Tatalaksana CHF berdasarkan duideline terbaru 2022

1. The war against Heart Failure
bases on the beyond latest
guidelines

2. European Journal of Heart Failure 3 2001 315 Ž . 322

3. Scope pembahasan
• Perubahan klasifikasi
• Terapi farmakologi, fokus pada HF with reduced EF(HFrEF)
• info terbaru

4. Definition of heart failure
Heart failure is not a single pathological diagnosis, but a clinical
syndrome consisting of cardinal symptoms (e.g. breathlessness, ankle
swelling, and fatigue) that may be accompanied by signs (e.g. elevated
jugular venous pressure, pulmonary crackles, and peripheral
oedema). It is due to a structural and/or functional abnormality of the
heart that results in elevated intracardiac pressures and/or inadequate
cardiac output at rest and/or during exercise.
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal (2021) 42, 35993726

5. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal (2021) 42, 35993726

6. 2021 ESC Guidelines for the diagnosis and treatment of
acute and chronic heart failure
European Heart Journal (2021) 42, 35993726

7. 2022 AHA/ACC/HFSA Guideline for the Management of Heart
Failure: A Report of the American College of Cardiology/American
Heart Association Joint Committee on Clinical Practice Guidelines
Circulation. 2022;145:00–00

8. Circulation. 2022;145:00–00

9. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal (2021) 42, 35993726

10. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal (2021) 42, 35993726

11. • 4 pilar

12. The search true key to open the heart therapy

13. Neurohormonal blocker
(regulatory system antagonis)

14. ACE 2
ACE 2
Ang (1-9)
Ang (1-7)
MAS R
ACE (1)
Ang 1 (10)
Ang 2 (8)
Angiotensinogen
AT1 R AT2 R
ACE (1)
ACE Inhibitor
Renin
14

15. Nature Reviews Cardiology volume 17, pages116–129(2020)
ACEI
15

16. Raas

18. RAAS (ACE-I, ARB, MRA antagonis)

21. Raas
Renin
aldosteron

22. Neurohormonal modulasi
(modulasi counter regulatory system)

23. • p
N Engl J Med 2014;371:993-1004.
PARADIGM -HF

26. • Kenapa tidak satu obat yang bisa memblok jalur RAAS dan Natriuretic
petide system / Neprilysin ?
• Kenapa harus kombinasi?
• Kenapa kombinasi Neprilisin inhibitor dengan ARB ? Bukan dengan
ACE Inhibitor?

27. OVERTURE trial
(Omapatrilat Versus Enalapril Randomized Trial of Utility in
Reducing Events)
• Omapatrilat, the first drug that combined NEP inhibition with
inhibition of angiotensin-converting enzyme (ACE).
Circulation. 2002;106:920–926

38. Sodium Glucose Co-Transporter-2 Inhibitors
(SGLT2- i)
• Latar belakang

41. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction
(DAPA-HF) 2019
N Engl J Med 2019;381:1995-2008
CONCLUSIONS
Among patients with heart failure and a
reduced ejection fraction, the risk of
worsening heart failure or death from
cardiovascular causes was lower
among those who received dapagliflozin
than among those who received
placebo, regardless of the presence
or absence of diabetes

42. Cardiovascular and Renal Outcomes with Empagliflozin in Heart Failure
(EMPEROR-Reduced ) 2020
CONCLUSIONS
Among patients receiving recommended therapy for heart
failure, those in the empagliflozin group had a lower risk of
cardiovascular death or hospitalization for heart failure than
those in the placebo group, regardless of the presence or
absence of diabetes.
N Engl J Med 2020;383:1413-24

43. Empagliflozin in Heart Failure with a Preserved Ejection Fraction
(EMPEROR-Preserved) 2021
N Engl J Med 2021;385:1451-61.
CONCLUSIONS
Empagliflozin reduced the combined risk of
cardiovascular death or hospitalization for heart failure
in patients with heart failure and a preserved ejection
fraction, regardless of the presence or absence of
diabetes.

44. dapagliflozin

45. Sotagliflozin in Patients with Diabetes and Recent Worsening Heart Failure
(SOLOIST-WHF ) 2021
Sotagliflozin in Patients with Diabetes and Chronic Kidney Disease
(SCORED) 2021
N Engl J Med 2021;384:117-28
N Engl J Med 2021; 384:129-139

47. Acute Heart Failure
AHF – the group with greatest symptomatic and
functional limitations

48. EMPULSE Trial

49. post hoc EMPULSE Trial
abstract at ACC Scientific Sessions, April 2-4, 2022
10.1161/CIRCULATIONAHA.122.059725

50. Summary
• Initiation of empagliflozin in patients hospitalized for AHF produced
clinical benefit regardless of the degree of symptomatic impairment
at baseline; and improved symptoms, physical limitations and quality
of life, with benefits seen as early as 15 days and maintained through
90 days.
• The findings were consistent across multiple subgroups, extending
the health status benefits of SGLT2 inhibitors to patients hospitalized
with acute heart failure regardless of ejection fraction, de novo versus
chronic decompensated HF status, and degree of symptomatic
impairment at baseline.

51. Glucose reabsorption
in the kidney
Nat Rev Cardiol. 2020 Dec;17(12):761-772

53. SGLT2 inhibitors: mechanisms of cardiovascular
benefit beyond glycaemic control

54. Proposed Mechanisms of Cardiovascular Benefits
of Sodium–Glucose Cotransporter 2 Inhibitors
Cardiac Failure Review 2022;8:e1

55. Journal of Molecular and Cellular Cardiology 167 (2022) 17–31

56. • Efek diuretic ? Natriuresis ?

59. Summary diagram of pharmacologic agents modulating
cardiomyocyte function and their molecular targets

60. Vericiguat in Patients with Heart Failure and Reduced
Ejection Fraction (VICTORIA trial)

63. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal (2021) 42, 35993726

65. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal (2021) 42, 35993726

67. Circulation. 2022;145:00–00.

68. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A
Report of the American College of Cardiology/American Heart Association
Joint Committee on Clinical Practice Guidelines
Circulation. 2022;145:00–00

69. 2022 AHA/ACC/HFSA Guideline for the Management of Heart
Failure: A Report of the American College of Cardiology/American
Heart Association Joint Committee on Clinical Practice Guidelines
Circulation. 2022;145:00–00

70. 2021 ESC Guidelines for the diagnosis and treatment of
acute and chronic heart failure
European Heart Journal (2021) 42, 35993726