SKRIPSI ROBIANA PRIHANDINI STUDI PENGGUNAAN ISOSORBID DINITRAT (ISDN) PADA PASIEN INFARK MIOKARD AKUT DI RSUD SIDOARJO
PROGRAM STUDI FARMASI FAKULTAS ILMU KESEHATAN UNIVERSITAS MUHAMMADIYAH MALANG 2015 i
Lembar Pengesahan
STUDI PENGGUNAAN ISOSORBID DINITRAT (ISDN) PADA PASIEN INFARK MIOKARD AKUT DI RSUD SIDOARJO
SKRIPSI Dibuat untuk memenuhi syarat mencapai gelar Sarjana Farmasi pada Program Studi Farmasi Fakultas Ilmu Kesehatan Universitas Muhammadiyah Malang 2015 Oleh :
ROBIANA PRIHANDINI 201110410311137
Disetujui Oleh :
Pembimbing I
Drs. Didik Hasmono, M.S., Apt NIP. 1195809111986011001
Pembimbing II
Hidajah Rachmawati, S.Si., Apt., Sp.FRS NIP UMM. 11406090449
ii
Lembar Pengujian
STUDI PENGGUNAAN ISOSORBID DINITRAT (ISDN) PADA PASIEN INFARK MIOKARD AKUT DI RSUD SIDOARJO
SKRIPSI Telah diuji dan dipertahankan di depan tim penguji Pada tanggal 19 Agustus 2015 Oleh :
ROBIANA PRIHANDINI 201110410311137
Tim Penguji
Penguji I
Drs. Didik Hasmono, M.S., Apt NIP. 1195809111986011001
Penguji II
Hidajah Rachmawati, S.Si., Apt., Sp.FRS NIP UMM. 11406090449
Penguji III
Penguji IV
Dra. Lilik Yusetyani, Apt., Sp. FRS Ika Ratna Hidayati, S.Farm., Apt., M.Sc NIP UMM. 11407040450 NIP UMM. 11209070480
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KATA PENGANTAR Puji syukur penulis panjatkan kehadirat Alloh SWT karena berkat rahmat dan karunia-Nya, alhamdulillah penulis dapat menyelesaikan penyusunan skripsi yang berjudul STUDI PENGGUNAAN ISOSORBID DINITRAT (ISDN) PADA PASIEN INFARK MIOKARD AKUT DI RSUD SIDOARJO untuk memenuhi satu persyaratan akademik dalam menyelesaikan Program Sarjana Farmasi Fakultas Ilmu Kesehatan Universitas Muhammadiyah Malang. Terselesaikannya skripsi ini tidak terlepas dari bantuan banyak pihak, sehingga pada kesempatan ini dengan segala kerendahan hati dan penuh rasa hormat bagi semua pihak yang telah memberikan bantuan moril maupun materiil baik langsung maupun tidak langsung dalam penyusunan skripsi ini hingga selesai, penulis meyampaikan terimakasih sebesar-besarnya kepada: 1.
Yoyok Bekti Prasetyo, M.Kep., Sp. Kom selaku Dekan Fakultas Ilmu Kesehatan Universitas Muhammadiyah Malang.
2.
Dr. Atok Irawan, Sp.P, selaku Direktur RSUD Sidoarjo yang telah memberikan izin untuk melaksanakan penelitian di RSUD Sidoarjo.
3.
Nailis Syifa’, S.Farm,. Apt,. M.Sc. selaku Ketua Program Studi Farmasi Universitas Muhammadiyah Malang.
4.
Drs. Didik Hasmono, M.S., Apt sebagai Pembimbing I dan
Hidajah
Rachmawati, S.Si., Apt., Sp.FRS sebagai Pembimbing II yang bersedia meluangkan waktu dengan tulus ikhlas dan penuh kesabaran memberikan bimbingan, nasihat, dan arahan kepada saya. 5.
Nailis Syifa’, S.Farm,. Apt,. M.Sc, Ika Ratna Hidayati, S.Farm., Apt., M.Sc dan Dra.Lilik Yusetyani, Apt.,Sp.FRS sebagai Tim Penguji yang memberikan kritik dan saran yang membangun terhadap skripsi yang saya kerjakan.
6.
Program Studi Farmasi beserta seluruh staf pengajar Program Studi Farmasi Universitas Muhammadiyah Malang
7.
Heru prabowo, S.Farm., Apt sebagai Dosen Wali yang telah memberikan bimbingan, arahan dan nasehat.
8.
Sendi Lia Yunita, S.Farm., Apt., selaku Sekretaris Program Studi yang telah melancarkan proses jalannya skripsi.
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9.
Teristimewa kepada orang tua saya tercinta ayah Adiwinarko dan bunda Rochmiasih yang dengan penuh kasih sayang selalu mendoakan, memberikan motivasi, semangat dan pengorbanannya baik segi moril maupun materiil. Serta adik-adik kesayangan Aqmarina Shabrina, Annisa Yumna Nabiilah, dan M. Roziq Hanan, terimakasih atas doa dan dukungan kalian untuk saya.
10. Teman-teman klinis geng darjo tersayang: Dila, Mahiru, Lili, Roura, mbak Sulis. Terimaksih atas bantuan yang selalu kalian berikan kepada saya dalam menyelesaikan skripsi ini, menemani dalam segala kesusahan, kebingungan, maupun kebahagiaan yang kita lalui. 11. Teman seperjuangan Khilmi Abdul Rahman. Terimakasih selalu ada untuk saya, mengantar, mengajak, mengingatkan, memberi dorongan, dukungan, canda dan tawa. Semoga kita tetap dapat saling menjaga dalam doa. 12. Teman-teman Farmasi C 2011: Anggi, Adel, Luluk, Sri, Irvan, Ilham, Izu, Hasby, Inna, Shinta, Yuli, Rizqi, Arin, Resti, Wanda, Della, Fina, Adis, Putri, Reza, Afnan dan teman-teman lainnya. 13. Sahabat terbaik yang saya miliki: Galih Nur Rendra Wijaya, Ridwana Syafaati Rohmah, Rizki Sulis Sanjaya, Shinta Rosdiana Anggraini, Fitri Eko Setyafani, Septi Aning Tyas Dwi Arti. Terimakasih telah memberikan doa, dukungan dan motivasi terus menerus. 14. Serta semua pihak yang tidak bisa saya sebutkan satu persatu, terimakasih telah membantu, memberikan dukungan, semangat, dan doa kepada saya. Akhir kata, semoga Alloh SWT membalas kebaikan dan ketulusan semua pihak yang telah membantu. Semoga skripsi ini dapat memberikan manfaat dan kebaikan bagi banyak pihak serta bernilai ibadah dihadapan Alloh SWT. Aamiin.
Malang, 19 Agustus 2015
Robiana Prihandini
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DAFTAR ISI Halaman HALAMAN JUDUL................................................................................................ i LEMBAR PENGESAHAN .................................................................................... ii LEMBAR PENGUJIAN ........................................................................................ iii KATA PENGANTAR ........................................................................................... iv RINGKASAN ........................................................................................................ vi ABSTRAK ........................................................................................................... viii DAFTAR ISI ............................................................................................................x DAFTAR GAMBAR ........................................................................................... xiv DAFTAR TABEL ..................................................................................................xv DAFTAR LAMPIRAN ........................................................................................ xvi DAFTAR SINGKATAN .................................................................................... xvii BAB 1 PENDAHULUAN .......................................................................................1 1.1 Latar Belakang .................................................................................................1 1.2 Rumusan Masalah ............................................................................................3 1.3 Tujuan Penelitian .............................................................................................3 1.3.1 Tujuan Umum ..........................................................................................3 1.3.2 Tujuan Khusus .........................................................................................4 1.4 Manfaat Penelitian ...........................................................................................4 BAB 2 TINJAUAN PUSTAKA ..............................................................................5 2.1 Definisi Infark Miokard Akut ..........................................................................5 2.2 Epidemiologi Infark Miokard Akut .................................................................5 2.3 Etiologi Infark Miokard Akut ..........................................................................6 2.3.1 Klasifikasi IMA Berdasarkan Jenis Penyebabnya ...................................6 2.3.1.1 Infark Miokard Tipe 1 ......................................................................6 2.3.1.2 Infark Miokard Tipe 2 ......................................................................7 2.3.1.3 Infark Miokard Tipe 3 ......................................................................7 2.3.1.4 Infark Miokard Tipe 4 ......................................................................7 2.3.1.5 Infark Miokard Tipe 5 ......................................................................7 2.3.2 Faktor Risiko ............................................................................................7 2.4 Patogenesis Infark Miokard Akut ....................................................................9 2.5 Patofisiologi Infark Miokard Akut ................................................................12 vi
2.6 Manifestasi Klinis ..........................................................................................13 2.6.1 Nyeri Dada .............................................................................................14 2.6.2 Bradikardi dan Takikardi .......................................................................14 2.6.3 Perubahan Elektrokardiografi (EKG) ....................................................15 2.6.4 Peningkatan Serum Biomarker Jantung .................................................15 2.7 Diagnosis Infark Miokard Akut .....................................................................16 2.7.1 Elektrokardiogram (EKG)......................................................................17 2.7.2 Tes Laboratorium ...................................................................................17 2.7.3 Cardiac Imaging .....................................................................................17 2.7.4 Serum Biomarker ...................................................................................18 2.7.4.1 Creatinin Kinase (CK) ....................................................................19 2.7.4.2 Serum Troponin..............................................................................20 2.7.4.3 Myoglobin ......................................................................................21 2.7.4.4 Serum Glutamic Oxalo-acetic Transaminase (SGOT) ...................21 2.7.4.5 Serum Lactate Dehydrogenase (SLDH) .........................................21 2.8 Komplikasi Infark Miokard Akut ..................................................................21 2.9 Penatalaksanaan Infark Miokard Akut ..........................................................23 2.9.1 Oksigen ..................................................................................................24 2.9.2 Antiplatelet .............................................................................................24 2.9.2.1 Aspirin ............................................................................................25 2.9.2.2 Klopidogrel.....................................................................................25 2.9.3 Beta Bloker ............................................................................................26 2.9.4 ACE Inhibitor .........................................................................................27 2.9.5 Calcium Chanel Blocker (CCB) ............................................................27 2.9.6 Analgesik. ..............................................................................................28 2.9.7 Nitrat. .....................................................................................................28 2.10 Penggunaan Isosorbid Dinitrat (ISDN) sebagai Terapi Farmakologis IMA........................................................................................30 BAB 3 KERANGKA KONSEPTUAL ..................................................................33 3.1 Uraian Kerangka Konseptual .........................................................................33 3.2 Bagan Alir Kerangka Konseptual ..................................................................35 3.3 Kerangka Operasional Terapi pada Pasien IMA ...........................................36
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BAB 4 METODE PENELITIAN...........................................................................37 4.1 Rancangan Penelitian.....................................................................................37 4.2 Populasi dan Sampel ......................................................................................37 4.2.1 Populasi ..................................................................................................37 4.2.2 Sampel. ...................................................................................................37 4.2.3 Kriteria Data Inklusi...............................................................................37 4.2.4 Kriteria Data Eksklusi. ...........................................................................37 4.3 Bahan Penelitian ............................................................................................38 4.4 Instrumen Penelitian ......................................................................................38 4.5 Tempat dan Waktu Penelitian ........................................................................38 4.6 Definisi Operasional ......................................................................................38 4.7. Metode Pengumpulan Data ...........................................................................39 4.8. Analisis Data .................................................................................................39 BAB 5 HASIL PENELITIAN ...............................................................................41 5.1 Data Demografi .............................................................................................42 5.1.1 Jenis Kelamin .........................................................................................42 5.1.2 Usia Pasien .............................................................................................42 5.1.3 Status Pasien ..........................................................................................43 5.2 Faktor Risiko .................................................................................................43 5.3 Penggunaan Obat pada Pasien Infark Miokard Akut ....................................44 5.4 Penggunaan Vasodilator Nitrat pada Pasien Infark Miokard Akut ...............46 5.5 Pola Penggunaan ISDN pada Pasien IMA.....................................................46 5.5.1 Pola Penggunaan ISDN ..........................................................................46 5.5.2 Penggunaan ISDN Tunggal ...................................................................47 5.5.3 Terapi ISDN Tunggal dengan Pergantian ..............................................47 5.5.4 Terapi Kombinasi ISDN dengan Satu Antihipertensi ............................47 5.5.5 Terapi Kombinasi ISDN dengan Dua Antihipertensi ............................47 5.5.6 Terapi Kombinasi ISDN dengan Tiga Antihipertensi............................49 5.5.7 Terapi Kombinasi ISDN dengan Empat Antihipertensi ........................50 5.6 Lama Penggunaan Isosorbid Dinitrat ............................................................50 5.7 Lama Perawatan .............................................................................................50 5.8 Kondisi Keluar Rumah Sakit .........................................................................51
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BAB 6 PEMBAHASAN ........................................................................................52 BAB 7 KESIMPULAN DAN SARAN .................................................................64 7.1 Kesimpulan ....................................................................................................64 7.2 Saran ..............................................................................................................64 DAFTAR PUSTAKA ............................................................................................65 LAMPIRAN ...........................................................................................................70
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DAFTAR GAMBAR Gambar
Halaman
2.1 Jantung dan Gambaran Pembuluh Darah dengan Plak Aterosklorosis .........10 2.2 Perbedaan aliran darah normal dan yg mengalami aterosklerosis............... ..11 2.3 Perubahan EKG pada IMA ............................................................................15 2.4 Kenaikan Biomarker Jantung setelah IMA ....................................................16 2.5 Biomarker Jantung pada IMA .......................................................................20 2.6 Rumus Struktur Isosorbid Dinitrat.................................................................30 3.1 Kerangka Konseptual .....................................................................................35 3.2 Kerangka Operasional ...................................................................................36 5.1 Skema Kriteria Inklusi dan Eksklusi Penelitian pada Pasien Infark Miokard Akut................................................................................................41 5.2 Jenis Kelamin Pasien Infark Miokard Akut dengan Terapi ISDN ................42 5.3 Usia Pasien Infark Miokard Akut dengan Terapi ISDN ................................42 5.4 Status Pasien Infark Miokard Akut dengan Terapi ISDN .............................43 5.5 Diagram Distribusi Kondisi 38 Pasien Infark Miokard Akut saat KRS di RSUD Sidoarjo .........................................................................................51
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DAFTAR TABEL Tabel
Halaman
II.1 Sediaan Isosorbid Dinitrat .............................................................................32 V.1 Faktor Risiko Infark Miokard Akut ..............................................................43 V.2 Pola Penggunaan Terapi Infark Miokard Akut tanpa ISDN .........................44 V.3 Pola Penggunaan Terapi Penyerta pada 38 Pasien Infark Miokard Akut di RSUD Sidoarjo .........................................................................................45 V.4 Tabel Penggunaan Vasodilator Nitrat ...........................................................46 V.5 Pola Penggunaan ISDN pada Pasien IMA ....................................................46 V.6 Pola Penggunaan ISDN Tunggal tanpa Pergantian ......................................47 V.7 Pola Penggunaan ISDN dengan Pergantian ..................................................47 V.8 Pola Penggunaan Kombinasi ISDN dengan Satu Antihipertensi .................47 V.9 Pola Penggunaan Kombinasi ISDN dengan Dua Antihipertensi ..................47 V.10 Pola Penggunaan Kombinasi ISDN dengan Tiga Antihipertensi ...............49 V.11 Pola Penggunaan Kombinasi ISDN dengan Empat Antihipertensi ............50 V.10 Lama Perawatan Pasien Infark Miokard Akut dengan Terapi ISDN .........50
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DAFTAR LAMPIRAN Lampiran
Halaman
1 Daftar Riwayat Hidup .......................................................................................67 2 Surat Pernyataan Bebas Plagiasi ......................................................................68 3 Keteranga Kelayakan Etik ................................................................................69 4 Daftar Nilai Normal Data Laboratorium ..........................................................71 5 Lembar Pengumpul Data ..................................................................................72
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DAFTAR SINGKATAN
ACC ACEI ACS ACTH ADH ADP AHA ALDH2 ALDH3 aPTT ARB ATP CABG CCB cGMP CK CKMB COX 2 cTnC cTnI cTnT CVD EKG ESC GC HIT IL-1 IMA LBBB LD LMWH LV MLC MLCK NO Non Q MI NSAID NSTEMI PCI PJK Q MI RISKESDAS rPa RV SA
: American College of Cardiology : Angiotensin Converting Enzyme Inhibitor : Acute Coronary Syndrome : Adrenocorticotropic Hormone : Anti Diuretic Hormone : Adenosine Di Phosphate : American Heart Association : Aldehide Dehydrogenase-2 : Aldehide Dehydrogenase-3 : Activated Partial Thromboplastine Time : Angiotensin Receptor Blocker : Adenosine Tri Phosphate : Coronary Artery Bypass Grafting : Calcium Channel Blocker : Cyclase Guanylyl Mono Phosphate : Creatine Kinase : Creatine Kinase Myocard Band : Cyclo-Oxygenase 2 : Serum Troponin C : Serum Troponin I : Serum Troponin T : Cardiovascular Disease : Elektrokardiogram : European Society of Cardiology : Guanylyl cyclase : Heparin Induced Thrombocytopenia : Interleukin 1 : Infark Miokard Akut : Left Bundle Branch Block : Laktat Dehidrogenase : Low Molecule Weight Heparin : Left Ventricular : Myosin Light Chain : Myosin Light Chain Kinase : Nitrat Oksida : Non Q Wave Myocardial Infarction : Non Steroid Anti Inflammation Drug : Non ST Elevation Myocardial Infarction : Percutaneous Coronary Intervention : Penyakit Jantung Koroner : Q Wave Myocardial Infarction : Riset Kesehatan Dasar : Reteplase : Right Ventricular : Sino Atrial
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SGOT SLDH STEMI TNF TNK-tPa tPa TPR UA UFH WHO
: Serum Glutamic Oxalo-Acetic Transaminase : Serum Laktat Dehidrogenase : ST Elevation Myocardial Infarction : Tumour Necrosis Factor : Tenekplase : Alteplase : Total Peripheral Resistency : Unstable Angina : UnFractionated Heparin : World Health Organization
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