Askep Pada Acute Coronary Syndrome (Acs)

ASKEP PADA ACUTE
CORONARY SYNDROME
(ACS)
{
Overview of ACS
Acute Coronary
Syndromes*
1.57 Million Hospital Admissions - ACS
UA/NSTEMI STEMI
1.24 million 0.33 million

Admissions per year Admissions per year
*Primary and secondary diagnoses. About 0.57 million NSTEMI and 0.67 million UA.
Heart Disease and Stroke Statistics 2007 Update. Circulation 2007; 115:69171.
DEFINISI
Suatu sindroma klinik yang menandakan
adanya iskemia miokard akut, terdiri dari :

Infark miokard akut Q wave (STEMI)
Infark miokard akut non-Q (NSTEMI)
Angina pektoris tidak stabil (UAP)
Spektrum ischemia akut

STEMI
NSTEMI
UAP
3
PATOGENESIS
Umumnya disebabkan oleh
aterosklerosis koroner
Plak aterosklerosis ruptur
terbentuk trombus diatas ateroma
yang secara akut menyumbat lumen
koroner
Apabila sumbatan terjadi secara total
hampir seluruh dinding ventrikel
4
akan nekrosis
The cardiovascular continuum of events
Ischemia = oxygen supply

and demand imbalance
Myocardial
Ischemia
CAD
plaque
Atherosclerosis
Risk Factors
( DYSLIPIDEMIA , BP, DM,
Insulin Resistance, Platelets,
Fibrinogen, etc)
Adapted from
Dzau et al. Am Heart J. 1991;121:1244-1263
Coronary
Thrombosis
Myocardial
Ischemia
CAD
Atherosclerosis
Risk Factors
Fibrinogen, etc)
Adapted from
ACS
Coronary
Thrombosis
Myocardial
Ischemia
CAD
Atherosclerosis
Risk Factors
Fibrinogen, etc)
Adapted from
Coronary
Plaque
Stable
UA/NSTEMI
STEMI
thrombosis
rupture
angina
Penyempitan
Pembuluh darah
Clinical Spectrum of Acute Coronary Syndrome
Acute Coronary Syndrome
Non-ST Segment ST Segment

Elevation Elevation
STEMI
NSTEMI
Unstable Non-Q-wave Q-wave
Angina Pectoris Acute Myocardial Infarction
Pathophysiology of Stable Angina and ACS
Pathophysiology ACS
Penurunan suplai O2
Asymptomatic
Stenosis
Myocardial Infarction
Anemia
Plaque rupture/clot
Peningkatan O2 Demand
Angina
Suplai dan demand tidak seimbang Ischemia
Myocardial ischemianecrosis
ACS PATHOPHYSIOLOGY
Distruption of coronary artery

plaque -> platelet
activation/aggregation
/activation of coagulation
cascade -> endothelial
vasoconstriction ->intraluminal
thrombus/embolisation ->
obstruction -> ACS
Severity of coronary vessel
obstruction & extent of
myocardium involved
determines characteristics of
clinical presentation
Unstable
NSTEMI STEMI
Angina
Non-occlusive
thrombus Complete thrombus
Non occlusive sufficient to cause occlusion
thrombus tissue damage &
mild ST elevations on
Non specific myocardial necrosis ECG or new LBBB
ECG
ST depression +/- Elevated cardiac
Normal cardiac T wave inversion on enzymes
enzymes ECG
More severe
Elevated cardiac symptoms
enzymes
Diagnosis
Anamnesis
Pemeriksaan Fisik
Pemeriksaan Penunjang :
1. Laboratorium
2. Elektrokardiografi
3. Thoraks Foto
HISTORY
PRODROMAL SYMPTOMS
History very valuable to establish D/. Prodoma : chest discomfort
unstable angina
1/3 symptoms for 1 4 wks
20% symptoms for < 24 hrs
Malaise, exhaustion
NATURE OF PAIN
Most patients
severe prolonged, 30 minutes - hours
Constricting, crushing, oppressing, compressing
heavy weight or squeezing in chest
Choking, vise-like, heavy pain or stabbing, knife-like, boring or
burning discomfort
Location : retrosternal, spreading frequently to both sides of the
chest with predilection to the left side
Often pain radiates down ulnar aspect of left arm, producing
tingling sensation in left wrist, hand and fingers
15
NATURE OF PAIN
SOME INSTANCES : pain begins in epigastrium, and simulates
abdominal disorder
Sometimes pain radiates to shoulders, upper extremities, neck, jaw and
interscapular region favoring the left side
Elderly : no chest pain but acute left ventricular failure and chest
tightness or marked weakness or syncope
Pain arises from nerve endings in ischemic or injured, but not necrotic,
myocardium
OTHER SYMPTOMS
50% nausea or vomiting in transmural infarcts
Occasionally diarrhea, profound weakness, dizziness, palpitation, cold
perspiration, sense of impending doom
Occasionally : cerebral embolism or systemic arterial embolism
16
Pain Patterns with Myocardial Ischemia
17
Anamnesis untuk UAP
3 kategori presentasi klinik UAP:

Angina saat istirahat (resting angina)
Angina awitan baru (new onset angina)
Angina yang bertambah berat
(increasing angina)
Riwayat penyakit dahulu :

Riwayat angina on effort, infark atau
operasi pintas
Riwayat penggunaan nitrogliserin
Identifikasi faktor-faktor risiko
18
PHYSICAL EXAMINATION
GENERAL APPEARANCE
Anxious, considerable distress, restless, fist on chest
(Levine sign)
LV failure & symp. stimulation : cold perspiration, pallor,
dyspnea, cough with frothy pink or blood-streaked
sputum.
Shock : cool, clammy skin, facial pallor, cyanosis,
confusion or disorientation
HEART RATE
Variable depending on underlying rhythm and degree or
ventr. failure
Most commonly, HR 100 110/min; > 95% patients :
VPBs within first 4 hours
19
BLOOD PRESSURE
Majority normotensive, but syst. BP may decline and diast.
BP may rise
Half of pts with inferior MI parasympathetic stimulation
: hypotension, bradycardia or both (Bezold Jarisch
reflex)
half of pts with anterior MI, sympathetic excess :
hypertension, tachycardia or both
TEMPERATURE AND RESPIRATION

Most pts with extensive MI fever within 24-48 hrs, fever
resolves by 4th or 5th day
Respiration due to anxiety and pain, in LV failure : resp.
rate correlates with degree of heart failure
20
JUGULAR VENOUS PULSE
JVP usually normal
RV infarction : marked jug. venous distension
CAROTID PULSE
Small pulse reduced stroke volume
Pulse alternans : severe LV dysfunction
21
CHEST
LV failure and/or LV compliance : moist rales
Severe failure : diffuse wheezing, cough + hemopthysis
1967 : Killip & Kimball : prognostic classification
Class I : patients free of rales or S3

II : rales < 50% lung fields +/- S3
III : rales > 50% lung fields, frequently
pulm. edema
IV : cardiogenic shock
22
Pemeriksaan Penunjang
Pemeriksaan EKG
Gambaran EKG infark miokard akut Q-wave

(STEMI) :
Elevasi segmen ST 1 mm pada 2

sadapan extremitas
Atau 2 mm pada 2 sadapan prekordial

yang berurutan
23Atau gambaran LBBB baru atau diduga baru

ST-segment elevation
Gambaran EKG infark miokard akut non-Q-wave (NSTEMI) atau
angina pektoris tidak stabil (UAP) :
Depresi segment ST atau gelombang T terbalik pada 2 sadapan

berurutan
Inversi gelombang T minimal 1 mm pada 2 sadapan atau lebih

yang berurutan.
Perubahan segment ST saat keluhan dan kembali normal saat

keluhan hilang sangat menyokong UAP
27
ST-segment depression
T-wave inversion
ELEKTROKARDIOGRAM
Current-of-injury patterns with acute

ischemia
30
Pemeriksaan Penanda Jantung/Enzim
jantung
(Cardiac Markers):
Yang lazim adalah CKMB, dapat pula troponin T

(TnT) atau troponin I (TnI)
Peningkatan marka jantung akan terlihat pada

infark miokard akut Q-wave (STEMI) dan non-Q-
wave (NSTEMI)
31
Plot of the appearance of cardiac markers in
blood versus time after onset of symptoms
32
A myoglobin C CK-MB
B troponin D troponin in UA
TIMI RISK SCORE increase in mortality with increasing score
~40% all cause mortality at 14 days for patients requiring urgent
revascularisation
Diagnosis Banding
1. Diseksi aorta
2. Perikarditis
3. Nyeri angina atipikal pada kardiomiopati
hipertrofi
4. Penyakit esofageal, GI atas atau traktus
biliaris
5. Penyakit paru-paru : pneumotoraks,
emboli, pleuritis
6. Sindroma hiperventilasi
7. Gangguan dinding dada : muskuloskeletal,
35
neurogen
8. Psikogen
Gangguan perfusi jaringan jantung b.d.
obstruksi (aterosklerosis, spasmus, trombus)
Nyeri b.d. ischemia mioakrdium
Cemas b.d. ancaman kematian
Resiko penurunan CO b.d aritmia, penurunan
kontraktilitas jantung
DIAGNOSA
KEPERAWATAN
Manajemen
ACS
Coronary
Thrombosis Arrhythmia and
Loss of Muscle
Myocardial
Ischemia Remodeling
Ventricular
CAD Dilatation
Atherosclerosis Congestive
Heart Failure
Risk Factors End-stage Heart

( DYSLIPIDEMIA , BP, DM, Disease
Fibrinogen, etc)
Adapted from
DELAY TO THERAPY
1. From onset of symptoms to patient

recognition
2. Out-hospital transport
3. In-hospital evaluation
ISCHEMIC CHEST PAIN ALGORYTHM
Chest pain suggestive of ischemia
ISCHEMIC CHEST PAIN
TYPICAL ANGINA EQUIVALENT ANGINA
1. NO CHEST DISCOMFORT
1. CHEST DISCOMFORT 2. LOCATION
2. LOCATION 3. INDIGESTION
3. RADIATION 4. UNEXPLAINED WEAKNESS
4. UNLIKELINESS 5. DIAPORESIS
6. SHORTNESS OF BREATH
Acute coronary syndrome
algorithm
Chest discomfort suggestive of ischemia
Immediate ED assessment and immediate ED general treatment
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
Immediate ED assessment ( 10 min) Immediate ED general treatment

Vital sign O2 at 4 L/min (maintain O2 sat 90%)
Oxygen saturation Aspirin 160-325 mg
Obtain IV access Nitroglycerin SL, spray, or IV
Obtain ECG 12 lead Morphine IV 2-4 mg repeated every
Brief history and physical exam 5-10 minutes (if pain not relieved
Check contraindication for fibrinolytic with nitroglycerine)
Initial serum cardiac markers
Initial electrolyte and coagulation Memory: MONA greets all patients
study
Portable chest x-ray ( 30 minutes)
Acute coronary syndrome algorithm
Review initial 12 lead ECG
ST elevation or new or
presumably new LBBB
strongly suspicious for
injury
ST elevation or new or ST-depression or

presumably new LBBB dynamic T-wave
strongly suspicious for inversion strongly
injury suspicious for injury
ST elevation or new or ST-depression or Normal or non-

presumably new LBBB dynamic T-wave diagnostic changes
strongly suspicious for inversion strongly in ST-segment or T-
injury (STEMI) suspicious for injury waves (intermediate/
(UA/NSTEMI) low-risk UA)
ST elevation or new or ST-depression or Normal or non-

presumably new LBBB dynamic T-wave diagnostic changes
strongly suspicious for inversion strongly in ST-segment or T-
injury (STEMI) suspicious for injury waves (intermediate/
(UA/NSTEMI) low-risk UA)
Start adjunctive treatment
ADJUNCTIVE TREATMENT
(Do not delay reperfusion)
1. Beta-adrenergic receptor
blocker
2. Clopidogrel
3. Heparin (UFH or LMWH)
ST elevation or new or ST-depression or dynamic Normal or non-

presumably new LBBB T-wave inversion strongly diagnostic changes in
strongly suspicious for suspicious for injury ST-segment or T-
injury waves
Start adjunctive treatment
Time from onset of

symptoms
12 hours
- Reperfusion strategy: PCI (90
min) or fibrinolysis (30 min)
- ACE-I/ARB
- Statin

injury waves
Start adjunctive treatment Start adjunctive treatment
Time from onset of

symptoms
12 hours
- Reperfusion strategy: PCI (90 min) or
fibrinolysis (30 min)
- ACE-I/ARB within 24 hours of onset
- Statin
Adjunctive treatment
Heparin (UFH/LMWH)
Glycoprotein IIb/IIIa receptor inhibitors
-Adrenoreceptor blockers
Clopidogrel

injury waves
Start adjunctive treatment Start adjunctive treatment
Time from onset of 12 hrs Admit to monitored bed

symptoms Assess risk status
12 hours
- Reperfusion strategy: PCI (90 - High risk: early invasive
min) or fibrinolysis (30 min) strategy
- ACE-I/ARB within 24 h of - Continue ASA, heparin,
symptom onset) ACE-I, statin
- Statin
VERY HIGH-RISK PATIENT
1. Refractory chest pain
2. Recurrent/persistent ST
deviation
3. Ventricular tachycardia
4. Hemodynamic instability
5. Sign of pump failure
6. Shock within 48 hours

injury waves
Start adjunctive treatment Start adjunctive treatment Develops high or

intermediate risk criteria
or troponin-positive
Time from onset of 12 hrs Admit to monitored bed
symptoms Assess risk status
Monitored bed in ED
12 hours
- Reperfusion strategy: PCI (90 - High risk: early invasive
strategy Develops high or
min) or fibrinolysis (30 min)
- ACE-I/ARB within 24 h of - Continue ASA, heparin, intermediate risk criteria
ACE-I, statin or troponin-positive
symptom onset)
- Statin
No evidence of ischemia and MI: discharge with follow-up
Early Invasive
Conservative
Evaluate for conservative vs. invasive strategy based upon:
Likelihood of actual ACS
Risk stratification by TIMI risk score
ACS risk categories per AHA guidelines
Low High
Unstable angina/NSTEMI
Intermediate cardiac care
Pengobatan Pasca Perawatan
Obat-obat untuk mengontrol keluhan iskemia
harus dilanjutkan
Aspirin
Beta-blocker
ACE inhibitor
Modifikasi Faktor Risiko

Berhenti merokok
Pertahankan BB optimal
Aktivitas fisik sesuai dengan hasil treadmill
Diet
Rendah lemak jenuh dengan kolesterol, bila
perlu dengan target LDL < 100 mg/dL
Pengendalian hipertensi
60
Pengendalian ketat gula darah pada
penderita DM
Terima Kasih
Selamat Belajar
Get regular medical checkups.
Control your blood pressure.
Check your cholesterol.
Prevention
Dont smoke.
Exercise regularly.
Maintain a healthy weight.
Eat a heart-healthy diet.
Manage stress.

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Askep Pada Acute Coronary Syndrome (Acs)

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ASKEP PADA ACUTE

1.57 Million Hospital Admissions - ACS

1.24 million 0.33 million

Suatu sindroma klinik yang menandakan

adanya iskemia miokard akut, terdiri dari :

Angina pektoris tidak stabil (UAP)

Spektrum ischemia akut

Ischemia = oxygen supply

Non-ST Segment ST Segment

Distruption of coronary artery

3 kategori presentasi klinik UAP:

Riwayat penyakit dahulu :

TEMPERATURE AND RESPIRATION

Class I : patients free of rales or S3

Gambaran EKG infark miokard akut Q-wave

Elevasi segmen ST 1 mm pada 2

Atau 2 mm pada 2 sadapan prekordial

23Atau gambaran LBBB baru atau diduga baru

Depresi segment ST atau gelombang T terbalik pada 2 sadapan

Inversi gelombang T minimal 1 mm pada 2 sadapan atau lebih

Perubahan segment ST saat keluhan dan kembali normal saat

Current-of-injury patterns with acute

Yang lazim adalah CKMB, dapat pula troponin T

Peningkatan marka jantung akan terlihat pada

Risk Factors End-stage Heart

1. From onset of symptoms to patient

TYPICAL ANGINA EQUIVALENT ANGINA

Immediate ED assessment and immediate ED general treatment

Immediate ED assessment ( 10 min) Immediate ED general treatment

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or Normal or non-

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or Normal or non-

3. Heparin (UFH or LMWH)

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or dynamic Normal or non-

Start adjunctive treatment

Time from onset of

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or dynamic Normal or non-

Start adjunctive treatment Start adjunctive treatment

Time from onset of

Glycoprotein IIb/IIIa receptor inhibitors

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or dynamic Normal or non-

Start adjunctive treatment Start adjunctive treatment

Time from onset of 12 hrs Admit to monitored bed