CONTINUING
CONTINUING
DEVELOPMENT
PROFESSIONAL
MEDICAL
DEVELOPMENT
EDUCATION
ABSTRAK
Sekitar 20% stroke iskemik disebabkan kardioemboli. Stroke yang berhubungan dengan kardioemboli cenderung bermanifestasi lebih berat,
berisiko tinggi berulang, serta mortalitasnya lebih tinggi. Pemberian antikoagulan lebih dianjurkan pada stroke iskemik kardioemboli sebagai
upaya pencegahan, baik primer maupun sekunder. Pada kasus stroke lain, antikoagulan belum menunjukkan manfaat nyata.
Kata kunci: Antikoagulan, iskemik, kardioemboli, stroke
ABSTRACT
Approximately 20% of ischemic stroke are caused by cardioembolism. Stroke associated with cardioembolism tend to be more severe, higher
risk for recurrence, and associated with a higher mortality rate. Anticoagulant is recommended in cardioembolic ischemic stroke, both for
primary and secondary prevention, but has not demonstrated any significant advantages in other type of stroke. Roveny. Anticoagulants for
Cardioembolic Ischemic Stroke.
Keywords: Anticoagulant, cardioembolic, ischemic, stroke
PENDAHULUAN
Secara umum, stroke dapat dibagi menjadi
stroke iskemik dan stroke hemoragik. Di negara
barat, 80% stroke berjenis iskemik.1 Sekitar
20% penderita stroke iskemik disebabkan oleh
kardioemboli.2,3
Stroke yang berhubungan dengan kardioemboli cenderung bermanifestasi lebih
berat, berisiko tinggi untuk berulang, serta
berhubungan dengan mortalitas yang lebih
tinggi.2,3 Kardioemboli akibat fibrilasi atrium
akan meningkatkan risiko stroke sebanyak
lima sampai enam kali lipat. Selain itu, kejadian
rekurensinya jauh lebih tinggi dibandingkan
dengan penyebab stroke lain.3,4
Terdapat sedikit perbedaan penatalaksanaan
pasien stroke iskemik kardioemboli, yaitu
dalam hal pemberian antikoagulan.
Antikoagulan lebih dianjurkan pada stroke
iskemik kardioemboli sebagai upaya pencegahan, baik primer maupun sekunder.3-6
Sedangkan pada stroke jenis lain, pemberian
antikoagulan belum menunjukkan manfaat
nyata.7 Pemberian antikoagulan pada kasus
Alamat korespondensi
email: dr.roveny@gmail.com
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Thrombosis
Atherosclerotic plaque
rupture
Small-vessel
lipohyalinosis
Vascular invasion by
tumor
HIT type II
Sickle cell disease
TTP
DIC
Antiphospholipid
antibody syndrome
Embolism
Luminal Obliteration
Artery-to-artery
Atheroma fragments
(thrombus from
dissection site)
Cardioaortic
Cardiac thrombus
fragments
Endocarditis vegetations
(mycotic)
Cholesterol
Tumor
Decompression illness
Paradoxical
Air
Cholesterol (especially
post-fracture)
Deep venous thrombus
fragments
Amniotic fluid
Noninflammatory
vasculopathy
Moyamoya disease
CADASIL
Sneddon syndrom
Fibromuscular dysplasia
Thromboangiltis
obliterans (Burger's
disease)
Malignant atrophic
papulosis (KohlemeierDegos disease)
Sickle cell disease
Migraine
Extrinsic artery
compression
Herniation
Masses
Vasculitis (see Table 3)
vasospasm
Subarachnoid
hemorrhage
Meningitis
Drug-induced (CallFleming syndrome)
Angiotrophic lymphoma
Intravascular lymphoma
Lymphomatoid
granulomatosis
CADASIL = cerebal autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy; DIC = disseminated
intravascular coagulation; HIT = heparin-induced thrombocytopenia; MI = myocardial infarction; TTP = thrombotic
thrombocytopenic purpura.
Tabel 2. Klasifikasi penyebab stroke iskemik emboli berdasarkan kecenderungan risiko1
High Risk Sources
Hypercoagulable state
Inherited thrombophilia
Antiphospholipid antibodies
Cancer
MI = myocardial infarction. (Data from Ay H, Furie KL, Singhal A, et al. An evidence-based causative classification system
for acute ischemic stroke. Ann Neurol 2005;58:688-97; and Doufekias E, Segal AZ, Kizer JR. Cardioenic and aortogenic brain
embolism. J Am Coll Cardiol 2008;51:1049-59.)
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347
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Rivaroxaban
Dabigatran
Apixaban
Edoxaban
Mengganggu
sintesis faktor
koagulasi terkait
vitamin K
Menghambat
faktor Xa
Menghambat
trombin
Menghambat
faktor Xa
Menghambat
faktor Xa
Oral
Oral
Oral
Oral
Oral
Tidak perlu
Tergantung INR
individual
Sesuai CrCl
Onset
36-72 jam
2-4 jam
0,5-2 jam
1-3 jam
1-3 jam
Waktu paruh
20-60 jam
9-13 jam
12-14 jam
8-15 jam
9-11 jam
Tidak terprediksi,
individual
Stabil
Stabil
Stabil
Stabil
Interaksi obat
CYP2C9, -3A4,
-1A2
Inhibitor p-gp
CYP3A4
CYP3A4, inhibitor
p-gp
Pemantauan
Dibutuhkan rutin
Tidak dibutuhkan
rutin
Tidak dibutuhkan
rutin
Tidak dibutuhkan
rutin
Tidak dibutuhkan
rutin
80% / 65%
66%
80%
27%
40%
Pengaturan dosis
Farmakokinetik
Eliminasi ginjal
Vitamin K, FFP,
PCC, antibodi
Antidotum
PCC
PCC
PCC
eksperimental
PCC
INR= International normalized ratio; CrCl= creatinine clearance; CYP3A4= cytochrome P450 3A4; p-gp= p-glycoprotein;
FFP= fresh frozen plasma; PCC= prothrombin complex concentrates
DAFTAR PUSTAKA
1.
Alireza A. Ischemic stroke: Patophysiology and principles of localization. Turner white communication [Internet]. 2009 [cited 2014 July 20]. Available from: http://www.turner-white.com/
2.
Adria A, Josefina A. Cardioembolic stroke: Clinical features, specific cardiac disorders and prognosis. Current Cardiology Reviews [Internet]. 2010 [cited 2014 July 25] 6(3):161-50. Available
pdf/brm_Neur_V13P1.pdf
from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2994107/
3.
Maurizio P, Giancarlo A, Sara M, Valeria C. Efficacy and safety anticoagulant treatment in acute cardioembolic stroke. American Heart Association [Internet]. 2007 [cited 2014 July 25]
38:423-30. Available from: http://stroke.ahajournals.org/content/38/2/423
4.
Vaishnav, Pettigrew. Stroke: Thrombolysis and antithrombotic therapy. In: Steen DK, ed. Therapeutic strategies in thrombosis. Oxford: Atlas Medical Publishing 2006. p.274-51.
5.
Ju-Hun L, Kwang-Yeol P, Ji HH, Sun UK. Immediate anticoagulant for acute cardioembolic stroke is still popular in selective cases in Korea. Korean J Stroke [Internet]. 2011 [cited 25 July
2011] 13(3):120-8. Available from: http://dx.doi.org/10.5853/kjs.2011.13.3.120
6.
Angel F, Jerzy K, Adria A. Antithrombotic medication for cardioembolic stroke prevention [Internet]. 2011 [cited 2014 July 25]. Available from: http://www.hindawi.com/journals/srt/2011/607852/
7.
Karen LF, Hakan A. Secondary prevention for specific causes of ischemic stroke and transient ischemic attack [Internet]. 2012 [cited 2014 July 19]. Available from: http://www.uptodate.
8.
Lip GY, Krishnamoorthy S. Thrombosis prophylaxis in patients with ischaemic (cardioembolic) stroke. Hamostaseologie [Internet] 2009 [cited 2011 July 27] 29(1):96-101. Available from:
9.
Giacomo G, Mohammed AA, Francesco C. Prevention strategies for cardioembolic stroke: Present and future perspective. The Open Neurology 2010; 4: 63-56.
com/contents/secondary-prevention-for-specific-causes-of-ischemic-stroke-and-transient-ischemic-attack
http://www.ncbi.nlm.nih.gov/pubmed/19151857
10. Warren JM. Stroke in patients with atrial fibrillation [Internet]. 2010 [cited 2014 July 20]. Available from: http://www.uptodate.com/contents/stroke-in-patients-with-atrial-fibrillation
11. Jamary OF, Walter JK. Antithrombotic treatment of acute ischemic stroke [Internet]. 2013 [cited 2014 July 20]. Available from: http://www.uptodate.com/contents/antithrombotictreatment-of-acute-ischemic-stroke-and-transient-ischemic-attack/contributors
12. FPINs clinical inquiries warfarin for prevention of ischemic stroke recurrence. Am Fam Physician [Internet]. 2006 [cited 2014 July 20] 73(11):2011-2. Available from: http://www.aafp.org/
afp/2006/0601/p2011.html
13. Leithuser B, Jung F, Park J-W. Oral anticoagulation for prevention of cardioembolic stroke in patients with atrial fibrillation: Focusing the elderly. Applied Cardiopulmonary Pathophysiology
[Internet] 2013 [cited 25 July 2014]. Available from: http://www.applied-cardiopulmonary-pathophysiology.com/fileadmin/downloads/acp-2009-4/05_leith%E4user.pdf
14. Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. European heart rhythm association practical guide on the use of new oral anticoagulants in patients with nonvalvular atrial fibrillation. Europace [Internet]. 2013 [cited 8 August 2014] 15: 625-51. Available from: http://www.escardio.org/communities/ehra/publications/novel-oral-anticoagulantsfor-atrial-fibrillation/documents/ehra-noac-practical-execsumm-ehj-2013.pdf. DOI: http://dx.doi.org/10.1093/europace/eut083
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