Kelompok 2:

Antiangina, Infark miokard, dan

Kardiotonik
Rika Masvira (1500029)
Abdul Wahab (1700001)
Alya Aqilla (1700004)
Anggi Aulia Pratiwi (1700005)
Hariati Kemelasari (1700017)
Lisa Kurnia (1700021)
Nurindah melati (1700025)
Nurtiti Hayati (1700028)
Salsabila Riyadini (1700034)
Ischemic heart disease
Ischemic heart disease (IHD) is defined as a lack of oxygen and
decreased or no blood flow to the myocardium resulting from
coronary artery narrowing or obstruction. IHD may present as an
acute coronary syndrome (ACS, which includes unstable angina and
non–ST-segment elevation or ST-segment elevation myocardial
infarction [MI]), chronic stable exertional angina, ischemia without
symptoms, or ischemia due to coronary artery vasospasm (variant or
Prinzmetal angina).
Ischemic Heart Disease Type:
 Stable Exertional Angina Pectoris
 Coronary Artery Spasm And Variant Angina
Pectoris
PATHOPHYSIOLOGY
o Major determinants of myocardial oxygen demand (MVo2) are
heart rate (HR), contractility, and intramyocardial wall tension
during systole. Because the consequences of IHD usually
result from increased demand with a fixed oxygen supply,
alterations in MVo2 are important in producing ischemia and
for interventions intended to alleviate it.
o The caliber of resistance vessels delivering blood to the
myocardium and MVo2 are the primary determinants in the
occurrence of ischemia.
CLINICAL PRESENTATION
 Patients often have a reproducible pattern of pain or other
symptoms that appear after a specific amount of exertion.
Increased symptom frequency, severity, or duration, and
symptoms at rest suggest an unstable pattern that requires
immediate medical evaluation.
 Features of high-risk unstable angina include (but are not
limited to): (1) accelerating tempo of ischemic symptoms in
the preceding 48 hours; (2) pain at rest lasting more than 20
minutes; (3) age greater than 75 years; (4) ST-segment
changes; and (5) clinical findings of pulmonary edema, mitral
regurgitation, S3, rales, hypotension, bradycardia, or
tachycardia.
 Symptoms may include a sensation of pressure or
burning over the sternum or near it, which often
radiates to the left jaw, shoulder, and arm. Chest
tightness and shortness of breath may also occur.
The sensation usually lasts from 30 seconds to 30
minutes.
Diagnosis
o The patient should be asked about existing personal risk
factors for coronary heart disease (CHD) including smoking,
hypertension, and diabetes mellitus.
o A detailed family history should be obtained that includes
information about premature CHD, hypertension, familial
lipid disorders, and diabetes mellitus.
o There are few signs on physical examination to indicate the
presence of coronary artery disease (CAD).
o A chest radiograph should be done if the patient has heart
failure symptoms.
DESIRED OUTCOME
The short-term goals of therapy for IHD are to
reduce or prevent anginal symptoms that limit
exercise capability and impair quality of life.
Longterm goals are to prevent CHD events such as
MI, arrhythmias, and heart failure and to extend the
patient’s life.
TREATMENT
PHARMACOLOGIC THERAPY
 β -Adrenergic Blocking Agents
o Decreased HR, contractility, and blood pressure reduce MVo2 and
oxygen demand in patients with effort-induced angina.
o Those with longer half-lives may be administered less frequently, but
even propranolol may be given twice a day in most patients.
Membrane stabilizing activity is irrelevant in the treatment of angina.
Cardioselective β -blockers may be used in some patients to
minimize adverse effects such as bronchospasm, intermittent
claudication, and sexual dysfunction. Combined nonselective β - and
α -blockade with labetalol may be useful in some patients with
marginal left ventricular (LV) reserve.
o Adverse effects of β-blockade include hypotension,
decompensated HF, bradycardia, heart block,
bronchospasm, altered glucose metabolism, fatigue,
malaise, and depression. Abrupt withdrawal has
been associated with increased severity and number
of angina episodes and MI. Tapering of therapy over
several days should minimize risk of withdrawal
reactions if therapy is to be discontinued.
Nama generic Dosis
Asebutolol Dosis awal 400 mg sekali sehari Corbutol Tablet 400 mg;
atau 200 mg dua kali sehari, 300 Sectral Kapusl 200mg, Tablet
mg tiga kali sehari
Atenolol 100mg sehari dalam satu atau
dua dosis
Bisoprolol Fumarat
Labetalol Hidroklorida
Metoprolol Tartrat 50-100mg dua sampai tiga kali
sehari
Nadolol 400mg sehari, jika perlu
tingkatkan dengan interval 1
minggu maksimal 160mg sehari
Oksprenolol hidroklorida 40-160mg tiga kali sehari
Pindolol 2,5 – 5mg sampai dengan tiga
kali sehari
Propanolol Hidroklorida Dosis awal 40mg dua sampai
Nama dagang
400mg; Sytalol Tablet 200mg,
400mg
Atenolol Tablet 25mg, 50mg,
100mg; Atecor Tablet 50mg;
Atencinol 50mg,100mg
Metoprolol Tablet 50mg, 100mg;
Ateksi Tablet Salut Selaput
100mg; Kalbitab Tablet 100mg
Farmagard Tablet 40mg, 80mg
Kombinasi dengan
Klortalodon
Trasitensin Tablet 80mg
Visken Tablet 5mg
Propanolol Tablet 10mg, 40mg;
 Nitrat
The action of nitrates appears to be mediated
indirectly through reduction of MVO2 secondary to
venodilation and arterial-arteriolar dilation, leading to
a reduction in wall stress from reduced ventricular
volume and pressure. Direct actions on the coronary
circulation include dilation of large and small
intramural coronary arteries, collateral dilation,
coronary artery stenosis dilation, abolition of normal
tone in narrowed vessels, and relief of spasm.
 Pharmacokinetic characteristics common to nitrates include a large
firstpass effect of hepatic metabolism, short to very short half-lives
(except for isosorbide mononitrate [ISMN]), large volumes of
distribution, high clearance rates, and large interindividual variations in
plasma or blood concentrations. The half-life of nitroglycerin is 1 to 5
minutes regardless of the route, hence the potential advantage of
sustained-release and transdermal products. Isosorbide dinitrate
(ISDN) is metabolized to ISMN. ISMN has a half-life of about 5 hours
and may be given once or twice daily, depending on the product
chosen.

 Nitrate therapy may be used to terminate an acute anginal attack, to

prevent effort- or stress-induced attacks, or for long-term prophylaxis,
usually in combination with β -blockers or calcium channel
antagonists.
 Calcium Channel Antagonists
 Direct actions include vasodilation of systemic
arterioles and coronar arteries, leading to reduced
arterial pressure and coronary vascular resistance, as
well as depression of myocardial contractility and
conduction velocity of the sinoatrial (SA) and
atrioventricular (AV)nodes.
 Verapamil and diltiazem cause less peripheral
vasodilation than dihydropyridines such as
nifedipine but greater decreases in AV node
conduction.
Ranolazine
Ranolazine reduces calcium overload in ischemic
myocytes through inhibition of the late sodium
current. It does not affect HR inotropic or
hemodynamic state, or increase coronary blood
flow.
a. Treatment of
stable exertional
angina pectoris
b. Treatment Of Coronary Artery Spasm And Variant Angina
Pectoris

 Nitrates are the mainstay of therapy, and most patients respond rapidly
to sublingualnitroglycerin or ISDN. IV and intracoronary nitroglycerin
may be useful for patients not responding to sublingual preparations.
 Because calcium channel antagonists may be more effective, have few
serious adverse effects, and can be given less frequently than nitrates,
some authorities consider them the agents of choice for variant angina.
Nifedipine, verapamil, and diltiazem are all equally effective as single
agents for initial management. Combination therapy with nifedipine
plus diltiazem or nifedipine plus verapamil is reported to be useful in
patients unresponsive to single-drug regimens.
 β -Blockers have little or no role in the management of variant angina
as they may induce coronary vasoconstriction and prolong ischemia.
NON PHARMACOLOGIC

 Stop smoking
 Moderate coffee and alcohol consumption till 2-3 cup
 Weight loss
 Avoid heavy burden, mental or physical, tackling after
eating or hot tub
 Walk 0,5-1 hours a day or 3-5 times. Powered (rather
quickly) or jogging to correct a heart circulation.
Infark Miokard
Suatu kondisi dimana aliran darah tidak terhantar kejantung,
sehingga otot jantung terhenti.
Gejalanya :
o Nyeri hebat dibelakang tulang dada
o Tidak mampu menggerakkan tangan dan kaki
o Muka membiru
o Takikardia
Penyebab infark miokard : tersumbatnya arteri coroner jantung
yang disebabkan oleh lemak, endapan kolesterol, obat-obatan
seperti nikotin.
Infark Miokard
Penggolongan obat:
a. Antitrombolitik
Fibrinolitik bekerja sebagai trombolitik dengan cara mengaktifkan
plasminogen untuk membentuk plasmin, yang mendegradasi fibrin dan
kemudian memecah thrombus .
o Obat-obat tersebut diindikasikan untuk infark miokard akut dan
thrombosis vena dalam.
o Efek samping yang biasa terjadi yaitu mual, muntah, dan hipotensi
serta risiko perdarahan pada otak meningkat pada stroke akut.
Contoh :
Streptokinase (fimakinase, streptase) : IV 30menit 250.000Unit
Urokinase (ukidan) : IV 4400kg/bb 10menit
Alteplase (actylise) : 10mg-15mg IV
b. Anti platelet
Bekerja dengan cara mengurangi agregasi platelet, sehingga
dapat menghambat pembentukan thrombus pada sirkulasi arteri,
dimana antikoagulan kurang efektif.
o Obat-obat ini diindikasikan untuk tambahan antikoagulan, untuk
pasien dengan coroner akut, infark miokard, stroke.
o Efek samping yang biasa terjadi yakni dyspepsia, nyeri perut,
diare, pusing, sakit kepala, gangguan saluran cerna, dan
myalgia.
Contoh obat ini:
Asetosal (ascardia, asgard) : 75mg sehari
Dipiridamol (cardial, persantin) : 3x4 sehari 300-600mg
Klopidogrel (Plavix) : 75mg sehari
c. Antikoagulan
bekerja dengan cara mencegah pembekuan darah pada
pembuluh darah.
o Obat-obat ini diindikasikan untuk pengobatan thrombosis
pembuluh darah dan embolisme paru, infark miokard
o Efek samping yang biasa terjadi yakni pendarahan hebat
Obat antikoagulan dibagi menjadi dua golongan yaitu :
Obat yang bekerja langsung : contoh obatnya Heparin
(Heparin, 5000 UI/ml) : Di injeksikan secara intravena Dosis
muatan 5000 unit
Obat yang bekerja tidak langsung : contohnya Warfarin
(Warfarin, Tablet 1 mg, 5 mg) : 10 mg sehari selama 2-4 hari.
d. β-bloker
Are only considered appropriate first-line agents to treat specific
compelling indications (eg, post-MI [myocardial infarction],
coronary artery disease). Their hypotensive mechanism may
involve decreased cardiac output through negative chronotropic
and inotropic effects on the heart and inhibition of renin release
from
the kidney.
• Atenolol, betaxolol, bisoprolol, and metoprolol are
cardioselective at low doses and bind more avidly to β1-
receptors than to β2-receptors. As a result, they are less likely to
provoke bronchospasm and vasoconstriction and may be safer
than nonselective β-blockers in patients with asthma, chronic
obstructive pulmonary disease (COPD), diabetes, and peripheral
arterial disease (PAD). Cardioselectivity is a dose-dependent
phenomenon, and the effect is lost at higher doses.
Kardiotonik
Obat-obat yang berkhasiat meningkatkan
kontaktilitas otot jantung. Terutama digunakan
pada gagal jantung untuk memperbaiki fungsi
pompanya.

Kelompok kardiotonik terdiri dari :

a. Glikosida jantung ( digoksin dan digitoksin)
b. Agonis β₁-Adrenergik (Dobutamin)
c. Penghambat Fosfodiesterase (Milrinon)
A. Glikosida Jantung
 Memperkuat kontraktilitas otot jantung terutama
digunakan pada gagal jantung untuk memperbaiki
fungsi pompanya
 Menghambat enzim Na/Cl ATPase
 Contoh Obat:
a) Digoksin (Lanoxin Tablet 0,25mg; fargoxin Tablet
0,25mg) : oral, 1-1,5 mg sehari; bila tidak
diperlukan cepat 250-500 mcg
b) Digitoksin (Digitoksin Tablet) : penunjang, 100
mcg sehari atau dua hari sekali; bila perlu dapat
dinaikkan sampai 200 mcg sehari
B. Agonis β₁-
Adrenergik
 Menduduki reseptor β₁ sehingga meningkatkan
kontraktilitas otot jantung
 Contoh Obat:
a) Dobutamin (Cardiject cairan injeksi 25mg/ml):
infus intravena, 2,5-10 mcg/kg bb permenit.
Sesuaikan dengan responnya.
C. Inhibitor
fosfodiesterase
 Menghambat enzim fosfodiesteraseyang
selektif bekerja pada jantung
 Contoh Obat:
a) Milrinon (coritrope 1 mg/ml): iv 50
mc/kg bb, max sehari 1,13 mg/ kg bb
TERIMAKASIH
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