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TERAPI OBAT YANG DIGUNAKAN DI BIDANG
JANTUNG
BENNY JOVIESUBDEP JANTUNG RSAL. DR. RAMELAN
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Atherogenesis and Atherothrombosis: A Progressive Process
NormalFatty
StreakFibrousPlaque
Athero-scleroticPlaque
PlaqueRupture/Fissure &
Thrombosis
Myocardial Infarction
Ischemic Stroke
Critical Leg Ischemia
Clinically SilentCardiovascular
Death
Increasing Age
AnginaTransient Ischemic Attack
Claudication/PAD
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OBAT UNTUK TERAPI IMA
STREPTOKINASE 1,5 juta unitdi pertimbangkan telah mendapatkan
streptokinase 2th terakhir, alergi thd streptokinase, hipotensi ( sistolik < 90 mmHg
efek samping perdarahan, alergi, hipotensi
ASPIRIN dosis awal 160 – 325 mg efek samping iritasi saluran pencernaan
( lambung )
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Thrombolisis & Lysis
Thrombin
Vit K
WARFARIN
Pro-thrombin
13
5
Protein C & S
Plasminogeninhibitors
CLOT LYSIS
Reteplase Tenecteplase
Plateletactivation
Platelet aggregation and adhesion to vessel wall
thrombinfibrinfibrin
thrombin
fibrinthrombin
thrombinfibrin
plasmin
HEPARIN molecule
Antithrombin-III
Fibrin
ogen
Gp IIb/IIIa INHIBITORS
SK-Plasminogen
tPA
HIRUDIN
ThrombinFibrin
+thrombin
Fibrin
ogen
etc
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Ruptured atherosclerotic plaque
Plt release of ADP
Thrombin
Plt Release Thromboxane A2
Collagen
Plt coagulantactivity
Aspirin
Glycoprotein llb/llla antagonists
Thrombin generation
Conformational activation of plateletGlycoprotein llb/llla receptors on platelet surface
Ticlopidine/clopidogrel
Platelet aggregation
Activation of platelets
Sites of action of platelet inhibitors
Anti platelet
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Anti ischemic Nitroglycerin - The drug directly dilates coronary stenoses - Low doses venodilator preload Higher doses arteriolar dilator afterload Oxygen demand
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Anti ischemic β blockers - Heart rate, contractility, afterload oxygen demand - Target HR in UA : 50 – 60 / min - Contraindication : reactive airway disease, sinus node dysfunction, AV block, and severe heart failure
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-BLOCKADE EFFECTS ON ISCHEMIC HEART
Heart rate
Heart rate
After loadAfter load Wall
stressWall
stressHeart size
Heart size
Contractility
ContractilityO2
wastageO2
wastageAnti-
arrhythmicAnti-
arrhythmic
Increased diastolic perfusion
Increased diastolic perfusion
Less exercise vasoconstriction
Less exercise vasoconstriction
More spasm?More spasm?
O2 deficitanaerobic
metabolism
O2 deficitanaerobic
metabolismC
olla
tera
ls
Subendocardial Ischemia
Subendocardial Ischemia
O2 deman
d
O2 deman
d
O2 supp
ly
O2 supp
ly
VSVS
Opie (2001)
DEMAND SUPPLY
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Anti ischemicCalcium Channel blockers - CCB increase Coronary blood flow - Heart rate, contractility, afterload oxygen demand - Verapamil or Diltiazem if β blocker
CI
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Beta bloker : bisoprolol, atenolol, propanololkontra indikasi, bradikardi, blok atrioventrikuler,
bendungan paru, asma
Nitrat : isdn, nitrogliserinkontra indikasi, hipotensi, bradikardia< 50 x/m, infark
ventrikel kanan.
Simvastatin : berfungsi untuk menstabilkan plaque, target menurunkan kadar LDL < 100mg/dl
Antagonis calcium ( CCB ) : diltiazem, amlodipinantagonis kalsium harus dihindari pada pasien
dengan disfungsi ventrikel kiri, sifat sbg vasodilator koroner
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Clopidogrel : pemberian loading 300 mg ( 4 tablet ), obat ini bekerja dalam menghambat reseptor ADP menghasilkan penghambatan agregasi trombosit.
Anti koagulan / heparin : heparin tak terfraksinasi (UFH) dan heparin berat molekul rendah (LMWH)
Keunggulan LMWH : efek samping perdarahan sangat minimal, tidak membutuhkan pengukuran APTT, pemakaian sub cutan shg mudah, jarang menyebabkan heparin induce trombositopenia (HIT)
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Terapi gagal jantung
DIURETIKA
Menurunkan preload Menghilangkan edema paru Menurunkan wall stress Merangsang myocardial remodeling
Awas Jangan diberikan bila tanpa gejala bendungan paru Aktivasi neurohormonal
Pilihan loop diuretika, efektif walaupun GFR yang menurun
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Inotropik Meningkatkan pelepasan kalsium pada
protein kontraktil Menambah kekuatan dan kecepatan
kontraksi ventrikel Digitalis, dopamin, dobutamin,
amrinon, milrinon Tidak untuk lesi obstruktif
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VasodilatorMenurunkan impedansi saat ejeksi
(afterload)Menurunkan tahanan sistemikMenurunkan volume regurgitanMenurunkan L to R shuntACE inhibitor adalah obat pilihan
(Captopril atau enalapril)
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Hipertensi
Hipertensi = tekanan darah tinggi “Silent killer” Biasanya tidak ada gejala sampai (tiba-
tiba) penderita terkena stroke, gagal jantung, kerusakan pada retina, penyakit ginjal
Hipertensi adalah tekanan darah diatas baku tertentu, atau disebut tekanan darah tinggi
Tekanan darah cenderung meningkat sesuai dengan usia dan berbeda-beda menurut ras dan jenis kelamin
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Mengapa hipertensi itu penting?
Hipertensi merupakan risiko kesehatan yang sangat serius bagi banyak orang
Hipertensi dapat menyebabkan kekakuan arteri, serangan jantung dan stroke.
Gagal jantung dan penyakit ginjal, juga berhubungan dengan hipertensi
Di Amerika : penderita hipertensi mencapai 50 juta jiwa.
Sekitar 30% tidak menyadari bahwa mereka menderita hipertensi
30% lagi menderita hipertensi yang tidak terkontrol. SBP/DBP (140/90)
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110atau180 Stage 3
100-109atau160-179 Stage 2
90-99atau140-159 Stage 1
Hypertension*
85-89atau130-139High-normal
<85dan<130Normal
<80dan<120Optimal
Diastolic(mm Hg)
Systolic(mm Hg)
Category
Definisi Hipertensi (JNC VI)Definisi Hipertensi (JNC VI)· Dikatakan Hipertensi apabila tekanan darah secara konsisten
terbaca 140/90 mm Hg pada orang dewasa. · Klasifikasi tekanan darah pada seseorang berumur 18 dan lebih
*Based on the average of two or more readings taken at each of two or more visits after an initial screening.
The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. November 1997. NIH publication 98-4080
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>100atau> 160 Stage 2
90-99atau140-159 Stage 1
Hipertensi
80-89atau120-139Pre Hipertensi
<80dan<120Normal
Diastolic(mm Hg)
Systolic(mm Hg)Category
Definisi Hipertensi (JNC VII)Definisi Hipertensi (JNC VII)
· Klasifikasi tekanan darah pada seseorang berumur 18 dan lebih
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Rekomendasi Follow-up Berdasarkan Pemeriksaan Awal
Tekanan Darah Awal
SBP DBP Rekomendasi Follow Up
< 130 < 85 cek ulang dalam 2 tahun
130-139 85-89 cek ulang dalam 1 tahun, lakukan perubahan gaya hidup
140-159 90-99 Konfirmasi dalam 2 bulan, lakukan perubahan gaya hidup
160-179 100-109 Evaluasi/periksa kedokter dalam 1 bulan
180 110 Evaluasi/periksa kedokter dalam 7 hari
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Antihipertensi
Alpha agonists Methyldopa
Beta blockers Atenolol, metoprolol, propanolol, labetatol, bisoprolol
Calcium antagonists Verapamil, diltiazem, nifedipin, amlodipin, felodipin
ACE inhibitors Captopril, lisinopril, ramipril, enalapril
Angiotensin II antagonists
Losartan, candesartan, valsartan, telmisartan
Diuretics Thiazides, Furosemide, Amiloride, Klortalidon
Direct Vasodilators Hydralazine, Minoxidil, Na-Nitroprusid
Adapted from JNC VI, 1997.
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CHOICE OF DRUGSFavourable Effect on Co-existing conditions
Co-existing disease, conditions
DRUG
Type I diabetes with proteinuria ACE Inhibitors
Heart failure ACE Inhibitors, Diuretics
Myocardial infarction Beta-blockers (without intrinsic sympathomimetic activity), ACE inhibitors (left ventricular dysfunction)
Angina Beta blockers,Calcium channel blockers
Isolated Systolic Hypertension (older person)
Diuretics, Long acting dihydropiridine Ca-antagonists
Adapted from JNC VI, 1997.
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CHOICE OF DRUGSUnfavourable Effect on Co-existing
conditions
Co-existing disease, conditions
DRUG
Asthma, COPD Beta-blockers
Bradychardia, second or third degree atrioventricular block
Beta blockersCa-channel blockers (except dihydropiridines)
Heart failure Calcium channel blockers (except amlodipine)Beta-blockers
Gout Diuretics
Renovascular disease, pregnancy
ACE inhibitors, Angiotensin II antagonists
Peripheral vascular disease Beta-blockers
Adapted from JNC VI, 1997.
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TERIMAKASIH