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ATRIAL FIBRILASI
RATE CONTROL ( Target HR < 110 bpm )
LVEF < 40% atau ada tanda-tanda gagal jantung kongesti TERAPI AKUT LONG TERM SIDE EFECT PERHATIAN 1. Beta Blokerdosisrendah Bisoprolol - 1.25–20 mg once Kelelahan, sakit kepala, Pada pasien asma : daily or split udem pada perifer, dapat menyebabkan Cervedilol - 3.125–50 mg gangguan saluran bronkospasme twice daily pencernaan, gangguan (kasusnya jarang) Metoprolol 2.5–10 mg 100–200 mg total saluran nafas bagian Rekomendasi agen intravenous daily dose atas, pusing , beta-1 selektif bolus (according to bradikardi, AV blok, (carvedilol) (repeated as preparation). hipotensi KI : gagal jantung required). akut, riwayat Nebivolol - 2.5–10 mg once bronkospasm daily or split severe Esmolol 0.5 mg/kg - intravenous bolus over 1 min; then 0.05–0.25 mg/kg/min. Hemodinamik tidak stabil, atau HFrEH severe Amiodaron 300 mg 200 mg daily Hypotension, Suggested as intravenously bradycardia, nausea,QT adjunctive therapy diluted in250 prolongation, in patients where mL 5% dextrose pulmonary heart rate over 30– toxicity, skin control cannot be 60minutes discolouration, achieved using (preferably via thyroid dysfunction, combination central venous corneal therapy. cannula) deposits and cutaneous ongoing reactionwith requirement for extravasation. amiodarone, follow with 900 mg i.v. over 24 h diluted in 500–1000 mL via a central venous cannula. 2. Dapat ditambahkan Glikosida Jantung (pilihan terakhir) Digoksin 0.5 mg 0.0625–0.25 mg Most common reported High plasma levels intravenous daily dose adverse symptoms are associated with bolus (0.75–1.5 gastrointestinal upset, increased risk of mg over 24 dizziness, blurred death. Check hours in vision, headache and renal function divided doses). rash. In toxic states before starting (serum levels >2 andadapt dose in ng/mL), digoxin is patients with proarrhythmic and can CKD.Contra- aggravate heart failure, indicated in particularly with patients with co-existent accessory hypokalaemia. pathways, ventricular tachycardia and hypertrophic cardiomyopathy with outflow tract obstruction LVEF ≥ 40% 1. Beta BlokerDosis Normal atau Dapatdilihat di atas 2. Calsium Channel Blockers atau Diltiazem 15–25 mg 60 mg 3 times daily dizziness, Use with caution in intravenous bolus up to malaise,lethargy, combination (repeated as 360 mg total daily headache, hot with beta-blockers. required). dose flushesgastrointestinal Reduce dose (120–360 mg once upset andoedema. with hepatic daily modified release). Adverse effects include impairment and bradycardia, start with smaller Verapamil 2.5–10 mg 40–120 mg 3 atrioventricular block dose in renal intravenous times daily and hypotension impairment. bolus (120–480 mg (prolonged Contra-indicated (repeated as once daily hypotension possible in LV failure with required). modified release withverapamil). pulmonary congestion or LVEF <40%. 3. Dapat ditambahkan Glikosida Jantung (pilihan terakhir) Dosis dapat dilihat diatas
RHYTHM CONTROL (Target sinus rhythm)
1. Elektrik Kardioversi (bila hemodinamik tidak stabil) 2. Dapat menjadi pilihan pasien kardioversi farmakologi ( bila hemodinamik stabil)
HFrEF Severe , Stenosis Aorta
TERAPI AKUT MAINTENANCE SIDE EFECT PERHATIAN Amiodaron 5–7 mg/kg 600 mg in divided Phlebitis, hypotension, Pertimbangkan over 1–2 hours doses for bradycardia/AV block. untuk dihentikan dilanjutkan50 4 weeks, 400 mg Will slow ventricular bila QT mg/hour to a for 4 weeks, rateDelayed conversion prolongation maximum then 200 mg to sinus rhythm (8–12 >500 ms of 1.0 g over 24 once daily hours) hours CAD, Moderate HFrEFatauHFmrEF/HFpEF, abnormal LVH Amiodaron Idem diatas Vernakalant 3 mg/kg over Sediaan oral tidak Hypotension, non- 10 min ada sustained ventricular dilanjutkan arrhythmias, QT and 2mg/kg over 10 QRS prolongation. min afterwaiting Avoid in patients with for 15 min SBP <100 mmHg, recent (<30 days) ACS, NYHA Class III and IV heart failure, QT interval prolongation (uncorrected QT >440 ms) and severe aortic stenosis. Tidak ada kelainan struktur jantung Vernakalant Idem diatas Flecainid 200–300 100–150 mg Hypotension, atrial Contra-indicated if mgpoatau1.5–2 twice daily flutter with 1:1 CrCl<50 mg/mL, mg/kg 200 mg conduction, QT liver disease, IHD over 10 min iv once daily prolongationAvoid in or reduced LV sediaan SR patients with IHD ejection fraction. and/or significant Caution in the structural heart disease presence of SAN or AV node or conduction diseaseCYP2D6 inhibitors (e.g. fluoxetine or tricyclic antidepressants) increase plasma concentration Pertimbangkan untuk penghentian bila QRS duration increase >25% above baseline Propafenon 1.5–2 mg/kg 150–300 mgpo Hypotension, atrial Contra-indicated in over 10 miniv three times daily flutter with 1:1 IHD or reduced LV atau conduction, QRS ejection fraction. 450–600 mg po 225–425 mgpo prolongation(mild)Avoi Caution in the twice daily d in patients with IHD presence of SAN or sediaan SR and/or significant AV node and structural heart disease conductiondisease, renal or liver impairment, and asthma.Increases concentration of digitalis and warfarin. Pertimbangkan untuk penghentian bila QRS duration increase >25%above baseline
Dronedaron - 400 mg Contra-indicated in
twice dailypo NYHA Class III or IV or unstable heart failure, during concomitant therapy with QT- prolonging drugs,or powerful CYP3A4 inhibitors (e.g. verapamil, diltiazem, azole antifungal agents), and when CrCl<30 ml/min. The dose of digitalis, beta- blockers, and of some statins should be reduced. Elevations in serum creatinine of 0.1– 0.2 mg/dL are common
TERAPI ANTITRHOMBOLITIK UNTUK PENCEGAHAN STROKE
(untuk prevalensi stroke) 1. Terapi NOAC (jika nilai faktor resiko stroke 1 atau >2) Nama Obat Dosis Efek samping Dabigatran 150mg 2x sehari Perdarahan
110mg 2x sehari Apixaban 5mg 2x sehari Perdarahan
2,5mg 2x sehari jika
2 dari 3 kriteria (usia > 80thn, BB < 60kg, creatinin > 1,5mg/dl Rivaroxaban 20mg/ hari dengan Perdarahan makan
15mg/ hari untuk
CrCl < 50mg/min with food Edoxaban 60mg/hari Perdarahan
