)
(Nitrates) yes yes ? no
ACEI yes YES yes YES
Other
Other neurohormonal
neurohormonal
control
control drugs
drugs
yes +/- ? YES
 TREATMENT

Normal
Asymptomatic
LV dysfunction
EF <40%
Symptomatic CHF
ACEI NYHA II
Symptomatic CHF
Diuretics mild
mild NYHA - III
Neurohormonal Symptomatic CHF
inhibitors Loop
Diuretics NYHA - IV
Digoxin?
Inotropes
Specialized therapy
Transplant
Secondary prevention
Modification of physical activity
Pharmacological therapy
 Stages in the evolution of HF and recommended therapy by stage

Stage A Stage B Stage C Stage D

Pts with : Pts with : Pts with : Pts who have

• Hypertension • Previous MI • Struct. HD marked symptoms
• CAD Struct. • LV systolic Develop Refract.
• Shortness of breath at rest despite
• DM dysfunction Symp.of
Heart Symp.of and fatigue, reduce
maximal medical
• Cardiotoxins • Asymptomatic
Disease HF exercise HF at rest therapy.
• FHx CM Valvular disease
tolerance

THERAPY THERAPY THERAPY THERAPY

• Treat Hypertension • All measures under • All measures under • All measures under
• Stop smoking stage A stage A stage A,B and C
• Treat lipid disorders • ACE inhibitor • Drugs for routine use: • Mechanical assist
• Encourage regular • Beta-blockers • diuretic device
exercise • ACE inhibitor • Heart transplantation
• Stop alcohol & drug • Beta-blockers • Continuous IV
use • digitalis inotrphic infusions for
• ACE inhibition palliation

ACC/AHA Guidelines for the

Evaluation and Management of Chronic Heart Failure in the Adult 2001
 P – Drug Diuretic
A. Loop Diuretics
No Nama Obat Effikasi Safety Suitability
1. Furosemid Duration of action 6-8 h Hipokalemia 1. Edem pada gagal
jantung kongestif
2. Dosis awal:
• Tab 20-40mg, 1x1
• IV/IM 20-40mg
dosis tunggal
3. Dosis Target:
• Tab 40-
240mg/hari
2. Bumetanid Duration of action 4-6 h idem 1. IV 0.5 to 1.0 mg
once or twice/day
2. Edem pada gagal
jantung kongestif
 P – Drug Diuretic
B. Thiazide Diuretic

No Nama Obat Effikasi Safety Suitability

1. Chlorothiazide Duration of action 6 to Hipokalemia 1. Edem pada gagal
12 h jantung kongestif
2. IV : 250 to 500 mg
once or twice/day
2. Metolazone Duration of action 12 idem 1. Edem pada gagal
to 24 h jantung kongestif
2. IV : 2.5 mg
once/day
 P – Drug Diuretic
C. Potassium-sparing diuretics

No Nama Obat Effikasi Safety Suitability

1. Spironolactone Duration of action 1 to Hipokalemia 1. Edem pada gagal
3h jantung kongestif
2. IV: 12.5 to 25.0
mg once/day
2. Amiloride Duration of actions 24 idem 1. IV: 5 mg once/day
jam
 P – Drug Beta Blocker
No Nama Obat Effikasi Safety Suitability
1. Bisoprolol Duration of action 24h Pusing, 1. IV: 1.25 mg
hipotensi, once/day
edem
pergelangan
kaki

2. Carvedilol 7 to 10 hours Idem 1. IV: 3.125 mg

twice/day
3. Metoprolol 6-8 h idem 1. iv: 12.5 to 25.0 mg
succinate once/day
extended
release
(metoprolol
CR/XL)
 P – Drug ACE Inhibitor
No Nama Obat Effikasi Safety Suitability
1. Enalapril Onset 1 h Renal damage Tab: 2.5 mg, 2x1
and sehari
pregnanncy
Pusing,
hipotensi,
edem
pergelangan
kaki

2. Kaptopril onset of action may idem Tab: 6.25 mg, 3x1

occur within 10-20 sehari
minutes, with the
maximal effect reached
within 1 hour. 
 P – Drug Antagonis Aldosteron

No Nama Obat Effikasi Safety Suitability

1. Spironolakton Waktu Paruh (Half Life) Pusing, Iv: 12.5–25 mg
Spironolactone: 1.4 jam. hipotensi, once/day
edem
pergelangan
kaki
2. Eplerenone Half-life:4–6hr idem IV: 25 mg once/day
 P – Drug Vasodilator

No Nama Obat Effikasi Safety Suitability

1. Hidralazin Half-life: 2–8 hr Pusing, Iv: 25–50 mg once or
hipotensi, twice/day
edem
pergelangan
kaki
2. Isosorbide It has high bioavailability idem Iv: 20–30 mg
dinitrate and a longer half-life (4- once/day
6 hours)