Post-therapeutic Response Evaluation of Patients Receiving

Percutaneous Coronary Intervention at the Regional Hospital in

Bantul, Yogyakarta

Pramitha Esha Nirmala Dewi

Department of Pharmacy Profession, Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta,

Indonesia

Keywords: Percutaneous Coronary Intervention, Response Evaluation, Yogyakarta

Abstract: Coronary Artery Disease (CAD) is the main cause of mortality in heart disease. Its treatment involves

complex therapies, such as pharmacological Percutaneous Coronary Intervention (PCI) to widen the clogged

artery and lifestyle intervention to decrease the severity of CAD and restenosis. The complexity of the

pharmacological therapy received by CAD patients may cause Adverse Drug Reaction (ADR) events.

Therefore, this study aimed to identify the response of CAD patients after receiving PCI therapy at the

Regional Hospital in Bantul, Yogyakarta. This descriptive research used retrospective data and a total

population sampling method. The samples were CAD outpatients who had received PCI at this hospital

from January to September 2017 and met the inclusion criteria. The sample size was 65 patients. The results

showed that the responses of the CAD patients to PCI therapy included restenosis symptoms (70.77%)

(namely, one restenosis symptom (43.08%) and two restenosis symptoms (27.69%)), uncontrolled lifestyle

intervention (namely, abnormalities in total cholesterol (58.62%), LDL cholesterol (93.10%), HDL

cholesterol (72.41%), triglyceride (70.69%), blood pressure (72.22%), and HbA1c (50%)), and adverse drug

reaction (4.62%).

1 INTRODUCTION

Coronary Artery Disease (CAD) is the main cause of

mortality in heart disease (WHO, 2011). Among the

33 provinces in Indonesia, the Special Region of

Yogyakarta has the 15th highest CAD cases that

affect 16,663 people according to the basic estimate

from doctor’s diagnosis and 36,104 people based on

doctor’s diagnosis on the exhibited symptoms

(National Primary Health Research, 2013). The high

number of CAD cases is caused by the influencing

risk factors (Anwar, 2004).

According to Rilantono (2012), the principle of

CAD treatment is generally a long-term effort to

improve cardiac function and increase life

expectancy. Apart from the use of pharmacological

drugs, CAD cases can diminish with mechanical

reperfusion using Percutaneous Coronary

Intervention (PCI). PCI uses a stent (ring) to reduce

the occurrence of sudden occlusion.

Based on the statistical report published by AHA

(2014), there is an increase in PCI procedure per

10,000 population. The number raised from 37.2

procedures per 10,000 people (37.2/10,000) in 1990-

1992 to 59.2/10,000 in 2002-2004. It reached

135.1/10,000 in men of 65-75 years old and

64.0/10,000 in women from the same age group. On

the contrary, the numbers of procedures in men and

women aged ≥75 years were 128.7/10,000 and

69.0/10,000, respectively. The revascularization of

coronary blood vessels with PCI increased from

264/100,000 in 2002 to 267/100,000 in 2005. Such

increase was higher than the rise of the Coronary

Artery Bypass Grafting (CABG) procedure in the

same years, i.e., from 121/100,000 to 94/100,000.

However, PCI may cause a problem, namely the

growth of tissue within the lumen of the arteries due

to the biological response of vascular injury that

causes the narrowing of arteries and the recurrence

of clogs within six months called restenosis (Levine

et al., 2011). The incidence of restenosis after PCI is

quite high, which is up to 30% six months after the

procedure (Aaronson & Ward, 2008).

Dewi, P.

Post-therapeutic Response Evaluation of Patients Receiving Percutaneous Coronary Intervention at the Regional Hospital in Bantul, Yogyakarta.

DOI: 10.5220/0008238800260032

In Proceedings of the 1st Muhammadiyah International Conference on Health and Pharmaceutical Development (MICH-PhD 2018), pages 26-32

ISBN: 978-989-758-349-0

Apart from taking medical interventions, the risk

of CAD can be managed with obedience to a healthy

lifestyle (lifestyle intervention). After receiving a

PCI procedure, patients are always advised to apply

a healthy lifestyle to reduce future cardiovascular

events. Also, lifestyle changes may advance the

benefits of the medical therapy and revascularization

procedures (Ruß et al., 2009).

Consuming different types of drugs routinely,

CAD patients need evaluation and monitoring to

achieve effective treatment. Therefore, the

comprehension of treatment failure and adverse drug

reaction (ADR), especially in chronic diseases such

as CAD, is necessary (Depkes RI, 2009).

Accordingly, a study identifying the patients’

response to PCI procedures, including the

occurrence of restenosis symptoms afterward like

chest pain and shortness of breath, the risk factor

control (namely, total cholesterol level, LDL

cholesterol, HDL cholesterol, triglyceride level,

blood pressure, and HbA1c), and Adverse Drug

Reaction (ADR) at the Regional Hospital in Bantul,

Yogyakarta is necessarily interesting.

2 MATERIALS AND METHOD

2.1 Materials

This study used the medical records of the

outpatients at Panembahan Senopati Regional

Hospital in Bantul, Yogyakarta as the research

materials.

2.2 Methods

This descriptive study relied on the collection of

retrospective data. These data were acquired from

the medical record of the research subjects, namely

65 CAD outpatients who had received PCI

procedures at Panembahan Senopati Regional

Hospital from January to September 2017. The

research subjects were selected with a total

population sampling technique.

2.3 Data Analysis

The response of the CAD patients after receiving

PCI procedures at the hospital was analyzed

descriptively. The data were presented qualitatively

and quantitatively in percentage. The assessed

response included restenosis symptoms (i.e., chest

pain and shortness of breath), controls over the risk

factor (i.e., total cholesterol, LDL cholesterol, HDL

cholesterol, triglyceride, blood pressure, and

HbA1c), and adverse drug reaction. These responses

were identified using in-depth analysis with

references to related literature.

3 RESULTS AND DISCUSSION

3.1 Patients’ Characteristics

3.1.1 The Characteristics Of Patients by Sex

The characteristics of patients by sex (Table 1) were

analyzed to determine the ratio of male to female

patients. The samples consisted of 51 male

outpatients (78.46%) and 14 female outpatients

(21.54%). Compared with women, men have a

higher risk of CADs with earlier occurrences.

However, the risk of COD in women increases after

menopause. Women produce estrogen as natural

protection against hypercholesterolemia and CAD.

Also, unhealthy lifestyles, such as smoking habit,

can also increase the risk factors for men (Sallam &

Watson, 2013).

The results showed that all female CAD patients

receiving PCI had reached menopause. According to

AHA (2014), the prevalence of PCI therapy for

CAD was higher in men (83.0/10,000) than in

women (38.7/10,000) because women have more

stable angina and fewer blockages in their blood

vessels (Lundberg & King, 2012; Nowakowska et

al., 2008).

3.1.2 The Characteristics of Patients by Age

The age grouping of the CAD patients in this

research is presented in Table 2. It shows that the

incidence of CAD is dominant in the age group of ≥

45 years. This finding is in line with the theory that

states that the risk level of CAD is higher at the age

of 40 years and over (AHA, 2014).

The results of this study are in line with the

National Primary Health Research (2013), which

Table 1: The characteristics of patients by sex

Sex

umber of

atien

s (n)

(%)

Male 51 78.46

Female 14 21.54

Total 65 100

(Source: Primary data analysis, 2018)

Post-therapeutic Response Evaluation of Patients Receiving Percutaneous Coronary Intervention at the Regional Hospital in Bantul,

Yogyakarta

indicates that the prevalence of CAD based on

doctor’s diagnosis and patient’s symptoms increase

with age. The highest group found at age 65-74

years that is 2.0% and 3.6 % but decreased slightly

in the age group ≥75 years that is 1.7% and 3.2%.

This research only found seven (7) CAD patients

aged ≥75 years (10.77%). This number is probably

attributable to the life expectancy in Indonesia,

which makes the population size of the CAD

patients at this group age seem small. Based on the

Statistics Indonesia (BPS, 2016), the life expectancy

of the Indonesian population increases from one year

to another. For instance, it extended from 69.8 years

in 2010 to 70.6 years. However, it has not reached

75 years.

3.1.3 The Characteristics of Patients Based

on Comorbidities

The data obtained from the medical history showed

that all patients in this study had comorbidities,

namely dyslipidemia, hypertension, dyspepsia,

Congestive Heart Failure (CHF) and hyperuricemia

(Table 3). Some of which are identified as the risk

factors of CAD. According to Karikaturijo (2010),

CHF is one of the complications of CAD. This

condition occurs when the arterial blood vessels

narrow and, therefore, decrease the oxygen supply to

the heart. Consequently, the heart muscle weakens.

Dyslipidemia had the highest proportion in this

research. Dyslipidemia, as well as hypertension, is

the risk factor of CAD. The results showed that after

receiving PCI procedures, the CAD outpatients at

the Regional Hospital in Bantul, Yogyakarta who

had dyslipidemia also showed the symptoms of

hypertension. Dyslipidemia and hypertension are

both known to have a close relationship with the

incidence of CAD because continuous high blood

pressure in CAD patients would result in damaged

blood vessels, allowing the accumulation of fatty

plaque and eventually the blockage of the blood

vessels (Budiman et al., 2015).

The other coexisting disease in CAD patients

after the PCI therapy was dyspepsia. Suspected

polypharmacy in CAD management may cause

upper gastrointestinal disorders. Aspirin as an

antiplatelet in CAD patients can cause

gastrointestinal disturbances. Dyspepsia, nausea, and

vomiting occur in 2-6% of patients after taking

aspirin (Meylers, 2006).

The association of uric acid with the incidence of

cardiovascular disease is still controversial and

under investigation (Torpy et al., 2009). An

experimental study reveals that uric acid stimulates

the release of chemo-attractant protein-1,

interleukin-1b (IL-1b), interleukin-6 (IL-6), and

tumor necrosis factor-a (TNF-a). Therefore, uric

acid may contribute to the development of vascular

disease and atherosclerosis through pro-

inflammatory pathways (Ruggiero et al., 2006).

3.2 The Effect of Drug Use Profile on

The Cardiovascular System

Table 4 shows that the CAD patients who have

received PCI therapy take acetylsalicylic acid,

clopidogrel, bisoprolol fumarate, candesartan, and

simvastatin. In this study, acetylsalicylic acid or

aspirin was quite largely used by the CAD patients

after receiving the therapy. For patients without

resistance or allergic to aspirin, or without bleeding

tendency, aspirin has to be given immediately to

continue their lifetime (AHA, 2011). The clinical

trials in Aaronson & Ward (2008) reveal that aspirin

at low doses can decrease infarcts and mortality by

more than 50%.

Clopidogrel has been proven as effective as

aspirin in the prevention of ischemic events in at-

risk patients. Clopidogrel and aspirin affect different

Table 2: The characteristics of patients by age

Age

(years old)

umber of

patients (n)

(%)

35-44 3 4.62

45-54 13 20.00

55-64 25 38.46

65-74 17 26.15

≥75 7 10.77

Total 65 100

(Source: Primary data analysis, 2018)

Table 3: The characteristics of patients based on

comorbidities

Comorbidities

= 65 (%)

Dyslipidemia 58 89.23

Hypertension 17 26.15

Dyspepsia 16 24.62

Congestive Heart

Failure (CHF)

10 15.38

Hyperuricemia 10 15.38

(Source: Primary data analysis, 2018)

MICH-PhD 2018 - 1st Muhammadiyah International Conference on Health and Pharmaceutical Development

pathways in the coagulation process. Therefore, their

combination can be administered to patients

undergoing stenting, and it has been proven to

reduce ischemic events by 20% in patients with

NSTEMI or unstable angina compared with the

single use of aspirin (Yusuf et al., 2001).

Beta blockers are used to treat hypertension,

angina, supraventricular heart arrhythmias,

myocardial infarction, and chronic heart failure

(Aaronson & Ward, 2008). A meta-analysis of 147

randomized controlled trials with 464,000 patients

proposes beta-blockers as the first-line therapy in

CAD patients. In the first two years after myocardial

infarction, beta blockers can reduce cardiovascular

events twice than other antihypertensive agents

(Law et al., 2009).

Besides beta-blockers, another widely prescribed

antihypertensive drug found in this research was

candesartan from the Angiotensin Receptor Blocker

class (ARB). Sakamoto et al. (2016) develop a

randomized controlled trial involving 1,145 patients

who received different treatments after the PCI

procedures, namely (1) candesartan plus standard

medical treatment and (2) conventional medical

treatment during the follow-up in the succeeding

three years. They prove that the administration of

candesartan soon after PCI treatment does not

improve the prognosis, but it reduces some cardiac

events for three (3) years.

Statins are the drug of choice for lowering LDL

cholesterol, and they are used up to the highest

tolerable dose to achieve targeted LDL cholesterol

concentrations (PERKI, 2013). According to Cerit et

al. (2016), patients who have stable CAD after PCI

and receive a long-term statin therapy are associated

with increased epicardial perfusion.

The description of the response of patients to

Percutaneous Coronary Intervention therapy is as

follows:

3.3 Restenosis Symptoms

The results showed that after PCI, CAD patients

could experience re-blockage (restenosis). The

restenosis symptoms observed in this research

included chest pain and dyspnea (Table 5).

Not every sampled patient in this research

exhibited the symptoms of restenosis. Nineteen (19)

patients (29.23%) had no symptoms of restenosis, 28

patients (43.08%) showed one symptom of

restenosis, and the remaining 18 patients (27.69%)

had two symptoms of restenosis. According to

Aaronson & Ward (2008), restenosis can occur in

30% of CAD patients within six months after the

PCI procedure. The results of this research showed

that CAD patients experienced the symptoms of

restenosis within ≤6 months (23.08%) and >6

months (76.92%) after the procedure.

3.4 Lifestyle Intervention

The goal of lifestyle intervention is to prevent

cardiovascular complications in patients with DM,

cholesterol, and hypertension to improve their

Table 4: The drug use

rofile

Type of drugs N= 493 (%)

Acetylsalicylic

acid

59 11.97

Clopidogrel 47 9.53

Bisoprolol

fumara

55 11.16

Candesartan 45 9.13

Simvastatin 60 12.17

hers 227 46.04

(Source: Primary data analysis, 2018)

Table 5: The incidence of restenosis

The incidence of

restenosis

Number of

patients (n)

(%)

o restenosis 19 29.2

1 symptom

(chest pain or

spnea)

28 43.1

2 symptoms

(chest pain and

spnea)

18 27.7

Total 65 100

(Source: Primary data analysis, 2018)

Table 6: The distribution of CAD patients with

dyslipidemia disease according to total cholesterol

levels post PCI therapy

Total cholesterol

= 58 (%)

ormal

(<200 mg/dL)

24 41.38

Abnormal

(≥200 mg/dL

34 58.62

(Source: Primary data analysis, 2018)

Post-therapeutic Response Evaluation of Patients Receiving Percutaneous Coronary Intervention at the Regional Hospital in Bantul,

Yogyakarta

glycemic control and reduce the occurrence of

dyslipidemia and hypertension (Blumenthal et al.,

2011). The following tables show the results of the

laboratory analysis of CAD patients with the

comorbidities of dyslipidemia, hypertension, and

diabetes mellitus (DM).

Tables 6, 7, 8, and 9 show that after receiving the

pharmacological and PCI procedures, the number of

patients with abnormal cholesterol levels is higher

than the normal ones. This condition indicates that

not every sampled patient in this research adheres to

the suggested pharmacological therapy and lifestyle.

According to Sari & Husna (2016), there is a

relationship between lifestyle and the ability to

control cholesterol in patients with

hypercholesterolemia. Unhealthy lifestyles may

induce high cholesterol levels. The choice of

lifestyle is influenced by the prominent development

of the era, such as the emergence of an environment

that somehow enables excessive consumption of

junk food, low physical activity, and lack of health

awareness. According to the ESC/EAS Guidelines

for the Management of Dyslipidaemias (ESC, 2011),

lifestyle interventions, including a dietary plan that

reduces saturated fatty acids, have a major impact on

LDL levels. An additional of 1% energy from the

saturated fat increases LDL levels by 0.02-0.04

mmol/L or 0.8-1.6 mg/dL.

The recommendations of the Eighth Joint

National Committee (JNC 8) on the blood pressure

targets for hypertensive patients without diabetes

mellitus and Chronic Kidney Disease (CKD) aged

<60 years and ≥60 years are <140/90 mmHg and

<150/90 mmHg, respectively. Meanwhile, in

hypertensive patients with diabetes mellitus or CKD,

the targeted blood pressure is different, that is

<140/90 mmHg (James et al., 2013).

In this research, there were 17 patients with

hypertension and 1 patient with Hypertensive Heart

Disease (HHD). Among these 18 patients, 13

(72.22%) had blood pressure above the target.

Meanwhile, the remaining five patients had normal

blood pressure (27.78%) (Table 10). This finding

indicates that not every patient in this research

adheres to the suggested pharmacological therapy

and lifestyle.

Lifestyle interventions for hypertensive patients

include weight loss for overweight or obese patients,

the reduction of salt intake to 1,5 grams per day, and

Table 7: The distribution of CAD

atients with

dyslipidemia disease according to LDL cholesterol

levels post PCI therapy

LDL cholesterol N= 58 (%)

ormal

(<100 mg/dL)

4 6.9

Abnormal

(≥100 mg/dL)

54 93.1

(Source: Primary data analysis, 2018).

Table 9: The distribution of CAD

atients with

dyslipidemia disease according to triglycerides post

PCI therapy

Triglycerides

= 58 (%)

ormal

(<150 mg/dL)

17 29.31

Abnormal

(≥150 mg/dL)

41 70.69

(

Source: Primar

data anal

sis

2018

)

Table 8: The distribution of CAD

atients with

dyslipidemia disease according to HDL cholesterol

levels post PCI therapy

HDL cholesterol N= 58 (%)

Normal

(≥40 mg/dL)

16 27.59

Abnormal

(<40 m/dL)

42 72.41

(Source: Primary data analysis, 2018)

Table 10: The distribution of CAD

atients with

hypertension according to blood pressure levels post

PCI therapy

Blood pressure

levels

= 18 (%)

ormal 5 27.78

Abnormal 13 72.22

(

Source: Primar

data anal

sis, 2018

)

Table 11: The distribution of CAD

atients with

diabetes mellitus disease according to HbA1c post

PCI therapy

HbA1c

= 8 (%)

ormal

(<7.0 %)

4 50

Abnormal

(≥7.0 %)

4 50

(Source: Primary data analysis, 2018)

MICH-PhD 2018 - 1st Muhammadiyah International Conference on Health and Pharmaceutical Development

regular physical activity. They also advise more

consumption of fruits and vegetables (300 grams)

and the reduction of saturated fat and cholesterol

intake (ESC, 2016).

Based on the results of this research, eight CAD

patients had Diabetes Mellitus (DM) after PCI

therapy. Half of them had normal HbA1c

(hemoglobin glycate) level, whereas the remaining

50% had abnormal HbA1c levels (Table 11). This

finding indicates that not every patient in this

research adheres to the recommended

pharmacological therapy and lifestyle.

According to the consensus PERKENI (2015),

physical exercise is one of the pillars in the

management of DM if not accompanied by

nephropathy. It is useful for maintaining the body’s

fitness and improving insulin sensitivity. It is not the

only factor that controls the HbA1c levels of DM

patients, but a good dietary intake (as recommended)

and oral hypoglycemic drugs or insulin also play a

role in shaping blood sugar levels.

3.5 Pharmacological Management

In this study, three (3) patients experienced the side

effects of Adverse Drug Reactions (ADRs) (Table

12), namely cough, as induced by the administration

of captopril and ramipril.

Captopril and ramipril are from the class of

Angiotensin Converting Enzyme Inhibitor (ACEi)

drug that inhibits Renin-Angiotensin System (RAS).

ACE is an important enzyme in the renin-

angiotensin system that converts angiotensin I to

angiotensin II on the surface of endothelial cells.

Angiotensin II is proven to cause vasoconstriction in

blood vessels. The inhibition of this enzyme can lead

to vasodilation and, consequently, decreased blood

pressure (Herman & Bhimji, 2017).

In addition to lowering blood pressure with the

inhibition of angiotensin II formation, ACEi also

inhibits bradykinin degradation and stimulates the

synthesis of other vasodilators, such as prostaglandin

E2 and prostacyclin. Bradykinin increases in the

body, accumulates in the respiratory tract, and then

stimulates the incidence of a dry cough (Zamora &

Parodi, 2010; Nishio et al., 2011).

4 CONCLUSIONS

Based on the results of this research, several

responses of CAD patients to PCI therapy include

restenosis symptoms (70.77%)―consisting of 1

restenosis symptom (43.08%) and 2 restenosis

symptoms (27.69%), uncontrolled lifestyle

intervention―such as abnormalities in total

cholesterol (58.62%), LDL cholesterol (93.10%),

HDL cholesterol (72.41%), triglyceride (70.69%),

blood pressure (72.22%), and HbA1c (50%), and

adverse drug reaction (4.62%).

ACKNOWLEDGMENTS

This research was supported by Universitas

Muhammadiyah Yogyakarta, Indonesia. The author

would like to thank the research assistant, Monia

Agni Wiyatami, for her insight and time that greatly

assisted the research.

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Yogyakarta

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MICH-PhD 2018 - 1st Muhammadiyah International Conference on Health and Pharmaceutical Development