WI MINX PENAMBAI-(AN TICLOPIDINE PA'DA PENGELOLAAN INFARK MIOKARD AKUr (PANDANGAN TER7-64DAP RISIKO FERDARA1-64N)

Abstract

Background : The early administration of thrombolytic agents for salvaging the myocardiurn during acute myocardium infarction (AMI) is still the first choice in management of AMI patients. Ticlopidine as an inhibitor of platelet aggregation has proved benefecial effect on unstable angina and stroke patients and also showed an effect as 'anticoagulant' during implantation stent on coronary diseases. Using combination ticlopidine, aspirin and heparin for treatment AMI had been reported with the result for the AMI patient with ticlopidine gave the better regression ST segment, but is this combination safe especially for the risk of bleeding ? Methods : This trial was a double blind randomized clinical trial designed to assess the risk of bleeding by measuring PTTK value and trombocyt count between non ticlopidine group (heparin 5000 u bolus continue with 1000 nth + aspirin 160 mg once daily + placebo once daily) and ticlopidine group (heparin 5000 u bolus continue with 1000 u/h + aspirin 160 mg once daily + ticlopidine 250 mg once daily) on Q wave AMI patients who cannot be treated with thrombolytic agents, during August 1997 — December 1998 in IC:CU Kariadi Hospital Semarang. PTTK value was measured each 12 hours after the treatment begin and trombocyte count before and 5 days after treatment . Results : During this trial period there were 98 AMI patients in ICCU Kariadi hospital Semarang, with 40 patients were enrolled in this trial and the other 58 patients were excluded because 13 of them were non Q wave AMT. 3 were treated with thrombolytic agents. 14 were without chest pain , 24 were having chest pain > 24 h and 2 reamed to enroll this trial. Patients on ticlopidine group showed PTTK value longer on . 12 hours observation than non ticlopidine group although this different was statistically insignificant. The different PTTK value between ticlopidine and non ticlopidine group on age dan sex group also showed that on 12 hours observation, PTTK value on ticlopidine group was longer than non ticlopidine group. On patient whom have the PTTK value before treatment between ticlopidine and non ticlopidine also showed that ticlopidine group the 12 hours PITK value longer than the non ticlopidine group. Age and sex not influence this result. PTTK value after the first 12 hours till the end of observation showed that the non ticlopidine group longer than the ticlopidine group. After 5 days treatment trombocyte count decreased between the two group althought statistically insignificant, on the non ticlopidine group give the lower trombocyte count than non ticlopidine group Conclisions PTTK value on combination aspirin, heparin and ticlopidine showed not different compared to combination aspirin and heparin on observation except on the first 12 hours. This trial cannot answer the different PTTK value on the first 12 hours. Trombocyte count between ticlopidine group and non ticlopidine group also statiscally not different. This combination seem not increasing the risk of bleeding during 5 days observation except for the first 12 hours. • Kcy word : Ticlopidine. Myocard Infarction, Risk of bleeding Pemberian dial obat trotnbolitik tuttuk metryelamatkan miokardium dart serangan infark miokard akut (IMA) masill menjadi pilihan utama dalam pengelolaan penderita CMA. Ticlopidine sebagai obat anti agregasi trombosit telah terbukti manfaatnya dan efikasinya tuituk pasien dengan angina pcktoris tak stabil dan stroke. Ualam pemasangan stent pada penderita koroner ticlopidinc juga terbukti mempunyai efek yang setara dengan antikoagulan. Kombinasi ticlopidine,aspirin dan heparin telah diujicobakan pada penderita IMA dengan hasil regcsi scgmen ST lebih haik pada kelompok ticlopidinc, tapi sejauh mana keamanan kombinasi ini terhadap risiko perdarahan mengingat kombinasi aspirin dan heparin saja stulah meningkatkan risiko perdarahan menjadi 1 ?6? Penclitian ini mcrupakan suatu uji klinik dengan buta Banda yang didesain untuk mcngetahui risiko perdarahan ditinjau dart parameter pemanjangan PTTK dan trombosit pada kelompok tanpa ticlopidine( heparin bolus 5000 u unit diikuti dengan 100011 /jam aspirin 1 x160 mg+ plasebo lx1 tablet) dan kelompok ticlopidinc (heparin bolus 5000 n diikuti dengan 10(0u/jam + aspirin 1 x160 rug +ticlopidine 13(250111g) pada penderita IMA gelontbang Q yang tidak mendapat terapi trombolitik selama bulan Agustus 1997 - Desember 1998 di ICCU RSVP dr Kariadi Semarang. PTTK dinilai tiap 12 jam sesudah pemberian obat sampai heparinsasi selesai sedangkan trombosit dinilai dart scbelum terapi dan akhir tempi Selama periode penelitian ada 98 pasien LMA yang dirawat di IC:Cu RSUPdr Kariadi. 40 pasicn ikut dalam penelitian ini sedangkan 58 pasicn lairuiya dikchiarkan dart penelitian karena IMA non Q (13), mendapat trombolitik (3), tanpa 'chest pain'(14), lama 'chest pain' 24 jam (26) dan tidak bersedia ikut dalam penelitian (2). Pendctita IMA yang mendapat ticlopidine menunjukkan PTTK yang lebih panjang pada 12 jam pertania dengan pemberian dosis heparin yang sama dibandingkan dengan kelompok non ticlopidine walaupun perbedaan ini secara statistik belum bermakna. Basil yang sama juga terlihat bila dianalisa dengan melihat ada tidaknya pengaruh umur dan jenis kelamin terhadap pernanjangan PTTK. dan bila dibandingkan dengan data awal PTTK sebelurn terapi dan 12 jam sesudah terapi sedangkan pada jam-jam pengamatan selanjutnya PTTK kelompok non ticlopidine justly' menunjukkan basil yang lebih panjang dibandingkan dengan kelompok ticlopidine meskipun ini secara statistik juga tidak bermakna. Faktor umur dan jenis kelatnin tidak berperanan terhadap perbedaan PTTK pada 12 jam pertama. Jundah trombosit menurun pada akhir pengamatan meskipun pada kelompok non ticlopidine penurunan lebih besar akin tetapi secara statistik hal ini tidak bermakna. Perbedaan nilai PTTK pada 12 jam pertama ini belum dapat terjawab dalam penelitian ini. dan kombinasi aspirin , heparin dan ticlopidine tidak meningkatkan risiko perdarahan dibanding dengan pemberian aspirin dun heparin selama 5 hart pengamatan dart sudut pemanjangan PTTK dan jumlah trombosit kecuali pada 12 jam pettama Kata kunci : Ticlopidine, Infark Miokard, Risiko Perdarahan