FARMAKOTERAPI GAGAL JANTUNG

1. a. Jelaskan patofisiologi gagal jantung, hubungannya dengan aktivasi neurohormonal sistem reninangiotensin dan sistem saraf simpatik!
b. Bedakan tanda dan gejala gagal jantung menurut klasifikasi New York Heart Association (Functional
Classification) dan American College of Cardiology/American Heart Association (Heart Failure
Staging )!
c. Obat-obat apa yang bisa memperburuk kondisi gagal jantung?
d. Apakah target terapi pasien gagal jantung akut dan kronis?
2. Studi kasus:
BE is a 62-year-old female with a history of known coronary artery disease and type 2 diabetes mellitus
who presents for a belated follow-up clinic visit (her last visit was 2 years ago). She states that she used to
be able to walk over one-half mile (0.8 km) and two flights of stairs before experiencing chest pain and
becoming short of breath. Since her last visit, she has had increasing symptoms and has now progressed
to shortness of breath (SOB) with walking only half a block and doing chores around the house. She also
notes her ankles are always swollen and her shoes no longer fit, therefore she only wears slippers.
Additionally, her appetite is decreased, and she often feels bloated. She also feels full after eating only a
few bites of each meal.
Medical history : Type 2 diabetes mellitus 15 years, Coronary artery disease 10 years (MIs in 1999
and 2002), Tobacco use, History of back surgery in 2001
Medications:
Diltiazem CD 240 mg once daily
Nitroglycerin 0.4 mg sublingual (SL) as needed (last use yesterday after showering)
Ibuprofen 600 mg twice daily for arthritis pain
Vitamin B12 once daily
Multivitamin daily
Aspirin 325 mg once daily
No known drug allergies
Family History: Significant for early heart disease in father (MI at age 53)
Social History: She is disabled from a previous accident; she is married, has
6 children, and runs her own business; she does not drink alcohol and smokes one to two packs of
cigarettes per day.
Physical Examination: Blood pressure 126/70 mm Hg, pulse 60 bpm and regular,
respiratory rate 16/minute, Ht 58 (173 cm), Wt 251 lb (114 kg), body mass index (BMI): 38.2 kg/m2
Lungs are clear to auscultation with a prolonged expiratory phase; rales are present bilaterally
CV: Regular rate and rhythm with normal S1 and S2; there is an S3 and a soft S4 present; there is a 2/6
systolic ejection murmur heard best at the left lower sternal border; point of maximal impulse is within
normal limits at the midclavicular line; there is no JVD
Abd: Soft, non-tender, and bowel sounds are present; 2+ pitting edema of extremities extending to below
the knees is observed
Chest x-ray: Bilateral pleural effusions and cardiomegaly
Echocardiogram: EF = 35%
Laboratory Values :
Hct: 41.1%
WBC: 5.3 103/L (5.3 109/L)
Sodium: 132 mEq/L (132 mmol/L)
Potassium: 3.2 mEq/L (3.2 mmol/L)
Bicarb: 30 mEq/L (30 mmol/L)
Chloride: 90 mEq/L (90 mmol/L)
Magnesium: 1.5 mEq/L (0.8 mmol/L)
Fasting blood sugar: 120 mg/Dl (6.7 mmol/L)
Uric acid: 8 mg/dL (476 mol/L)
Blood urea nitrogen (BUN): 40 mg/dL (14 mmol/L)
SCr: 0.8 mg/dL (71 mol/L)
Alk Phos: 120 IU/L (2 Kat/L)
Aspartate aminotransferase: 100 IU/L (1.7 Kat/L)

Questions:
a. What other laboratory or other diagnostic tests are required for assessment of BEs condition?
b. How would you classify BEs NYHA functional class and ACC/AHA heart failure stage?
c. Identify exacerbating or precipitating factors that may worsen BEs heart failure.
d. What are your treatment goals for BE?
e. Based on the information presented, and your problem based assessment, create a care plan for BEs
heart failure. Your plan should include:
(1) Nonpharmacologic treatment options;
(2) Acute and chronic treatment plans to address BEs symptoms and prevent disease deterioration;
(3) Monitoring plan for acute and chronic treatments.

FARMAKOTERAPI PENYAKIT GINJAL KRONIS

1. a. Apa saja faktor resiko perkembangan penyakit ginjal kronis (PGK)?

b. Jelaskan mekanisme perkembangan PGK!
c. Apa saja tujuan terapi PGK?
d. Pendekatan terapi apa yang bisa dilakukan untuk menunda perkembangan PGK (modifikasi gaya hidup
dan terapi farmakologi)!
e. Konsekuensi spesifik apa saja yang berhubungan dengan PGK?
f. Pendekatan terapi apa saja yang bisa dilakukan untuk mencegah dan menangani konsekuensi spesifik
akibat PGK?
2. Studi kasus:
A 62-year-old obese female with a history of diabetes and hypertension presents to clinic for routine
follow-up. Her fasting blood sugars have been elevated recently, averaging
180 to 250 mg/dL (10 to 13.8 mmol/L).
Medical History : Diabetes mellitus for 8 years, not currently controlled
Hypertension for 5 years, not currently controlled
Hyperlipidemia, currently managed by diet therapy
Family History: Mother is alive at age 87 with coronary artery disease; father is deceased from diabetes;
she has no siblings.
Social History: She does not work; she smokes 1 pack of cigarettes per day, but denies alcohol or illicit
drug use; she is sedentary.
Medications:
Furosemide 20 mg orally daily
Nifedipine XL 30 mg orally daily
Glyburide 10 mg orally daily
Physical Examination:
Vital Signs: Blood pressure 145/92 mm Hg, pulse 82 beats per minute, temperature 36.9C (98.4F), Ht
54 (162.5 cm), Wt 190 lb (86.4 kg)
CV: Regular rate and rhythm, normal S1, S2; no murmurs, rubs or gallops; lungs clear
Abd: Obese; no organomegaly, bruits or tenderness, (+) bowel sounds; heme () stool
Exts: Trace pedal edema bilaterally; decreased sensation in feet to light touch; no lesions
Labs (fasting):
Sodium 145 mEq/L (145 mmol/L); potassium 3.2 mEq/L (3.2 mmol/L); chloride 112 mEq/L (112
mmol/L); carbon dioxide 26 mEq/L (26 mmol/L); blood urea nitrogen 20 mg/dL (7.14 mmol/L urea);
serum creatinine 1.4 mg/dL (123.76 mol/L); glucose 240 mg/dL (13.32 mmol/L); total cholesterol 196
mg/dL (5.07 mmol/L); low-density lipoprotein cholesterol 112 mg/dL (2.90 mmol/L); highdensity
lipoprotein cholesterol 28 mg/dL (0.72 mmol/L); triglycerides 280 mg/dL (3.16 mmol/L);
hemoglobinA1c (HbA1c) 10% (0.1); urine microalbumin 270 mg/dL (2.7 g/L)
Questions:
a. What risk factors does the patient have for the development of CKD?
b. What signs and symptoms are consistent with CKD?
c. How would you classify her CKD?
d. Identify your treatment goals for the patient.
e. What lifestyle modifications would you recommend for the patient with CKD?
f. What pharmacologic alternatives are available for the patient for treatment of CKD?
g. What other interventions are appropriate to minimize the progression of CKD?
3. Kasus lanjutan:

The patient returns to your clinic 2 years later with complaints of feeling tired all of the time. She had
been trying to exercise more, but has not had enough energy to exercise for the past 6 months or so. She
also complains that she feels cold all of the time, despite increasing the temperature in her house.
Current Medications:
Furosemide 80 mg orally daily
Lisinopril 40 mg orally daily
Metoprolol 50 mg orally twice daily
Insulin glargine 25 units subcutaneously at bedtime
Insulin lispro subcutaneously per sliding scale with meals
Physical Examination: Slightly pale skin color; fatigue daily in the afternoon; otherwise unremarkable
Vital Signs : Blood pressure 135/85 mm Hg, pulse 72 beats per minute, temperature 35.9C (96.6F);
Wt 175 lb (79.5 kg)
Chest: Regular rate and rhythm, normal S1, S3 present.
Abd: Obese; no organomegaly, bruits or tenderness, (+) bowel sounds; heme () stool
Exts: 1+ pedal edema bilaterally; decreased sensation in feet; small lesion on left ankle that appears to
be healing slowly
Labs:
Sodium 142 mEq/L (142 mmol/L); potassium 4.8 mEq/L (4.8 mmol/L); chloride 103 mEq/L (103
mmol/L); carbon dioxide 20 mEq/L (20 mmol/L); BUN 58 mg/dL (20.71 mmol/L urea); SCr 3.2 mg/dL
(282.88 mol/L); glucose 130 mg/dL (7.28 mmol/L); WBC 4.8 103 cells/m3 (4.8 109/L); RBC 2.5
103 cells/m3 (2.5 1012/L); Hgb 8.0 g/dL (4.96 mmol/L); Hct 25% (0.25); mean corpuscular volume
(MCV) 88 fL; mean corpuscular hemoglobin concentration (MCHC) 35 g/dL (350 g/L); platelets 250
103 cells/m3 (250 109/L); iron 35 mcg/dL (6.26 mmol/L); TIBC 150 mcg/dL (26.85 mol/L); ferritin
75 ng/mL (168 pmol/L); TSAT 15% (0.15); HbA1c 7.5% (0.075)
Questions:
a. What signs and symptoms are consistent with anemia of CKD?
b. What additional information could you request to determine other causes of anemia in this patient?
c. What treatment would you recommend for this patient for treatment of anemia?
d. How would you evaluate the effectiveness of treatment of anemia?