tentang penyakit jantung

1. DRUGS USED IN ANGINA
PECTORIS & MYOCARDIAL
INFARCTION
WIWIK RAHAYU, dr., M.Kes
Depart.of.Pharmacology & Therapy
Faculty Of Medicine – Riau University

2. ANGINA PECTORIS
A syndrome of inadequate oxygen delivery to
the myocardium relative to the oxygen
requirement of this tissue
• Symptom
Severe, transient retrosternal pain
radiated to the left arm, back or jaw
• Duration:
0,5 – 30 minute
• ECG:

3. ANGINA PECTORIS
↓ O2 Supply
Ischemic
PAIN

4. TYPE OF ANGINA PECTORIS
1. CLASSIC ANGINA
– Atherosklerosis
– Precipitating factor (+)
2. PRINZMETALS
– Vasospasm
– Precipitating factor (-)
3. UNSTABLE
A rapid increase in frequency and intensity of
anginal pain occurs, which is thought to herald
imminent myocardial infection.

5. Angina Pectoris PATHOPHYSIOLOGY (I)
RISK FACTOR
• Age • Hypertension
• Smoking • Hypercholesterolemia
• DM • Oral contraception
• Genetic ?
atherosklerosi
s
OBSTRUCTION (a.coronary)
Decreased 02 supply

6. Angina Pectoris
PATHOPHYSIOLOGY II
O2 supply & O2 demand
Precipitating factors
ISCHEMIA
PAIN

7. PRINCIPLES IN THE TREATMENT OF
ANGINA PECTORIS
• O2 supply to the tissue
• O2 demand of the tissue
3. Risk Factor

8. ANTI ANGINAL DRUGS
1. ORGANIC NITRATES
– AMIL NITRIT
– NITROGLYCERIN
– ISOSORBIDE DINITRATE
• Ca ++ CHANNEL BLOCKERS (CCB)
– NIFEDIPINE, AMILODIPINE
– DILTIAZEM
– VERAPAMIL
• β ADRENERGIC BLOCKERS
– PROPANOLOL cs

9. NITROGLYCERINE
Nitroglycerine – the prototype nitrate drug.
All nitrates have the same mechanism of Action.
MECHANISM OF ACTION
Administrated nitrates
↑ Nitrites
↑ Nitric oxide (NO)
↑ cGMP
↑ Dephosphorylation of myosin light chain
Vascular smooth muscle relaxation

10. Nitroglycerin
EFFECT
Venodilatation
Relief of
Preload coronary a spasm Collateral flow
O2 demand O2 supply O2 supply
Inotropic ?
Chronotropic ?

12. Nitroglycerin
EFFECT
High Dose
Vasodilatation
BP
tachycardia
Paradoxal effect O2 demand

13. Nitroglycerin
EFFECT
• Increased O2 supply
• Decreased O2 demand
Preload
Afterload
• Contractility (N)
• Heart rate
• Decreased in platelet aggregation (?)

14. Dosage

15. Nitroglycerin
INDICATION
• ANGINA PECTORIS
• Acute
• Prophylaxis
• ACUTE MYOCARDIAL INFARCTION
• CONGESTIVE HEART FAILURE

16. Nitroglycerin
ADVERSE DRUG REACTIONS
• Common side – effects
Headaches
• Serious SE
– Hypotension – Syncope ( cause cerebral ischemia)
tachycardia
• Others
Edema
Methemoglobinemia
SL: Burning sensation
• Withdrawal symptoms
• Tolerance

17. Nitroglycerin
ADVERSE DRUG REACTIONS
Tolerance
• Appears within 12 hours
• Long acting preparation
Continuous infusion
Caused: - BM depletion
• Avoid by a nitrate free interval
• Cross tolerance

18. Nitroglycerin
CONTRAINDICATION
• Hypotension
• Severe anemia
• Brain injury
• Tachyaritmia

19. CALCIUM CHANNEL BLOCKERS
(CALCIUM ANTAGONIST)
I. NIFEDIPINE
AMLODIPINE, FELODIPINE,
NICARDIPINE, NIMODIPINE, ETC
II. DILTIAZEM
III. VERAPAMIL

20. CCB
MECHANISM OF ACTION
• Inhibit the influx of Calcium into CARDIAC
& VASCULAR cells MUSCLE TONE

21. CCB
EFFECTS (I)
Vascular Effects Cardiac Effects
Vasodilatation Heart Rate ↓ Conduction
↑ O2 supply After load↓ BP ↓ Contraction
↓ O2 demand ↓ O2 demand

22. CCB
EFFECTS (II)
Phenylalkylamines Dihydropyridines Benzothiazepines
A (Verapamil) D (Diltiazem)
B(Nifedipine) C(Nimodipine)
Vasodilatation
Peripheral ++ +++ + +
Coronary ++ +++ + +++
Cerebral
+ + +++ +
Heart Rate ↓ ↑ - ↓
SA Node ↓ - - ↓↓
AV Node ↓↓ - - ↓
Contractility ↓↓ ↑ - ↓

23. Pharmacokinetics
Drug Absorption Bioavailability Active Half Onset Peak
Metabolites Life of Effect
(hr) Action after
after oral
Oral Dosing
Dosing
Verapamil >90% 10%-35% + 5 <1hr 1-2hr
Nifedipine >90% 60%-70% - 2 <20min 30min
(2-3
min)*
<1hr
Diltiazem >80% 40% + 3,5 2-3hr

24. CLINICAL PROBLEMS AND SIDE EFFECTS
VERAPAMIL
Problems in 8% to 10% of patients
Major Cardiodepression
Moderate Hypotension
AV node block
Peripheral edema
Minor Headache
Constipation
NIFEDIPINE
Problems in 17% to 20% of patients
Major Hypotension
Headache
Peripheral edema
DILTIAZEM
Problems in 2% to 5% of patients
Minor Hypotension -AV Node Block
Peripheral edema -Cardiodepression

25. NIFEDIPINE
• Effects (?)
• SE: VD flushing, dizziness, headache,
palpitation, peripheral edema
rare myalgia, hypokalemia,
gingival swelling
• Drug Interaction
Cimetidine
Prazosin

26. Nifedipine
• Indication
1.PRINZMETAL,S (VASOSPASTIC) ANGINA
Monotherapy, 40-80 mg
More effective when combined with Isosorbid
4.CHRONIC STABLE ANGINA
Combined with Beta Blocker
6.UNSTABLE ANGINA
Monotherapy is contraindication
Combined with Beta Blocker

27. Nifedipine
SECOND GENERATION DHP
AMLODIPIN: Dosage:
5-10 mg, once daily
NICARDIPINE: Dosage: 20-40 mg, every 8 hours
NIMODIPINE : Subarachnoid Hemorrhage
Migraine

28. BETA BLOCKER
• CARDIOSELECTIVE
– Acebutolol
– Atenolol *
– Metoprolol *
• NON CARDIOSELECTIVE
– Propanolol *
– Nadolol *
– Carteolol
– Sotalol
• VASODILATOR NONSELECTIVE
– Labetolol
– Pindolol
– Carvedilol

29. PROPANOLOL
Is the prototype β adrenergic blocker
↓Inotropic
chronotropic ↓ O2 demand
β Adrenergic domotropic
blocker
↓Renin → Ag → peripheral →BP ↓
resistance
aldosteron
↓ Sodium, water BP ↓
retention

30. INDICATION
I. ANGINA PECTORIS
For Chronic management of stable angina
III. MYOCARDIAL INFARCTION
Reduces infarct size and has tens recovery
Reduce the incidence f sudden arrhythmic death
after myocardial infarct
VI. HYPERTENSION
VII. ARRYTHMIA
VIII.MIGRAINE
IX. GLAUCOMA
X. HYPERTHYROIDISM

31. Propanolol
SIDE EFFECTS

32. SELECTION OF DRUGS
Drugs ESR Liposoluble FPE Elimination T 1/2
Propanolol +++ ++ L 1-6
Nadolol 0 0 0 K 20-24
Atenolol + 0 0 K 6-7
Metoprolol + + ++ L 3-7

33. CONTRAINDICATION
• Severe bradycardia, heart block
• Asthma or bronchospasm
• Severe depression
• Peripheral vascular (gangrene, skin,
necrosis, Raynaud’s phenomenon)
• DM
• Renal failure

34. ACUTE MYOCARD INFARCT
↓ O2 Supply
Infarct
PAIN

35. THERAPY
1. Oksigen
2. Morfin
3. Metaklopramide
4. Nitrogliserin
5. Aspirin
6. Streptokinase
7. Heparin
8. Laksativ (bila perlu)

36. Other Drugs
ACE INHIBITOR
Reduce:
1. Remodeling ventricle
2. Haemodinamic
3. Reduce heart failure
BETA BLOCKER
– Reduce O2 myocard demand
– Reduce size of infarct

38. Kasus:
Seorang laki-laki 56 tahun, datang dengan
keluhan sering nyeri dada (khas)
PD: TD= 200/100 mmHg
Diagnosis: Angina Pectoris Klasik
Pertanyaan:
- Bagaimana terapi akut, kronis, lainnya

39. Seorang wanita 62 tahun, datang dengan
keluhan nyeri dada terutama pagi hari.
PD: TD=180/90, Riwayat DM (+)
Diagnosis: Angina Pectoris Vasospastik
Pertanyaan:
- Bagaimana terapi akut, kronis, lainnya ?

40. Seorang laki-laki, 60 tahun datang ke UGD
dengan keluhan nyeri dada hebat, muntah,
keringat dingin
PD: TD= 180/100
Diagnosis: Acute Myocard Infarct
Pertanyaan:
- Bagaimana penanganan pasien tersebut?

41. Wassalam,