Tesis

Hubungan antara Kadar Hemoglobin A1C dan High Sensitivity C-Reactive Protein dengan Obstruksi Mikrovaskular pada Pasien Infark Miokard Akut Dengan Elevasi Segmen ST pasca Intervensi Koroner Perkutan Primer = Relationship between Hemoglobin A1C and High Sensitivity C-Reactive Protein with Microvascular Obstruction in ST Segment Elevation acute Myocardial Infarction after Primary Percutaneous Coronary Intervention

Latar belakang. Kemajuan terapi reperfusi pada pasien infark miokard akut
menimbulkan satu fenomena yang turut berperan dalam prognosis pasien, yaitu
fenomena no reflow atau obstruksi mikrovaskular. Mekanisme OMV diduga
memiliki 4 komponen patogenik utama yaitu embolisasi distal aterotrombotik,
cedera reperfusi, cedera iskemia, dan kerentanan individu. Hiperglikemia akut
diketahui berhubungan dengan OMV pada pasien IMA, namun peran hiperglikemia
kronik masih kontroversial. Hiperglikemia berperan dalam komponen kerentanan
individu, serta mempengaruhi peningkatan faktor inflamasi yang berperan dalam
komponen cedera reperfusi. Kedua faktor ini yaitu hiperglikemia kronik yang
digambarkan HbA1C dan inflamasi yang digambarkan hsCRP belum pernah diteliti
secara bersamaan dalam menilai OMV dengan satu metode. Penelitian ini akan
meneliti hubungan antara HbA1C dan hsCRP dengan OMV yang dinilai
menggunakan indeks resistensi mikrovaskular, suatu metode terbaru dalam menilai
OMV dengan akurat pada fase awal dan memiliki nilai prognostik yang signifikan.
Metode. Sebanyak 55 pasien IMA-EST yang menjalani IKPP dipilih secara
konsekutif sejak Januari-Juni 2014. HbA1C dan hsCRP diambil saat masuk UGD,
penilaian IMR diambil segera setelah tindakan IKPP. Perhitungan statistik
menggunakan SPSS 17.
Hasil. Dari 55 pasien didapatkan proporsi laki-laki sebesar 93%, dengan rerata
umur 51,91 ± 8,87 tahun. Faktor resiko penyakit jantung koroner terbanyak adalah
merokok yaitu 69%. Semua pasien menjalani tindakan IKPP dengan waktu iskemia
489,45±169,95 menit dan waktu perfusi 124,91±76,49 menit. Nilai rerata IRM
53,22±41,11 dengan nilai rerata HbA1C 6,46±1,22 %, dan rerata hsCRP 4,98±3,39
mg/dL. Dari analisis bivariat didapatkan HbA1C tidak berhubungan dengan IRM
(r=0,22,p=0,10), dan hsCRP juga tidak berhubungan dengan IRM (r=0,24,p=0,08).
Setelah disesuaikan dengan variabel perancu pada analisis multivariat, didapatkan
hubungan signifikan antara HbA1C dengan IRM (p=0,03) namun hsCRP tidak
berhubungan dengan IRM (p=0,31).
Kesimpulan. Kadar HbA1C saat admisi berhubungan dengan IRM pada pasien
IMA-EST yang menjalani IKPP dan hsCRP saat admisi tidak berhubungan dengan
IRM pasien IMA-EST yang menjalani IKPP.
Kata kunci: IMA-EST, IKPP, obstruksi mikrovaskular, IRM, HbA1C, hsCRP


Background: Advances in reperfusion therapy for acute myocardial infarction led
to a phenomenon of distal no reflow or myocardial obstruction (MVO), which
associated with worse outcome and prognosis. The potential mechanism of MVO
had four major pathogenic components: distal atherotrombotic embolization,
reperfusion injury, ischemic injury, and individual susceptibility. Association
between acute hyperglycemia and MVO in acute myocardial infarction has been
found, but the role of chronic hyperglycemia remained controversial.
Hyperglycemia affected individual susceptibility to microcirculatory injury, and
also induced systemic inflammation which had a role in reperfusion injury.
Association of both these factors--chronic hyperglycemia, determined by
Hemoglobin A1C, and inflammation factor, measured by high sensitivity CReactive
Protein--with MVO had never been studied simultaneously. This crosssectional
study will determine the association between HbA1C and hsCRP with
MVO assessed with index of microvascular resistance, an invasive novel method
to assess MVO in acute phase and had significant prognostic factor.
Methods: 55 patients with acute ST-elevation myocardial infarction underwent
primary percutaneous coronary intervention were taken consecutively from January
to June 2014. Blood samples for HbA1C and hsCRP were taken before the
procedure. IMR was taken immediately after the primary percutaneous coronary
intervention procedure. Statistical calculation used SPSS 17.
Results: From 55 patients included in the study, there were 93% men, with mean
age of 51.91 ± 8.87 years. The most common risk factors for coronary heart disease
was smoking (69%). All patients underwent primary percutaneous coronary
intervention with mean onset to balloon time was 489.45 ± 169.95 minutes and
mean door to balloon time was 124.91 ± 76.49 minutes. Mean IMR was 53.22 ±
41.11, with mean HbA1c was 6.46 ± 1.22% and mean hsCRP was 4.98 ± 3.39
mg/dL . From bivariate analysis, there was no association between HbA1C and
IMR (r=0,22, p = 0,10), and between hsCRP and IMR (r = 0,24 , p=0,08). In
multivariate analysis , there was relationship between HbA1C with IRM ( p = 0,03)
and hsCRP were also not associated with IRM ( p = 0,31 ).
Conclusions. There was association between hemoglobin A1C levels on admission
with IMR and no association between hsCRP levels on admission with IMR, in
patients with acute ST-elevation myocardial infarction underwent primary
percutaneous coronary intervention.
Keywords: STEMI, PPCI, microvascular obstruction, IMR, HbA1C, hsCRP