Coronary Emergency

Cardiovascular
Emergency
Ns. Ryan Budiyanto,Skep
INTENSIVE & ACUTE CARDIOVASCULAR CARE UNIT

NATIONAL CARDIOVASCULAR CENTER HARAPAN KITA
budiyantoryan@gmail.com
Outline
Blood stops causing damage or
death to the heart muscle
• Introduction
• Background/epidemiology
• Definition
• Etiology
• Pathophysiology
• Classification
• Complication
• Management
• Every 40 seconds,
someone in the United
States has a heart attack
• More than half of the
deaths due to heart
disease in 2015 were in
men
• Heart disease costs the
United States about $200
billion each year
CDC. (2015). Heart Attack Facts & Statistics. Retrieved from http://www.cdc.gov/heartdisease/heart_attack.htm
Introduction
Ischemic heart disease is the single most common cause of death and its
frequency is increasing.
now accounts for almost 1.8 million annual deaths, or 20% of all deaths
in Europe, large variations between countries1.
Myocardial infarction (MI) can be recognized by clinical features,

including electrocardiographic (ECG) findings, elevated values of
biochemical markers (biomarkers) of myocardial necrosis, and by
imaging, or may be defined by pathology2.
1. Ibanez, B.,et al. (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal, 39(2), 119–
177.
2. Thygesen, K., et al. (2012). Third universal definition of myocardial infarction. Circulation, 126(16), 2020–2035. https://doi.org/10.1161/CIR.0b013e31826e1058
Epidemiology
• The relative incidences of STEMI and NSTEMI are decreasing and increasing, respectively1
• European STEMI registry is found in Sweden, STEMI was 58 per 100 000 per year in
2015.1
• incidence rates from the USA decreased from 133 per 100 000 in 1999 to 50 per 100 000
in 20081.
• consistent pattern for STEMI to be relatively more common in younger than in older
people, and more common in men than in women1. NSTEMI remained constant or
increased slightly
• JACS Registry (2014-2015) Total amount 3015 patients with acute coronary syndrome,
which 1024 patients had STEMI 2.
• 2007, the ACS mortality was 6.6% and decreased to 4.1% in 20093.
• 2016, In hospital mortality of non-reperfused patients with STEMI was significantly
higher than patients with STEMI receiving primary PCI or fibrinolytic therapy (9.1% vs
3.2% vs 3.8%, p<0.0012.
1. Ibanez, B.,et al (2018). European Heart Journal, 39(2), 119–177.

2. Dharma, S., et al (2016). BMJ Open, 6(8), e012193.
3. Dharma, S., et al (2012). Netherlands Heart Journal, 20(6), 254–259. budiyantoryan@gmail.com
Classification of ACS
ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: European Heart Journal, 2011
The Universal Definition
• AMI should be used when there is evidence of myocardial infarction
in clinical setting consistent with acute myocardial ischemia.
Thygesen, K., et al. (2012). Third universal definition of myocardial infarction. Circulation, 126(16), 2020–2035. https://doi.org/10.1161/CIR.0b013e31826e1058
Etiology
• Atherosclerosis is the disease primarily responsible for most acute
coronary syndrome. Approximately 90% of myocardial infarctions
(MIs) result from an acute thrombus
• Non modifiable risk:
• Age
• Sex
• Family history of premature coronary heart disease
• Male-pattern baldness
Modifiable risk
• Smoking or other tobacco use
• Hypercholesterolemia and hypertriglyceridemia, including inherited lipoprotein disorders
• Dyslipidemia
• Diabetes mellitus
• Hypertension
• Obesity (abdominal obesity)
• Psychosocial stress
• Sedentary lifestyle and/or lack of exercise
• Reduced consumption of fruits and vegetables
• Type A personality
• Elevated homocysteine levels
• Presence of peripheral vascular disease
Zafari, A. M. (2018). Myocardial Infarction: Practice Essentials, Background, Definitions. Retrieved from https://emedicine.medscape.com/article/155919-overview
Pathophysiology
Classification
Sign and Symptoms
• Chest Pain > 20 minutes
• Chest Discomfort
• Anxiety
• Nausea with/Wo Vomitting
• Shortness of breath
• Profuse sweating
• Fullness, indigestion or choking
feeling
Zafari, A. M. (2018). Myocardial Infarction: Practice Essentials, Background, Definitions. Retrieved from
https://emedicine.medscape.com/article/155919 budiyantoryan@gmail.com
Suggestive Clinical Symptoms
Fadil, M. (2013). Pre Hospital and Initial Management of Acute Coronary Syndrome
Diagnosis
Roffi, M., et al. (2016). 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European
Heart Journal, 37(3), 267–315. https://doi.org/10.1093/eurheartj/ehv320
Diagnostic tools
✓ Physical examination
✓ Electrocardiogram
✓ Biomarkers
✓ Imaging
• Non-invasive imaging techniques
• Invasive imaging (CAG)
Acute pain in Myocardial infarct
Gaúcha De Enfermagem, R., Maria, S., Santos, J. Dos, Leite De Araújo, T., Cavalcante, T. F., Miguel, N., & Neto, G. (2015). Acute pain in myocardial infarction: analysis of
concept, 36(3), 102–8. https://doi.org/10.1590/1983-1447.2015.03.51203
ECG Criteria
• ST-segment elevation at the J point in
two contiguous leads
• ≥0.25 mV in men below the age of 40
years,
• ≥0.2 mV in men over the age of 40 years,
or ≥0.15 mV in women in leads V2–V3
and/or ≥0.1 mV in other leads
• Advisable to record right precordial
leads (V3R and V4R) seeking
• ST elevation identify concomitant right
ventricular
1. Thygesen, K., et al. (2012). Third universal definition of myocardial infarction. Circulation, 126(16), 2020–2035. https://doi.org/10.1161/CIR.0b013e31826e1058
2. Ibanez, B., et al. (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal, 39(2), 119–177.
https://doi.org/10.1093/eurheartj/ehx393
Moloney, B. (2012). Nursing Management of Patients with Cardiovascular Disease Part II : Acute Myocardial Infarction. Retrieved from http://www.crudem.org budiyantoryan@gmail.com
Cardiac biomarker
• Troponins are more specific

and sensitive than the
traditional cardiac enzymes such
as creatine kinase (CK), its
isoenzyme MB (CK-MB), and
myoglobin.
• Elevation of cardiac troponins
reflects myocardial cellular
damage
Cardiac-Biomarkers. (n.d.). Retrieved from http://www.cardiac-biomarkers.com/
ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: European Heart Journal, 2011
Biomarker detection of myocardial injury
1. Thygesen, K., et al. (2012). Third universal definition of myocardial infarction. Circulation, 126(16), 2020–2035.
https://doi.org/10.1161/CIR.0b013e31826e1058
Chest X ray
• Determine Acute heart failure

• Cardiac abnormality
Coronary Angiography
Complications
• Myocardial dysfunction
• Heart failure
• Arrhythmias
• Mechanical complication
• Pericarditis/ pericardial effusion
Ibanez, B., et al. (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal,
39(2), 119–177. https://doi.org/10.1093/eurheartj/ehx393
Management
What is the
new in 2017
version?
Principle of ACS management
Pre-hospital logistics of care
Reperfusion Therapy
Periprocedural Pharmacotherapy
Fibrinolytic therapy
Fibrinolysis Strategy is Preferred
• When Time To PCI > 12 Hour.

• The Goal to inject lytic bolus is
< 10 minutes after STEMI
diagnosis
Contraindication of fibrinolytic Therapy
Absolute
• Previous Intracranial haemmorage Relative
• Transient ischemic attack in the
• Ischemic stroke in the preceding 6 months preceding 6 months
• Central nervous system damage or neoplasma • Oral Anticoagulant therapy
or arteriovenous malformation • Pregnancy or within 1 Week post
partum
• GIT bleeding within the past month • Refractory Hypertension (SBP>180
and/or CBP >110 mmHg)
• Known Bleeding disorder (excluded menses) • Advanced Liver disease
• Aortic Dissection • Infective Endocardities
• Non-compressible puncture in the past 24 H( • Active peptic ulcer
Liver Biopsy, Lumbar Puncture) • Prolonged or traumatic resuscitation
Adapted from Ibanez, B., et al. (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European
Heart Journal, 39(2), 119–177. https://doi.org/10.1093/eurheartj/ehx393
Nursing Management
Priorities
• Relieve pain, anxiety.
• Reduce myocardial workload.
• Prevent/detect and assist in treatment of life-threatening
dysrhythmias or complications.
• Promote cardiac health, self-care.
Guidelines for management
• Assess : chest pain,
• Monitor : dysrhythmia Medication
M : Morphine
• ECG within 10 minutes
O : Oxygen
• IV access / Blood draw
N : Nitrate
• Oxygen/ medication
A : Aspirin
• Chest X ray
CO : Clopidogrel
Primary Assessment
Medical Cardiac Arrest Other Presentation

• D: Danger • D : danger
• R: response • R : Response
• C: Circulation • A : Airway
• A: Airway • B : Breathing
• B : Breathing • C : Circulation
Secondary Survey
Goal is To obtain detailed history
History O: onset S: sign and symptoms

P : Provocation A: Alergies
Q: Quality M : Medication
R : radiation P: past Medication
S : Severity L : Last Meal
T : Timing E : even prior
Vital Signs BP, HR, RR, Temp, SpO2 GCS, 12 Lead ECG
Physical Examination Head to Toe Complete assessment
Queensland Goverment. (2015). Clinical Practice Procedures: Assessment/Primary and secondary survey,
(October budiyantoryan@gmail.com
Nursing management
Triage and first assessment
• Physical Assessment Best Practice Recommendation

• Vital sign All nursing stations are
• history, past medication equipped with the following
• 12 lead ECG within 10 minutes minimum equipment:
• Cardiac Biomarker Blood is drawn • 12-Lead ECG,
on arrival of the patient in hospital • Cardiac monitors,
and the results should be available • Defibrillators.
within 60 min
Kingsbury, K. (2013). Management of Acute Myocardial Infarction, (September), 1–39. https://doi.org/10.1136/bmj.1.5171.497
Possible Nursing Diagnosis
• Acute pain related to myocardial ischemia
• Ineffective tissue perfusion (cardiac) related to myocardial injury and
potential pulmonary congestion
• Anxiety related to perceived or actual threat of death, pain, possible
lifestyle changes
• Ineffective therapeutic regimen management related to lack of
knowledge of risk factors, disease process, rehabilitation, home
activities, and medications
Nursing Intervention
Diagnosis NIC in Acute Cardiac Care
Acute pain related to myocardial Cardiac Care: Acute
ischemia • Evaluate chest pain
• Monitor effectiveness of oxygen therapy
• Administer medications to relieve/prevent pain and ischemia to
decrease anxiety and cardiac workload.
• Obtain 12-lead ECG during pain episode
• Monitor cardiac rhythm and rate and trends in blood pressure and
hemodynamic parameters
Ineffective tissue perfusion (cardiac) Monitor vital signs frequently to determine baseline and ongoing
related to myocardial injury and potential changes.
pulmonary congestion • Monitor for cardiac dysrhythmias,
• Monitor respiratory status for symptoms of heart failure
• Monitor fluid balance
• Arrange exercise and rest periods
Diagnosis NIC in Acute Cardiac Care
Anxiety related to perceived or actual Observe for verbal and nonverbal signs of anxiety.
threat of death, pain, possible lifestyle • Identify level of anxiety
changes • Use a calm, reassuring approach so as not to increase patient’s
anxiety.
• Instruct patient in use of relaxation techniques (e.g., relaxation
breathing, imagery)
• Encourage family to stay with patient to provide comfort.
• Encourage verbalization of feelings, perceptions, and fears to
decrease anxiety and stress.
• Provide factual information concerning diagnosis, treatment, and
prognosis to decrease fear of the unknown
Ineffective therapeutic regimen Teaching: Disease Process
management related to lack of knowledge • Appraise the patient’s current level of knowledge
of risk factors, disease process, • Explain the pathophysiology of the disease
rehabilitation, home activities, and • Discuss lifestyle
medications • Refer the patient to local community agencies/support groups
Teaching: Prescribed Medication •
Instruct the patient on the purpose and action of each medication.
• Instruct the patient on the dosage, route, and duration of each
medication
Nursing Role
Critical Point During Acute Phase
Evaluate/
Assess Action MONITOR
Review
These Should not delayed reperfusion treatment
Relief of pain, breathlessness, and
anxiety
Morphine Nitates
• Act : Pain killer • Action: Vasodilates, Dilates
• Dose 3-5 mg IV/SC coronary arteries, Increases
collateral blood flow
• Nurse Consideration :
• Dose: 5 mg SL ,Give every 5
Monitor for bradypnea, minutes for a total of 3 doses if
intoxication. Routine used is not needed, IV rute are more effective.
recommended
• Nursing considerations :Assess pain
and blood pressure after each dose
Relief of pain, breathlessness, and anxiety
ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation,2011 budiyantoryan@gmail.com
Double Anti-platelet
Aspirin Clopidogrel
• Action: Decrease platelet • Action : Inhibits platelet
aggregation aggregation
• Dose 160-300 mg chewed as • Dose : loading dose (300-600mg)
soon as ACS is suspected followed by 75mg daily
• Nursing considerations : • Nursing considerations : Allergy
Allergy ,Bleeding, Discontinue steroids &
avoid NSAIDS
Reperfusion
strategy in the
Infarct Related
Artery
Long term Strategies
• Lifestyle intervention and risk
factor control
• Smoking cessation
• Diet, alcohol, weight control
• Exercise based cardiac
rehabilitation
• Resumption of activities
• Blood pressure control
• Adherence to treatment
Time Is muscle
Favourable
outcome
Myocardial Infarct With Non-Obstructive
coronary arteries
Conclusions
• The very early stages of STEMI • Optimizing treatment of care
are most vulnerable time, should be based on
when most sudden cardiac implementing of network
death occur. between hospital, with various
• To minimize patient delay, it is level technologies linked by
recommended to increase prioritized and efficient
public awareness. ambulance service
• Reducing of total ischemic • Nurses has an important role to
time is a critical point provide high quality care,
minimizing delay, thereby
improving clinical outcomes.
References
• Cardiac-Biomarkers. (n.d.). Retrieved from http://www.cardiac-biomarkers.com/
• CDC. (2015). Heart Attack Facts & Statistics. Retrieved from http://www.cdc.gov/heartdisease/heart_attack.htm
• Dharma, S., Andriantoro, H., Purnawan, I., Dakota, I., Basalamah, F., Hartono, B., … Rao, S. V. (2016). Characteristics, treatment and in-hospital outcomes of patients
with STEMI in a metropolitan area of a developing country: an initial report of the extended Jakarta Acute Coronary Syndrome registry. BMJ Open, 6(8), e012193.
https://doi.org/10.1136/bmjopen-2016-012193
• Dharma, S., Juzar, D. A., Firdaus, I., Soerianata, S., Wardeh, A. J., & Jukema, J. W. (2012). Acute myocardial infarction system of care in the third world. Netherlands
Heart Journal, 20(6), 254–259. https://doi.org/10.1007/s12471-012-0259-9
• Fadil, M. (2013). Pre Hospital and Initial Management of Acute Coronary Syndrome. Retrieved from https://cardiologyupdateunand.files.wordpress.com
• Gaúcha De Enfermagem, R., Maria, S., Santos, J. Dos, Leite De Araújo, T., Cavalcante, T. F., Miguel, N., & Neto, G. (2015). Acute pain in myocardial infarction: analysis
of concept, 36(3), 102–8. https://doi.org/10.1590/1983-1447.2015.03.51203
• Hamm, C. W., Bassand, J.-P., Agewall, S., Bax, J., Boersma, E., Bueno, H., … Widimsky, P. (2011). ESC Guidelines for the management of acute coronary syndromes in
patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting
without persistent ST-segment elevation of the European Society of Cardiology (ESC). European Heart Journal, 32(23), 2999–3054.
https://doi.org/10.1093/eurheartj/ehr236
• Ibanez, B., James, S., Agewall, S., Antunes, M. J., Bucciarelli-Ducci, C., Bueno, H., … Zeymer, U. (2018). 2017 ESC Guidelines for the management of acute myocardial
infarction in patients presenting with ST-segment elevation. European Heart Journal, 39(2), 119–177. https://doi.org/10.1093/eurheartj/ehx393
• Kingsbury, K. (2013). Management of Acute Myocardial Infarction, (September), 1–39. https://doi.org/10.1136/bmj.1.5171.497
• Moloney, B. (2012). Nursing Management of Patients with Cardiovascular Disease Part II : Acute Myocardial Infarction. Retrieved from http://www.crudem.org/wp-
content/uploads/2012/01/Nursing-Management-Patients-w-CVD-Part2_Myocardial-Infarction_English.pdf
• Queensland Goverment. (2015). Clinical Practice Procedures: Assessment/Primary and secondary survey, (October).
• Roffi, M., Patrono, C., Collet, J.-P., Mueller, C., Valgimigli, M., Andreotti, F., … Windecker, S. (2016). 2015 ESC Guidelines for the management of acute coronary
syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal, 37(3), 267–315. https://doi.org/10.1093/eurheartj/ehv320
• Thygesen, K., Alpert, J. S., Jaffe, A. S., Simoons, M. L., Chaitman, B. R., White, H. D., … Wagner, D. R. (2012). Third universal definition of myocardial infarction.
Circulation, 126(16), 2020–2035. https://doi.org/10.1161/CIR.0b013e31826e1058
• Zafari, A. M. (2018). Myocardial Infarction: Practice Essentials, Background, Definitions. Retrieved from https://emedicine.medscape.com/article/155919-
overview?pa=tsgIZuFuw62Bw8Q6hyNbtlSeSjuZMO%2FBZt%2FW3mGLVJ8qdINVIg2s1NXhLEfE3uTJ43mU9jD%2B1DtnxY47OmyybA%3D%3D
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Cardiovascular

INTENSIVE & ACUTE CARDIOVASCULAR CARE UNIT

Myocardial infarction (MI) can be recognized by clinical features,

1. Ibanez, B.,et al (2018). European Heart Journal, 39(2), 119–177.

• Troponins are more specific

• Determine Acute heart failure

• When Time To PCI > 12 Hour.

Medical Cardiac Arrest Other Presentation

History O: onset S: sign and symptoms

Physical Examination Head to Toe Complete assessment

• Physical Assessment Best Practice Recommendation

Kingsbury, K. (2013). Management of Acute Myocardial Infarction, (September), 1–39. https://doi.org/10.1136/bmj.1.5171.497

Critical Point During Acute Phase

These Should not delayed reperfusion treatment

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