infark miokard akut

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
ii
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
iii
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
iv
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
v
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
vii
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
viii
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
ix
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
x
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
xi
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
xii
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
xiii
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
xiv
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