Keterangan
Beban finansial dari kejadian trombotik pada penyakit kardiovaskular sangat besar. Obat antikoagulan disarankan untuk pengobatan dan pencegahan sekunder sindrom koroner akut serta pencegahan kejadian trombotik pada berbagai gangguan kardiovaskular, seperti stroke pada fibrilasi atrium. Antikoagulan parenteral saat ini terdiri dari fondaparinux, heparin berat molekul rendah (LMWH), dan heparin tak terfraksi. Ketika dirawat di rumah sakit, pasien dengan sindrom koroner akut biasanya diberikan heparin tak terfraksi atau heparin berat molekul rendah (LMWH). Kedua pengobatan tersebut sama efektifnya dalam menurunkan risiko kematian dan infark miokard, meskipun LMWH mungkin lebih aman dan tidak perlu dipantau untuk pembekuan darah. Penggunaan fondaparinux mengurangi mortalitas dari sindrom koroner akut secara signifikan jika dibandingkan dengan LMWH atau heparin tak terfraksi. Namun, penggunaan obat parenteral rawat jalan jangka panjang tidak nyaman. Satu-satunya antikoagulan oral yang tersedia saat ini adalah antagonis vitamin K. Masih terdapat kebutuhan besar yang belum terpenuhi untuk antikoagulan oral baru yang praktis dan dapat ditoleransi dengan baik yang tidak memerlukan pemantauan rutin.
Ringkasan
- Dr. Abishek discusses anticoagulants in the context of cardiovascular disease (CVD), defining CVD as diseases involving the heart and major vessels. Common examples include atherosclerotic coronary artery disease, pulmonary thromboembolism, aortic dissection, aortic aneurysm, peripheral vascular disease, and stroke. He emphasizes the importance of understanding fluid dynamics and clinical aspects for effective treatment.
- The talk delves into the history of understanding thrombosis, highlighting contributions from Hippocrates, William Harvey, and Virchow. Key concepts include the Virchow triad (stasis, hypercoagulability, endothelial injury) and the role of endothelium in thrombosis. Antithrombotic drugs are classified as antiplatelet, anticoagulant, and fibrinolytic agents, each targeting different stages of thrombus formation.
- Arterial thrombosis is primarily driven by platelet activation, requiring antiplatelet drugs, whereas venous thrombosis is associated with stasis and coagulation, necessitating anticoagulants. Atrial fibrillation, due to ineffective atrial contraction leading to blood stasis, also requires anticoagulants. Acute fibrin generation, as in acute ST-elevation myocardial infarction, calls for fibrinolytic agents.
- The discovery and mechanisms of action of heparin are discussed. Heparin acts by enhancing antithrombin activity, inhibiting factor 2a (thrombin) and factor 10a. However, its variable binding to plasma proteins affects predictability of action, requiring monitoring via aPTT. Heparin resistance, often seen in ICU patients due to inflammatory mediators, is addressed.
- Low molecular weight heparins (LMWHs) are discussed as smaller molecules primarily targeting Factor 10a. Warfarin, initially a rodenticide, inhibits vitamin K-dependent coagulation factors. Starting warfarin requires bridging with an injectable anticoagulant due to the initial prothrombotic effect caused by the early reduction in protein C and S. Specific scenarios where warfarin remains the preferred option are emphasized.
- Newer oral anticoagulants (NOACs) offer advantages like low bleeding risk and no need for routine INR monitoring. Management of anticoagulation around procedures involves balancing thrombotic and bleeding risks. Bridging strategies with heparin are often used. Specific considerations for pregnancy and anticoagulation are discussed, including the teratogenic effects of warfarin.
- Special scenarios, such as anticoagulation post-stroke, are addressed. Additionally, low platelet counts and their impact on antiplatelet therapy strategies are examined. Practical considerations such as peri-gastric bypass surgery drug absorption and drug interactions, including with PPIs, which can be used to reduce the rate of upper GI bleeds in patients taking oral anticoagulants, are discussed.
- The speaker concludes by addressing the management of patients who experience myocardial infarction while already on anticoagulation, underscoring the importance of assessing thrombotic and bleeding risks for optimal management of triple therapy. The Compass trial is highlighted for demonstrating the effectiveness of low-dose rivaroxaban with a single antiplatelet agent in high-risk patients.
Contoh Sertifikat
Tentang Pembicara
Dokter Abhishek Tiwari
Konsultan Kardiologi Intervensional, Rumah Sakit Ahalia, Coimbatore
Pengungkapan Keuangan
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