21042012

Pleno pakar Pc Blok CVS

Dr.Datten Bangun MSc,SpFK Dep.Farmakologi & Therapeutik Fak.Kedokteran USU ,MEDAN

Bee Gees
I started a joke, which started the whole world crying, but I didn't see that the joke was on me, oh no. Alfred Nobel

Treatments for a heart attack

Cardiovascular medications Angioplasty Coronary artery bypass surgery Lifestyle changes to reduce the risk of a repeat heart attack or other heart problems, called secondary prevention

Cardiovascular medications
used in the hospital as well as after hospital discharge. Medications in the hospital setting are used to: Relieve chest pain and anxiety Limit the size of the heart attack Reduce the work of the heart Prevent and treat complications

Medications To Relieve Chest Pain And Anxiety:

include : = nitrates such as nitroglycerin and = narcotic pain relievers such as morphine. =Benzodiazepines, which are minor tranquilizers or antianxiety agents can help relieve anxiety.

Coagulation Modifier Drugs

Anticoagulants
Inhibit the action or formation of clotting factors Prevent clot formation Inhibit platelet aggregation Prevent platelet plugs Lyse (break down) existing clots
Promote blood coagulation

Antiplatelet drugs

Thrombolytic drugs

Hemostatic or Antifibrinolytic drugs

Nitrates:
Dilates both the artery and vein which is not sclerotic yet Reduce heart work thru decreasing total peripheral resistance ==== hati-hati pada low BP=== semaput or reflex tachycardia heart work increase

ORGANIC NITRATES
Organic nitrates & nitrites are simple nitric & nitrous esters of glycerol. cause a rapid decrease in myocardial oxygen demand leading to rapid resolution of symptoms. Nitrates are effective for all types of angina. Activation of guanylate cyclase increases cGMP activating a cGMP kinase leading to dephosphorylation of myosin light chains decreasing contractile force.
Requires normal vascular endothelium Diffuses to local vascular smooth muscle

Nitrates:
Intravenous nitroglycerin is recommended for the first 24 to 48 hours after a heart attack in patients with : An acute heart attack complicated by congestive heart failure A large heart attack affecting the front wall of the heart, called an anterior-wall myocardial infarction Persisting insufficient blood flow to heart muscle, as detected by pain and ECG Hypertension or high blood pressure

to relieve chest discomfort

Morphine and other narcotic pain relievers are used to relieve chest discomfort associated with a heart attack. Repeat dosages of morphine can be given intravenously frequently if breathing remains normal and no signs of toxicity occur. Side effects of narcotic pain relievers include nausea and pruritus (itching).

Medications To Limit The Size Of The Heart Attack: Most heart attacks are caused by a blood clot blocking a coronary artery===use Thrombolytic drugs: = Streptokinase = Anisoylated plasminogen-streptokinase activator complex (antistreplase) = Tissue plasminogen activator (t-PA)

Anticoagulant, Fibrinolytic and Antiplatelet Drugs

Used to treat or prevent thromboembolism In a normal individual, blood remains fluid in vessels
will clot when a vascular injury occurs

If an intravascular thrombus is formed, it is promptly dissolved by a fibrinolytic system If bleeding occurs, there is spontaneous arrest of bleeding from a damaged blood vessel (Haemostasis)

Haemostasis and Thrombosis

Sequence of events in haemostasis:
Vasospasm platelet adhesion platelet aggregation white thrombus red thrombus

In case of thrombosis:
Arteries: mainly white thrombi (ischemia) Low-pressure veins (particularly if stasis): mainly red thrombi, often with long tails emboli (e.g., in lung)

Fibrinolysis
Achieved through the conversion of inactive plasminogen to active plasmin Plasmin remodels the thrombus and prevents its excessive growth
Via proteolytic digestion of fibrin

Injured cells release tissue plasminogen activator - tPA

Drugs to Be Discussed
Anticoagulant drugs:
Heparin, low molecular weight heparins Oral anticoagulants: warfarin

Fibrinolytic drugs: streptokinase, tissue plasminogen activator Anti-platelet drugs: aspirin, clopidogrel, Abciximab

Standard or high molecular weight heparin

Obtained from mast-cell rich tissues in animals
just for curiosity: porcine intestinal mucosa or bovine lung

Despite the differences in composition among commercial preparations, biological activity is similar Doses are expressed in units of activity, USP units

Contraindication for thrombolytics:

Recovering from recent surgery With active bleeding from stomach ulcers With very high blood pressure With a history of a recent stroke, head injury, or a bleeding disorder

Medications To Reduce The Work Load Of The Heart

decrease the work load===oxygen needs decrease Drugs that decrease the work load of the heart include: Nitrates Beta blockers Angiotensin converting enzyme (ACE) inhibitors

Medications To Prevent And Treat Complications

including: =Aspirin =Antiarrhythmic agents =Drugs for heart failure =Anticoagulants or blood thinners

Digoxin
increases the strength of heart muscle contractions and is useful in the treatment of heart failure ----- inotropic action (+) Because digoxin also slows conduction of the heart's electrical impulses, it is also useful in controlling atrial fibrillation, atrial flutter, and atrial tachycardia -- chronotropic action (+)

ACE-Inhibitor ,bergunakah pada CAD tanpa heart failure ?

Warfarin -- Nursing Implications

Many herbal products have potential interactionsincreased bleeding may occur
Capsicum pepper Garlic Ginger Gingko Ginseng Feverfew

Drugs for Heart failure

Diuretics, which reduce the blood volume by causing the kidneys to get rid of more sodium and water Nitrates ACE inhibitors