Hotel Harries, Surabaya, 21 Agustus 2016 EduPharma...
Transcript of Hotel Harries, Surabaya, 21 Agustus 2016 EduPharma...
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Hotel Harries, Surabaya, 21 Agustus 2016 EduPharma II
PELAYANAN KEFARMASIAN PADA PENYAKIT
JANTUNG KORONER
SUHARJONO
DEP FARMASI KLINIK
UNIVERSITAS AIRLANGGA
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DEFINISI
• ATHEROSCLEROSIS adalah penumpukan lemak di bagian intima arteri, yang awalnya lunak dan mengeras bila lama
• ARTERY DISEASE (CAD) adalah tipe kelainan pembuluh darah karena adanya atherosclerosis
• ACUTE CORONARY SYNDROME (ACS) adalah keadaan klinik yamg ditandai dengan adanya oklusi arteri coroner. Ada tiga ACS meliputI angina unstable, non-ST segmen elevasi MI dan ST-segmen elevasi MI atau sudden death
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Normal Coronary Artery
• LAYERS:
• Tunica Adventia (outer coat) ,
• Tunica Media ( muscle coat),
• Tunica Intima ( lining)
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Fakta tentang Jantung
• Bila jantung berdenyut 70 kali / menit
• Sekali denyut 70cc darah 5 liter /menit Curah Jantung
• 70cc darah mengitari ± 100.000 km pembuluh
• berdenyut ± 100.000 x/hari
• 2,5 milyar x/ sepanjang hidup
• memompakan darah lebih dari 227 juta liter
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Pembuluh Darah Koroner
Pembuluh Darah Koroner Berfungsi :
Memberi makan dan Oksigen ke otot- otot Jantung.
Terdiri Dari:
1. Pembuluh Darah Koroner Kiri , cabang :
kedepan : LAD ( Left Anterior Descendens Artery)
melingkar ke kiri : LCx ( Left Circumflex Artery)
2. Pembuluh Darah Koroner Kanan
( RCA = Right Coronary Artery)
Bercabang-cabang ke dalam otot-otot jantung
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kematian sebagian otot jantung disebabkan
oleh terhentinya pasokan darah akibat
tersumbatnya satu / lebih pembuluh koroner
oleh gumpalan darah (trombus).
Serangan Jantung
Akibat Serangan jantung
Fungsi pompa jantung ( memompakan darah
dgn segala nutrisi ) gagal
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Angina Pektoris Stabil
Angina Pektoris Tidak Stabil
Infark Miokard
Penyakit Jantung koroner
Iskemia Otot Jantung
Serangan Jantung
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INFARK JANTUNG Myocardial infarct
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Serangan jantung sering kali terjadi antara
pukul 4 - 10 pagi, karena:
jumlah adrenalin lebih tinggi dikeluarkan oleh
kelenjar adrenal
dpt menyebabkan pecahnya lesi aterosklerosis.
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Untaian proses aterosklerosis
Normal Pembentukan sel busa
Ruptur / bocor Trombus/tersumbat
Komposisi plak dan sumbatan: LDL-C, sel2 radang dan bekuan darah ( trombus )
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PROSES PERKEMBANGAN ATEROSKLEROSIS
(Schaefer, 2010) 15
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Diagnosis ditegakkan, bila:
( 2 dari 3 indikator )
kriteria WHO terpenuhi, yaitu
• Keluhan klinis
• Gambaran khas elektrokardiografi (EKG)
• Peningkatan kadar enzim jantung :
(CK, CKMB dan troponin)
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TES DIAGNOSTIK (LAB & KLINIK)
1. Electrocardiogram (ECG)
2. Exercise Tolerance Testing
Test toleransi/treadmill
Dapat dikombinasi dengan test perfusi miokardial dg Thallium
(201Tl) utk reversible/ireversible aliran darah jantung
3. Cardiac Imaging
Test radionukleid angiografi (techtenium-99m) mengukur EF (ejection fraction)
4. Echocardiography
Pharmacologic stress echocardiography (dobutamine, dipyridamole or adenosine) or pacing may be done to identify abnormalities during stress
5. Cardiac Catheterization & Coronary Arteriography
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TERAPI PADA PENYAKIT JANTUNG KORONER
(Libby, 2005)
21
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Treatments
Non Pharmacology Therapy
Revascularization
- Percutaneous Coronary Intervension (PCI) – Percutaneous Transluminal Coronary Angioplasty (PTCA)
- Coronary Artery Bypass Grafting (CABG)
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Treatments
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Based on document prepared by Clopidogrel Guidelines Working Group for Anglia Cardiac Network
May 2006
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Platelet activation
& receptors involved
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Tinjauan Aspirin
• Irreversibly acetylates cyclooxygenase and inhibiting COX-1, aspirin interferes with the synthesis of prothrombotic TXA2, important in the platelet activation cycle.
• Dosing: – PCI: Oral: Initial: 75-325 mg (300-325 mg in aspirin native patients) starting
at least 2 hours (preferably 24 hours) before procedure; post procedure: 162-325 mg once daily (dose and duration varies with type of stent implanted); Note: Dose may be reduced to 75-162 mg once daily after appropriate duration based on stent-type is complete
Opie et al, 2012. Drug for the Heart. 8th Ed Lacy et al, 2009. Drug Information Handbook. 17th Ed
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Tinjauan Clopidogrel
• Inhibitor of the platelet ADP receptor P2Y12 and preventing the transformation and activation of the GpIIb/IIIa receptor.
• Dosing
– ST-segment elevation myocardial infarction (STEMI): 75 mg once daily (in combination with aspirin 75-162 mg/day). CLARITY used a 300 mg loading dose of clopidogrel (with thrombolysis). The duration of therapy was <28 days (usually until hospital discharge) (Sabatine, 2005).
– The American College of Chest Physicians (Goodman, 2008) recommends: Patients <75 years: Initial: 300 mg loading dose, followed by 75 mg once daily for up to 28 days (in combination with aspirin). Patients >75 years: 75 mg once daily for up to 28 days (with or without thrombolysis)
– Note:Coronary artery stents: Duration of clopidogrel (in combination with aspirin): According to the ACC/AHA/SCAI guidelines, ideally 12 months following drug-eluting stent (DES) placement in patients not at high risk for bleeding
Opie et al, 2012. Drug for the Heart. 8th Ed Lacy et al, 2009. Drug Information Handbook. 17th Ed
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Isosorbide Dinitrat
Effect of NO on myocardial relaxation and contractile protein
Opie LH and Jorowitz JD. Nitrates and newer antianginal. s. In: Opie LH and Gersh BJ (Eds.) Drugs for The Heart. 8th edition. 2013. Philadelphia:
Elsevier Saunders. P.93-105
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Pharmacokinetics
Munzel and Gori, 2013
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First Line Therapies to Prevent Nitrate Tolerance
Nitrate-Free Intervals • Certain dosing of organic nitrates to provide a nitrate-free interval
(10-12 hours) Disadvantage : • potentially confusing dosing schedules and • inconvenience to the patient, • may be associated with worsening endothelial dysfunction and rebound
ischemia, with increased frequency and intensity of ischemic events.
Munzel, 2013
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Alternatives Therapies to Prevent Nitrate Tolerance
ACE-Is and ARBs • Tolerance to nitrates is thought to partially involve counterregulatory mechanisms
including volume expansion via sodium and water retention mediated through the renin/angiotensin system
(Katz, et al, 1991; Holden, 2013)
Antioxidants • 2 randomized trials found oral vitamin C to be effective in ameliorating nitrate tolerance
(Münzel, 2013)
Statin • Statin prevents both GTN-induced endothelial dysfunction and nitrate tolerance, likely
by counteracting the GTN-induced increase in oxidative stress (Liuni, et al. 2011)
Folic Acid • Our data demonstrate that supplemental folic acid prevents both nitric oxide synthase
dysfunction induced by continuous GTN and nitrate tolerance in the arterial circulation of healthy volunteers. (Gori, et al,2001)
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ESO : RHABDOMYOLISIS DAN
HEPATOTOKSIK
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BARU : EZETIMID
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Terapi Simvastatin
Patrick T. O’Gara et al. 2013. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, Journal of the American College of Cardiology Vol. 61, No. 4
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HEPARIN DAN LMWH
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PELAYANAN KEFARMASIAN
• EDUKASI KE PASIEN :
• KIE OBATNYA
• KIE PENYAKIT DAN KOMPLIKASINYA
• KIE POLA HIDUP SEHAT
• KIE KEPATUHAN MINUM OBAT DENGAN BENAR DAN KONTROL TERATUR
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Salahuddin, et al, 2014. Pathophysiological Mechanisms of Tobacco-related CVD. Global Heart Vol 7 no 2 2012
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PELAYANAN KEFARMASIAN
• EDUKASI KE PASIEN :
• KIE OBATNYA
• KIE PENYAKIT DAN KOMPLIKASINYA
• KIE POLA HIDUP SEHAT
• KIE KEPATUHAN MINUM OBAT DENGAN BENAR DAN KONTROL TERATUR
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Terima kasih