Heart illness in the elderly have a multifactorial cause overlapping. For that they must first understand the idea of Risk Factors and Degenerative Diseases. The risk factor is a habit, disorders and other factors which if found / owned by anyone will cause people were significantly more likely to suffer from positive degenerative diseases.
Degenerative illness is a illness that has a cause and is always associated with or more risk factors, where these risk factors work together cause the degenerative illness. Degenerative illness itself can be a risk factor for other degenerative diseases. For example: heart illness and hypertension is a risk factor for stroke.
Heart failure is a syndrome, not a diagnosis. Syndrome of CHF (Chronic Heart Failure / CHF) also have high prevalence in the elderly with a poor prognosis. The prevalence of CHF is dependent age / age-dependent. According to research, rare heart failure at age below 45 years, but rose sharply at the age of 75-84 years.
Epidemiology
Etiology and Pathophysiology
With the increasing life expectancy, will be found the prevalence of CHF is increasing as well. This is because the increasing number of elderly individuals who have hypertension would probably finish with CHF. Also getting better safety rate (survival) post-infarction in middle age, causing the increasing number of elderly with the risk of CHF.
There's five changes that directly affect the capacity of cardiac output in the face of the load:
CHF occurs when the heart is no longer strong to pump blood to meet the needs of the network. Sitolik cardiac function is determined by major determinants, ie: myocardial contractility, ventricular preload (finish diastolic volume and resultant ventricular fiber length before contraction), towards the ventricular afterload, and heart rate.
* The reduced response to beta-adrenergic stimulation due to increasing age. The etiology is not known for positive. The result is a decreased heart rate and contractility in the face of limited load.
* The walls of the blood vessels become more rigid in the elderly because of the increase in collagen connective tissue in tunica media and adventisia medium and sizable arteries. As a result, blood vessel resistance (impedance) increases, which increases afterload because it often occurs isolated systolic hypertension.
* In addition, stiffness of the heart so that cardiac compliance is reduced. Several factors cause: increased interstitial connective tissue, compensatory hypertrophy myocytes because plenty of cell apoptosis (death) and relaxation of myocytes late due to the disruption of non-calcium ion liberation.
* Energy metabolism in mitochondria changes in the elderly.
These factors are at an advanced age will adjust the structure, function, physiology together reduce cardiovascular reserve and increase the occurrence of heart failure in the elderly.
Common causes is the decrease in myocardial contractility due to coronary heart illness, cardiomyopathy, cardiac workload is increased by conditions such as extreme aortic stenosis or hypertension, abnormal mitral valve as regurfitasi.
Cause
Relative frequency
Dilated cardiomyopathy / unknown
45%
Ischemic Heart Illness
Valve abnormalities
40%
9%
Hypertension
Source: Cardiology and Respiratory Medicine 2001
6%
* Excess sodium in the diet
* Excess liquid intake
* Not taking medication adherence
* Iatrogenic volume overload
* Arrhythmias: flutter, ventricular arrhythmias
* Drugs: alcohol, calcium antagonists, beta blockers
* Sepsis, hyper / hypothyroidism, anemia, kidney failure, vitamin B deficiency, pulmonary embolism.
There's also other factors that can trigger the precipitation of heart failure, namely:
To decide the diagnosis of CHF in the elderly is difficult. The signs are not typical. Signs such as shortness of breath while on the move or get worn out often regarded as of due method of aging or thought about because of other comorbidities such as lung illness, thyroid dysfunction, anemia, depression, etc..
Diagnosis
In elderly age, diastolic dysfunction is often exacerbated by the CHD. Myocardial ischemia can lead to increased filling pressure in to the left ventricle and the pulmonary venous pressure also increased, making it simple going pulmonary edema and shortness of breath complaints.
Signs are often found is shortness of breath, Orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, fatigue, decreased ability to move and cough with clear sputum. Often also obtained physical weakness, anorexia, falls and confusion.
On physical examination, receive the JVP (jugular Venous Pressure) rising. Often there is also the third heart sound, pitting edema, atrial fibrillation, systolic noisy due to mitral regurgitation and pulmonary ronkhi.
CHF according to New York Heart Association is divided in to:
Additional checks that can be done:
* Grade one: Decrease in left ventricular function without signs.
* Grade two: Shortness of breath in the coursework of strenuous activity
* Grade five: Shortness of breath in the coursework of everyday activities.
* Grade five: Shortness of breath while resting.
The worth of the heart, the existence of pulmonary edema and pleural effusion. But plenty of patients with CHF without a kardiomegali.
* Thorax X-ray Inspection
EKG
*
* Echocardiography
Value of rhythm, whether there's signs of left ventricular strain, former myocardial infarction and bundle branch block (left ventricular dysfunction is seldom found when the ECG lead a normal-12).
Possibly show a decrease in left ventricular ejection fraction, ventricular enlargement and mitral valve abnormalities.
Management
In general, drugs that effectively cope with heart failure showed the benefits for systolic dysfunction. Left ventricular systolic dysfunction is always accompanied by neuro-endocrine system activity, because it is of the drugs of choice are ACE inhibitors.
Heart failure with systolic dysfunction
Diuretics, aims to overcome liquid retention, thereby reducing the burden that inhibits the circulation volume of the heart. The most widely used for the treatment of congestive heart failure from this group are furosemide. In the elderly often have no impairment of kidney function in which furosemide is less effective and in these circumstances can be added metolazone. In the administration of diuretics ought to be monitored since blood potassium levels due to furosemide diuresis was always accompanied by the release of potassium. In the state of hypocalcaemia simple going heart rhythm disturbances.
Inotropic drugs, such as digoxin is given in cases of heart failure to improve ventricular contraction. Digoxin dose ought to be adjusted dengn magnitude creatinine clearance of patients. Drugs other positive inotropic drugs are dopamine (5-10 Ugr / kg / min) that is used when the blood pressure of less than 90 mmHg. When blood pressure was above 90 mmHg can be added dobutamin (5-20 Ugr / kg / min). When blood pressure was above 110 mmHg, the dose of dopamine and dobutamin reduced gradually until terminated.
ACE inhibitors, in addition to overcoming neurohumoral disorders in heart failure, may also improve the tolerance of physical work that was evident after 3-6 months of treatment. From the class of ACE-I, captopril is the drug of choice because it does not cause extended hypotension and not much interfere with renal function in cases of heart failure. Kontraindikasinya is extreme kidney dysfunction and when there is bilateral renal artery stenosis.
Heart failure with diastolic dysfunction
Spironolactone, used as therapy for congestive heart failure with low ejection fraction, if even if treated with diuretics, ACE-I and digoxin showed no improvement. Dose of 25 mg / day and is proven to reduce mortality of heart failure by 25%.
* Improving the coronary circulation in addressing myocardial ischemia (in the case of CHD)
* Control of blood pressure in hypertension to prevent left ventricular myocardial hypertrophy in the long term.
* Aggressive Treatment of comorbid diseases that worsen the burden blood circulation, such as anemia, weakened kidney function and some metabolic diseases such as Diabetes Mellitus.
* Efforts to improve cardiac rhythm disorders for atrial systolic function is maintained within the framework of ventricular diastolic filling.
In the elderly more often have heart failure with diastolic dysfunction. To cope with diastolic heart failure can be a way:
The drugs used include:
one. Calcium antagonist, to improve myocardial relaxation and cause coronary vasodilation.
two. Beta blockers, to address and fix the charging ventricular tachycardia.
five. Diuretics, for heart failure with pulmonary edema due to diastolic dysfunction. If signs of lung edema is gone, then the provision of diuretics ought to be cautious not to happen hypovolaemia which ventricular filling is reduced so that cardiac output and blood pressure decreases.
Resynchronisation Cardiac Therapy
Provision of calcium antagonists and beta blockers ought to be thought about because they may decrease myocardial contractility thus worsen heart failure.
To CHF with conduction abnormalities (Left bundle branch block) may be surgery-biventricular pacing tool implantation to overcome dissinkronisasi ventrikelnya. But it is also even can lead to arrhythmia-induced sudden death. Therefore used a combination of tools and biventricular pacing cardioverter-defibrillation.
Heart transplant
However, heart transplant surgical procedure is a major operation which is impossible and demanding, given:
Heart transplants performed in patients with CHF that if no surgical procedure will die within a few weeks. Usually performed in elderly patients with less than 65 years, which has no other serious health issues. Over 75% of heart transplant patients live longer than two years after operation. Some may even live up to over 12 years.
* The necessity for an appropriate donor organ.
* The procedure itself is complicated operation and traumatic.
* It needs a specialist middle.
* The necessity imunosupressan drugs after surgical procedure to reduce the risk of organ rejection by the body.
* Some cases arise antibodies that assault the inside of coronary arteries within about a year after surgical procedure. This issue no treatment and can finish up with a deadly heart assault.
Prognosis
Prognosis of CHF depends on the degree of myocardial dysfunction. According to the New York Heart Association, CHF class I-III obtained mortality one and five years respectively 52% 25% dab. While class IV one year mortality is about 40% -50%.
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