KAJIAN PUSTAKA
INFARK MIOKARD AKUT
Oleh: Pratama Rizky Ardi 06020049
FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH MALANG 2013
INFARK MIOKARD AKUT
KAJIAN PUSTAKA
Diajukan kepada Universitas Muhammadiyah Malang untuk Memenuhi Salah Satu Persyaratan dalam Menyelesaikan Program Sarjana Fakultas Kedokteran
Oleh: Pratama Rizky Ardi 06020049
FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH MALANG 2013
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LEMBAR PENGESAHAN KARYA TULIS AKHIR
Telah disetujui sebagai Karya Tulis Akhir Untuk memenuhi persyaratan Pendidikan Sarjana Fakultas Kedokteran Universitas Muhammadiyah Malang Tanggal: 03 Agustus 2013
Pembimbing I
Dr. Isbandiyah, Sp.PD
Pembimbing II
dr. Indah Serunurani
Mengetahui, Dekan Fakultas Kedokteran Universitas Muhammadiyah Malang
dr. Irma Suswati, M.Kes
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LEMBAR PENGUJIAN
Karya Tulis Akhir oleh Pratama Rizky Ardi ini Telah diuji dan dipertahankan di depan Tim Penguji Pada tanggal 03 Agustus 2013
Tim Penguji
dr. Isbandiyah, Sp.PD
Ketua
dr. Indah Serunurani
Anggota
dr. Meddy Setiawan, Sp.PD
Anggota
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KATA PENGANTAR
Puji syukur penulis panjatkan kepada Allah SWT atas segala rahmat dan karunia-Nya sehingga dapat terselesaikannya karya tulis akhir dengan judul “Infark Miokard Akut”, sebagai salah satu persyaratan dalam menyelesaikan program sarjana program pendidikan dokter di Universitas Muhammadiyah Malang. Di dalam tulisan ini, disajikan pokok-pokok bahasan yang epidemiologi, faktor resiko, patogenesis, diagnose dan tata laksana terkini dari IMA. Pada kesempatan ini penulis sampaikan terima kasih dan penghargaan yang setinggi-tingginya kepada dr. Isbandiyah, Sp.PD selaku pembimbing 1 dan dr. Indah Serunurani selaku pembimbing 2 yang telah sabar dan telaten memberikan motivasi, koreksi, serta saran sehingga karya tulis akhir ini dapat terselesaikan dan tidak lupa pula penulis sampaikan terima kasih kepada: 1.
dr. Irma Suswati, M.Kes. selaku dekan Fakultas Kedokteran Universitas Muhammadiyah Malang yang telah memberikan kemudahan dalam penelitian ini
2. dr. Meddy Setiawan, Sp.PD. selaku pembantu dekan 1 Fakultas Kedokteran Universitas Muhammadiyah Malang yang telah memberikan dorongan untuk menyelesaikan karya tulis akhir ini 3. dr. Fathiyah Safithri, M.Kes selaku pembantu dekan II Fakultas Kedokteran Universitas Muhammadiyah Malang yang telah memberikan motivasi sehingga karya tulis akhir ini dapat terselesaikan 4. dr. Iwan Sys, Sp.KJ selaku pembantu dekan III Fakultas Kedokteran Universitas Muhammadiyah Malang yang telah memberikan motivasi sehingga karya tulis akhir ini dapat terselesaikan
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5. dr Diah Hermayanti, Sp.PK. selaku Kaprodi FK-UMM. Terima kasih atas semua arahan dan bimbingan yang senantiasa diberikan 6. Kedua orang tua, Papa Khoirul Anam dan Mama Elly Ardianty, emak dan ai yang senantiasa tanpa henti mendoakan penulis 7. Kedua adik saya, Auliya dan Rio yang selalu memberikan semangat 8. Wildanessa P.S yang selalu memberikan semangat dan bantuan dalam menyelesaikan karya tulis ini 9. Sahabat-sahabat saya, dr. Agus, dr. Jimmy, dr. Bayu, dan dr. Andika atas dorongan dan bantuan dalam menyelesaikan karya tulis akhir ini 10. Teman-teman seperjuangan akhir, Ade, Taufik, Dorin, Zein, Rhy2, Andy, Fandy dan Huei. Sukses buat kita semua, perjuangan masih panjang kawan. 11. Staf TU FK UMM terima kasih atas bantuannya selama ini pada penulis 12. Penjaga parkiran, mas ndut yang selalu mempertanyakan perkuliahan saya 13. Semua pihak yang tidak dapat penulis sebutkan satu persatu yang turut membantu terselesaikannya penyusunan karya tulis akhir ini. Penulis menyadari karya tulis akhir ini masih banyak kekurangan dan keterbatasan baik dari segi materi maupun penulisnnya, oleh karena itu kritik dan saran yang sifatnya membangun sangat penulis harapkan guna perbaikan.
Malang, 26 Juli 2013
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ABSTRAK
Pratama Rizky Ardi. 2013. Infark Miokard Akut (IMA). Fakultas Kedokteran Universitas Muhammadiyah Malang. Pembimbing : (I) Isbandiyah, (II) Indah Serunurani Rangkuman: Kematian akibat penyakit kardiovaskuler menempati urutan pertama (20,5%) untuk umur di atas 40 tahun. Sindrom koroner akut (SKA) merupakan keadaan darurat jantung dengan manifestasi klinis rasa tidak enak didada atau gejala lain sebagai akibat iskemia miokardium. SKA terdiri atas angina pektoris tidak stabil, dan Infark Miokard Akut (IMA). Infark Miokard Akut (IMA) merupakan salah satu spektrum dari Sindroma Koroner Akut (SKA) yang ditandai dengan adanya nekrosis jaringan otot jantung dan perubahan pada gelombang EKG. Dari gambaran EKG IMA dibagi menjadi adanya elevasi segmen ST (STEMI) dan tanpa elevasi segmen ST (NSTEMI). Patofisiologi dari IMA sendiri tak lepas dari adanya proses aterogenesis yang nantinya akan mengakibatkan penyempitan bahkan penyumbatan pembuluh darah koroner dan menyebabkan iskemi jaringan. Faktor resiko terjadinya IMA antara lain diabetes, usia, jenis kelamin, ras, riwayat keluarga, rokok, dislipidemia, obesitas, dan banyak lagi dimana kesemuanya juga memegang andil dalam proses terjadinya aterosklerosis. Tingginya mortalitas penyakit ini menjadikan cepatnya penegakan diagnosis dan intervensi terapi menjadi sangat penting. Diagnosis terjadinya IMA yang paling akurat sampai saat ini adalah dengan menggunakan enzim kardiak spesifik yakni Troponin, namun beberapa enzim kardiak juga dapat digunakan dalam mendetaksi IMA fase awal. EKG juga sangat bermanfaat untuk menegakkan diagnose IMA tanpa adanya dukungan enzim kardiak. Adapun terapi IMA sampai menurut pedoman terapi terbaru antara lain terdiri dari agen reperfusi, penghilang nyeri, anti platelet, anti kolesterol bahkan dengan pemasangan stent. Kata Kunci: Infark miokard akut, NSTEMI, STEMI, Enzim Kardiak, Ateroskerosis
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ABSTRACT Pratama Rizky Ardi. 2013. Infark Miokard Akut (IMA). Fakultas Kedokteran Universitas Muhammadiyah Malang. Pembimbing : (I) Isbandiyah, (II) Indah Serunurani Summary: Deaths from cardiovascular disease ranks first (20.5%) to the age of 40 years. Acute coronary syndrome (ACS) is a cardiac emergency with clinical manifestations of chest discomfort or other symptoms due to myocardial ischemia. ACS consists of unstable angina pectoris and acute myocardial infarction (AMI). Acute myocardial infarction (AMI) is one of a spectrum of acute coronary syndrome (ACS) is characterized by necrosis of cardiac muscle tissue and changes in the ECG waveform. ECG of IMA is divided into the ST segment elevation (STEMI) and non-ST segment elevation (NSTEMI) myocardial infarction. Pathophysiology of AMI itself always related to atherogenesis process which will lead to narrowing and even blockage of coronary arteries and lead to tissue ischemia. AMI risk factors include diabetes, age, gender, race, family history, smoking, dyslipidemia, obesity, and much more all of which also holds a stake in the process of atherosclerosis. The high mortality of this disease makes rapid diagnosis and therapeutic intervention becomes very important. The most accurate to date diagnosis tools of AMI is to use the specific cardiac enzyme troponin, but some cardiac enzymes can also be usefull in detecting the initial phase of the AMI. ECG is also very useful to establish the diagnosis of AMI without the support of cardiac enzymes. The AMI therapy according to the latest guidelines, include reperfusion agents, pain relievers, anti-platelet, anti-cholesterol even with stent implantation. Keywords: Acute myocardial infarction, NSTEMI, STEMI, Cardiac Enzymes, Atherosclerosis
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DAFTAR ISI Halaman HALAMAN SAMPUL .................................................................................... i LEMBAR PENGESAHAN ............................................................................. iii LEMBAR PENGUJIAN .................................................................................. iv KATA PENGANTAR ..................................................................................... v ABSTRAK ....................................................................................................... vii ABSTRACT .................................................................................................... viii DAFTAR ISI .................................................................................................... ix DAFTAR TABEL ............................................................................................ xii DAFTAR GAMBAR ....................................................................................... xiii DAFTAR SINGKATAN ................................................................................. xiv BAB I PENDAHULUAN ................................................................................ 1 1.1 Latar Belakang................................................................................. 1 1.2 Rumusan Masalah ........................................................................... 2 1.3 Tujuan Penulisan ............................................................................. 3 1.4 Manfaat Penulisan ........................................................................... 3 BAB II TINJAUAN PUSTAKA...................................................................... 4 2.1 Epidemiologi Penyakit Jantung Koroner dan Miokard Infark Akut ................................................................................................. 4 2.2. Definisi Infark Miokard Akut .......................................................... 6 2.3 Arteriosklerosis dan Kematian Otot Jantung .................................. 11 2.3.1 Patogenesis Umum Ateroskerosis .......................................... 12 2.3.2 Hipotesis Modifikasi Oksidatif Terhadap Pembentukan Atheroskeloris ........................................................................ 18
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2.3.3 Radikal Bebas dan Aterosklerosis .......................................... 22 2.4. Manifestasi Klinis Infark Miokard Akut ......................................... 26 2.4.1. Serangan Jantung ................................................................... 27 2.4.2. Angina Pectoris ...................................................................... 27 2.4.3. Gangguan irama Jantung ........................................................ 28 2.5. Faktor Risiko Infark Miokard Akut ................................................. 28 2.5.1. Lipid ...................................................................................... 29 2.5.2. Merokok ................................................................................ 30 2.5.3. Obesitas ................................................................................. 32 2.5.4. Diabetes Mellitus ................................................................... 33 2.5.5. Riwayat Keluarga .................................................................. 34 2.5.6. Hipertensi Sistemik ............................................................... 36 2.5.7. Jenis Kelamin dan Hormon Seks ........................................... 37 2.5.8. Ras ......................................................................................... 38 2.5.9. Geografi ................................................................................. 38 2.5.10. Kelas Sosial ......................................................................... 39 2.5.11. Stres dan Kepribadian.......................................................... 40 2.5.12. Aktivitas Fisik ..................................................................... 40 2.5.13. Pembekuan Darah ................................................................ 41 2.5.14. Hiperhomosisteinemia ......................................................... 41 2.5.15. Infeksi .................................................................................. 42 2.5.16. Alkohol ................................................................................ 43 2.6 Diagnosa Miokard Infark Akut ....................................................... 44 2.6.1 EKG sebagai Penegakan Diagnosis Infark Miokard .............. 47
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2.6.2 Pertanda Biokimia Troponin T pada Infark Miokard ............. 50 2.7 Tatalaksana Infark Miokard Akut ................................................... 55 2.7.1 Tatalaksana Sebelum Dirujuk ke Rumah Sakit ...................... 56 2.7.2. Tatalaksana Di Rumah Sakit/UGD........................................ 57 BAB III PENUTUP ......................................................................................... 59 3.1 Kesimpulan ....................................................................................... 59 3.2 Saran ................................................................................................. 60 DAFTAR PUSTAKA ...................................................................................... 61
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DAFTAR TABEL
Tabel
Halaman
2.1 Lima Besar Kasus Penyebab Kematian di USA ....................................... 5 2.2 Efek seluer LDL yang Teroksidasi ........................................................... 22 2.3 Perbedaan Sifat Sakit Dada Penyakit Jantung dengan Penyakit Non Jantung ...................................................................................................... 28 2.4 Perbandingan Kadar Kolesterol Total dan LDL Serum ............................ 30 2.5 Klasifikasi berat badan (BB) berdasarkan indek massa tubuh .................. 32 2.6 Kelainan Genetik Berkaitan dengan Penyakit Jantung Koroner ............... 35 2.7 Klasifikasi tekanan darah pada orang dewasa (18 tahun keatas) menurut kriteria JNC7............................................................................... 36 2.8 Odds Ratio Faktor Risiko Penyakit Jantung Koroner ............................... 42 2.9 Lokasi infark miokard berdasarkan perubahan gambaran EKG ............... 49 2.10 Spektrum Sindroma Koroner Akut dan Patologinya .............................. 50 2.11 Perbandingan Penggunaan Berbagai Biomarker Jantung ....................... 54
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DAFTAR GAMBAR Gambar
Halaman
2.1 Kematian global akibat penyakit kardiovaskuler ....................................... 4 2.2 Anatomi arteri koroner jantung .................................................................. 8 2.3 Spektrum Sindrom Koroner Akut .............................................................. 9 2.4 Proses Aterogenesis ................................................................................... 17 2.5 Hipotesis modifikasi oksidatif aterosklerosis ............................................ 19 2.6 Interaksi stres oksidatif dan atheromatosis ................................................ 20 2.7 Hubungan antara diabetes dengan penyakit jantung koroner .................... 34 2.8 Pengaruh hipertensi pada jantung .............................................................. 37 2.9 Gambaran EKG pada IMA......................................................................... 44 2.10 Dinamika enzim kardiak dalam IMA ....................................................... 46 2.11 Gambar kompleks troponin, tropomiosin, aktin dan miosin .................... 51
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DAFTAR SINGKATAN APTS
: Angina pectoralis tak stabil
CABG
: Coronary artery bypass grafting
CAD
: Coronary artery disease
CK
: Creatin kinase
CKMB
: creatinin kinase MB
cTnT
: Cardiag troponin
EKG
: Elektrokardiografi
HDL
: High Density Lipoprotein
IMA
: Infark Miokard Akut
IMT
: Indeks Massa Tubuh
ICCU
: Intensive Cardiac care unit
LDH
: Laktat dehidrogenase
LDL
: Low Density Lipoprotein
LOX
: Lipoksigenase
MMD
: minor myocardial damage
NO
: Nitric Oxide
NOS
: Nitric oxide sintease
NSTEMI
: Non ST Elevation Miocardial Infarct
Ox-LDL
: Oxidized Low Density Lipoprotein
PJPD
: Penyakit jantung dan pembuluh darah
PJK
: Penyakit Jantung Koroner
RAS
: Renin angiotensin system
ROS
: reactive Oxigen species
SKA
: Sindroma Koroner Akut
SR
: scavenger receptor
STEMI
: ST Elevation Miocardial Infarct
UGD
: Unit Gawat Darurat
VCAM-1
: Vascular cell adhesion molecule
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