PENGARUH TICLOPIDINE TERHADAP REPERFUSI MIOKARDIUM PADA PENGOBATAN PENDERITA DENGAN DIAGNOSIS KLINIK INFARK MIOKARD AKUT

Abstract

The use of glycoprotein receptor inhibitor has not been routinely used in the treatment of acute myocard infarct (AMI) in Indonesia. Since a systematic research has not been conducted. This study was conducted to test the hypothesis whether adding ticlopidine in treatment of subject with clinical diagnosis of AMI improve the myocardial reperfusion. Methods Subjects were ICCU patients in Dr. Kariadi Hospital with AMI characterized by ST segment elevation, typical chest pain during less than 24 hours and did not receive thrombolytics. The research design was a pre test-post test double blind randomized control trial based on 20 number random permuted blocks. All object received standard treatment : heparin, aspirin and isosorbid dinitrate. Ticlopidine 250 mg/day was administered to treatment group, while placebo was administered to control group. Myocardial reperfusion was considered successful if within 2 hours after treatment; 2 of 3 criterias : the ST segment regressed > 30%, chest pain disappear and CICMB enzym doubled the baseline level are met. The association between treatment and the result of treatment was analyzed using logistic regression. Result Twenty subjects of each group were involved in the study. Factors considered as confounders were not statistically different between the groups (P > 0, 05). Within 2 hours after treatment, the myocardial reperfusion was significantly better (P=0,025) in treatment group (75%) than of control (35%). The association between treatment and the result was also statistically significant (P=0.014) RR=2,14 ; 95% CI=0.05-0.70; RRR=53.33%. Therefore the hypothesis "adding ticlopidine in patients with clinical diagnosis of AMI will improve the myocardial reperfusion" is accepted. It is very unlikely that the myocardial reperfusion which was obtained within 2 hours was due to prevention of rethrombosis process by ticlopidine. The side effects of treatment (nausea, urticaria) were minimal. Conclusion It seems that adding ticlopidine in patients with clinical diagnosis of AMI improve myocardial reperfusion. The use of ticlopidine in patients with clinical diagnosis of AMI can therefore be recommended. A further study need to be conducted to explore the synergism of ticlopidine, aspirin and heparin in the management of AMI. Penelitian terhadap kegunaan obat golongan penghambat reseptor glikoprotein platelet pada tata laksana infark miokard akut (IMA) bel urn dilakukan di Indonesia. Penelitian berikut dilakukan untuk membuktikan hipotesis: apakah penambahan ticlopidine pada pengobatan penderita dengan diagnosis klinik IMA memperbaiki reperfusi miokardium. Metodologi penelitian Subjek penelitian adalah penderita IMA ber-petanda elevasi segmen ST, nyeri dada khas infark miokard dalam waktu kurang dari 24 jam dan tidak mendapatkan obat trombolitik; yang dirawat di ICCU RSUP Dr Kariadi Semarang. Desain penelitian adalah double blind randomised control trial pre test — post test design berdasar random permuted block 20 angka. Semua penderita mendapat pengobatan dasar : heparin, aspirin dan isosorbid dinitrat. Kelompok perlakuan mendapatkan tambahan ticlopidine 250 mg perhari. Kelompok kontrol (kelola) mendapat tambahan plasebo. Usaha reperfusi miokardium dianggap berhasil apabila dalam waktu dua jam setelah pengobatan; didapatkan 2 dari 3 kriteria : regresi segmen ST > 30%, nyeri dada menghilang dan enzim CKMB naik 2 kali nilai awal. Hubungan antara perlakuan dengan kejadian reperfusi diuji secara analisis regresi logistik. Hasil Kelompok perlakuan dan kelompok kelola masing-masing terdiri dari 20 orang. Faktor-faktor yang digolongkan sebagai variabel pengaruh kelompok perlakuan dan kelompok kelola tidak berbeda secara bermakna ( p > 0,05 ). Dalam waktu dua jam setelah pengobatan, keberhasilan pengobatan kelompok perlakuan (75%) lebih tinggi secara bermakna (p = 0,025) bila dibandingkan dengan kelompok kelola (35%). Hubungan antara perlakuan dengan keberhasilan pengobatan juga bersifat bermakna ( p = 0,014 ), RR = 2,14 ; CI-95% 0,046 — 0,704, RRR = 53,33%. Dengan demikian hipotesis : penambahan ticlopidine pada pengobatan penderita dengan diagnosis klinik IMA memperbaiki reperfusi miokardium dapat diterima. Karena reperfusi miokardium tercapai dalam waktu 2 jam setelah pengobatan, hal tersebut nampaknya bukan akibat pencegahan proses retrombosis oleh ticlopidine. Efek samping akibat pengobatan pada kelompok perlakuan sedikit (mual 5%, urtikaria 5%) dan tidak membahayakan. Kesimpulan Dan hasil penelitian ini dapat disimpulkan bahwa : penambahan ticlopidine pada pengobatan penderita dengan diagnosis klinik IMA memperbaiki reperfusi miokardium, sehingga penggunaannya dapat dipertimbangkan. Diperlukan penelitian lebih lanjut untuk mengetahui sinergisme ticlopidine, aspirin dan heparin dalam tata laksana penderita IMA.