DAMPAK TROMBOSISDAMPAK TROMBOSIS

DAMPAK LOKAL:DAMPAK LOKAL:

bergantung lokasi dan derajat sumbatanbergantung lokasi dan derajat sumbatan

DAMPAK JAUH:DAMPAK JAUH:

gejala gejala akibat fenomena tromboemboligejala gejala akibat fenomena tromboemboli

DAMPAK TROMBOSIS ARTERIDAMPAK TROMBOSIS ARTERI

Arteri koroner --> Infark jantung (MCI)Arteri koroner --> Infark jantung (MCI)

Arteri serebral --> Infark otak (Stroke)Arteri serebral --> Infark otak (Stroke)

Arteri mesenterial --> Akut abdomenArteri mesenterial --> Akut abdomen

Arteri/Vena mata --> Visus terganggu/butaArteri/Vena mata --> Visus terganggu/buta

Arteri telinga --> Sudden Arteri telinga --> Sudden deafness/Tuli deafness/Tuli mendadakmendadakdlldll

TROMBOSIS VENATROMBOSIS VENA

Trombus vena Vena superficial varises venaVena dalam DVT

DVTTrombosis vena pada daerah betisTrombosis vena pada daerah lututTrombosis vena proksimal (paha)(Deep Vein

Thrombosis)

FAKTOR RISIKO terjadinya FAKTOR RISIKO terjadinya TROMBOSIS VENATROMBOSIS VENA

Usia tuaUsia tua ObesitasObesitas Imobilisasi/ParalisisImobilisasi/Paralisis Pembedahan otopedikPembedahan otopedik Trauma ekstremitas bawahTrauma ekstremitas bawah StrokeStroke Pembedahan umumPembedahan umum KankerKanker MCIMCI Insufisiensi jantungInsufisiensi jantung dlldll

TRIAD

VIRCHOW

SV

HKKE

Clinical Conditions :Clinical Conditions :ArterialArterial

Clinical Conditions :Clinical Conditions :VenousVenous

Defect of Blood Defect of Blood Protein/PlateletProtein/Platelet

AtherosclerosisAtherosclerosis

Cigarette smokingCigarette smoking

HypertensionHypertension

Diabetes MellitusDiabetes Mellitus

Low-density Low-density lipoprotein lipoprotein cholesterolcholesterol

HypertriglyceridemiaHypertriglyceridemia

Positive family Positive family historyhistory

Left ventricular Left ventricular failurefailure

Oral contraceptivesOral contraceptives

EstrogensEstrogens

Lipoprotein(a)Lipoprotein(a)

PolycythemiaPolycythemia

Hyperviscosity Hyperviscosity syndromessyndromes

Leukostasis Leukostasis syndromessyndromes

General surgeryGeneral surgery

Orthopaedic Orthopaedic surgerysurgery

ArthroscopyArthroscopy

TraumaTrauma

MalignancyMalignancy

ImmobilityImmobility

SepsisSepsis

Congestive Heart Congestive Heart FailureFailure

Nephrotic Nephrotic syndromesyndrome

ObesityObesity

Varicose veinsVaricose veins

Postphlebitic Postphlebitic syndromesyndrome

Oral Oral contraceptivescontraceptives

EstrogensEstrogens

Antiphospholipid Antiphospholipid syndromesyndrome

Activated protein C Activated protein C resistance (factor V Leiden)resistance (factor V Leiden)

Sticky platelet syndromeSticky platelet syndrome

Protein S defectsProtein S defects

Protein C defectsProtein C defects

Antithrombin defectsAntithrombin defects

Heparin cofactor II defectsHeparin cofactor II defects

Plasminogen defectsPlasminogen defects

Tissue plasminogen Tissue plasminogen activators defectsactivators defects

Plasminogen activator Plasminogen activator inhibitor defectsinhibitor defects

Factors XII defectsFactors XII defects

DysfibrinogenemiaDysfibrinogenemia

HomocystinemiaHomocystinemia

Predisposisi TrombosisPredisposisi Trombosis

Trombosis VenaTrombosis Vena: : Pembentukan bekuan di lumen venaPembentukan bekuan di lumen vena

Aliran turbulensi yang perlahan pada vena menginduksi stasis dan menyebabkan terjadinya koagulasi

1.

Polimerisasi fibrin menstabilkan bekuan

2.Bekuan terbentuk

3.

Trombosis VenaTrombosis Vena: : Patogenesis dan konsekuensi klinisPatogenesis dan konsekuensi klinis

Deep vein thrombosis

Trombus terus berkembang sepanjang vena

Pulmonary embolism

Prandoni P, et al. Haematologica 1997; 82:423–428.

Emboli

VTEVTE(Venous Thromboembolism)(Venous Thromboembolism)

DVT (Deep Vein Thrombosis)DVT (Deep Vein Thrombosis)

Gejala minimal/tanpa gejala (asimptomatik pada Gejala minimal/tanpa gejala (asimptomatik pada 85 % pasien)85 % pasien)Gejala-gejala DVT:Gejala-gejala DVT:- Nyeri/kaku tungkai- Nyeri/kaku tungkai- Suhu kulit meningkat- Suhu kulit meningkat- Eritema- Eritema- Edema akut- Edema akut- Pitting edema- Pitting edema- Dilatasi vena permukaan- Dilatasi vena permukaan

DVTDVT

Pemeriksaan diagnostik:Pemeriksaan diagnostik:

- USG- USG

- MRI- MRI

- Venografi- Venografi

- Pemeriksaan darah: D-dimer- Pemeriksaan darah: D-dimer

Vena-vena tempat terjadinya DVT

DVT di Vena ileofemoral kanan

DVT : Perkembangan Selanjutnya

1. Mengalami penghancuran bekuan secara spontan (fibrinolisis) dan menghilang sendiri

2. Rekanalisasi (lubang pembuluh darah membuka kembali)

3. Meluas sepanjang dinding dan lumen (lubang) pembuluh darah

4. Obstruksi (penyumbatan) aliran darah vena

5. Menyebabkan emboli paru (PE)

PE (Pulmonal Emboli)PE (Pulmonal Emboli)

Gejala PE tergantung pada luasnya sumbatan Gejala PE tergantung pada luasnya sumbatan arteri pulmonalis (asimptomatik arteri pulmonalis (asimptomatik kematian kematian mendadak)mendadak)

Gejala-gejala:Gejala-gejala:

- dyspnea- dyspnea

- pleuritic chest pain- pleuritic chest pain

- batuk- batuk

- takikardi- takikardi

- tachypnea- tachypnea

PEPE

Pemeriksaan diagnostik:Pemeriksaan diagnostik:

- angiografi- angiografi

- scan paru- scan paru

- perfusion lung scan- perfusion lung scan

- ventilation lung scan- ventilation lung scan

Penatalaksanaan DVT dan PE

Tujuan penatalaksanaan pasien DVT• Mencegah PE• Mencegah perluasan trombus dan terjadinya emboli• Mencegah komplikasi

(Sindrom Post Phlebitik: ulkus varikosa dll)

Thrombosis in IndonesiaThrombosis in Indonesia

Epidemiology data not availableEpidemiology data not available

MortalityMortality

The first cause of death 20.5%, The first cause of death 20.5%,

(11.8 % cerebrovascular, 8.7 % coronary (11.8 % cerebrovascular, 8.7 % coronary heart disease) (informasi Depkes 1997)heart disease) (informasi Depkes 1997)

Incidence of thrombosis in Incidence of thrombosis in United States of AmericaUnited States of America

DiseaseDisease US incidence Total in US /year Definable US incidence Total in US /year Definable /100.000 cases reason/100.000 cases reason

Deep Vein Thrombosis Deep Vein Thrombosis 159/100.000 398.000 159/100.000 398.000 80% 80% Pulmonary EmbolusPulmonary Embolus 139/100.000 347.000 139/100.000 347.000 80 % 80 %Fatal Pulmonary Emb. Fatal Pulmonary Emb. 94/100.000 235.000 94/100.000 235.000 80 % 80 %Myocardial InfarctionMyocardial Infarction 600/100.000 1.500.000 600/100.000 1.500.000 67 % 67 %Fatal MI Fatal MI 300/100.000 750.000 300/100.000 750.000 67 % 67 % Cerebrovascular thromb.Cerebrovascular thromb. 600/100.000 1.500.000 600/100.000 1.500.000 30 % 30 %Fatal Cereb. Trhromb.Fatal Cereb. Trhromb. 396/100.000 990.000 396/100.000 990.000 30 % 30 % Total serious thromb. In USTotal serious thromb. In US 1498/100.000 3.742.000 1498/100.000 3.742.000 50 % 50 %Total deaths from above thrmb.Total deaths from above thrmb. 790/100.000 1.990.000 790/100.000 1.990.000 50 % 50 %

Bick RL, Clin Appl Throm Hemos 3, Suppl 1, Bick RL, Clin Appl Throm Hemos 3, Suppl 1, 19971997

CV thrombosis1,000,000

Other causes400,000

COPD90,000

Cancer500,000

Pulmonary disease/flu80,000

Trauma/accident90,000

Leading causing Mortality in the USA

Semin Thromb 21,Sup 1, 2000

Clinical manifestation of arterial Clinical manifestation of arterial thrombosisthrombosis

1.1. Stroke non haemorrhagic / TIAStroke non haemorrhagic / TIA

2.2. Myocardial infarction / unstable anginaMyocardial infarction / unstable angina

3.3. Acut abdomen (mesentrial thrombosis )Acut abdomen (mesentrial thrombosis )

4.4. Fetal loss syndrome/recurrent miscarriageFetal loss syndrome/recurrent miscarriage

5.5. Loss of visionLoss of vision

6.6. Loss of hearingLoss of hearing

7.7. GangrenGangren

Clinical manifestation of venous Clinical manifestation of venous thrombosisthrombosis

1. Deep Vein Thrombosis(DVT)

2. Pulmonal Emboli(PE)

} Venous Thromboembolism (VTE)

VTE: Often undetected until too VTE: Often undetected until too latelate

Approximately 80% of DVTs are clinically

silent2,3

Over 70% of fatal PE are detected post

mortem1,3

1. Stein PD, et al. Chest 1995;108:978–81.2. Lethen H, et al. Am J Cardiol 1997;80:1066–9.3. Sandler DA, et al. J R Soc Med 1989;82:203–5.

Incidence of VTE among autopsies in a single hospital

VTE: A life threatening condition,VTE: A life threatening condition,

10% of hospitalized patients die from it10% of hospitalized patients die from it

0

5

10

15

20

25

30

35

40

VTE PE Fatal PE

Lindbald B, et al. BMJ 1991;302:709–11.

% of VTE among

autopsies

26%

35%

9.4%

VTE: Still a leading cause of VTE: Still a leading cause of mortalitymortality

• A common disease across a range of different populations

• Often silent, but always life-threatening (PE)

• Various therapeutic alternatives have been developed through intensive research over many years

• Even with the range of treatments now available, both short- and long-term morbidity remain high

10 Penyebab kematian di Indonesia10 Penyebab kematian di Indonesia

1.1. Penyakit cerebrovascularPenyakit cerebrovascular 11.8 % 11.8 %2.2. Penyakit saluran napas bawahPenyakit saluran napas bawah 11.1 % 11.1 %3.3. Penyakit jantungPenyakit jantung 8.7 % 8.7 % 4.4. Penyakit bermula pada perinatalPenyakit bermula pada perinatal 8.3 % 8.3 %5.5. Penyakit karena cedera & keracunan 6.8 %Penyakit karena cedera & keracunan 6.8 %6.6. Neoplasma 5.9 %Neoplasma 5.9 %7.7. Tuberkulosis (semua bentuk) 4.7 % Tuberkulosis (semua bentuk) 4.7 % 8.8. Penyakit susunan saraf 4.7 %Penyakit susunan saraf 4.7 %9.9. Penyakit hati 4.5 %Penyakit hati 4.5 %10.10. Penyakit sistem kemih 4.3 %Penyakit sistem kemih 4.3 %

Bulletin : Informasi Dep Kes 1997Bulletin : Informasi Dep Kes 1997

Penatalaksanaan DVTI. Penanganan pada fase akut:

- bed rest & elevasi kaki - mobilisasi dini

II. Terapi: (= terapi PE)a. Antikoagulan:

- Heparin pemantauan aPTT 1,5-2,5 kali nilai normal

- Fraxiparine: 2 x per hari (10 hari, dosis /LMWH sesuai berat badan) aPTT (-)

- Dilanjutkan dengan antikoagulan oral (warfarin)

b. Fibrinolitikc. Operasi

Pencegahan VTEPencegahan VTE

Fraxiparine dan Arixtra juga diberikan untuk Fraxiparine dan Arixtra juga diberikan untuk pencegahan VTE pasca operasi dengan resiko pencegahan VTE pasca operasi dengan resiko trombosis (operasi orthopedi, operasi ginekologi, trombosis (operasi orthopedi, operasi ginekologi, operasi urologi, dll)operasi urologi, dll)

Dosis Dosis ARIXTRAARIXTRA pada operasi ortopedik pada operasi ortopedik mayormayor::

2,5 mg per hari SC2,5 mg per hari SC, ,

dimulai 6 jam pasca operasi (selama 5-9 dimulai 6 jam pasca operasi (selama 5-9 hari) hari)

Venous thromboembolisVenous thromboembolism (VTE)m (VTE): : CCommon, silentommon, silent, , life-threateninglife-threatening

A common vascular diseaseA common vascular disease

Debilitating and costly Debilitating and costly

Often silent and potentially life-threateningOften silent and potentially life-threatening

Very large population at riskVery large population at risk

Very high incidence in surgeryVery high incidence in surgery

VTEVTE Deep Vein Thrombosis (DVT) Deep Vein Thrombosis (DVT)

Pulmonal Emboli (PE)Pulmonal Emboli (PE)

A common vascular diseaseA common vascular disease

Debilitating and costly Debilitating and costly

Often silent and potentially life-threateningOften silent and potentially life-threatening

Very large population at riskVery large population at risk

Very high incidence in surgeryVery high incidence in surgery

VTEVTE Deep Vein Thrombosis (DVT) Deep Vein Thrombosis (DVT)

Pulmonal Emboli (PE)Pulmonal Emboli (PE)

VTE: A strong relationship VTE: A strong relationship between DVT and PEbetween DVT and PE

About 50% of patients with proximal DVT of the leg have asymptomatic PE1

DVT (mainly asymptomatic) is found in around 80% of patients with PE2

1. Pesavento R, et al. Minerva Cardioangiol 1997;45(7-8):369–375.2. Girard P, et al. Chest 1999;116(4):903–908.

Embolus

Migration

Thrombus

VTE risk factors:VTE risk factors: Numerous and commonNumerous and common

VTE risk factors include:Protein C deficiency1

Protein S deficiency1 Antithrombin deficiency1

Activated protein C resistance1 Prothrombin G20210A1 High factor VIII concentration1 Hyperhomocysteinemia1 Age1

1. Rosendaal FR. Semin Hematol 1997;34(3):171–87.2. Clagett GP, et al. Chest 1998;114 Suppl 5:531–60S. 3. Fraisse F, et al. Am J Respir Crit Care Med 2000;161 (4 Pt 1):1109–14.4. Samama MM, et al. N Engl J Med 1999;341(11):793–800.5. Goldhaber SZ, et al. JAMA 1997;277(8):642–5.6. Cruickshank JM, et al. Lancet 1988; 2(8609):497–8.7. Hirsh J, Hoak J. Circulation 1996; 93:2212–45.

Lack of identification of the patient’s overall risk profile may lead to unexpected events.2,7

Surgery1

Trauma2

Malignant disease1

Acute MI3,4

Acute infection3,4

Acute heart failure2

Acute respiratory failure3,4

Antiphospholipid syndrome1

Stroke2

Congestive heart failure2

Hypertension5 Myeloproliferative disorders1

Nephrotic syndrome2

Inflammatory bowel disease2

Obesity2

Varicose veins2

Immobility1

Long-distance travel6 Pregnancy and puerperium1

Previous venous thrombosis1

3535

Deep Vein Thrombosis ProphylaxisDeep Vein Thrombosis Prophylaxis

Severe sepsis patiens should receive Severe sepsis patiens should receive deep vein thrombosis (DVT) prophylaxis deep vein thrombosis (DVT) prophylaxis with either lowe-dose unfractionated with either lowe-dose unfractionated heparin or low-molecular weight heparin.heparin or low-molecular weight heparin.

(Crit Care Med 2004 Vol.32, No. 3)(Crit Care Med 2004 Vol.32, No. 3)

Patients with serious medical illness, who should Patients with serious medical illness, who should

be considered for DVT prophylaxisbe considered for DVT prophylaxis Severe Respiratory failureSevere Respiratory failure - Acute exacerbations of Chronic Obstructive Pulmonary- Acute exacerbations of Chronic Obstructive Pulmonary- Adult Respiratory Distress Syndrome - Adult Respiratory Distress Syndrome - Community – Acquired Pneumonia- Community – Acquired Pneumonia- Non cardiogenic pulmonary edema- Non cardiogenic pulmonary edema- Pulmonary malignancy- Pulmonary malignancy- Interstitial Lung Disease- Interstitial Lung Disease

Class III – IV Congestive Heart FailureClass III – IV Congestive Heart Failure- Ischemis Cardiomyopathy- Ischemis Cardiomyopathy- Non-ischemic cardiomyopathy- Non-ischemic cardiomyopathy- CHF Secondary to valvular Disease- CHF Secondary to valvular Disease- Chronic idiopathic cardiomyopathy- Chronic idiopathic cardiomyopathy- CHF Secondary to arrythmias- CHF Secondary to arrythmias

Serious InfectionsSerious Infections- - PneumoniaPneumonia- Urinary Tract Infection- Urinary Tract Infection- Abdominal Infection- Abdominal Infection

Elderly PatientsElderly PatientsAll hospitalized elderly patients who are immobilized for 3 days or more and who have serious All hospitalized elderly patients who are immobilized for 3 days or more and who have serious underlying medical conditions known to be risk factor for DVT should be considered for underlying medical conditions known to be risk factor for DVT should be considered for prophylaxis with Low Molekular Weight Heparinprophylaxis with Low Molekular Weight Heparin

Reference : Bosker G. Thrombosis Prophylaxis in Seriously ill Mediccal Patients : Evidence-Based Management, Patient Risk Stratification, and Outcome Optimizing Pharmacological Management. Internal Medicine Consensus Reports. Juni 1, 2001: 1-8

PENUTUPPENUTUP

Trombosis merupakan salah satu penyebab Trombosis merupakan salah satu penyebab kematian utama di duniakematian utama di duniaTrombosis & VTE Trombosis & VTE tidak hanya di negara- tidak hanya di negara-negara Barat tetapi juga masalah di negara-negara Barat tetapi juga masalah di negara-negara Asianegara AsiaTrombosis penyebab kematian utama di Trombosis penyebab kematian utama di IndonesiaIndonesia