stroke basic knowledge bhs indonesia
DESCRIPTION
Stroke is spesialTRANSCRIPT
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dr. Sholihul Muhibbi, Sp.S, M.Si.Meddr. Sholihul Muhibbi, Sp.S, M.Si.MedLetkol CKM NRP. 32554Letkol CKM NRP. 32554
Kabag Yanmed Dep Saraf RSPAD Gatot SoebrotoKabag Yanmed Dep Saraf RSPAD Gatot Soebroto
DikmilDikmil• Sepamilsuk 1989Sepamilsuk 1989• Sepasuk tahap II 1993Sepasuk tahap II 1993• Selapa 2006Selapa 2006
DikumDikum• Fak Kedokteran UNIBRAW Fak Kedokteran UNIBRAW
MalangMalang• Spesialisasi I.P. Saraf FK Spesialisasi I.P. Saraf FK
UNDIP SemarangUNDIP Semarang• S II Biologi Molekuler Pasca S II Biologi Molekuler Pasca
Sarjana UNDIP SmgSarjana UNDIP Smg
PenugasanPenugasan• Dokter Yonif 741 / SBW Dokter Yonif 741 / SBW
SingarajaSingaraja• Dokter Rumkitlap BaucauDokter Rumkitlap Baucau• Waka Rumkit Wirahusada Waka Rumkit Wirahusada
Dili Dili • Kadep I.P. Saraf & Jiwa RS. Kadep I.P. Saraf & Jiwa RS.
Dr Harjanto BalikpapanDr Harjanto Balikpapan• Kasi Diklitbang dep Saraf Kasi Diklitbang dep Saraf
RSPAD Gatot SoebrotoRSPAD Gatot Soebroto• Kasub Instal Gadar Medik Kasub Instal Gadar Medik
IGD RSPAD Gatot SoebrotoIGD RSPAD Gatot Soebroto
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STROKESTROKE
Sholihul MSholihul M
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STROKE = Brain STROKE = Brain AttackAttack
• Kematian ………Kematian ……… no 3no 3
• Kecacatan ………Kecacatan ……… no 1no 1
(Stroke is the champion)
Stroke adalah suatu Stroke adalah suatu gangguangangguan fungsifungsional otak onal otak yang terjadi secara yang terjadi secara mendadakmendadak dengan tanda dengan tanda
dan gejala klinis baik fokal maupun global yang dan gejala klinis baik fokal maupun global yang berlangsung lebih dari 24 jam, atau dapat berlangsung lebih dari 24 jam, atau dapat menimbulkan kematian, disebabkan oleh menimbulkan kematian, disebabkan oleh
gangguan peredaran darah otakgangguan peredaran darah otak
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FoamCells
FattyStreak
IntermediateLesion Atheroma
FibrousPlaque
ComplicatedLesion/Rupture
Endothelial dysfunction
Smooth muscleand collagen
From first decade From third decade From fourth decade
Growth mainly by lipid accumulation Thrombosis,Thrombosis,haematomahaematoma
Adapted from Stary HC et al. Circulation 1995;92:1355-1374.
Atherosclerosis TimelineAtherosclerosis Timeline
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Coronary remodeling hypothesis: compensatory expansion maintains the lumen diameter despite increasing plaque size.
(Glagov et al, 1987)
Progression
Compensatory expansionmaintains constant lumen
Expansion overcome:lumen narrows
Normalvessel
MinimalCAD
ModerateCAD
SevereCAD
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Atherosclerosis: Atherosclerosis: Penyakit Yang ProgresifPenyakit Yang Progresif
CRP=C-reactive protein; LDL-C=low-density lipoprotein cholesterol.
Libby P. Circulation. 2001;104:365-372; Ross R. N Engl J Med. 1999;340:115-126.
•Monocyte •LDL-C
•Adhesion molecule
•Macrophage
•Foam cell
•OxidizedLDL-C
•Plaque rupture
•Smooth muscle cells
•CRP
•Plaque instability
•and thrombus•Oxidation•Inflammation
•Endothelial dysfunction
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Vaskularisasi Serebral
Dari BawahDari Bawah Potongan MendatarPotongan Mendatar
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KlasifikasiKlasifikasi
NINDS, 1990 :
1. PERDARAHAN SEREBRAL
2. PERDARAHAN SUBARAHNOID
3. PERDARAHAN INTRAKRANIAL
OLEH KARENA AVM
4. INFARK SEREBRI
•STROKE•HEMORAGIK
• STROKE NON HEMORAGIK• T I A• R I N D• S I E• COMPLETED STROKE
• Definisi• Chandra B
• Definisi• W H O
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•Apa yang terjadi pada strokeApa yang terjadi pada stroke
•O T A KO T A K
•PERLU MAKANAN YANG CUKUPPERLU MAKANAN YANG CUKUP
•DAN TERATURDAN TERATUR
•TIAP MENIT : 800 CC OKSIGENTIAP MENIT : 800 CC OKSIGEN
•100 MGR GLUKOSA100 MGR GLUKOSA
•TERHENTI
•30 DETIK•TERHENTI
•3 MENIT•TERHENTI
•8 MENIT
•SEL
•TERGANGGU
•KECACATAN
•MENINGGAL
•SEL MATI
•BERAT :BERAT :
•1.200 - 1.400 GRAM1.200 - 1.400 GRAM
•(2 % BB)(2 % BB)
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The molecular events initiated in brain tissue
•by acute cerebral ischemia
•(Brott & Bogousslavsky 2000)
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•DiagnosisDiagnosis
1.1. Gold Standard : CT-Scan kepala tanpa zat Gold Standard : CT-Scan kepala tanpa zat kontraskontras
• - Stroke Hemoragik - Stroke Hemoragik : Lesi hiperdens: Lesi hiperdens• - Stroke Non Hemoragik- Stroke Non Hemoragik : Lesi : Lesi
hipodenshipodens
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Ischemic Ischemic StrokeStrokeSTROKE PENYUMBATANSTROKE PENYUMBATAN
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Intracerebral Intracerebral HemorHemorrhrhagageeSTROKE PERDARAHANSTROKE PERDARAHAN
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SubSubaarachnoidrachnoid Hemorrhage HemorrhageSTROKE DISELA LIPATAN OTAKSTROKE DISELA LIPATAN OTAK
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•DiagnosisDiagnosis
• 2. Bila CT-Scan tidak ada : 2. Bila CT-Scan tidak ada :
• - Anamnesis- Anamnesis
• - Pemeriksaan neurologis- Pemeriksaan neurologis
• - Algoritma dan atau skor stroke- Algoritma dan atau skor stroke
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Perbedaan Stroke Hemoragik dan Perbedaan Stroke Hemoragik dan Stroke Infark berdasarkan anamnesisStroke Infark berdasarkan anamnesis
Gejala/SimtomGejala/Simtom StrokeStroke Stroke nonStroke non
hemoragikhemoragik hemoragikhemoragik
Saat onsetSaat onset Sedang aktifSedang aktif IstirahatIstirahat
Peringatan (Peringatan (warningwarning) ) -- ++
Nyeri kepalaNyeri kepala +++ +++ ++
KejangKejang + + --
Muntah Muntah + + --
Penurunan kesadaran Penurunan kesadaran ++++++ ++
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Tanda (sign) Tanda (sign) Stroke HemoragikStroke Hemoragik Stroke Non Stroke Non
Hemoragik Hemoragik
BradikardiBradikardi ++ (dari awal)++ (dari awal) ± (hari ke-4)± (hari ke-4)
Udem papilUdem papil Sering +Sering + --
Kaku kudukKaku kuduk + + --
Tanda Kernig,Brudzinski Tanda Kernig,Brudzinski ++++ --
•Perbedaan Stroke Hemoragik dan Stroke Perbedaan Stroke Hemoragik dan Stroke Infark berdasarkan tanda-tandanyaInfark berdasarkan tanda-tandanya
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PemeriksaanPemeriksaan Stroke HemoragikStroke Hemoragik Stroke NonStroke Non
HemoragikHemoragik
a.a. FunduskopiFunduskopi Perdarahan retina danPerdarahan retina dan Crossing phenomenCrossing phenomen
korpus vitreumkorpus vitreum Silver wire arteriesSilver wire arteries
b. Pungsi lumbalb. Pungsi lumbal
- tekanan- tekanan MeningkatMeningkat NormalNormal
- warna- warna MerahMerah JernihJernih
c. Arteriografic. Arteriografi Ada Ada shiftshift OklusiOklusi
d. CT-Scand. CT-Scan Lesi hiperdensLesi hiperdens Lesi hipodensLesi hipodens
•Perbedaan jenis stroke dengan alat bantuPerbedaan jenis stroke dengan alat bantu
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PENDERITA STROKE AKUT• Dengan atau tanpaDengan atau tanpa
PENURUNAN KESADARAN NYERI KEPALA REFLEKS BABINSKI
Ketiganya atau 2 dari ketiganya ada (+)
Stroke perdarahan intraserebral
Penurunan kesadaran (+)Nyeri kepala (-)Refleks Babinski (-)
Penurunan kesadaran (-)Nyeri kepala (+)Refleks Babinski (-)
Penurunan kesadaran (-)Nyeri kepala (-)Refleks Babinski (+)
Penurunan kesadaran (-)Nyeri kepala (-)Refleks Babinski (-)
Stroke perdarahan intraserebral
Stroke iskemik akut atau stroke infark
•ALGORITMA STROKE GADJAH MADAALGORITMA STROKE GADJAH MADA
TidakTidak
TidakTidak
TidakTidak
TidakTidak
Stroke perdarahan intraserebral
Stroke iskemik akut atau stroke infark
YaYa
YaYa
YaYa
YaYa
YaYa
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DJOENAEDI STROKE SCORE
1. TIA sebelum serangan 1 2. Permulaan serangan -Sangat mendadak (1-2 menit) 6,5 -Mendadak (menit-1jam) 6,5 -Pelan-pelan (beberapa jam) 1 3. Waktu serangan -Bekerja (aktivitas) 6,5 -Istirahat/duduk/tidur 1 -Bangun tidur 1 4. Sakit kepala waktu -Sangat hebat 10
serangan -Hebat 7,5 -Ringan 1 -Tidak ada 0 5. Muntah -Langsung sehabis serangan 10 -Mendadak (beberapa menit-jam) 7,5 -Pelan-pelan (1 hari / >) 1 -Tidak ada 0 6. Kesadaran -Menurun langsung waktu serangan 10 -Menurun mendadak (menit-jam) 10 -Menurun pelan-pelan (1 hari / >) 1 -Menurun sementara lalu sadar lagi 1 -Tidak ada gangguan 1 7. Tekanan darah sistolik -Waktu serangan sangat tinggi (>200/110) 7,5 -Waktu MRS sangat tinggi (>200/110) 7,5 -Waktu serangan tinggi (>140/100) 1 -Waktu MRS tinggi (>140/100) 1 8. Tanda rangsangan -Kaku kuduk hebat 10 selaput otak -Kaku kuduk ringan 5 -Tidak ada kaku kuduk 0 9. Pupil -Isokor 5 -Anisokor 10 -Pinpoint kanan/kiri 10 -Midriasis kanan/kiri 10 -Kecil dan reaksi lambat 10 -Kecil dan reaktif 10 10. Fundus okuli -Perdarahan subhialoid 10 -Perdarahan retina (flame shaped) 7,5 -Mormal 0 TOTAL SCORE 20 STROKE HEMORAGIK < 20 STROKE NON HEMORAGIK
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NoNo Gejala/TandaGejala/Tanda PenilaianPenilaian IndeksIndeks SkorSkor
11 KesadaranKesadaran (0) Kompos mentis(0) Kompos mentis
(1) Mengantuk(1) Mengantuk
(2) Semi koma/koma(2) Semi koma/koma
X 2,5X 2,5 ++
22 MuntahMuntah (0) Tidak(0) Tidak
(1) Ya(1) Ya
X 2X 2 ++
33 Nyeri kepalaNyeri kepala (0) Tidak(0) Tidak
(1) Ya(1) Ya
X 2X 2 ++
44 Tekanan darahTekanan darah DiastolikDiastolik X 10%X 10% ++
55 AteromaAteroma
a. D Ma. D M
b. Angina pektorisb. Angina pektoris
c. Klaudikasio intermitenc. Klaudikasio intermiten
(0) Tidak(0) Tidak
(1) Ya(1) Ya
X (-3)X (-3) --
66 KonstanteKonstante - 12- 12 - 12- 12
H A S I L S S SH A S I L S S S
SIRIRAJ STROKE SCORE (SSS)SIRIRAJ STROKE SCORE (SSS)
•Catatan :1. SSS > 1 = Stroke hemoragik• 2. SSS < -1 = Stroke non hemoragik
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PengelolaanPengelolaan
Tujuan : Memperbaiki aliran darah ke otak secepat Tujuan : Memperbaiki aliran darah ke otak secepat mungkin dan melindungi neuron dengan memotong mungkin dan melindungi neuron dengan memotong kaskade iskemikkaskade iskemik1.1. Pengelolaan Umum (5B)Pengelolaan Umum (5B)2.2. Berdasarkan penyebabnyaBerdasarkan penyebabnya
a.a. Stroke IskemikStroke Iskemik* Reperfusi* Reperfusi* Anti koagulansia* Anti koagulansia* Proteksi neuronal* Proteksi neuronal
b.b. Stroke hemoragikStroke hemoragik* Konservatif* Konservatif* Operatif* Operatif
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Pengelolaan umum : 5BPengelolaan umum : 5B
1. Breathing1. Breathing• • Jalan nafas harus bebas, ventilasi Jalan nafas harus bebas, ventilasi
dan oksigenasi harus tetap baik.dan oksigenasi harus tetap baik.
• • Intubasi bila GCS < 8Intubasi bila GCS < 8
• • Alih baring miring kiri-kanan tiap Alih baring miring kiri-kanan tiap
2 jam2 jam
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Pengelolaan umum : 5BPengelolaan umum : 5B
2. Blood2. Blood• • Tekanan darah tidak boleh segera Tekanan darah tidak boleh segera diturunkan, kecuali:diturunkan, kecuali:
* Iskemik :* Iskemik : > 220 / 120> 220 / 120* Hemoragik :* Hemoragik : >180 / 100>180 / 100* Obat :Diltiazem, Nitroprusid, * Obat :Diltiazem, Nitroprusid, Nitrogliserin, Labetolol & Nitrogliserin, Labetolol &
kaptopril kaptopril • • Jaga komposisi darah yang baik. Jaga komposisi darah yang baik.
Perhatikan Hb, Albumin, Kalium, Natrium Perhatikan Hb, Albumin, Kalium, Natrium & Gula darah& Gula darah
• • Gula darah diturunkan bila > 200 mg/dLGula darah diturunkan bila > 200 mg/dL
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Pengelolaan umum : 5BPengelolaan umum : 5B3. Brain3. Brain
•• Jaga supaya tidak timbul kejangJaga supaya tidak timbul kejang•• TIK meningkat TIK meningkat manitol manitol•• Cegah hipertermi, kalau mungkin sedikit Cegah hipertermi, kalau mungkin sedikit
hipotermihipotermi4. Bladder4. Bladder
• • Perhatikan baik-baik kemungkinan Perhatikan baik-baik kemungkinan adanya retensio maupun inkontinensia urineadanya retensio maupun inkontinensia urine
• • Bila perlu pasang kateterBila perlu pasang kateter5. Bowel5. Bowel
•• Jaga jumlah kalori dan berikan cairan yangJaga jumlah kalori dan berikan cairan yangcukupcukup
• • Hindari obstipasiHindari obstipasi
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ReperfusiReperfusi
TrombolisisTrombolisis• FDA 1996 FDA 1996 r-TPA r-TPA
• Dosis 0,9 mg/kgBB, max 90 mgDosis 0,9 mg/kgBB, max 90 mg
• < 3 jam, sarana, tenaga & persyaratan < 3 jam, sarana, tenaga & persyaratan ketat ketat
HemoreologikHemoreologik• PentoxifillinPentoxifillin
• Naftidrofuril Naftidrofuril
•PENGOBATAN STROKE ISKEMIK
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Before tPA After tPA
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Anti KoagulansiaAnti Koagulansia
Anti KoagulansiaAnti Koagulansia• Obat : Heparin, LMWHObat : Heparin, LMWH• Diberikan pada pasien dengan risiko Diberikan pada pasien dengan risiko
emboli dari jantung : emboli dari jantung : fibrilasi atrium non fibrilasi atrium non valvular, thrombus mural dalam valvular, thrombus mural dalam ventrikel kiri, infark miokard baru & ventrikel kiri, infark miokard baru & katup jantung buatankatup jantung buatan
• Prevensi : Prevensi : paresis berat yang berbaring paresis berat yang berbaring lama berisiko terjadi trombosis vena lama berisiko terjadi trombosis vena dalam dan emboli parudalam dan emboli paru
•PENGOBATAN STROKE ISKEMIK
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Obat - Obat Antiplatelet Obat - Obat Antiplatelet • Thromboxane AThromboxane A2 2 inhibitorinhibitor
– Acetylsalicylic acid (ASA)Acetylsalicylic acid (ASA)• Phosphodiesterase inhibitorPhosphodiesterase inhibitor
– DipyridamoleDipyridamole• Glycoprotein (GP) IIb/IIIa blockers Glycoprotein (GP) IIb/IIIa blockers
– Parenteral : abciximab, eptifibatide, tirofibanParenteral : abciximab, eptifibatide, tirofiban• ADP-receptor antagonistsADP-receptor antagonists
– ClopidogrelClopidogrel– TiclopidineTiclopidine
•PENGOBATAN STROKE ISKEMIK
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•COX (cyclo-oxygenase)
•ADP (adenosine diphosphate)
•TXA2 (thromboxane A2)
•CLOPIDOGREL
•TICLOPIDINE
•ASA •COX
•ADP
•ADP
•C
•GPllb/llla•(Fibrinogen receptor)
•Collagen thrombin•TXA •2
•Activation
•TXA•2
Cara Kerja AntiplateletCara Kerja Antiplatelet
•1. Schafer AI. Am J Med 1996; 101: 199–209.
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NeuroprotektorNeuroprotektor
CDP-CholinCDP-Cholin• menambah sintesa menambah sintesa
phospatidylcholine,dan mengurangi phospatidylcholine,dan mengurangi kadar asam lemak bebas (free fatty kadar asam lemak bebas (free fatty acid) menghambat terbentuknya radikal acid) menghambat terbentuknya radikal bebas dan juga menaikkan sintesis bebas dan juga menaikkan sintesis asetilkolin yang merupakan asetilkolin yang merupakan neurotransmiter untuk fungsi kognitifneurotransmiter untuk fungsi kognitif
• Terapeutic windows 24 - 48 jamTerapeutic windows 24 - 48 jam• dosis 500 - 2000 mg selama 14 haridosis 500 - 2000 mg selama 14 hari
•PENGOBATAN STROKE ISKEMIK
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NeuroprotektorNeuroprotektor
PiracetamPiracetam• Memperbaiki integritas sel, memperbaiki fluiditas Memperbaiki integritas sel, memperbaiki fluiditas
membran dan menormalkan fungsi membran. membran dan menormalkan fungsi membran. • Terapeutic windows Terapeutic windows 7 – 12 jam7 – 12 jam• Dosis bolus 12 gr IV dilanjutkan 4 x 3 gr iv Dosis bolus 12 gr IV dilanjutkan 4 x 3 gr iv
Statin Statin • Mempunyai efek anti oksidan “Mempunyai efek anti oksidan “downstream downstream dandan
upstreamupstream”.”.
CerebrolisinCerebrolisin• Anti calpain, penghambat caspase dan sebagai Anti calpain, penghambat caspase dan sebagai
neurotropik dosis 30 – 50 cc selama 21 harineurotropik dosis 30 – 50 cc selama 21 hari
•PENGOBATAN STROKE ISKEMIK
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STROKE HEMORAGIKSTROKE HEMORAGIK
Terapi Terapi I. Terapi Umum I. Terapi Umum Perhatikan 5 B Perhatikan 5 B
II. Terapi KhususII. Terapi Khusus
1. Kausal1. Kausal
2. Medisinal : - Antifibrinolitik 2. Medisinal : - Antifibrinolitik (Asam Traneksamat) (Asam Traneksamat)
- Neuroprotektor- Neuroprotektor
3. Tindakan Operatif3. Tindakan Operatif
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STROKE HEMORAGIKSTROKE HEMORAGIK
Tindakan Operatif, tergantung pada:Tindakan Operatif, tergantung pada:
1. Tingkat kesadaran1. Tingkat kesadaran
2. Tempat lesi2. Tempat lesi
3. Penampang hematom3. Penampang hematom
4. Volume darah4. Volume darah
5. Waktu yang tepat untuk operasi5. Waktu yang tepat untuk operasi
6. Petunjuk prognosis operasi6. Petunjuk prognosis operasi
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STROKE HEMORAGIKSTROKE HEMORAGIKKontra indikasi operasiKontra indikasi operasi
1. Kegagalan kardio-respiratorius1. Kegagalan kardio-respiratorius2. Koma dalam 2. Koma dalam 3. Tanda penekanan batang otak hebat3. Tanda penekanan batang otak hebat4. Kesadaran umum jelek4. Kesadaran umum jelek5. Usia lanjut5. Usia lanjut6. Penyakit lain:6. Penyakit lain:
- Gula darah tinggi sekali- Gula darah tinggi sekali- Hipertermia- Hipertermia- Tekanan darah tinggi sekali- Tekanan darah tinggi sekali
7. Letak hematom : dalam dan sukar7. Letak hematom : dalam dan sukar
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Left image arrow -Angio with Large aneurysmRight image arrow – Angio showing aneurysm post clipping
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Guglielmi Coil system (GDC) embolization: immediate result
•Angio showing large ICA aneurysm •Same aneurysm - Post GDC Coiling
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Pencegahan StrokePencegahan Stroke
PrimerPrimer
(Sebelum Stroke)(Sebelum Stroke) Gaya hidup sehat Modifikasi faktor
risiko
SekunderSekunder
(Sesudah Stroke) Gaya hidup sehat Mengendalikan
faktor risiko Anti platelet / anti
koagulan Terapi bedah
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I. Gaya hidup sehat
1. Pola makan sehat
2. Stop rokok, alkohol & narkoba
3. Olah raga teratur
4. Menghindari kecemasan
Guideline Stroke PERDOSSI 2001
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II. Faktor RisikoII. Faktor Risiko
MayorMayor• Hipertensi • Penyakit jantung• DM • Riwayat stroke
MinorMinor• Dislipidemia • Fibrinogen • Stress• Hiperuricemia • Obesitas
Stroke kriptogenikStroke kriptogenik• Protein S • Anti trombin III • Homosistein• Protein C • Antifosfolipid antibodi
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Risiko relatif StrokeRisiko relatif Stroke
Faktor RisikoFaktor Risiko Risiko Risiko
RelatifRelatif
Hipertensi ……………………… 6 X
Diabetes Melitus ………………. 2 – 4 X
Pernah menderita Stroke …….. 10 X
Fibrilasi Atrium ………………… 3 X
Merokok ………………………... 2 X
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Pengendalian faktor Pengendalian faktor risikorisiko
1. Hipertensi : • Upayakan S<140 mmHg, D<90 mmHg• Kurangi garam & obesitas, olah raga, hidup rilek
2. Diabetes mellitus : • Kendalikan kadar gula darah dengan
diet, obat diabet, olah raga3. Fibrilasi atrium :
• Rekomendasi : ASA atau antikoagulan4. Dislipidemia :
• Modifikasi diet dan obat ( Statin )
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Terima kasihTerima kasihTerima kasihTerima kasihTerima kasihTerima kasih
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Tekanan Darah TinggiTekanan Darah Tinggi(Sistolik > 140, Diastolik >90)(Sistolik > 140, Diastolik >90)
KeturunanKeturunan Obat-obatanObat-obatan
• Pil anti Pil anti HamilHamil
• Obat FluObat Flu
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Tekanan Darah TinggiTekanan Darah Tinggi
KegemukanKegemukan Garam >Garam >
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Tekanan Darah TinggiTekanan Darah Tinggi
StressStress
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Bagaimana kontrol
Tekanan Darah Tinggi
Kurangi garam
Berat badan seimbang
Kurangi makanan berlemak
Olah raga
Hidup rileks
Stop merokok, kopi
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The JNC SEVENTH REPORTThe JNC SEVENTH REPORT
(JAMA 2003)
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A or BInhibit the
Renin-AngiotensinSystem
C or DDo not inhibit the
Renin-AngiotensinSystem
More EffectiveIn Younger
More EffectiveIn Older
Adapted from : ‘Better blood pressure control: how to combine drugs’Journal of Human Hypertension (2003) 17, 81-86 www.bhsoc.org
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(ABCD)
A = ACE-Inhibitor atau Angiotensin Receptor Blocker
B = - Blocker
C = Calcium Channel Blocker
D = Diuretic (thiazide)
Obat – obat anti hipertensiObat – obat anti hipertensi
(Golongan Pril) (Golongan Sartan)
(Golongan Lol)
(Golongan Pin)
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PenyakitPenyakit Kencing ManisKencing ManisGejala 3 BGejala 3 B
Banyak minumBanyak minumBanyak makanBanyak makanBanyak kencingBanyak kencing(Gula darah puasa > 110 mg%(Gula darah puasa > 110 mg%
2 jam PP > 200 mg%)2 jam PP > 200 mg%)
PengobatanPengobatanDietDietOlah ragaOlah ragaMinum obat teraturMinum obat teratur
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Nasehat DM
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Obat oral hipoglikemi
33300 mg300 mg50 mg50 mg
inhibitor inhibitor glukosidaseglukosidaseAcarboseAcarbose
1 – 31 – 32500 mg2500 mg500 mg500 mgBiguanidBiguanidMetforminMetformin
1 – 21 – 21 – 2 1 – 2 2 – 32 – 31 – 21 – 2sekalisekalisekali sekali sekalisekali
15 – 20 mg15 – 20 mg240 240 mgmg120 120 mgmg20 20 mgmg20 20 mgmg6 6 mgmg500 500 mgmg
2,5 2,5 mgmg80 80 mgmg30 30 mgmg5 5 mgmg5 5 mgmg1 1 mgmg50 50 mgmg
SulfonilureaSulfonilureaGlibenkamidGlibenkamidGlikasidGlikasidGlikuidonGlikuidonGlipisidGlipisidGlipisid GITSGlipisid GITSGlimepiridGlimepiridKlorpropamidKlorpropamid
Frekuensi / hariFrekuensi / hariDosis maxDosis maxDosis awalDosis awalObatObat
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Obat DislipidemiaObat Dislipidemia
• ResinResin
• Asam NikotinatAsam Nikotinat
• Asam FibratAsam Fibrat
• ProbucolProbucol
• StatinStatin
• EzetimideEzetimide
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III. Mencegah penggumpalan III. Mencegah penggumpalan darah (Anti platelet)darah (Anti platelet)
1. Aspirin
2. Dipiridamol + ASA
3. Ticlopidin
4. Clopidogrel
5. Cilostasol
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IV. Anti pembekuan IV. Anti pembekuan (Antikoagulan)(Antikoagulan)
• Antikoagulan diberikan pada penderita dengan
penyakit jantung (fibrilasi atrium, kelainan katup, dll)
• Obat yang dipakai :
- Warfarin (Simarc-2), Dikumarol
- Melagatran
• Monitoring dengan INR (2,0 - 3,0)
• Parenteral : Heparin, LMWH
Trombolitik : r-tPA
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V. Tindakan invasifV. Tindakan invasif
• Plebotomi pada pasien polisitemia
• Endarterektomi karotis : untuk
pasien yang mengalami stenosis
karotis simptomatik berat lebih dari
70%
• Stenting dan angioplasti karotis• Guideline Stroke PERDOSSI 2001• European Stroke Initiative 2001
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Pencegahan lebih penting Pencegahan lebih penting dari pengobatandari pengobatan
(Prevention is much-much better than cure)(Prevention is much-much better than cure)
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Petunjuk PraktisPetunjuk Praktis untuk pasienuntuk pasien
Gaya Hidup SehatGaya Hidup Sehat
I.I. 3 K 3 K
(kecemasan, kelelahan, kemalaman)(kecemasan, kelelahan, kemalaman)
II.II. 3 O 3 O
(olah raga, olah seni, olah batin)(olah raga, olah seni, olah batin)
III.III. Sabu sabu Sabu sabu
(sayur buah, sayur buah)(sayur buah, sayur buah)
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Factor Risiko Factor Risiko 11
Non modifiableNon modifiable UsiaUsia Ras (suku)Ras (suku) SexSex Riwayat keluarga stroke.Riwayat keluarga stroke.
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Faktor Risiko Faktor Risiko 22
Bisa diubahBisa diubah HypertensionHypertension atrial fibrillation atrial fibrillation Diabetes mellitusDiabetes mellitus hyperhomocysteinemia hyperhomocysteinemia Hyperlipidemia Hyperlipidemia hypercoagulability hypercoagulability Cigarette smokingCigarette smoking oral contraceptive oral contraceptive Infection: chlamydia, helicobacter, viruses.Infection: chlamydia, helicobacter, viruses. Prior stroke/TIA Prior stroke/TIA carotid stenosis carotid stenosis Physical inactivity, obesity, sleep apnea/ Physical inactivity, obesity, sleep apnea/
snoring.snoring. Alcohol abuse. Alcohol abuse. (Stroke, February 2001) (Stroke, February 2001)
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Golongan StatinGolongan Statin
DosisDosis
FluvastatinFluvastatin 20 – 80 mg20 – 80 mg
LovastatinLovastatin 20 – 80 mg20 – 80 mg
PravastatinPravastatin 10 – 40 mg10 – 40 mg
SimvastatinSimvastatin 20 – 40 mg20 – 40 mg
AtorvastatinAtorvastatin 10 – 40 mg10 – 40 mg
RosuvastatinRosuvastatin 10 – 20 mg10 – 20 mg
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Efek Pleiotropik StatinEfek Pleiotropik Statin
• Memperbaiki disfungsi endotel
• Stabilisasi “atherosclerotic
plaque”
• Mengurangi stress oksidatif
• Mengurangi inflamasi vaskuler
• Efek anti trombosis
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Terjadi Aggregasi platelets dan terjadi
thrombus
Platelets
Endothelial cells
Platelets adhering to subendothelial space
Platelet thrombus
Normal platelets Dalam Aliran Darah
Platelets Menempel pada endothelium yang rusak
Agregrasi PlateletAgregrasi Platelet
Subendothelial space
Adapted from: Ferguson JJ. The Physiology of Normal Platelet Function. In: Ferguson JJ, Chronos N, Harrington RA (Eds). Antiplatelet Therapy in Clinical Practice. London: MartinDunitz; 2000: pp.15–35.