DAFTAR RIWAYAT HIDUP

1. Nama : Dr.dr.Trisulo Wasyanto, SpJP (K), FIHA, FAPSC, FAsCC

2. Tempat & tanggal lahir : Poso , 8 – 2 - 1956
3. Pangkat / Golongan : Dokter Pendidik Klinis Utama / IV E
4. Alamat kantor : RSUD Dr. Moewardi Surakarta.
Jln. Kolonel Sutarto No. 132 Surakarta - 57126.
Telepon (0271) 663188.
5. Posisi saat ini : Kepala SMF/Bagian Jantung RS Dr. Moewardi / FK UNS
Kepala Instalasi Peyananan Jantung Terpadu RSDM
6. Perguruan Tinggi Strata 1 : Fak. Kedokteran UNDIP, lulus 1982
Strata 2 : Kardiologi & Kedokt. Vascular FK UNAIR, lulus 1995
Strata 3 : Program Doktor Fak. Kedokteran UNS, lulus 2014

Konsultan Jantung dan Pembuluh Darah : Tahun 2005.

Fellow Asian Pacific Society of Cardiology , Taipei 2007.
Fellow Asian College of Cardiology , Philippine 2010 .
 CURRENT MANAGEMENT OF
CONGESTIVE HEART FAILURE

Dr. dr. TRISULO WASYANTO, SpJP (K), FIHA, FAPSC, FAsCC

DEPT OF CARDIOLOGY & VASCULAR MEDICINE
UNIV OF SEBELAS MARET/Dr MOEWARDI HOSPITAL
S U RAKAR TA
 Outline
Definition, Epidemiology, Diagnosis and
Classification of CHF

Therapeutic Approach of CHF

Clinical Management of CHF in Indonesia

Conclusion
 Heart Failure Definition
• HF is a clinical syndrome characterized by
typical symptoms (e.g. breathlessness, ankle
swelling and fatigue) that may be accompanied
by signs (e.g. elevated jugular venous pressure,
ESC 2016 pulmonary crackles and peripheral oedema)
caused by a structural and/or functional cardiac
abnormality, resulting in a reduced cardiac
output and/ or elevated intracardiac pressures
at rest or during stress.

• HF is a complex clinical syndrome that results

ACCF/AHA
from any structural or functional impairment of
2013 ventricular filling or ejection of blood2
ESC: European Society of Cardiology; AHA: American Heart Association; ACCF: American College of Cardiology Foundation
1. Ponikowski et al. Eur Heart J 2016; 37(27): 2129-2200; 2. Yancy et al. JACC 2013;62:e147–239 4
 Global Pandemic of Heart Failure
Heart failure: preventing disease and death worldwide

GLOBAL PANDEMIC
> 26 mio people and increasing

Indonesia : > 500.000 cases

Ambrosy PA et al. The Global Health and Economic Burden of Hospitalizations for Heart Failure. Lessons Learned From Hospitalized
Figure 3. Proportion
Heart Failure Registries.
of the population living with heart failure in individual countries across the
J Am Coll Cardiol. 2014;63:1123–1133.
4,8,9,11,42–46
5 RI
globe. Dasar 2013, Badan Litbangkes Kementerian Kesehatan RI dan Data Penduduk Sasaran, Pusdatin Kementerian Kesehatan
Data Riset Kesehatan
a
Bui AL, Horwich TB, Fonarow GC. Epidemiology and 54. risk profile of heart failure. Nat Rev Cardiol 2011;8:30–41.
 However, mortality rates in heart failure are
highHeart
evenfailure mortality statistics
for patients compliant with
the best available treatments1

~50 %
DIE WITHIN
5 YEARS
OF DIAGNOSIS2

When heart failure symptoms are stabilised by current treatments,

it may seem that patients are doing well, but the neurohormonal
imbalance underlying heart failure is still silently occurring,
resulting in disease progression.1
1. Fauci AS, Braunwald E, Kasper DL, et al, eds. Harrison's Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008.
2. Gerber et al. JAMA Intern Med 2015;175:996-1004 and Zarrinkoub et al. European Journal of Heart Failure 2013;15: 995–1002
Heart Failure has a worse 5-year prognosis
than a number of common cancers

8
Cardiovascular Continuum of Heart Failure

Normal LV structure LV remodelling Clinical

and function and dysfunction Heart Failure

Years Years/months
Dzau, et al. Circulation. 2006
 Type of Heart Failure :
Heart Failure with Preserved (HFpEF), Mid-range (HFmrEF)
and Reduced Ejection Fraction (HFrEF)
Systolic dysfunction Diastolic dysfunction

HFrEF HFmEF HFpEF

Symptoms ± Signs Symptoms ± Signs Symptoms ± Signs

LVEF≤ 40% LVEF 40-49% LVEF ≥ 50%

1. Elevated levels of 1. Elevated levels of
Natriuretic peptide Natriuretic peptide
2. At least one 2. At least one
additional criterion : additional criterion :
a. Relevant a. Relevant
structural heart structural heart
*Left ventricular
(LVH and/or LAE) (LVH and/or LAE)
ejection fraction b. Diastolic b. Diastolic
(LVEF) is evaluated by dysfunction dysfunction
echocardiography
ESC Guideline 2016
 Classification of Heart Failure
ACC/AHA HF Stage NYHA Functional Class
A At high risk for heart failure but
without structural heart disease or None
symptoms of heart failure (eg,
patients with hypertension or
coronary artery disease)
I Asymptomatic
B Structural heart disease but
without symptoms of heart failure

II Symptomatic with moderate exertion

C Structural heart disease with prior or
current symptoms of heart failure
III Symptomatic with minimal exertion

D Refractory heart failure requiring

specialized interventions IV Symptomatic at rest
11
Heart Failure Diagnostic Flowchart

ESC Guideline 2016

Heart Failure Diagnostic Flowchart

ESC Guideline 2016

Biomarkers Indications for Use (ACC-AHA Guideline 2017)
 Outline
Definition, Epidemiology, Diagnosis and
Classification of CHF

Therapeutic Approach of CHF

Clinical Management of CHF in Indonesia

Conclusion
Treatment of HFrEF Stage C and D (ACC-AHA 2017)
(ACC-AHA 2017)
 Pharmacological Treatment for Stage C
HF With Reduced EF (ACC-AHA 2017)
Renin-Angiotensin System Inhibition With
ACE-Inhibitor or ARB or ARNI
Comment/
COR LOE Recommendations
Rationale

The clinical strategy of inhibition of the renin- NEW: New clinical

ACE-I: A angiotensin system with ACE inhibitors (Level trial data
of Evidence: A), OR ARBs (Level of Evidence: prompted
A), OR ARNI (Level of Evidence: B-R) in clarification and
conjunction with evidence-based beta important
I ARB: A blockers, and aldosterone antagonists in updates.
selected patients, is recommended for
patients with chronic HFrEF to reduce
morbidity and mortality.
ARNI: B-R
 Neprilysin as a Therapeutic Target
Natriuretic peptides
• Neprilysin breaks down endogenous
Adrenomedullin
vasoactive peptides, including the
Bradykinin
natriuretic peptides
Substance P
• Inhibition of neprilysin potentiates the
(angiotensin II)
action of those peptides
• Because angiotensin II is also a substrate Neprilysin
for neprilysin, neprilysin inhibitors must
be co-administered with a RAAS blocker Inactive
• The combination of a neprilysin inhibitor fragments
and an ACEI is associated with
unacceptably high rates of angioedema

Sacubitril/Valsartan (LCZ696):
Angiotensin Receptor–Neprilysin Inhibitor (ARNI)
Corti R et al. Circulation. 2001;104:1856-1862.
 Pharmacological Treatment for Stage C
HF With Reduced EF (ACC-AHA 2017)
Renin-Angiotensin System Inhibition With
ACE-Inhibitor or ARB or ARNI
Comment/
COR LOE Recommendations
Rationale
ARNI should not be administered NEW: Available
concomitantly with ACE inhibitors or evidence demonstrates
within 36 hours of the last dose of an a potential signal of
III: Harm B-R ACE inhibitor. harm for a concomitant
use of ACE inhibitors
and ARNI.

ARNI should not be administered to NEW: New clinical trial

patients with a history of angioedema. data.
III: Harm C-EO
 Pharmacological Treatment for Stage C
HF With Reduced EF (ACC-AHA 2017)
Ivabradine
Comment/
COR LOE Recommendations
Rationale

Ivabradine can be beneficial to reduce NEW: New clinical trial

HF hospitalization for patients with data.
symptomatic (NYHA class II-III) stable
chronic HFrEF (LVEF ≤35%) who are
IIa B-R receiving GDEM*, including a beta
blocker at maximum tolerated dose, and
who are in sinus rhythm with a heart
rate of 70 bpm or greater at rest.

*In other parts of the document, the term “GDMT” has been used to denote guideline-directed management and therapy. In this
recommendation, however, the term “GDEM” has been used to denote this same concept in order to reflect the original wording of the
recommendation that initially appeared in the “2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An
Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure”.
 Pharmacological Treatment for Stage C
HF With Preserved EF (ACC-AHA 2017)
Comment/
COR LOE Recommendations
Rationale

In appropriately selected patients with NEW: Current

HFpEF (with EF ≥45%, elevated BNP levels recommendation
or HF admission within 1 year, estimated reflects new RCT
IIb B-R glomerular filtration rate >30 ml/min, data.
creatinine <2.5 mg/dL , potassium <5.0
mEq/L), aldosterone receptor antagonists
might be considered to decrease
hospitalizations.

The use of ARBs might be considered to 2013

decrease hospitalizations for patients with recommendation
IIb B HFpEF. remains current.
 Pharmacological Treatment for Stage C
HF With Preserved EF (ACC-AHA 2017)

Comment/
COR LOE Recommendations
Rationale
Routine use of nitrates or NEW: Current
phosphodiesterase-5 inhibitors to recommendation
III: No increase activity or QoL in patients reflects new data
B-R
Benefit with HFpEF is ineffective. from RCTs.

Routine use of nutritional 2013

III: No supplements is not recommended recommendation
C for patients with HFpEF. remains current.
Benefit
ACE Inhibitors Reduced Mortality in
Heart Failure and/or LV dysfunction
Mortality reduction by
about 20-30% in NYHA class II-III patients
and nearly 40% in class IV patients

R
E R
E C

E L
 -Blockers Reduce the Risk of
All-cause Mortality in HFrEF
Risk reduction
(versus placebo)

35%
34% 34%

CIBIS II (1999) COPERNICUS (2001 MERIT-HF (1999)

p<0.0001 p<0.001 p=0.0062

 The Key Disease-Modifying Drugs
Targeting Renin-angiotensin and Sympathetic Signalling
Reduce Mortality Risks in Chronic HF
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 24%
median follow
up of 41.4 (7.6% ARR;
up of 33.7 34%
months) mean follow
months) (3.8% ARR;
SOLVD4,5 up of 24
CHARM- mean follow months)
Alternative6 up EMPHASIS-
of 1.3 years) HF1,8
MERIT-HF7
Drugs that inhibit RAS have modest
effects on survival rate
*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; 1. Go et al. Circulation 2014;129:e28-e292; 2. Yancy et al. Circulation 2013;128:e240–327;
HFrEF=heart failure with reduced ejection fraction; LVEF=left 3. Levy et al. N Engl J Med 2002;347:1397–402; 4. McMurray et al. Eur Heart J 2012;33:1787–847;
ventricular ejection fraction; MRA=mineralocorticoid receptor 5. SOLVD Investigators. N Engl J Med 1991;325:293–302; 6. Granger et al. Lancet 2003;362:772–66;
antagonist 7. MERIT-HF study group. Lancet 1999;353: 2001-7; 8. Pitt et al. N Engl J Med 1999;341:709-17
 Medical Therapy for Stage C HFrEF:
Magnitude of Benefit in RCTs
(American Heart Journal, 2012)

RR NNT to ↓ mortality RR
↓ Mortality (standardized 36 ↓ HF Hospital.
months)

ACE I / ARB 17% 26 31%

Beta-Blockers 34% 9 41%

Aldosterone
30% 6 35%
Antagonists

Nitrates/Hydralazine 43% 7 33%

 HFrEF: Medications & Devices
↓ Symptoms ↓ Hospitalizations ↓ Mortality

Diuretics √ √ (?) ?
ACE I /ARBs √ √ √
Beta-Blockers √ √ √
Aldosterone Antagonists √ √ √
Digitalis √ √ X
Nitrates/Hydralazine √ √ √
ARNI √ √ √
Ivabradine √ √ X
AICD (Defibrillators) X X √
CRT (BiV pacemakers) √ √ √
 Outline
Definition, Epidemiology, Diagnosis and
Classification of CHF

Therapeutic Approach of CHF

Clinical Management of CHF in Indonesia

Conclusion
 HF patients in Indonesia has relatively
high rate of in-hospital mortality1,2

7.6% 8.2%
6.7% 6.5%
5.4% 5.4% 4.8%
3.0%
2.0%

Indonesia Singapore Phillipines Malaysia Taiwan Asia Pacific Australia Latin US

America

1. Siswanto et al, 2010. Heart Failure in NCVC Jakarta and 5 hospitals in Indonesia. CVD Prevention and Control, 5, 35– 38
2. Ponikowski et al, 2014. Heart failure: preventing disease and death worldwide. ESC Heart Failure, 1: 4–25
 Indonesian HF patients were younger, yet have
more severe clinical features and worse outcome
(ADHERE study) Mean age
Characteristics1
70 75
EF < 40% 62.7% 60 65
(54% in US)
Mean EF 33.0%
Prior HF 66.7% Indonesia Asia Pacific Europe US

Compared to those without a prior HF hospitalization, patients with a history of HF

hospitalization had2 :
► worse NYHA functional status, ►↓ receive ACEI/ARB
► ↑ symptoms and signs of HF, ►↓ receive guideline-indicated b-blockers
► ↑ risk-factor comorbidity burden, ►↑ diuretics
► ↑ atrial fibrillation (ECG), ►↑ risk of dead after 6- months discharge
► ↑ diastolic dysfunction (echocardio) (despite similar age)
1. Siswanto et al, 2010. Heart Failure in NCVC Jakarta and 5 hospitals in Indonesia. CVD Prevention and Control, 5, 35– 38
31 31
2. Lam et al, 2016. Regional and ethnic differences among patients with heart failure in Asia: the Asian sudden cardiac death in heart failure
registry. European Heart Journal, 37, 3141–3153
 Mean length of stay are relatively similar,
but mortality rate 30-days after discharge are very high

Reyes et al, 2016. Heart failure across Asia, International Journal of Cardiology, 223, 163–167 32
 Outline
Definition, Epidemiology, Diagnosis and
Classification of CHF

Therapeutic Approach of CHF

Clinical Management of CHF in Indonesia

Conclusion
 Conclusion
• HF patients in Indonesia has relatively
high rate of in-hospital mortality
• Under-usage of guideline-recommended
HF pharmacological therapies in
Indonesian patients.
• We need a more comprehensive and
organized approach to HF care in
Indonesia.
35