KEJADIAN KARDIOVASKULAR MAYOR PADA PENDERITA INFARK MIOKARD AKUT DENGAN ELEVASI SEGMEN ST (IMA-EST) YANG DILAKUKAN TERAPI TROMBOLITIK DIBANDING INTERVENSI KORONER PERKUTAN (IKP) PRIMER SELAMA PERAWATAN DI RUMAH SAKIT

IRSAD ANDI ARSO, dr. Budi Yuli Setianto, SpPD (K), SpJP (K),

2012 | Tesis | ILMU PENYAKIT JANTUNG DAN PEMBULUH DARAH

Latar belakang: Penelitian yang membandingkan terapi trombolitik dan intervensi koroner perkutan (IKP) primer pada penderita IMA-EST telah banyak dilaporkan di negara maju. Di negara berkembang terutama di rumah sakit daerah tindakan IKP primer baru dikerjakan pada akhir-akhir ini sehingga penelitian belum banyak dilaporkan. Tujuan penelitian: Untuk mengetahui kejadian kardiovaskular mayor pada penderita IMA-EST yang mendapatkan terapi trombolitik dibanding tindakan IKP primer selama perawatan di rumah sakit. Metodologi dan cara penelitian: Penelitian kohort retrospektif dengan melihat rekam medik penderita IMA-EST onset <12 jam yang dilakukan terapi trombolitik dan tindakan IKP primer di rumah sakit umum Dr. Sardjito Yogyakarta mulai 1 Januari 2008 sampai dengan 31 Maret 2010. Luaran klinik: Luaran klinik utama: kejadian kardiovaskular mayor yaitu gabungan dari kematian sebab kardiovaskular, reinfark dan stroke selama perawatan di rumah sakit. Luaran klinik sekunder: angina pektoris pasca infark, gagal jantung, syok kardiogenik dan efek samping perdarahan. Hasil penelitian: Dari 78 penderita yang mendapat terapi trombolitik dan 53 penderita yang dilakukan tindakan IKP primer ditemukan kejadian kardiovaskular mayor selama perawatan di rumah sakit tidak berbeda bermakna yaitu 10,3% vs 9,4% (RR 1,09; 95% CI 0,33-3,55; p=0,87), kematian sebab kardiovaskular 6,4% vs 7,5% (RR 0,83; 95% CI 0,21- 3,28; p=0,80), reinfark 1,3% vs 0% (RR 0,98; 95% CI 0,96-1,01; p=0,4), stroke 2,6% vs 5,7% (RR 0,43; 95% CI 0,07-2,71; p=0,36). Kejadian angina pektoris pasca infark pada terapi trombolitik 7% vs 3,8% pada IKP primer (RR 2,51; 95% CI 0,50-12,60; p=0,24) dengan penurunan risiko relatif 57,7%, gagal jantung lebih tinggi dan berbeda bermakna pada terapi trombolitik 17,9% vs 5,7% (RR 3,64; 95% CI 0,99-13,38, p=0,04), penurunan risiko relatif 68,1%, syok kardiogenik 3,8% vs 1,9% (RR 2,08; 95% CI 0,21-20,55; p=0,52). Efek samping perdarahan mayor tidak berbeda bermakna yaitu 1,3% vs 0% (RR 1,68; 95% CI 1,46-1,94; p=1,0), perdarahan minor 12,8% vs 3,8% (RR 3,75; 95% CI 0,78-19,72; p=0,12) Simpulan: Tidak ditemukan perbedaan bermakna kejadian kardiovaskular mayor penderita IMA-EST yang diterapi trombolitik vs IKP primer selama perawatan di rumah sakit. Kejadian angina pektoris pasca infark walaupun tidak berbeda bermakna IKP primer menurunkan risiko relatif 57,7%, sedangkan kejadian gagal jantung lebih tinggi pada terapi trombolitik, IKP primer menurunkan risiko relatif 6,81%. Efek samping perdarahan tidak berbeda bermakna.

Background: A study comparing thrombolytic therapy and primary percutaneous coronary intervention (PCI) in patients with STEMI has been reported in developed countries. There has not been many studies reporting the outcome of pirmary PCI in developing countries where this intervention had just recently performed. Objective: To observed the major cardiovascular events in patients with STEMI who recieved thrombolytic therapy compared with primary PCI during hospitalization. Methodology and Methods: we performed retrospective cohort study using medical record of STEMI patients with the onset <12 hours who recieved thrombolytic therapy and primary PCI at Dr. Sardjito Hospital at Yogyakarta starting January 1 st , 2008 until March 31 st , 2010. Clinical outcomes: primary clinical outcomes: major cardiovascular events are composit of cardiovascular death, reinfarction and stroke during hospitalization. Secondary clinical outcomes: post-infarction angina pectoris, heart failure, cardiogenic shock and side effects of bleeding. Results: from 78 patients who recieved thrombolytic therapy and 53 patients with primary PCI we found that major cardiovascular events during hospitalization was not significantly different,10.3% vs 9.4% (RR 1.09; 95% CI 0.33-3,55; p=0.87), for cardiovascular mortality was 6.4% vs 7.5% (RR 0.83; 95% CI 0.21-3.28; p=0.80), reinfarction was 1.3% vs 0% (RR 0.98; 95% CI 0.96-1.01; p=0.4), stroke was 2.6% vs 5.7% (RR 0.43; 95% CI 0.07-2.71; p=0.36) respectively. The iincidence of postinfarction angina pectoris was 7% vs 3.8% for thrombolytic as compare to primary PCI (RR 2.51; 95% CI 0.50-12.60; p=0.24) with 57.7% relative risk reduction, heart failure is higher and significantly different in thrombolytic therapy 17.9% vs 5.7% (RR 3.64; 95% CI 0.99-13.38; p=0.04), with relative risk reduction 68.1% while cardiogenic shock 3.8% vs 1.9% (RR 2.08; 95% CI 0.21-20.55; p=0.52). Side effects of major bleeding were not significantly different with was 1.3% vs 0% (RR 1.68; 95% CI 1.46-1.94; p=1.0), minor bleeding 12.8% vs 3.8% (RR 3.75; 95% CI 0.78-19.72; p=0.12), for thrombolytic vs primary PCI respectively. Conclusion: we found there were no significant differences of major cardio-vascular events in STEMI patient recieving thrombolytic therapy compared with primary PCI during hospitalization. Incidence of post-infarction angina pectoris was not significantly different although the primary PCI reduces relative risk of 57.7%, while the incidence of heart failure was higher in thrombolytic therapy, primary PCI reduces relative risk of 6.81%. The side effects of bleeding did not differ significantly.

Kata Kunci : kejadian kardiovaskular mayor, IMA-EST, terapi trombolitik, tindakan IKP primer.