Acut Coronary Sindrome

Dr.Hariyono
Medical Surgical Nursing
Department
2017
OBJECTIVES
 To describe ECG changes in angina and AMI
 to differentiate the different types of infarct using
a 12-lead ECG
ANGINA

 Coronary arteries are unable to deliver enough blood

due to narrowing, platelet clumping, thrombus formation
or vasospasm
 Usually lasts 2 - 10 minutes

3
Stable vs. Unstable Angina
 Stable - triggered by exertion & relieved by rest or
GTN
 Unstable - pain comes on easily & gets worse;
warning sign of impending AMI
 Drugs - nitrates, beta blockers, calcium channel
blockers, & aspirin to reduce platelet aggregation
History of IMA

• 1980’s – pathology of acute MI was recognized

to be > 90% thrombus formation
Management Revolution
• Thrombolytic therapy
• Percutaneous transluminal coronary
angioplasty (PTCA)
•Coronary Stent Placement
Epidemiology

• Rapidly growing cause of

death world wide
• 45% of acute MI occur in
people less than 65 years old
 DEFINITION
 Kematian / nekrosis sel jantung akibat
 keb metabolik jtg dan/  O2 &
nutrien ke jtg mell sirkulasi koroner
(Bajzer, 2002)

 Heart attack, oklusi koroner : suatu

kondisi mengancam jiwa yg
dikarakteristikkan o/ formasi area
nekrosis yg terlokalisir pada
miokardium (Black & Jacobs, 1997)
Physiology - ACS

• Acute Myocardial Infarction (AMI)

• Myocardial necrosis
• WHO guidelines
• 2 of 3 criteria need to be met
• Clinical history
• EKG changes (ST elevation MI)
• Cardiac Serum Markers
Pathology - ACS

Steps to Coronary Artery Occlusion

• Endothelial damage occurs
• Atherosclerotic plaque disruption
• Platelet aggregation
• Thrombus formation
Coronary Artery Without Evidence of
Plaque

Source: University of Utah WebPath

Coronary Artery with Significant
Plaque Formation

In addition
to reduced
Lumen size,
there is also
a calcified
portion (right
side of
photo)

Source: University of Utah WebPath

Coronary Artery with Significant Plaque
Formation

Source: University of Utah WebPath

 Coronary Artery With Plaque and
Thrombus Formation
A - Coronary
Artery cross-
section

B - Lumen

C - Fissured
Plaque w/o
Cap

D - Acute
thrombus

Source: Emergency Cardiovascular Care Library (CD-ROM), American Heart Association, Dallas 1997
Plaque and Thrombus Formation
Resulting in Occlusion

Source: University of Utah WebPath

Coronary Artery Thrombus

The external
anterior
view of the
heart shows
a dark clot
formation in
this artery

Source: University of Utah WebPath

Pathology - ACS

Vasospasm
• Post-thrombus  release of mediators
• Epinephrine  platelet aggregation
• Increased alpha receptors within minutes
• Vasospasm can be primary
• Vasospasm  thrombus formation
• 10% of MI’s occurring with no CAD
 ETIOLOGY
Aterosklerosis (Most common)

Risk Factors :
  kolesterol darah
 DM
 Hipertensi
 Merokok
 Gender 
 Riw penyakit klg.
Taken from dr.Dadang H material in Seminar Regional Keperawatan Critical Care in Coronary Heart Disease
Taken from dr.Dadang H material in Seminar Regional Keperawatan Critical Care in Coronary Heart Disease
Taken from dr.Dadang H material in Seminar Regional Keperawatan Critical Care in Coronary Heart Disease
Presentation - ACS
History
• Chest Pain, Pressure “crushing pain”
• Dyspnea
• Diaphoresis
• Jaw and neck pain – viseral pain
• Radiation of pain to arms
• Nausea
• Flu like symptoms
 Clinical Characteristics of Angina

Characteristic More likely to be angina Less likely to be angina

Type of pain Dull, pressure Sharp, stabbing

Duration 2 to 5 min, always <15– Seconds or hours

20 min
Onset Gradual Rapid

Location Substernal Lateral chest wall, back

Reproducible With exertion With inspiration

Associated Present Absent

symptoms
Palpation of chest Not painful Painful, exactly
wall reproduces pain
Signs & Symptoms

  TD (pain response) or
TD (CO akibat iskemia)
 Khawatir dan takut
 Dengan/tanpa mual, muntah

PARAMETER EVALUASI IMA

2 of 3 from :
1. Klinis : chest pain, history
2. ECG : Q patologis, ST elevasi
3. Enzim : CPK, LDH, CKMB
SGOT, SGPT
 PATHOPHYSIOLOGY
Plak pada arteri koroner

Aktivasi Platelet
Aspirin
Agregasi Platelet Pbentukan Trombus
Terapi
Trombolitik
Iskemia jaringan

Suplai darah koroner < dari keb

Nitrat
Beta Bloker Nekrosis sel miokard
 Nekrosis sel miokard

1. Prbhn repolarisasi miokard  Segmen ST

Muncul glmb Q

2. Pelepasan enzim lisosom

 CPK-MB
 LDH

3. Glikolisis anaerob Prod as. laktat

Angina Nitrogliserin

4. Iritabilitas miokard
Antidisritmia

Disritmia
5. Kontraktilitas  Fgs ventrikel kiri

Keb O2  Pre Load Inhibitor

 HR enzim
Converting
Restriksi
Angiotensin
Cairan
 after load
CO
Nitrat  CVP
PCWP
TD 
Vasokonstriksi
Syok Kardiogenik

†

MYOCARDIAL NECROSIS

Q waves
•are seen only in leads that face the infarcted area.
•may develop within an hour of an infarct / a few days
later.
•1/3 R wave.
2
:

2
3
3
 Assessing AMI

3
 TREATMENT
American Heart Association (2000)

Immediate Immediate Assessment

Treatment  TTV, Saturasi O2, infus
Morfin  ECG 12 lead
Oksigen  Riw & PF singkat dan tepat
(identifikasi reperfusi therapy)
Nitrogliserin  Lab : enzim, elektrolit, koagulasi
Aspirin  CXR < 30 menit
 Kaji : RR>100x/mnt, Sis<100mm Hg
or Edema pulmonal or tanda2 syok
MORFIN
 Action: Venodilator, CNS analgesia ( ansietas),
 resistensi vaskular sistemik
 Dose : 2-4 mg IV, ulangi tiap 5 menit
 Contraindication : hipotensive, depresi napas

OKSIGEN
 Action : Limit ischemic myocard,  ST elevasi
 Dose : 4 L/menit per nasal cannula
NITRAT/NITROGLISERIN
 Action : Vasodilation, relaks otot polos vaskuler
 Dose : IV (25g bolus, 10-20g/min infusion) or
SL (0,4 mg, ulangi 2x dlm interval 5 menit)
 Contraind : Sistolik <90 mm Hg, bradi/takikardia

ASPIRIN
 Action : Hambat agregasi platelet
 Dose : 160-325 mg Orally, crushed/chewed
325 mg supositoria if nausea, vomiting
 Contraind : peptic ulcer disease (use rctal supp),
alergi, bleeding disorder, severe hepatic disease
 ED Algorithm/Protocol
for Patients with symptoms & signs of AMI
(AHA/ACC, 2000)

Onset of symptoms

ED triage or charge nurse triages patients

•AMI symptoms and signs
•12 lead ECG
•Brief, targeted history
ED NurseEmergency
nursing care
ED Physician
•Cardiac monitor evaluates patients
•Oxygen Therapy
•IV D5W •History
•Blood Studies •Physical exam
•Nitrogliserin •Interpret ECG
•Aspirin

uncertain
AMI Patients? Consult
 Yes AMI Patients No
Uncertain

Candidate for Consult Evaluate Further

fibrinolytic therapy

Conduct education
Fibrinolytic & follow-up
Indikasi Pengobatan
Therapy Lain :
instruction

•Obat lain utk AMI

(b bloker, heparin,
aspirin, nitrat)
•Transfer to cath lab for Release
PTCA/surgery for CABG
Admit
 NURSING CARE
PENGKAJIAN

AKTIVITAS
 Tanda : kelemahan, kelelahan, tdk dpt tidur,
olahraga yg tdk teratur
 Gejala : takikardia, dispnea saat istrht

NEUROSENSORI
 Tanda : perubahan mental & kelemahan
 Gejala : pusing, berdenyut slm tidur/saat bgn
(duduk/istirahat)

HIGIENE
 Gejala : kesulitan merawat diri
SIRKULASI
 Gejala : riw. IMA, PJK, GJK, hipertensi, DM
 Tanda : TD = /, hipotensi postural
N = dpt N, lemah/kuat, disritmia mgk terjadi
BJ = S3/S4 tunjukkan adanya gagal jantung,
irama jantung dapat teratur atau tidak
Edema = dist vena jugularis, edema
Warna = pucat/sianosis

INTEGRITAS EGO
 Gejala : menyangkal, takut mati, marah, kuatir
 Tanda : kontak mata -, gelisah, marah, fokus
pada diri sendiri/nyeri
ELIMINASI
 Tanda : normal/fungsi menurun

MAKANAN/CAIRAN
 Gejala : mual, nafsu makan, nyeri ulu hati
 Tanda : muntah, turgor , perubhn BB, keringat

PERNAPASAN
 Gejala : dispnea dgn/tnpa aktivitas, batuk
dgn/tnpa sputum, riw mrokok, peny napas kronis
 Tanda : RR, sesak, pucat, sianosis, bunyi napas
bersih/krekels/mengi.
 NURSING CARE
PENGKAJIAN

PEMERIKSAAN DIAGNOSTIK

1. ECG : ST elevasi, T inversi, Q patologis

2. Enzim Jtg :
*CPK :  3-6 h,  12-24 h, N 36-48 h
*CK-MB :  2-4 h, 12-20 h, N 48-72 h
*LDH :  12-24 h,  24-48 h,N dlm wk lama
3.Lab : elektrolit (hiperkalemia & hipokalemia),
SDP , sedimentasi , BGA (hipoksia),
kolesterol 
4. CXR : N / kardiomegali
 NURSING CARE
PRIORITAS KEPERAWATAN & TUJUAN PEMULANGAN

PRIORITAS TUJUAN
KEPERAWATAN PEMULANGAN

 Nyeri/cemas hilang  Nyeri dada

hilang/terkontrol
  kerja miokard
 Irama/kec jtg mampu
 Mcegah/mdeteksi & pertahankan CO
mbantu pengobatan  Tahap aktivitas
disritmia yg perawatan dasar 
mengancam  ansietas /teratasi
hidup/komplikasi  Pahami proses peny, renc
  kes jtg, self care pengobatan & prognosis
 NURSING CARE
DAFTAR DIAGNOSA KEPERAWATAN

1. Nyeri (akut) b.d iskemia jar sekunder thd

sumbatan arteri koroner
2. Penurunan curah jantung bd ketidak stabilan
elektrofifiologis dan ganguan status inotropik
3. Penurunan perfusi jaringan b.d curah jantung
tidak efektif
 Diagnosa Keperawatan 1
Tujuan : K myatakn nyeri dada -/tkontrol
Intervensi & Rasional
MANDIRI
1. Pantau/catat karakteristik nyeri, petunjuk
verbal & nonverbal, respons hemodinamik
(meringis, menangis, keringat, RR, TD brubah)
R/ katekolamin  TD & RR
2. Kaji nyeri untuk memvalidasi sumber iskemic
R/ sumber iskemic dapatmengevaluasi
keparahan nyeri
3.Bantu lakukan teknik relaksasi spt napas dalam,
distraksi, visualisasi, bimbingan imajinasi
R/ mbantu dlm p persepsi sensori, kontrol
situasi & perilaku positif
4.Periksa TTV sblm & ssudah pemb obat narkotik
R/ hipotensi & depresi napas dpt tjd sbg akibat
pemberian narkotik.
KOLABORASI
5.Berikan O2 dgn nasal kanul/masker
R/  kadar O2 untuk uptake miokard &
ketidaknyamanan  krn iskemia
6. Berikan obat : antiangina, analgesik,
penyekat saluran kalsium, b bloker
 Hazinski, et al (2000). Handbook of Emergency Cardiovascular Care. American
Heart Association
 Lanros & Barber (1997). Emergency Nursing : with certification, Preparation, &
Review. USA : Appleton & Lange
 Springhouse corporation book division (1985). Nurse’s Reference Library
:Emergencies. Pennsylvania : Springhouse corporation
 Talbot & Marquadt (1995). Pengkajian Keperawatan Kritis. Edisi 2. Jakarta :
EGC
 Doengoes et al (1995). Nursing Care Plans : Guidelines for Planning and
Documenting Patient Care. Edition 3. Philadelphia : F.A Davis Company
 Bajzer (2002). Acute Myocardial Infarction. The Cleveland Clinic Foundation
 Huddleston & Ferguson (1990). Critical Care And Emergency Nursing : A Study
Learning Tool. Pennsylvania : Springhouse
 Black & Jacobs (1997). Medical Surgical Nursing : Clinical Management for
Continuity Care. Edition 5. USA : W.B Saunders Company
 Makalah Seminar Regional Keperawatan : Critical Care in Coronary Heart
Disease (2003). Malang
 http://medlib.med.utah.edu/WebPath/TUTORIAL/MYOCARD/MYOCARD.html
 http://www.critical-nurse.org/AACN/jrnlccn.nsf/Get...
 http://www.acc.org/clinical/guidelines/nov96/jac1716plVa.htm
 http://www.americanheart.org/
 IMA merupakan kematian pada jaringan
jantung yang diakibatkan kekurangan suplai
darah & oksigen.
 Diagnosis awal IMA adalah penting mengingat
kematian banyak terjadi pada beberapa jam
pertama dari kejadian
 Penanganan yang paling efektif dilakukan
secepat mungkin setelah awitan kejadian