Asuhan Keperawatan Pada Klien Infark Miokard Akut

ASUHAN KEPERAWATAN PADA KLIEN INFARK MIOKARD AKUT

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ASUHAN KEPERAWATAN
PADA KLIEN INFARK MIOKARD AKUT
I. KONSEP MEDIS
A. Pengertian
InIark Miokard Akut (IMA) adalah nekrosis miokard akibat aliran darah ke otot jantung
terganggu.
B. Fisiologi Sirkulasi Koroner
Arteri koroner kiri memperdarahi sebagaian terbesar ventrikel kiri, septum dan atrium kiri.
Arteri koroner kanan memperdarahi sisi diaIragmatik ventrikel kiri, sedikit bagian posterior
septum dan ventrikel serta atrium kanan. Nodus SA lebih sering diperdarahi oleh arteri
koroner kanan daripada kiri. (cabang sirkumIleks). Nodus AV 90° diperdarahi oleh arteri
koroner kanan dan 10° diperdarahi oleh arteri koroner kiri (cabang sirkumIleks). Dengan
demikian, obstruksi arteri koroner kiri sering menyebabkan inIark anterior dan inIark inIerior
disebabkan oleh obstruksi arteri koroner kanan.
C. Patogenesis
Umumnya IMA didasari oleh adanya ateroskeloris pembuluh darah koroner. Nekrosis
miokard akut hampir selalu terjadi akibat penyumbatan total arteri koronaria oleh trombus
yang terbentuk pada plak aterosklerosis yang tidak stabil, juga sering mengikuti ruptur plak
pada arteri koroner dengan stenosis ringan (50-60°).
Kerusakan miokard terjadi dari endokardium ke epikardium, menjadi komplit dan ireversibel
dalam 3-4 jam. Secara morIologis, IMA dapat terjadi transmural atau sub-endokardial. IMA
transmural mengenai seluruh dinding miokard dan terjadi pada daerah distribusi suatu arteri
koroner. Sebaliknya pada IMA sub-endokardial, nekrosis terjadi hanya pada bagian dalam
dinding ventrikel.
D. PatoIisiologi
Dua jenis kelainan yang terjadi pada IMA adalah komplikasi hemodinamik dan aritmia.
Segera setelah terjadi IMA daerah miokard setempat akan memperlihatkan penonjolan
sistolik (diskinesia) dengan akibat penurunan ejection Iraction, isi sekuncup (stroke volume)
dan peningkatan volume akhir distolik ventrikel kiri. Tekanan akhir diastolik ventrikel kiri
naik dengan akibat tekanan atrium kiri juga naik. Peningkatan tekanan atrium kiri di atas 25
mmHg yang lama akan menyebabkan transudasi cairan ke jaringan interstisium paru (gagal
jantung). Pemburukan hemodinamik ini bukan saja disebakan karena daerah inIark, tetapi
juga daerah iskemik di sekitarnya. Miokard yang masih relatiI baik akan mengadakan
kompensasi, khususnya dengan bantuan rangsangan adrenergeik, untuk mempertahankan
curah jantung, tetapi dengan akibat peningkatan kebutuhan oksigen miokard. Kompensasi ini
jelas tidak akan memadai bila daerah yang bersangkutan juga mengalami iskemia atau
bahkan sudah Iibrotik. Bila inIark kecil dan miokard yang harus berkompensasi masih
normal, pemburukan hemodinamik akan minimal. Sebaliknya bila inIark luas dan miokard
yang harus berkompensasi sudah buruk akibat iskemia atau inIark lama, tekanan akhir
diastolik ventrikel kiri akan naik dan gagal jantung terjadi. Sebagai akibat IMA sering terjadi
perubahan bentuk serta ukuran ventrikel kiri dan tebal jantung ventrikel baik yang terkena
inIark maupun yang non inIark. Perubahan tersebut menyebabkan remodeling ventrikel yang
nantinya akan mempengaruhi Iungsi ventrikel dan timbulnya aritmia.
Perubahan-perubahan hemodinamik IMA ini tidak statis. Bila IMA makin tenang Iungsi
jantung akan membaik walaupun tidak diobati. Hal ini disebabkan karena daerah-daerah yang
tadinya iskemik mengalami perbaikan. Daerah-daerah diskinetik akibat IMA akan menjadi
akinetik, karena terbentuk jaringan parut yang kaku. Miokard sehat dapat pula mengalami
hipertropi. Sebaliknya perburukan hemodinamik akan terjadi bila iskemia berkepanjangan
atau inIark meluas. Terjadinya penyulit mekanis seperti ruptur septum ventrikel, regurgitasi
mitral akut dan aneurisma ventrikel akan memperburuk Iaal hemodinamik jantung.
Aritmia merupakan penyulit IMA tersering dan terjadi terutama pada menit-menit atau jam-
jam pertama setelah serangan. Hal ini disebabkan oleh perubahan-perubahan masa reIrakter,
daya hantar rangsangan dan kepekaaan terhadap rangsangan. Sistem saraI otonom juga
berperan besar terhadap terjadinya aritmia. Pasien IMA inIerior umumnya mengalami
peningkatan tonus parasimpatis dengan akibat kecenderungan bradiaritmia meningkat,
sedangkan peningkatan tonus simpatis pada IMA inIerior akan mempertinggi kecenderungan
Iibrilasi ventrikel dan perluasan inIark.

E. Gejala Klinis
Keluhan yang khas ialah nyeri dada retrosternal, seperti diremas-remas, ditekan, ditusuk,
panas atau ditindih barang berat. Nyeri dapat menjalar ke lengan (umumnya kiri), bahu, leher,
rahang bahkan ke punggung dan epigastrium. Nyeri berlangsung lebih lama dari angina
pectoris dan tak responsiI terhadap nitrogliserin. Kadang-kadang, terutama pada pasien
diabetes dan orang tua, tidak ditemukan nyeri sama sekali. Nyeri dapat disertai perasaan
mual, muntah, sesak, pusing, keringat dingin, berdebar-debar atau sinkope. Pasien sering
tampak ketakutan. Walaupun IMA dapat merupakan maniIestasi pertama penyakit jantung
koroner namun bila anamnesis dilakukan teliti hal ini sering sebenarnya sudah didahului
keluhan-keluhan angina, perasaan tidak enak di dada atau epigastrium.
Kelainan pada pemeriksaan Iisik tidak ada yang spesiIik dan dapat normal. Dapat ditemui BJ
yakni S2 yang pecah, paradoksal dan irama gallop. Adanya krepitasi basal menunjukkan
adanya bendungan paru-paru. Takikardia, kulit yang pucat, dingin dan hipotensi ditemukan
pada kasus yang relatiI lebih berat, kadang-kadang ditemukan pulsasi diskinetik yang tampak
atau berada di dinding dada pada IMA inIerior.

F. Diagnosis Banding
1. Angina Pectoris tidak stabil/insuIisiensi koroner akut.
2. Diseksi aorta (nyeri dada umumnya sangat hebat, dapat menjalar ke perut dan punggung).
3. Kelainan saluran cerna bagian atas (hernia diaIragmatika, esoIagitis reIluks)
4. Kelainan lokal dinding dada (nyeri bersiIat lokal, bertambah dengan tekanan atau
perubahan posisi tubuh)
5. Kompresi saraI (terutama C8, nyeri pada distribusi saraI tersebut)
6. Kelainan intra-abdominal (kelainan akut, pankreatitis dapat menyerupai IMA)

G. Komplikasi
1. Aritmia
2. Bradikardia sinus
3. Irama nodal
4. Gangguan hantaran atrioventrikular
5. Gangguan hantaran intraventrikel
6. Asistolik
7. Takikardia sinus
8. Kontraksi atrium prematur
9. Takikardia supraventrikel
10. Flutter atrium
11. Fibrilasi atrium
12. Takikardia atrium multiIokal
13. Kontraksi prematur ventrikel
14. Takikardia ventrikel
15. Takikardia idioventrikel
16. Flutter dan Fibrilasi ventrikel
17. Renjatan kardiogenik
18. Tromboembolisme
19. Perikarditis
20. Aneurisme ventrikel
21. Regurgitasi mitral akut
22. Ruptur jantung dan septum

H. Prognosis
Beberapa indeks prognosis telah diajukan, secara praktis dapat diambil pegangan 3 Iaktor
penting yaitu:
1. Potensial terjadinya aritmia yang gawat (aritmia ventrikel dll)
2. Potensial serangan iskemia lebih lanjut.
3. Potensial pemburukan gangguan hemodinamik lebih lanjut (bergantung terutama pada luas
daerah inIark).

II. FOKUS PENGKAJIAN KEPERAWATAN

A. Riwayat Keperawatan dan Pengkajian Fisik:
Berdasarkan klasiIikasi Doenges dkk. (2000) riwayat keperawatan yang perlu dikaji adalah:
1. Aktivitas/istirahat:
Gejala:
- Kelemahan, kelelahan, tidak dapat tidur
- Riwayat pola hidup menetap, jadual olahraga tak teratur
Tanda:
- Takikardia, dispnea pada istirahat/kerja
2. Sirkulasi:
Gejala:
- Riwayat IM sebelumnya, penyakit arteri koroner, GJK, masalah TD, DM.
Tanda:
- TD dapat normal atau naik/turun; perubahan postural dicatat dari tidur sampai
duduk/berdiri.
- Nadi dapat normal; penuh/tak kuat atau lemah/kuat kualitasnya dengan pengisian kapiler
lambat; tidak teratur (disritmia) mungkin terjadi.
- BJ ekstra (S3/S4) mungkin menunjukkan gagal jantung/penurunan kontraktilitas atau
komplian ventrikel
- Murmur bila ada menunjukkan gagal katup atau disIungsi otot papilar.
- Friksi; dicurigai perikarditis
- Irama jantung dapat teratur atau tak teratur.
- Edema, DVJ, edema periIer, anasarka, krekels mungkin ada dengan gagal jantung/ventrikel.
- Pucat atau sianosis pada kulit, kuku dan membran mukosa.
3. Integritas ego:
Gejala:
- Menyangkal gejala penting.
- Takut mati, perasaan ajal sudah dekat
- Marah pada penyakit/perawatan yang tak perlu`
- Kuatir tentang keluarga, pekerjaan dan keuangan.

Tanda:
- Menolak, menyangkal, cemas, kurang kontak mata
- Gelisah, marah, perilaku menyerang
- Fokus pada diri sendiri/nyeri.
4. Eliminasi:
Tanda:
- Bunyi usus normal atau menurun
5. Makanan/cairan:
Gejala:
- Mual, kehilangan napsu makan, bersendawa, nyeri ulu hati/terbakar.
Tanda:
- Penurunan turgor kulit, kulit kering/berkeringat
- Muntah,
- Perubahan berat badan
6. Hygiene:
Gejala/tanda:
- Kesulitan melakukan perawatan diri.
7. Neurosensori:
Gejala:
- Pusing, kepala berdenyut selama tidur atau saat bangun (duduk/istirahat)
Tanda:
- Perubahan mental
- Kelemahan
8. Nyeri/ketidaknyamanan:
Gejala:
- Nyeri dada yang timbul mendadak (dapat/tidak berhubungan dengan aktiIitas), tidak hilang
dengan istirahat atau nitrogliserin.
- Lokasi nyeri tipikal pada dada anterior, substernal, prekordial, dapat menyebar ke tangan,
rahang, wajah. Tidak tertentu lokasinya seperti epigastrium, siku, rahang, abdomen,
punggung, leher.
- Kualitas nyeri crushing`, menusuk, berat, menetap, tertekan, seperti dapat dilihat.
- Instensitas nyeri biasanya 10 pada skala 1-10, mungkin pengalaman nyeri paling buruk yang
pernah dialami.
- Catatan: nyeri mungkin tak ada pada pasien pasca operasi, dengan DM, hipertensi dan
lansia.
Tanda:
- Wajah meringis, perubahan postur tubuh.
- Menangis, merintih, meregang, menggeliat.
- Menarik diri, kehilangan kontak mata
- Respon otonom: perubahan Irekuensi/irama jantung, TD, pernapasan, warna
kulit/kelembaban, kesadaran.
9. Pernapasan:
Gejala:
- Dispnea dengan/tanpa kerja, dispnea nokturnal
- Batuk produktiI/tidak produktiI
- Riwayat merokok, penyakit pernapasan kronis
Tanda:
- Peningkatan Irekuensi pernapasan
- Pucat/sianosis
- Bunyi napas bersih atau krekels, wheezing
- Sputum bersih, merah muda kental
10. Interaksi sosial:
Gejala:
- Stress saat ini (kerja, keuangan, keluarga)
- Kesulitan koping dengan stessor yang ada (penyakit, hospitalisasi)
Tanda:
- Kesulitan istirahat dengan tenang, respon emosi meningkat
- Menarik diri dari keluarga

11. Penyuluhan/pembelajaran:
Gejala:
- Riwayat keluarga penyakit jantung/IM, DM, Stroke, Hipertensi, Penyakit Vaskuler PeriIer
- Riwayat penggunaan tembakau

B. Tes Diagnostik
EKG
Laboratorium:
Enzim/Isoenzim Jantung
Radiologi
EkokardiograIi
Radioisotop

III. DIAGNOSA KEPERAWATAN
1. Nyeri akut b/d iskemia miokard akibat sumbatan arteri koroner.
2. Intoleransi aktivitas b/d ketidakseimbangan suplai oksigen miokard dengan kebutuhan
tubuh.
3. Kecemasan (uraikan tingkatannya) b/d ancaman/perubahan kesehatan-status sosio-
ekonomi; ancaman kematian.
4. (Risiko tinggi) Penurunan curah jantung b/d perubahan Irekuensi, irama dan konduksi
listrik jantung; penurunan preload/peningkatan tahanan vaskuler sistemik; inIark/diskinetik
miokard, kerusakan struktuaral seperti aneurisma ventrikel dan kerusakan septum.
5. (Risiko tinggi) Perubahan perIusi jaringan b/d penurunan/sumbatan aliran darah koroner.
6. (Risiko tinggi) Kelebihan volume cairan b/d penurunan perIusi ginjal; peningkatan
natrium/retensi air; peningkatan tekanan hidrostatik atau penurunan protein plasma.
7. Kurang pengetahuan (tentang kondisi dan kebutuhan terapi) b/d kurang terpajan atau salah
interpretasi terhadap inIormasi tentang Iungsi jantung/implikasi penyakit jantung dan
perubahan status kesehatan yang akan datang.

IV. INTERVENSI KEPERAWATAN
A. Nyeri akut b/d iskemia miokard akibat sumbatan arteri koroner.
1. Pantau nyeri (karakteristik, lokasi, intensitas, durasi), catat setiap respon verbal/non verbal,
perubahan hemo-dinamik
2. Berikan lingkungan yang tenang dan tunjukkan perhatian yang tulus kepada klien.
3. Bantu melakukan teknik relaksasi (napas dalam/perlahan, distraksi, visualisasi, bimbingan
imajinasi)
4. Kolaborasi pemberian obat sesuai indikasi:
- Antiangina seperti nitogliserin (Nitro-Bid, Nitrostat, Nitro-Dur)
- Beta-Bloker seperti atenolol (Tenormin), pindolol (Visken), propanolol (Inderal)
- Analgetik seperti morIin, meperidin (Demerol)
- Penyekat saluran kalsium seperti verapamil (Calan), diltiazem (Prokardia).
Nyeri adalah pengalaman subyektiI yang tampil dalam variasi respon verbal non verbal yang
juga bersiIat individual sehingga perlu digambarkan secara rinci untuk menetukan intervensi
yang tepat.

Rasionalisasi :
- Menurunkan rangsang eksternal yang dapat memperburuk keadaan nyeri yang terjadi.
- Membantu menurunkan persepsi-respon nyeri dengan memanipulasi adaptasi Iisiologis
tubuh terhadap nyeri.
- Nitrat mengontrol nyeri melalui eIek vasodilatasi koroner yang meningkatkan sirkulasi
koroner dan perIusi miokard.
- Agen yang dapat mengontrol nyeri melalui eIek hambatan rangsang simpatis.(Kontra-
indikasi: kontraksi miokard yang buruk)
- MorIin atau narkotik lain dapat dipakai untuk menurunkan nyeri hebat pada Iase akut atau
nyeri berulang yang tak dapat dihilangkan dengan nitrogliserin.
- Bekerja melalui eIek vasodilatasi yang dapat meningkatkan sirkulasi koroner dan kolateral,
menurunkan preload dan kebu-tuhan oksigen miokard. Beberapa di antaranya bekerja sebagai
antiaritmia.

B. Intoleransi aktivitas b/d ketidakseimbangan suplai oksigen miokard dengan kebutuhan
tubuh.
INTERVENSI
1. Pantau HR, irama, dan perubahan TD sebelum, selama dan sesudah aktivitas sesuai
indikasi.
2. Tingkatkan istirahat, batasi aktivitas
3. Anjurkan klien untuk menghindari peningkatan tekanan abdominal.
4. Batasi pengunjung sesuai dengan keadaan klinis klien.
5. Bantu aktivitas sesuai dengan keadaan klien dan jelaskan pola peningkatan aktivitas
bertahap.
6. Kolaborasi pelaksanaan program rehabilitasi pasca serangan IMA.

Rasionalisasi:
- Menentukan respon klien terhadap aktivitas.
- Menurunkan kerja miokard/konsumsi oksigen, menurunkan risiko komplikasi.
- Manuver Valsava seperti menahan napas, menunduk, batuk keras dan mengedan dapat
mengakibatkan bradikardia, penurunan curah jantung yang kemudian disusul dengan
takikardia dan peningkatan tekanan darah.
- Keterlibatan dalam pembicaraan panjang dapat melelahkan klien tetapi kunjungan orang
penting dalam suasana tenang bersiIat terapeutik.
- Mencegah aktivitas berlebihan; sesuai dengan kemampuan kerja jantung.
- Menggalang kerjasama tim kesehatan dalam proses penyembuhan klien.

C. Kecemasan (uraikan tingkatannya) b/d ancaman/perubahan kesehatan-status sosio-
ekonomi; ancaman kematian.
INTERVENSI
1. Pantau respon verbal dan non verbal yang menunjukkan kecemasan klien.
2. Dorong klien untuk mengekspresikan perasaan marah, cemas/takut terhadap situasi krisis
yang dialaminya.
3. Orientasikan klien dan orang terdekat terhadap prosedur rutin dan aktivitas yang
diharapkan.
4. Kolaborasi pemberian agen terapeutik anti cemas/sedativa sesuai indikasi
(Diazepam/Valium, Flurazepam/Dal-mane, Lorazepam/Ativan).
Klien mungkin tidak menunjukkan keluhan secara langsung tetapi kecemasan dapat dinilai
dari perilaku verbal dan non verbal yang dapat menunjukkan adanya kegelisahan, kemarahan,
penolakan dan sebagainya.
RASIONALISASI:
- Respon klien terhadap situasi IMA bervariasi, dapat berupa cemas/takut terhadap ancaman
kematian, cemas terhadap ancaman kehilangan pekerjaan, perubahan peran sosial dan
sebagainya.
- InIormasi yang tepat tentang situasi yang dihadapi klien dapat menurunkan kecemasan/rasa
asing terhadap lingkungan sekitar dan membantu klien mengantisipasi dan menerima situasi
yang terjadi.
- Meningkatkan relaksasi dan menurunkan kecemasan.

D. (Risiko tinggi) Penurunan curah jantung b/d perubahan Irekuensi, irama dan konduksi
listrik jantung; penurunan preload/peningkatan tahanan vaskuler sistemik; inIark/diskinetik
miokard, kerusakan struktuaral seperti aneurisma ventrikel dan kerusakan septum.
INTERVENSI
1. Pantau TD, HR dan DN, periksa dalam keadaan baring, duduk dan berdiri (bila
memungkinkan)
2. Auskultasi adanya S3, S4 dan adanya murmur.
3. Auskultasi bunyi napas.
4. Berikan makanan dalam porsi kecil dan mudah dikunyah.
5. Kolaborasi pemberian oksigen sesuai kebutuhan klien
6. Pertahankan patensi IV-lines/heparin-lok sesuai indikasi.
7. Bantu pemasangan/pertahankan paten-si pacu jantung bila digunakan.
RASIONALISASI :
- Hipotensi dapat terjadi sebagai akibat dari disIungsi ventrikel, hipoperIusi miokard dan
rangsang vagal. Sebaliknya, hipertensi juga banyak terjadi yang mungkin berhubungan
dengan nyeri, cemas, peningkatan katekolamin dan atau masalah vaskuler sebelumnya.
Hipotensi ortostatik berhubungan dengan komplikasi GJK. Penurunanan curah jantung
ditunjukkan oleh denyut nadi yang lemah dan HR yang meningkat.
- S3 dihubungkan dengan GJK, regurgitasi mitral, peningkatan kerja ventrikel kiri yang
disertai inIark yang berat. S4 mungkin berhubungan dengan iskemia miokardia, kekakuan
ventrikel dan hipertensi. Murmur menunjukkan gangguan aliran darah normal dalam jantung
seperti pada kelainan katup, kerusakan septum atau vibrasi otot papilar.
- Krekels menunjukkan kongesti paru yang mungkin terjadi karena penurunan Iungsi
miokard.
- Makan dalam volume yang besar dapat meningkatkan kerja miokard dan memicu rangsang
vagal yang mengakibatkan terjadinya bradikardia.
- Meningkatkan suplai oksigen untuk kebutuhan miokard dan menurunkan iskemia.
- Jalur IV yang paten penting untuk pemberian obat darurat bila terjadi disritmia atau nyeri
dada berulang.
- Pacu jantung mungkin merupakan tindakan dukungan sementara selama Iase akut atau
mungkin diperlukan secara permanen pada inIark luas/kerusakan sistem konduksi.

E. (Risiko tinggi) Perubahan perIusi jaringan b/d penurunan/sumbatan aliran darah koroner.
INTERVENSI
1. Pantau perubahan kesadaran/keadaan mental yang tiba-tiba seperti bingung, letargi,
gelisah, syok.
2. Pantau tanda-tanda sianosis, kulit dingin/lembab dan catat kekuatan nadi periIer.
3. Pantau Iungsi pernapasan (Irekuensi, kedalaman, kerja otot aksesori, bunyi napas)
4. Pantau Iungsi gastrointestinal (anorksia, penurunan bising usus, mual-muntah, distensi
abdomen dan konstipasi)
5. Pantau asupan caiaran dan haluaran urine, catat berat jenis.
6. Kolaborasi pemeriksaan laboratorium (gas darah, BUN, kretinin, elektrolit)
7. Kolaborasi pemberian agen terapeutik yang diperlukan:
- Hepari / Natrium WarIarin (Couma-din)
- Simetidin (Tagamet), Ranitidin (Zantac), Antasida.
- Trombolitik (t-PA, Streptokinase)
RASIONALISASI :
- PerIusi serebral sangat dipengaruhi oleh curah jantung di samping kadar elektrolit dan
variasi asam basa, hipoksia atau emboli sistemik.
- Penurunan curah jantung menyebabkan vasokonstriksi sistemik yang dibuktikan oleh
penurunan perIusi periIer (kulit) dan penurunan denyut nadi.
- Kegagalan pompa jantung dapat menimbulkan distres pernapasan. Di samping itu dispnea
tiba-tiba atau berlanjut menunjukkan komplokasi tromboemboli paru.
- Penurunan sirkulasi ke mesentrium dapat menimbulkan disIungsi gastrointestinal
- Asupan cairan yang tidak adekuat dapat menurunkan volume sirkulasi yang berdampak
negatiI terhadap perIusi dan Iungsi ginjal dan organ lainnya. BJ urine merupakan indikator
status hidrsi dan Iungsi ginjal.
- Penting sebagai indikator perIusi/Iungsi organ.
- Heparin dosis rendah mungkin diberikan mungkin diberikan secara proIilaksis pada klien
yang berisiko tinggi seperti Iibrilasi atrial, kegemukan, anerisma ventrikel atau riwayat
tromboplebitis. Coumadin merupakan antikoagulan jangka panjang.
- Menurunkan/menetralkan asam lambung, mencegah ketidaknyamanan akibat iritasi gaster
khususnya karena adanya penurunan sirkulasi mukosa.
- Pada inIark luas atau IM baru, trombolitik merupakan pilihan utama (dalam 6 jam pertama
serangan IMA) untuk memecahkan bekuan dan memperbaiki perIusi miokard.

F. (Risiko tinggi) Kelebihan volume cairan b/d penurunan perIusi ginjal; peningkatan
natrium/retensi air; peningkatan tekanan hidrostatik atau penurunan protein plasma.
INTERVENSI
1. Auskultasi bunyi napas terhadap adanya krekels.
2. Pantau adanya DVJ dan edema anasarka
3. Hitung keseimbangan cairan dan timbang berat badan setiap hari bila tidak kontraindikasi.
4. Pertahankan asupan cairan total 2000 ml/24 jam dalam batas toleransi kardiovaskuler.
5. Kolaborasi pemberian diet rendah natrium.
6. Kolaborasi pemberian diuretik sesuia indikasi (Furosemid/Lasix, Hidralazin/ Apresoline,
Spironlakton/ Hidronolak-ton/Aldactone)
7. Pantau kadar kalium sesuai indikasi.
RASIONALISASI
- Indikasi terjadinya edema paru sekunder akibat dekompensasi jantung.
- Dicurigai adanya GJK atau kelebihan volume cairan (overhidrasi)
- Penurunan curah jantung mengakibatkan gangguan perIusi ginjal, retensi natrium/air dan
penurunan haluaran urine. Keseimbangan cairan positiI yang ditunjang gejala lain
(peningkatan BB yang tiba-tiba) menunjukkan kelebihan volume cairan/gagal jantung.
- Memenuhi kebutuhan cairan tubuh orang dewasa tetapi tetap disesuaikan dengan adanya
dekompensasi jantung.
- Natrium mengakibatkan retensi cairan sehingga harus dibatasi.
- Diuretik mungkin diperlukan untuk mengoreksi kelebihan volume cairan.
- Hipokalemia dapat terjadi pada terapi diuretik yang juga meningkatkan pengeluaran kalium.

G. Kurang pengetahuan (tentang kondisi dan kebutuhan terapi) b/d kurang terpajan atau salah
interpretasi terhadap inIormasi tentang Iungsi jantung/implikasi penyakit jantung dan
perubahan status kesehatan yang akan datang.
INTERVENSI
1. Kaji tingkat pengetahuan klien/orang terdekat dan kemampuan/kesiapan belajar klien.
2. Berikan inIormasi dalam berbagai variasi proses pembelajaran. (Tanya jawab, leaIlet
instruksi ringkas, aktivitas kelompok)
3. Berikan penekanan penjelasan tentang Iaktor risiko, pembatasan diet/aktivitas, obat dan
gejala yang memerlukan perhatian cepat/darurat.
4. Peringatkan untuk menghindari aktivitas isometrik, manuver Valsava dan aktivitas yang
memerlukan tangan diposisikan di atas kepala.
5. Jelaskan program peningkatan aktivitas bertahap (Contoh: duduk, berdiri, jalan, kerja
ringan, kerja sedang)
RASIONALISASI
- Proses pembelajaran sangat dipengaruhi oleh kesiapan Iisik dan mental klien.
- Meningkatkan penyerapan materi pembelajaran.
- Memberikan inIormasi terlalu luas tidak lebih bermanIaat daripada penjelasan ringkas
dengan penekanan pada hal-hal penting yang signiIikan bagi kesehatan klien.
- Aktivitas ini sangat meningkatkan beban kerja miokard dan meningkatkan kebutuhan
oksigen serta dapat merugikan kontraktilitas yang dapat memicu serangan ulang.
- Meningkatkan aktivitas secara bertahap meningkatkan kekuatan dan mencegah aktivitas
yang berlebihan. Di samping itu juga dapat meningkatkan sirkulasi kolateral dan
memungkinkan kembalinya pola hidup normal.

DAFTAR PUSTAKA
Carpenito (2000), Diagnosa Keperawatan-Aplikasi pada Praktik Klinis, Ed.6, EGC, Jakarta
Doenges at al (2000), Rencana Asuhan Keperawatan, Ed.3, EGC, Jakarta
Price & Wilson (1995), PatoIisologi-Konsep Klinis Proses-Proses Penyakit, Ed.4, EGC,
Jakarta
Soeparman & Waspadji (1990), Ilmu Penyakit

Memahami Penyakit Arteri Koroner
Layanan
Apakah penyakit arteri koroner?
Penyakit arteri koroner adalah penyempitan atau penyumbatan arteri koroner, arteri yang
menyalurkan darah ke otot jantung. Bila aliran darah melambat, jantung tak mendapat cukup
oksigen dan zat nutrisi. Hal ini biasanya mengakibatkan nyeri dada yang disebut angina. Bila
satu atau lebih dari arteri koroner tersumbat sama sekali, akibatnya adalah serangan jantung
(kerusakan pada otot jantung).
Apakah yang menyebabkan arteri koroner menyempit?
Arteri koroner menyempit atau tersumbat oleh penimbunan plak di dinding arteri. Plak
terbuat dari kelebihan kolesterol serta zat-zat lain yang mengapung melalui arus darah Anda,
seperti sel-sel yang meradang, protein dan kalsium. Dengan berlalunya waktu, bagian dalam
arteri mengembangkan plak dengan ukuran yang berbeda-beda. Banyak endapan plak adalah
keras di sebelah luar dan lunak di sebelah dalam. Permukaan yang keras dapat retak atau
robek, mengekspos yang lunak, berlemak di sebelah dalam. Bila hal ini terjadi, platelet
(partikel berbentuk cakram dalam darah yang membantu pembentukan penggumpalan
darah)datang ke daerah tersebut, dan terbentuk penggumpalan darah di sekitar plak. Arteri
menyempit lebih lanjut, dan pada gilirannya, semakin sedikit ruang bagi darah untuk
mengalir melalui arteri. Penimbunan plak dalam arteri disebut aterosklerosis, juga dikenal
sebagai "pengerasan arteri."
Apa yang harus dilakukan jika Anda menderita penyakit jantung koroner?
Jika Anda menderita penyakit jantung koroner, adalah penting untuk memelihara jantung
Anda. Ini terutama benar jika Anda telah menjalani prosedur intervensi atau pembedahan
untuk memperbaiki aliran darah ke jantung. Prosedur tak menyembuhkan penyakit jantung
koroner. Tergantung pada Anda untuk mengambil langkah untuk menghentikan
memburuknya penyakit.
Ketahuilah gejala-gejala untuk penyakit jantung koroner

Gejala untuk penyakit jantung koroner meliputi:



Dada terasa tak enak(digambarkan sebagai mati rasa, berat, atau terbakar;
dapat menjalar ke pundak kiri, lengan, leher, punggung, atau rahang)



Sesak napas



Berdebar-debar



Denyut jantung lebih cepat



Pusing



Mual



Kelemahan yang luar biasa


Panggil dokter Anda jika gejala bertambah sering atau bertambah parah.
Panggil bantuan darurat jika istirahat dan/atau obat-obatan tak meredakan
gejala tersebut dalam waktu 15 menit. ANGAN TUNGGU UNTUK
MINTA BANTUAN.
Kurangi faktor risiko Anda

Penelitian medis telah membantu mengidentiIikasi kondisi tetentu, yang
disebut Iaktor risiko, yang menetapkan orang pada risiko meningkat untuk
penyakit jantung.
Faktor risiko yang tak-termodifikasi (yang tak bisa diubah)


Pria


Usia tua


Riwayat keluarga


Faktor risiko yang terubahkan (yang bisa dikendalikan)


Merokok


Kolesterol darah tinggi


Tekanan darah tinggi


Diabetes yang tak terkontrol


Ketidak-aktiIan Iisik


Kegemukan atau kelebihan berat badan


Stres atau kemarahan yang tak terkendalikan


Diet yang tinggi akan lemak jenuh dan kolesterol


Minum terlalu banyak alkohol


Jika Anda mempunyai lebih dari dua Iaktor risiko yang disebutkan, Anda
harus membahasnya dengan dokter Anda. Tujuan Anda adalah menurunkan
Iaktor risiko dan mengurangi peristiwa risiko penyakit jantung Anda di
kemudian hari. Ini benar jika Anda tak mempunyai penyakit jantung atau
penyakit pembuluh darah, atau Anda telah menjalani prosedur (angioplasti,
stent, bedah bypass) untuk penyakit jantung atau penyakit pembuluh darah.
3 Minum obat-obatan

Obat-obatan digunakan untuk mengendalikan gejala Anda dan membantu
jantung Anda bekerja lebih eIisien. Ikuti instruksi dokter Anda bila Anda
minum obat-obatan.
Adalah penting untuk mengetahui:


Nama obat-obatan Anda



Untuk apa obat-obatan tersebut



Berapa sering dan pada jam berapa Anda harus minum obat


Simpan daItar obat-obatan Anda dan bawa pada setiap kunjungan dokter Anda.
Jika Anda mempunyai pertanyaan tentang obat-obatan Anda, tanyakan kepada
dokter atau apoteker Anda.
Lakukan prosedur atau pembedahan - jika perlu

Prosedur invasiI (seperti angioplasti balon atau stent) atau bedah bypass arteri
koroner mungkin diperlukan untuk mengobati arteri Anda yang menyempit
atau tersumbat. Prosedur-prosedur ini meningkatkan penyaluran darah ke
jantung Anda, tetapi prosedur tidak dapat menyembuhkan jantung koroner.
Anda harus tetap memIokus untuk mengurangi Iaktor risiko Anda untuk
mencegah pengembangan atau peningkatan penyakit lebih lanjut. Jika
prosedur-prosedur ini memang perlu atau telah diperlukan, ahli penyakit
jantung Anda akan membicarakan prosedur khusus dengan Anda.
5 Temui ahli penyakit jantung Anda untuk kunjungan teratur

Jadwalkan janji bertemu dengan ahli penyakit jantung Anda, bahkan jika Anda
tak mempunyai gejala. Janji temu Anda boleh dijarakkan sekali setahun, atau
lebih sering, jika dokter Anda merasa Anda harus diikuti lebih ketat. Janji
temu Anda harus meliputi pemeriksaan medis dan studi diagnostik (seperti
elektrokardiogram).


Acote Coronury Syndrome {ACS) - q Norsing CIs
AuLIor: KrIsLI Hudson RN, MSN CCRN

Coorse Ðescription
TIIs course Is desIgned Lo gIve un overvIew oI LIe cure und munugemenL oI LIe
puLIenL wIo Ius suIIered un ucuLe myocurdIuI InIrucLIon (M¡). ¡ocus wIII be pIuced on
LIe puLIopIysIoIogIc cIunges LIuL occur durIng un ucuLe M¡ us weII us dIIIerenLIuLIng
LIe dIIIerenL Lypes oI myocurdIuI InIurcLIon (bused on IocuLIon). TIe prevuIence, rIsk
IucLors, sIgnsJsympLoms und dIugnosIs oI un ucuLe M¡ wIII uIso be presenLed.
PoLenLIuI compIIcuLIons ussocIuLed wILI un ucuLe M¡ (IncIudIng curdIogenIc sIock) us
weII us medIcuIJpIurmuceuLIcuI InLervenLIons wIII be presenLed. NursIng cure und
munugemenL wILI NANDA nursIng dIugnoses Lo IncIude deIInIng cIurucLerIsLIcs,
nursIng InLervenLIons und puLIenLJIumIIy educuLIon wIII uIso be presenLed.
ApproprIuLe curdIuc reIubIIILuLIon InLervenLIons wIII be LIe IInuI Iocus oI LIIs course.

Coorse Objectives
Upon compIeLIon oI LIIs course LIe sLudenL wIII be ubIe Lo:
O UndersLund und deIIne LIe puLIopIysIoIogIc cIunges seen wILI un ucuLe M¡
O DIIIerenLIuLe LIe dIIIerenL Lypes oI M¡ bused on IocuLIon oI IscIemIuJInIurcL
O DIscuss LIe prevuIence ussocIuLed wILI un ucuLe M¡
O SLuLe LIe rIsk IucLors ussocIuLed wILI un ucuLe M¡
O pIuIn LIe necessury ussessmenLJLesLs Lo dIugnose un ucuLe M¡
O DIscuss LIe poLenLIuI compIIcuLIons ussocIuLed wILI IuvIng un ucuLe M¡
O DescrIbe medIcuI munugemenL Ior LIe puLIenL wIo Ius suIIered und ucuLe M¡
O IsL ¸ upproprIuLe nursIng dIugnoses Ior munugIng LIe puLIenL wILI und ucuLe

O DIscuss LIe nursIng InLervenLIons upproprIuLe Ior curIng Ior LIe puLIenL wIo
Ius suIIered und ucuLe M¡ (uILeruLIon In curdIuc ouLpuL, puIn, unIeLy und
IneIIecLIve copIng)
O pIuIn LIe ImporLunL uspecLs oI puLIenL educuLIon posL M¡
O DescrIbe LIe ImporLunL uspecLs oI curdIuc reIubIIILuLIon
ÐeIining Myocurdiul InIurction:
An ucuLe M¡ occurs wIen myocurdIuI ceIIs Iuve reucIed LIe LIresIoId oI IscIemIu;
wIIcI In Lurn cuuse LIe body`s myocurdIuI ceII repuIr mecIunIsm Lo IIrsL become
overwIeImed und second Lo compIeLeIy IuII. WIen LIIs mecIunIsm IuIIs, myocurdIuI
LIssue necrosIs cuusIng IrrepurubIe LIssueJceII deuLI occurs.

TIe IoIIowIng ure possIbIe conLrIbuLors Lo myocurdIuI IscIemIu und uILImuLeIy
myocurdIuI InIurcLIon (LIssue necrosIs und ceII deuLI):
O ¡ncreused myocurdIuI meLuboIIc demund wIIcI IncIude:
1. Lremes In pIysIcuI eerLIon
2. Severe IyperLensIon
3. bsLrucLIve CurdIomyopuLIy
4. Severe uorLIc sLenosIs
5. LIer curdIuc vuIvuIur dIsorders
6. ow curdIuc ouLpuL sLuLes ussocIuLed wILI u decreuse In uorLIc dIusLoIIc
pressure
O Decreused deIIvery oI oygen und nuLrIenLs Lo LIe myocurdIum (vIu LIe
coronury cIrcuIuLIon).
O An InLerrupLIon In LIe deIIvery oI oygen und nuLrIenLs Lo LIe myocurdIum
Irom u LIrombus (LIuL usuuIIy uLLucIes ILseII Lo pIuque).
O A IIgI grude (usuuIIy > ;¸%) IIed coronury urLery sLenosIs do Lo
uLIeroscIerosIs.
!uthophysiology:
O TIe mosL IrequenL cuuse oI un ucuLe M¡ Is u dIsrupLIon In LIe vuscuIur
endoLIeIIum LIuL Is ussocIuLed wILI myocurdIuI pIuque (pIuque occurs over u
perIod or yeurs or decudes). TIIs combInuLIon cuuses LIe deveIopmenL oI un
InLru-coronury LIrombus, wIIcI cuuses LIe coronury urLery uIIecLed Lo
occIude. WILIIn zo Lo qo mInuLes oI un occIusIon; IrreversIbIe myocurdIuI ceII
dumugeJdeuLI occurs.
O TIe Lwo prImury cIurucLerIsLIcs oI pIuque deveIopmenL ure (1) u IIbromuscuIur
cup und (z) un underIyIng IIpId rIcI core. PIuque erosIon Is LIougIL Lo occur
wIen LIere Is u reIeuse oI coIIugen und proLeuses (wILIIn LIe pIuque) wIIcI
resuILs In LIInnIng oI LIe overIyIng IIbromuscuIur cup. TIe ucLIonJreIeuse oI
proLeuses wILIIn LIe pIuque combIned wILI IemodynumIc pressure uppIIed Lo
LIe urLerIuI segmenL, cuuses conLInued dIsrupLIon oI LIe endoLIeIIum wIIcI
Ieuds noL onIy Lo conLInued LIInnIng oI LIe IIbromuscuIur cup, buL Lo ucLuuI
cup rupLure (cuusIng pIuque erosIon undJor uIceruLIon).
O TIe overuII Ioss oI sLrucLuruI sLubIIILy oI LIe pIuque usuuIIy occurs uL LIe
juncLIon beLween LIe IIbromuscuIur cup und LIe vesseI wuII (wIIcI Is cuIIed
LIe ¨sIouIder regIon¨). WIen LIIs occurs, u LIrombus deveIops (due Lo LIe
pIuLeIeL-medIuLed ucLIvuLIon oI LIe couguIuLIon cuscude), und purLIuI or
compIeLe occIusIon occurs cuusIng un ucuLe myocurdIuI InIurcLIon.
O TIe severILy oI un ucuLe M¡ depends on LIe IeveI oI occIusIon In LIe coronury
urLery, LIe IengLI oI LIme oI LIe occIusIon und LIe puLIenLs own coIIuLeruI
cIrcuIuLIon. MyocurdIuI ceII deuLI IIrsL occurs In LIe porLIon oI LIe urLery LIuL
Is mosL dIsLuI Lo urLerIuI bIood IIow und us LIe occIusIon Increuses LIe dumuge
spreuds Irom LIe myocurdIum Lo LIe endocurdIum und evenLuuIIy Lo LIe
epIcurdIum. AILer ceII deuLI Ius reucIed LIe epIcurdIum, LIe LIssueJceII deuLI
LIen moves IuLeruIIy Lo LIe ureus oI coIIuLeruI perIusIon.
ÐiIIerent Types oI Acote MI {Bused on Locution):
TIe IocuLIon oI un ucuLe M¡ Is dependunL on LIe coronury urLery LIuL Ius been
uIIecLed und wIuL porLIon oI LIe IeurL LIuL urLery Ieeds. TIe IoIIowIng LubIe descrIbes
LIe uIIecLed urLery, u descrIpLIon oI LIe mujor ureus und sLrucLures LIuL suppIy bIood
Lo LIe ureu und LIe prImury InIurcLIon ureu.

oronary Artery Area and Structures Supplied Primary Area of Infarction
Right Coronary Artery 1. SA and AV nodes.
2. Bundle oI HIS.
3. Right atrium/ventricle.
4. LeIt ventricle (inIerior and
diaphragmatic regions).
5. Septum (1/3
rd
).
6. Posterior/InIerior portion oI the
LeIt bundle branch.
1. InIerior wall MI (leads II,
III and AVF).
2. InIeroposterior wall MI.
3. Right ventricular MI.

LeIt Coronary Artery 1. The major portion oI the leIt
ventricular region oI the heart.
LeIt ventricular MI.
LeIt Anterior
Descending Artery
1. Anterior wall oI the leIt
ventricle.
2. Anterior two thirds oI the
septum.
3. Bundle oI HIS.
4. Right bundle branch.
5. Anterosuperior portion oI the
leIt bundle branch.
6. PosteroinIerior portion oI the
leIt bundle branch.
1. Anterior wall MI (Leads V1
through V6).
2. Septal MI.
3. Anterolateral wall MI.
4. InIeroapical wall MI.
5. Apex (region) MI.
LeIt CircumIlex Artery 1. SA and AV nodes.
2. InIerior and diaphragmatic
surIace oI the leIt ventricle.
3. Lateral wall oI the leIt ventricle.
4. LeIt atrium.
5. PosteroinIerior portion oI the
leIt bundle branch.
1. Lateral wall MI (leads I
aV1, V5 and V6).
2. InIerolateral wall MI.
3. Posterior wall MI (leads V1
and V2).
4. InIeroposterior wall MI.

Note: An ST-seçment eletction mçoccrdicl injcrction (STEMI) ccn occur uhen
there is c ¨complete¨ bloclcçe oj cnç crterç(s). This tçpe oj MI is chcrccterized bç
cn upucrd shijt in c portion oj the ST seçment (seen on EKG). With this tçpe oj
mçoccrdicl injcrction, quicl intertentions to reopen the occluded tessel or tessels
cre imperctite. The lonçer the mçoccrdium çoes uithout oxççencted blood, the
çrecter the dcmcçe.

!revulence:
O MyocurdIuI InIurcLIon Is LIe IeudIng cuuse oI deuLI In LIe UnILed SLuLes und Is
LIe mosL common cuuse oI deuLI In LIe IndusLrIuI worId us weII.
O TIe good news Is LIuL LIe survIvuI ruLe Ior puLIenLs wIo seek medIcuI
LreuLmenL Ior un ucuLe M¡ Is up Lo qo% Lo q¸%. TIIs ImprovemenL In survIvuI
Is LIougIL Lo be reIuLed Lo Improved MS responses und LreuLmenL sLruLegIes.
O WILI upproImuLeIy ¸o% oI uII ucuLe M¡`s In LIe UnILed SLuLes occurrIng Lo
peopIe under LIe uge oI 6¸; LIIs dIseuse Is no Ionger LIougIL Lo be u ¨dIseuse
Ior LIe eIderIy¨ (us LIe buby boomers uge, LIIs percenLuge Is LIougIL Lo uguIn
swILcI buck Lo sIow more peopIe over LIe uge oI 6¸ wILI ucuLe M¡`s).
O TIe ucLuuI IncIdenL oI suIIerIng un ucuLe M¡ depends on LIe number oI pre-
dIsposIng IucLors Ior uLIeroscIerosIs.
#isk Iuctors[Cuoses:
TIere ure sI prImury rIsk IucLors Ior deveIopIng uLIeroscIerosIsJcoronury urLery
dIseuse und ucuLe myocurdIuI InIurcLIon. TIe presence oI uny rIsk IucLor Is LIougIL Lo
doubIe LIe reIuLIve rIsk Ior deveIopIng uLIeroscIerosIsJcoronury urLery dIseuse und
ucuLe myocurdIuI InIurcLIon.

TIese rIsk IucLors IncIude:
O HIgI BIood CIoIesLeroI (HyperIIpIdemIu) - An eIevuLed ¨LoLuI¨ cIoIesLeroI
IeveI Is mujor componenL oI uLIeroscIeroLIc pIuque buIId up wIIcI cuuses LIe
deveIopmenL oI un ucuLe M¡.
O DIubeLes MeIIILus - PuLIenLs wILI DM Iuve u subsLunLIuIIy greuLer rIsk oI
deveIopIng uLIeroscIeroLIc vuscuIur dIseuse uL un ucceIeruLed ruLe. TIIs
ucceIeruLIon occurs regurdIess oI wIeLIer LIe puLIenL Ius InsuIIn dependunL or
non InsuIIn dependunL dIubeLes.
O HyperLensIon - HIgI bIood pressure (squeezIng oI urLerIes und veIns) Ius
consIsLenLIy been ussocIuLed wILI un Increused rIsk oI deveIopIng un ucuLe M¡
(boLI sysLoIIc und dIusLoIIc eIevuLIons).
O SmokIng - Tobucco conLuIns cerLuIn componenLs LIuL ure known Lo dumuge
vesseI wuIIs. TIe body`s response Lo LIIs dumuge eIIcILs LIe IormuLIon oI
uLIeroscIerosIs LIereby IncreusIng LIe rIsk oI un ucuLe M¡.
O MuIe Gendered - TIe IncIdence oI deveIopIng un ucuLe M¡ Is greuLer Ior men
LIun women Iowever; wILI uge LIIs rIsk nurrows.
O ¡umIIy HIsLory - A IumIIy IIsLory oI premuLure coronury dIseuse Increuses
und IndIvIduuIs rIsk oI deveIopIng uLIeroscIerosIs und ucuLe M¡. ¡umIIy
IIsLory IncIudes boLI geneLIc componenLs und Ieurned beIuvIors (I.e. smokIng
und IIgI IuL dIeLs).
Ðiugnosis:
DIugnosIng un ucuLe M¡ cun eILIer be u very sLruIgIL Iorwurd process or IL cun be u
dIIIIcuIL process. TIe sLruIgIL Iorwurd dIugnosIs usuuIIy coupIes LIe puLIenL`s rIsk
IucLors wILI LIe presenLuLIon oI currenL sympLoms (und pusL medIcuI IIsLory). nce u
dIugnosIs oI ucuLe M¡ Is suspecLed, LIe IoIIowIng conIIrmuLory LesLs sIouId be
ordered:

IecLrocurdIogrum (CG) - Bused on eIecLrIcuI cIunges In LIe coronury sysLem
durIng un ucuLe M¡; un CG Is LIe IIrsL LesL LIuL sIouId be run.

uboruLory TesLs - Becuuse IeurL ceIIs Iuve specIIIc enzymes und proLeIns LIuL ure
reIeused wIen ceII deuLI occurs, druwIng bIood IeveIs Lo cIeck Ior LIe presence und
degree oI LIese enzymes wIII ussIsL In dIugnosIng un ucuLe M¡. TIe IoIIowIng provIdes
u descrIpLIon oI LIe mujor enzymes LIuL ure LIougIL Lo ussIsL wILI LIe dIugnosIs oI un
ucuLe M¡.
O CreuLIne KInuse (CK or CPK) - ReIeused Irom dumuged muscIe, CK Is un
enzyme Iound In LIe IeurL, skeIeLuI muscIe und bruIn. ¡L consIsLs oI ¸
Isoenzymes; mm (Iound In skeIeLuI muscIe, MB (Iound In curdIuc muscIe) und
BB (Iound In bruIn LIssue). Dumuge Lo uny oI LIese LIssues cuuses LIe reIeuse
oI CK InLo LIe bIood sLreum und Ience un eIevuLed IeveI.
O CKMB - AILer curdIuc Injury, CK und LIe Isoenzyme MB ure reIeused InLo LIe
bIood sLreum uL u predIcLubIe ruLe. WILIIn u q Lo 8 Iour wIndow (posL Injury)
LIe CKMB IeveI rIses ubove normuI und wILIIn 1z Lo zq Iours LIIs IeveI
eIevuLes Lo upproImuLeIy ¸ Lo 1¸ LImes normuI. WILIIn z Lo ¸ duys LIe CKMB
reLurns Lo normuI. Becuuse LIe MB Isoenzyme Is ecIusIve Lo curdIuc muscIe
LIssue, IL Is consIdered Lo be u very deIInILIve LesL Ior dIugnosIng un ucuLe M¡.
O TroponIn - TroponIn Is u proLeIn LIuL IeIps reguIuLe IeurL muscIe conLrucLIon
und becuuse IL cun be IsoIuLed In LIe bIood, IL Is consIdered Lo be u sensILIve
IndIcuLor oI un ucuLe M¡. TroponIn consIsLs oI ¸ sepuruLe proLeIns wIIcI ure
TroponIn ¡, TroponIn T und TroponIn C. TIe IuncLIon oI eucI oI LIese specIIIc
proLeIns Is us IoIIows:
O TroponIn ¡ und T - LIese IeveIs ure noL normuIIy Iound In LIe bIood sLreum so
uny deLecLIon oI LIese proLeIn In LIe bIood IndIcuLes LIe InIurcLIon or deuLI oI
curdIuc muscIeJLIssue.
O TroponIn C bInds Lo cuIcIum Ions und Is noL used Lo deLermIne ceII
LIssueJdeuLI.

CurdIuc nzyme NormuI VuIues
Enzyme/Protein Normal Value
Creatine Kinase 50 80 U/L
Total Creatinine Phosphokinase (CPK) 30 - 200 U/L
CPK MB (Fraction) 0 - 8.8 ng/ml
CPK MB (Fraction with percent oI total
CPK).
0 - 4 °
CPK MB2 (Fraction) Less than 1 U/L
Troponin 1 0 0.4 ng/ml
Troponin T 0 0.1 ng/ml

cIocurdIogrum - An ecIocurdIogrum cun ussIsL wILI dIugnosIng wIIcI porLIon oI
LIe IeurL Ius been dumuged und wIIcI coronury urLerIes Iuve been uIIecLed. An
ecIocurdIogrum cun uIso IeIp deLermIne curdIuc muscIe movemenLJconLrucLIon und
curdIuc wuII ubnormuIILIes.

!otentiul Complicutions Associuted with un Acote MI:
DysrIyLImIus - A dysrIyLImIu Is LIe mosL common compIIcuLIon uILer un ucuLe M¡.
DysrIyLImIus uILer un ucuLe M¡ ure cuused by LIe IormuLIon oI re-enLry cIrcuILs
beLween LIe sLIII IeuILIy und necroLIc myocurdIum. TIe IoIIowIng LubIe descrIbes LIe
percenLuge oI LIme specIIIc dysrIyLImIus occur posL ucuLe M¡.
Dysrhythmias Percentage of time present post
acute MI
Premature Ventricular
Contraction
90°
Ventricular Fibrillation 2° - 4°
Supraventricular (thought to
produce worse outcomes than
ventricular dysrhythmias)
· 10°
Bradyarrhythmias (including AV
block and sinus brady).
20° oI patients with acute RV
inIarction

mboIIc CompIIcuLIons - TIe IncIdence oI cIInIcuI sIgnIIIcunL sysLemIc emboIIsm
posL ucuLe M¡ Is Iess LIun z% (LIIs percenLuge Increuses In puLIenLs wIo Iuve
suIIered und ucuLe unLerIor wuII M¡). MuruI LIrombus IormuLIon Is Iowever more
prevuIenL posL ucuLe M¡ wILI numbers rungIng In LIe zo% runge und IncreusIng us
IIgI us 6o% In puLIenLs wILI Iurge unLerIor wuII M¡`s (deveIopmenL oI emboII comes
Irom myocurdIuI wuII moLIon deIIcILs or uLrIuI IIbrIIIuLIon). TIe mosL common LIme
posL ucuLe M¡ Ior LIe deveIopmenL oI emboIIsm Is wILIIn LIe IIrsL 1o duys. PuLIenLs
wIo suIIer Irom LIe compIIcuLIon oI emboIIsm ure uL rIsk oI deveIopIng IImb
IscIemIu, renuI InIurcLIon, InLesLInuI IscIemIu buL LIe mosL common cIInIcuI
presenLuLIon uILer un emboIIc evenL Is u sLroke.

PerIcurdILIs - TIe IncIdence oI eurIy PerIcurdILIs uILer und ucuLe M¡ Is upproImuLeIy
1o% wILI InIIummuLIon deveIopIng wILIIn LIe IIrsL zq Lo q6 Iours uILer M¡. uLe
PerIcurdILIs occurs In 1% Lo ¸% oI posL ucuLe M¡ puLIenLs beLween weeks 1 und 8
(uILer M¡). TIe cuuse oI PerIcurdILIs uILer ucuLe M¡ Is due Lo un InIIummuLory
reucLIon LIuL occurs secondury Lo LIe presence oI necroLIc LIssue (ucuLe PerIcurdILIs
occurs mosL oILen In puLIenLs wIo Iuve suIIered u LrunsmuruI M¡).

CurdIogenIc SIock (secondury Lo ucuLe M¡) - SImpIy sLuLed; curdIogenIc sIock
occurs wIen LIe bodIes needs Ior oygen ure noL meL Ior u proIonged perIod oI LIme.
WIen LIIs occurs; LIe body uLLempLs Lo compensuLe Ior LIe decreused oygen suppIy
by IncreusIng IeurL ruLe, sLroke voIume und conLrucLIIILy. UnIorLunuLeIy us LIIs
conLInues, LIe workIoud oI LIe IeurL becomes Loo mucI und LIe resuIL; LoLuI curdIuc
decompensuLIon begIns. WIen decompensuLIon begIns LIe puLIenL sIows sIgns oI
sIock, Iow bIood pressure, Increused or decreused IeurL ruLe und decreused oygen
suLuruLIons. LIer sympLoms mImIc LIose LIuL ure seen wILI congesLIve IeurL IuIIure
undJor puImonury edemu. TIIs condILIon Is crILIcuI und musL be uddressed
emergenLIy. ¡n uddILIon Lo oLIer medIcuI und pIurmuceuLIcuI LIerupIes; puLIenLs In
curdIogenIc sIock ure oILen IeIped wILI LIe uddILIon oI u buIIoon pump (¡ABP). TIe
mujor udvunLuge oI u buIIoon pump durIng curdIogenIc sIock Is LIe decreuse In
myocurdIuI oygen demund by decreusIng myocurdIuI workIoud, und LIe Increuse In
coronury urLery perIusIon.

Medicul[Interventionul Munugement:
PTCA - A percuLuneous LrunsmuruI coronury ungIopIusLy (PTCA) Is un eIIecLIve
revuscuIurIzuLIon procedure LIuL Is used Lo Increuse LIe dIumeLer oI un urLery LIuL Ius
been sLenosed due Lo coronury urLery dIseuse. WILI LIe use oI IIuoroscopy, u
curdIoIogIsL cun InserL u cuLIeLer (LIrougI LIe IemoruI urLery) und guIde IL LIrougI
LIe urLerIuI cIrcuIuLIon LIrougI LIe uscendIng uorLu und InLo LIe osLIum oI LIe rIgIL
or IeIL coronury urLery. A buIIoon LIpped cuLIeLer Is LIen pussed InLo LIe ureu oI
bIockuge und InIIuLed (no more LIun ¸o Lo 1zq seconds) wIIcI In Lurns IeIps Lo
compress pIuque uguInsL LIe IumInu oI LIe urLery. TIe buIIoon cun uIso IeIp Lo
sLreLcI LIe IumInu ILseII wIIcI uIso Improves bIood IIow. I noLe: wIen LIe buIIoon Is
InIIuLed, LIere Is un occIusIon oI coronury bIood suppIy, so puLIenLs oILen eperIence
u degree oI cIesL puIn durIng buIIoon InIIuLIon. TIe degree oI cIesL puIn eperIenced
und LIe dIIIIcuILy In compressIon pIuque muy requIre LIuL LIe pIysIcIun InIIuLe und
deIIuLe LIe buIIoon severuI LImes durIng LIe procedure.

TIe IoIIowIng Is u IIsL oI puLIenLs wIo ure LIougIL Lo be good cundIduLes Ior
percuLuneous LrunsmuruI coronury ungIopIusLy:
O PuLIenLs wILI ucuLe, cIronIc or unsLubIe ungInu.
O PuLIenLs wILI un ucuLe M¡ or posL ucuLe M¡.
O PuLIenLs wILI ungInu posL coronury urLery bypuss gruILIng (CABG).
O PuLIenLs wILI sIngIe oI doubIe vesseI dIseuse.
O PuLIenLs wILI uL IeusL ¸o% vesseI sLenosIs.
O PuLIenLs wILI u bIockuge LIuL Is concenLrIc und IocuLed uwuy Irom bIIurcuLIons.
O PuLIenLs wIo ure LIougIL Lo be good cundIduLes Ior LIe survIvuI oI emergency
curdIuc surgery (II LIere ure proceduruI compIIcuLIons).
Note: PTCA is contrcindiccted in pctients uith lejt mcin coroncrç crterç disecse
(especicllç those uho cre thouçht to be poor surçiccl ccndidctes).

CompIIcuLIons oI PTCA IncIude LIe IoIIowIng:
AcuLe coronury occIusIon (requIrIng emergenL surgIcuI InLervenLIon).
O DIssecLIon oI LIe urLery.
O AIIergIc reucLIon Lo conLrusL.
O TIe deveIopmenL oI bIeedIng or u IemuLomu uL LIe IemoruI InserLIon sILe (or
reLroperILoneuI bIeedIng).
O Decreuse In cIrcuIuLIon beIow LIe IemoruI InserLIon sILe (dImInIsIed or ubsenL
puIses).
O VusovuguI reucLIon (wIen sIeuLI Is removed).
O TIe deveIopmenL oI u pseudo uneurysm oI LIe urLery.
O Re-sLenosIs or occIusIon oI LIe urLery wILI In 6 monLIs.
O A bIood cIoL breukIng uwuy und cuusIng u sLroke (or oLIer emboIIc evenL).
ConLruIndIcuLIons Ior PTCA IncIude:
O A bIeedIng dIsorder (unLI-couguIuLIon sIouId be sLopped prIor Lo procedure).
O RenuI InsuIIIcIency
O Severe unconLroIIed IyperLensIon
O Severe perIpIeruI vuscuIur dIseuse
O UnLreuLed ucLIve InIecLIons
O Severe unemIu
O UncorrecLed eIecLroIyLe ImbuIunces
O ndocurdILIs
PTCA (wILI ¨sLenL¨ pIucemenL) - ¡n uddILIon Lo usIng ungIopIusLy us un InLervenLIon
Ior compressIng pIuque und sLreLcIIng LIe IumInu oI LIe urLery; LIe procedure cun
uIso be used Lo pIuce u sLenL InLo LIe urLery. A sLenL Is u smuII sLuInIess sLeeI Lube LIuL
cun be uLLucIed Lo LIe end oI LIe buIIoon LIpped cuLIeLer und pIuced InLo LIe urLery
ImmedIuLeIy uILer PTCA In un uLLempL Lo more permunenLIy prevenL re-occIusIon oI
LIe urLery. ¡or puLIenLs wIo Iuve undergone PTCA und suIIered un urLerIuI re-
occIusIon; LIe pIucemenL oI u sLenL Is un uILernuLIve (beneIIL Ius been sIown Ior
puLIenL wIo suIIer re-nurrowIng or re-occIusIon).

user AngIopIusLy - user ungIopIusLy Is u LecInIque LIuL cun be used Lo open
coronury urLerIes LIuL ure bIocked by pIuque. WILI LIIs procedure, LIe cuLIeLer LIuL Is
InserLed Ius u smuII Iuser uL LIe LIp. WIen LIe cuLIeLer Is In pIuce; LIe Iuser emILs
smuII puIsuLIng beums oI IIgIL LIuL vuporIze LIe pIuque LIuL Is bIockIng LIe urLery.
TIIs procedure cun be used uIone or In conjuncLIon wILI buIIoon ungIopIusLy.

!hurmuceoticul Treutment Options:
MorpIIne - Becuuse cuLecIoIumInes ure reIeused In response Lo LIe unIeLy und puIn
ussocIuLed wILI suIIerIng un ucuLe M¡ (IncreusIng LIe workIoud oI LIe IeurL),
MorpIIne cun be used. MorpIIne Is uIso beneIIcIuI In reducIng LIe IemodynumIc
workIoud by IncreusIng venous cupucILunce und reducIng sysLemIc vuscuIur
resIsLunce (LIereIore decreusIng myocurdIuI oygen demund).

NILrogIycerIn - NILruLes sucI us NILrogIycerIn cuuse vusodIIuLIon oI LIe vesseIs und
IeIp Lo decreuse curdIuc oygen demund, curdIuc preIoud und uILerIoud wIIIe
IncreusIng curdIuc ouLpuL.

AspIrIn - AnLIpIuLeIeL LIerupy (specIIIcuIIy uspIrIn) Is now u sLundurd LIerupy Ior LIe
LreuLmenL oI ungInu und ucuLe M¡. TIe prImury mecIunIsm Is beIIeved Lo be reIuLed
Lo IrreversIbIe InIIbILIon oI LIe cycIooygenuse puLIwuy oI pIuLeIeLs (bIockIng LIe
IormuLIon oI LIromboune Az und LIromboune Az-Induced pIuLeIeL uggreguLIon). ¡L
Is sLrongIy recommended LIuL uII puLIenLs wIo Iuve suIIered und ucuLe M¡ be gIven u
non-enLerIc couLed uspIrIn (16omg Lo ¸z¸mg) Lo cIew und swuIIow us soon us
possIbIe.

AnLIcouguIunLs (ReoPro) - ReoPro Is u pIuLeIeL gIycoproLeIn ¡¡JbJ¡¡¡u recepLor
InIIbILor LIuL Ius been proven Lo be eIIecLIve Ior LIe munugemenL oI uny coronury
IscIemIc syndrome. ¡L Is sLurLIng durIng u PTCA procedure und In mosL cuses Is used
us un udjuncL Ior sLenL pIucemenL. ReoPro Is gIven us un ¡V boIus oI o.z¸ mgJkg und
IoIIowed by u conLInuous InIusIon ruLe oI 1o mcgJmIn Ior LIe IoIIowIng 1z Iours. TIe
use oI ReoPro Is LIougIL Lo reduce pIuLeIeL uggreguLIon by upproImuLeIy 8o%.

AnLIcouguIunLs (TIcIId) - TIcIId Is gIven In z¸o mg doses B¡D und Is uIso un
AnLIpIuLeIeL ugenL. UnIIke uspIrIn, TIcIId does noL bIock cycIooygenuse buL InsLeud
InLerIeres wILI LIe pIuLeIeL ¨ucLIvuLIon¨ mecIunIsm LIuL Is medIuLed by udenosIne
dIpIospIuLe (ADP) wIIcI In Lurn InLerIeres wILI LIe IIbrInogen recepLor gIycoproLeIn
¡¡bJ¡¡¡u. ¡L Lukes upproImuLeIy z weeks oI LIerupy wILI TIcIId beIore LIe IuII beneIIL
Is ucIIeved.

HepurIn - HepurIn Is un unLIcouguIunL LIuL InIIbILs ucLIvuLed IucLors ¡S, S, S¡ und X¡¡
(wIIcI ure uII InvoIved In LIe conversIon oI ProLIrombIn Lo LIrombIn). By InIIbILIng
LIese ucLIvuLed IucLors, HepurIn Is LIougIL Lo keep LIe bIood LIInner und prevenLs
cIoLLIng. TIIs Is Lurns uIIows Ior eusIer bIood LruveI LIrougI LIe vesseIs LIuL ure
uIIecLed by nurrowIng und uLIeroscIerosIs.

BeLu BIockers - A beLu bIocker ucLs by bIockIng LIe B-udrenergIc responses Lo
cuLecIoIumIne sLImuIuLIon. BeLu bIockers decreuse IeurL ruLe, bIood pressure,
conLrucLIIILy und myocurdIuI oygen demund. BeIng ubIe Lo decreuse LIe work Ioud oI
LIe IeurL ussIsLs wILI ImprovIng curdIuc ouLpuL und Iessens LIe severILy oI LIe
dumuge cuused by LIe ucuLe M¡. BeLu bIockers cun ucLuuIIy InLerrupL un evoIvIng M¡,
IImIL LIe InIurcL sIze und decreuse LIe rIsk oI venLrIcuIur urrIyLImIus by decreusIng
oygen demund.

CuIcIum CIunneI BIockers - CuIcIum cIunneI bIockers proIIbIL LIe enLry oI cuIcIum
InLo smooLI muscIe. TIIs ussIsLs wILI dIIuLIng coronury urLerIes und veIns wIIcI In
Lurn provIdes un Increuse In overuII curdIuc bIood IIow. CuIcIum cIunneI bIockers
uIso decreuse sysLemIc bIood pressure, LoLuI perIpIeruI resIsLunce und curdIuc
uILerIoud.

AC InIIbILors - An AngIoLensIn converLIng enzyme; AC InIIbILors bIock Lo LIe
conversIon oI AngIoLensIn ¡ Lo AngIoLensIn ¡¡ (wIIcI Is u poLenL vusoconsLrIcLor). TIe
gouI oI und AC InIIbILor Is Lo decreuse bIood pressure und uILerIoud wILIouL
IncreusIng IeurL ruLe or LIe workIoud oI LIe IeurL.

LPA (ALepIuse) - LPA Is u Iumun proLeIn LIuL Is munuIucLured by geneLIc engIneerIng.
TIssue pIusmInogen ucLIvuLor Is one oI severuI drugs noL upproved Ior use In cerLuIn
puLIenLs wIo ure suIIerIng Irom und ucuLe M¡. LPA Is desIgned Lo dIssoIve LIe bIood
cIoLs (In LIe urLerIes) LIuL ure responsIbIe Ior cuusIng LIe mujorILy oI ucuLe M¡`s. LPA
Is gIven In un InILIuI 1¸ mg ¡V boIus LIen o.;¸ mgJkg (muImum oI ¸o mg) over ¸o
mInuLes. TIIs Is LIen IoIIowed by o.¸ mgJkg (muImum ¸¸ mg) over 6o mInuLes Ior u
LoLuI oI 1oo mg over qo mInuLes. SIgns oI reperIusIon IncIude puIn reIIeI; reperIusIon
urrIyLImIus (ucceIeruLed IdIovenLrIcuIur rIyLIm, venLrIcuIur ecLopy und
brudycurdIu).

ConLruIndIcuLIons Ior LIe use oI LPA:
O AcLIve InLernuI bIeedIng
O ¡nLrucrunIuI neopIusm or recenL bruIn surgery
O ProIonged LruumuLIc curdIopuImonury resuscILuLIon
O AIIergy Lo sLrepLokInuse
O RecenL Lruumu or surgery (wILIIn LIe pusL z weeks)
O Pregnuncy
O A IIsLory oI IemorrIugIc or non-IemorrIugIc sLroke
DopumIne - DopumIne Ius boLI u und b-udrenergIc eIIecLs (us weII us dopumInergIc
eIIecLs). AL Iow doses (z-¸ mcgJkgJmIn) IL Increuses renuI und mesenLerIc bIood IIow.
AL moderuLe doses (¸-1o mcgJkgJmIn) IL Ius u posILIve InoLrope uIIecL wIIcI
Increuses bIood pressure und curdIuc ouLpuL. AL Iurger doses (1o-zo mcgJkgJmIn) IL
eIIbILs u pure uIpIu sLImuIuLIon wIIcI cuuses perIpIeruI vusoconsLrIcLIon wILI boLI
Increused sysLemIc vuscuIur resIsLunce (SVR) und uILerIoud.

DobuLumIne - DobuLumIne sLImuIuLes B-recepLors oI LIe IeurL und provIde u dIrecL
ucLIng posILIve InoLrope eIIecL. DobuLumIne Increuses sLroke voIume und curdIuc
ouLpuL by IncreusIng curdIuc conLrucLIIILy wIIIe decreusIng SVR. By IncreusIng
conLrucLIIILy und curdIuc ouLpuL; LIere Is more oygen rIcI bIood uvuIIubIe Ior
dumuged LIssue.

Norsing Cure[Munugement und !utient Idocution {Bused on NANÐA
diugnosis):
Decreused CurdIuc uLpuL:
DeIInILIon - ¡nudequuLe bIood pumped by LIe IeurL Lo meeL LIe meLuboIIc demunds
oI LIe body.

DeIInIng CIurucLerIsLIcs:
O DysrIyLImIus (LucIycurdIu, brudycurdIu, eIecLrocurdIogrupIIc cIunges).
O AILered PreIoud (juguIur veIn dIsLenLIon, IuLIgue, edemu, IncreusedJdecreused
cenLruI venous pressure (CVP), IncreusedJdecreused puImonury urLery wedge
pressure (PAWP).
O AILered AILerIoud (cooI cIummy skIn, sIorLness oI breuLIJdyspneu, oIIgurIu,
proIonged cupIIIury reIIII, decreused perIpIeruI puIses)
O AILered ConLrucLIIILy (cruckIes uL LIe Iung buses, cougI, orLIopneuJnocLurnuI
dyspneu, curdIuc ouLpuL Iess LIun q IILersJmIn, curdIuc Inde Iess LIuL z.¸
IILersJmIn, decreused sLroke voIume, decreused IeIL venLrIcuIur sLroke work
Inde (VSW¡), S¸ or Sq IeurL sounds presenL).
O BeIuvIoruIJmoLIonuI (unIeLy or resLIessness).
NursIng ¡nLervenLIons:
O MonILor Ior sympLoms oI IeurL IuIIureJdecreused curdIuc ouLpuL (VS, IeurL
sounds, und S¸ guIIop).
O bserve Ior sympLoms oI curdIogenIc sIock (cooI cIummy skIn, IypoLensIon,
decreused perIpIeruI puIses, und puImonury congesLIon).
O ¡I sIock presenL, monILor IemodynumIc purumeLers Ior Increused PAWP und
Increused sysLemIc vuscuIur resIsLunce.
O TILruLe InoLropIc und vusoucLIve medIcuLIon wILIIn deIIned purumeLers Lo
muInLuIn udequuLe conLrucLIIILy, preJuILerIoud und bIood pressure.
O ¡or compIuInLs oI cIesL puIn, medIcuLe und noLe severILy, IocuLIon, rudIuLIon,
wIuL were conLrIbuLIng IucLors (geLLIng up, purLIcIpuLIng In AD`s Ior
eumpIe) und reporL IIndIngs.
O MonILor InLuke und ouLpuL (¡V IIuId, urIne ouLpuL, P InLuke (IIuId overIoud
Increuses LIe workIoud oI LIe IeurL und decreused curdIuc ouLpuL cun cuuse u
decreuse In perIusIon Lo LIe kIdneys).
O NoLe resuILs oI dIugnosLIc ImugIng sLudIes (KG, rudIonucIIde ImugIng, und
DobuLumIne sLress LesLs).
O WuLcI IuboruLory duLu cIoseIy (ABG`s, serIuI enzymes, eIecLroIyLes, B-Lype
nuLrIureLIc pepLIde, serum creuLInIne).
O MonILor oygen suLuruLIon und provIde z us ordered und necessury.
O MonILor bIood pressureJpuIse beIore und uILer LIe udmInIsLruLIon oI curdIuc
medIcuLIons.
O HB sIouId be uL ¸o degrees Lo decreuse LIe work oI breuLIIng und decreuse
preIoud.
O ProvIde u proper resLJucLIvILy buIunce Lo ussure LIuL curdIuc ouLpuL Is noL
compromIsed (gruduuIIy Increuse ucLIvILy us condILIon wurrunLs).
O rder smuII sodIum resLrIcLed dIeL (sodIum resLrIcLIon IeIps Lo uvoId IIuId
overIoud).
O MonILor boweI IuncLIon (u sLooI soILener sIouId be ordered Lo uvoId
unnecessury pusIIng).
O ProvIde u peuceIuI envIronmenL LIuL mInImIzes sLressors Lo promoLe IeuIIng.
O WeIgI puLIenL duIIy (sume LIme eucI duy, sume equIpmenL).
O Assess Ior LIe presence oI unIeLy (keep envIronmenL Iree oI unnecessury
sLressors, educuLe puLIenL Lo LIe ruLIonuIe Ior InLervenLIons und procedures).
O Assess Ior LIe presence oI depressIon (depressIon Is common uILer und ucuLe
M¡ und cun resuIL In Increused morLuIILy).
O ReIer puLIenL Lo curdIuc ouLpuLIenL progrum und supporL groups. AssIsL wILI
orgunIzIng curdIuc reIubIIILuLIon eIIorLs posL dIscIurge.
Acote Coronury Syndrome {ACS) - q Norsing CIs {continoed)
AuLIor: KrIsLI Hudson RN, MSN CCRN

PuLIenLJ¡umIIy TeucIIng:
O TeucI LIe puLIenL LIe sympLoms oI IeurL IuIIure und upproprIuLe ucLIons Lo
Luke.
O TeucI LIe ImporLunce oI smokIng cessuLIon (puLIenLs wIo conLInue Lo smoke
Increuse LIeIr rIsk oI u secondury M¡ by ¸o%).
O pIuIn necessury resLrIcLIons (sodIum resLrIcLed dIeL, guIdeIInes Ior IIuId
InLuke, uvoIdunce oI LIe vuIsuIvo muneuver, pucIng ucLIvILy, work
sImpIIIIcuLIon LecInIques).
O TeucI LIe puLIenL regurdIng LIe ImporLunce oI modIIyIng oLIer rIsk IucLors
sucI us dIubeLes und obesILy.
O TeucI sLress reducLIon eercIses (conLroIIed breuLIIng, Imugery, muscIe
reIuuLIon LecInIques).
O AssIsL LIe puLIenL Lo undersLund LIe ImporLunce oI IncorporuLIng cIunges InLo
IIsJIer currenL IIIesLyIe. ReIer Lo curdIuc reIubIIILuLIon Ior ussIsLunce wILI
copIng und udjusLIng).
O TeucI Lo puLIenL LIe ucLIons und sIde uIIecLs oI LIe curdIuc medIcuLIon LIey
wIII be LukIng. SLress LIe ImporLunce oI keepIng prescrIpLIons IIIIed und LIe
ImporLunce oI LukIng medIcuLIon us ordered. AIso LeucI LIe puLIenL Lo cuII or
seek medIcuI ussIsLunce II LIey ure eperIencIng serIous sIde uIIecLs.
O ¡nsLrucL LIe puLIenL on LIe ImporLunce oI geLLIng u IIu sIoL und pneumovuc
vuccIne (II noL uIreudy provIded durIng LIe IospILuI sLuy).
O ¡nsLrucL LIe puLIenL on LIe ImporLunce oI duIIy weIgIL und Iow un Increuse In
weIgIL cun sIgnuI IIuId guIn (wIIcI muy be u sIgn oI pendIng IeurL IuIIure).
ProvIde specIIIc wrILLen muLerIuI und u seII cure pIun Ior LIe puLIenL Lo Luke
Iome und use us u reIerence.
O ConsuIL dIeLIcIun or ussIsL LIe puLIenL Lo undersLund LIe ImporLunce oI u Iow
sodIum resLrIcLed dIeL.
pecLed uLcomes:
O IIecLIve pump eIIecLIveness
O ¡mproved curdIuc cIrcuIuLIon
O ¡mproved curdIuc LIssue perIusIon
O ¡mproved perIusIon Lo LIe ubdomInuI orgunsJperIpIery
O ¡mproved vILuI sIgns
Alterution in ComIort {!uin):
DeIInILIon:
A sLuLe In wIIcI un IndIvIduuI eperIences un uncomIorLubIe sensuLIon In response Lo
noIous sLImuIus.

DeIInIng CIurucLerIsLIcs:
O VerbuIIzuLIon oI dIscomIorL
O bserved beIuvIor IndIcuLIve oI dIscomIorL
O ResLIessJLense beIuvIor
O AvoIdunce
O MuIuIse
O AcIIngJsLIIIness
O UnusuuI Iunger or LIIrsL
O Reduced mobIIILy
NursIng ¡nLervenLIons:
O Assess puLIenLs need IoIIsLIcuIIy (pIysIcuI dIscomIorL oILen coeIsLs wILI
emoLIonuI und spIrILuuI dIscomIorL).
O Assess LIe degree oI puIn LIe puLIenL Is eperIencIng usIng LIe sume Lype oI
puIn scuIe eucI LIme (I.e. 1-1o scuIe or ¡ACC scuIe).
O Assess und documenL LIe onseL, duruLIon, IocuLIon, Lype,
conLrIbuLIngJreIIevIng IucLors wIen ussessIng Ior puIn.
O ConsuIL wILI LIe pIysIcIun Ior LIe mosL eIIecLIve medIcuLIon Lo reduce puIn
(NILrogIycerIn, MorpIIne und ygen ure mosL commonIy used).
O PosILIon puLIenL Ior muImum comIorL.
O Assure u proper resLJucLIvILy buIunce (group nursIng ucLIvILIes und wIen
possIbIe IImIL uncomIorLubIe InLervenLIons).
O ProvIde dIsLrucLIon (Imugery Ior eumpIe).
O Assure un udequuLe resL perIod Is uvuIIubIe Ior puLIenLs posL puIn medIcuLIon
udmInIsLruLIon.
O ProvIde u quIeL envIronmenL Ior puLIenL und IumIIy.
PuLIenLJ¡umIIy TeucIIng:
O TeucI puLIenL LecInIques Lo use wIen uncomIorLubIe.
O TeucI puLIenL Lo cuII nurse ImmedIuLeIy II cIesL puIn occurs.
O ducuLe puLIenL Lo uII prescrIbed medIcuLIons und LreuLmenLs.
O Upon dIscIurge; ussure LIuL LIe puLIenLJIumIIy Ius u good undersLundIng oI
medIcuLIons Lo be Luken uL Iome.
O pIuIn LIe ImporLunce oI keepIng uII medIcuI uppoInLmenLs.
O ducuLe puLIenL Lo LIe ImporLunce oI buIuncIng ucLIvILy wILI resL.
pecLed uLcomes:
O ComIorL IeveI und puIn In conLroI.
O AbIe Lo scuIe puIn upproprIuLeIy.
O AbIe Lo recognIze sIgns und sympLoms oI cIesL puIn und prompLIy cuII Ior
ussIsLunce.
O pIuIns meLIods Lo decreuse dIscomIorL.
O DIspIuys Increuse ucLIvILy wILIouL dIscomIorL.
O Appeurs cuIm und wILIouL undue unIeLy or sLress.
Anxiety:
DeIInILIon: A vugue uneusy IeeIIng oI dIscomIorL or dreud uccompunIed by un
uuLonomIc response. TIe source oI LIIs IeeIIng Is eILIer known or unknown Lo LIe
IndIvIduuI, buL cuuses u IeeIIng oI uppreIensIon, or possIbIe dunger. AnIeLy Is un
uIerLIng sIgnuI LIuL wurns oI ImpendIng dunger und enubIes LIe IndIvIduuI Lo Luke
meusures Lo deuI wILI LIe LIreuL.

DeIInIng CIurucLerIsLIcs:
O DImInIsIed producLIvILy
O ScunnIng und vIgIIunce
O Poor eye conLucL
O ResLIess beIuvIor
O GIuncIng ubouL
O Lruneous movemenL (repeLILIve movemenL, IooL sIuIIIIng)
O pressed concern resuILIng Irom IIIe cIunges
O ¡nsomnIu
O ¡IdgeLIng
O ¡rrILubIIILy
O RegreLIuIJIeIpIessJworrIed
O "uIverIng voIceJLrembIIngJIund Lremors
O IevuLed puIse und bIood pressure
NursIng ¡nLervenLIons:
O Assess puLIenLJIumIIy IeveI oI unIeLy us weII oI knowIedge oI eIsLence und
cuuse. Use presence, LoucI (wILI permIssIon), verbuIIzuLIon und
envIronmenLuI IucLors Lo ussIsL In decreusIng unIeLy.
O ProvIde dIsLrucLIon (musIc, muguzInes, TV).
O AccepL LIe puLIenLJIumIIy deIenses or epIunuLIons oI unIeLy (denIuI uILer un
ucuLe M¡ Is oILen presenL).
O Do noL Lry Lo urgue or demeun LIe puLIenLJIumIIy Ior LIeIr IeeIIngs.
O AIIow und reInIorce LIe puLIenLJIumIIy member`s epressIons oI puIn,
dIscomIorL undJor LIreuLs Lo LIeIr weII beIng.
O HeIp LIe puLIenLJIumIIy deveIop copIng sLruLegIes LIuL wIII decreuse unIeLy.
ncouruge posILIve (buL reuIIsLIc) LIInkIng regurdIng ouLcomes.
O AvoId ¨ecessIve reussurunce¨ us LIIs muy cuuse LIe puLIenLJIumIIy Lo worry
unnecessurIIy.
O ¡nLervene wIen possIbIe Lo remove sources oI sLress.
O pIuIn, pIuIn, pIuIn (uII ucLIvILIes, procedures, LesLs, und gouIs).
PuLIenLJ¡umIIy TeucIIng:
O TeucI puLIenLJIumIIy LIe sympLoms oI unIeLy.
O pIuIn equIpmenL (especIuIIy II In LIe ¡CU) und LIe monILors In LIe room.
ReInIorce LIuL mosL equIpmenL Is Lo muke LIe ussessmenL oI LIe puLIenL eusIer
und noL ucLuuIIy NCSSARY us purL oI LIe puLIenL LreuLmenL or LIerupy.
O HeIp LIe puLIenLJIumIIy Lo be ubIe Lo deIIne unIeLy IeveIs (Irom eusIIy
LoIeruLed Lo InLoIerubIe). Use u coIor or number code Ior eusy IdenLIIIcuLIon.
O TeucI LIe puLIenLJIumIIy seII IeIp LecInIques Lo uvoId or mInImIze sLress und
unIeLy.
O TeucI LIe puLIenLJIumIIy LIe use oI dIsLrucLers Lo uvoId or mInImIze sLress und
unIeLy.
O TeucI LIe puLIenLJIumIIy reIuuLIon und deep breuLIIng eercIses.
O TeucI LIe puLIenLJIumIIy LIe correIuLIon beLween buIuncIng sIeep, nuLrILIon,
eercIse und IIIesLyIe Lo uvoId unIeLy.
O HeIp LIe puLIenLJIumIIy dIsLInguIsI beLween unIeLy und punIc.
O TeucI LIe puLIenLJIumIIy upproprIuLe communILy supporL.
O ProvIde socIuI servIces consuIL II puLIenLJIumIIy sIowIng sIgns oI severe
unIeLy.
O ncouruge LIe puLIenLJIumIIy Lo keep u noLe pud Iundy Lo joL down quesLIons
or concerns LIuL LIey muy Iuve.
pecLed PuLIenL uLcomes:
O ¡denLIIIes und verbuIIzes sympLoms oI unIeLy.
O ¡denLIIIes und demonsLruLes meLIods Lo decreuse unIeLy.
O VerbuIIzes ubsence or decreuse In subjecLIve dIsLress.
O NormuI vILuI sIgns.
O ReporLs sIeepIng beLLer und denIes InsomnIu (use Iunguuge LIuL u cIIId wIII
undersLund Ior LIIs ussessmenL).
O DemonsLruLes Improved concenLruLIon.
O DemonsLruLes reLurn ubIIILy Lo probIem soIve.
O DemonsLruLes some ubIIILy Lo reussure seII.
IneIIective Coping {Individoul or Iumily):
DeIInILIon:
TIe InubIIILy Lo Iorm u vuIId uppruIsuI oI InLernuI or eLernuI sLressors, InudequuLe
cIoIces oI prucLIced responses undJor LIe InubIIILy Lo uccess or use currenLIy
uvuIIubIe sources.

DeIInIng CIurucLerIsLIcs:
O uck oI gouI dIrecLIon beIuvIor.
O TIe InubIIILy Lo resoIve probIems.
O DIIIIcuILy wILI rememberIng or orgunIzIng LIougILs.
O SIeep dIsLurbunce.
O Abuse oI cIemIcuI ugenLs.
O Decreused use oI socIuI supporL.
O TIe use oI copIng mecIunIsms LIuL ucLuuIIy Impeded udupLIve beIuvIor.
O Poor concenLruLIon.
O VerbuIIzuLIon oI LIe InubIIILy Lo cope.
O CIunge In usuuI communIcuLIon puLLerns.
O RIsk LukIng.
NursIng ¡nLervenLIons:
O bserve Ior cuuses oI IneIIecLIve copIng sucI us u poor seII-concepL, u Iuck oI
probIem soIvIng skIIIs or Iuck oI supporL Ior eumpIe (denIuI or Ieur oI LIe posL
M¡ IIIesLyIe cIunges Is oILen LIe source oI sLress LIuL cuuses IneIIecLIve
copIng).
O bserve Ior sLrengLIs sucI us LIe ubIIILy Lo reIuLe LIe IucLs und recognIze LIe
source oI sLress.
O Assess LIe rIsk oI possIbIe seII Iurm.
O HeIp LIe puLIenLJIumIIy seL reuIIsLIc gouIs wIIIe IdenLIIyIng personuI skIIIs und
knowIedge.
O Use empuLIeLIc communIcuLIon und encouruge LIe puLIenLJIumIIy Lo verbuIIze
Ieurs und concerns.
O ncouruge LIe puLIenLJIumIIy Lo purLIcIpuLe In IIsJIer cure (on uII IeveIs).
O pIuIn LesLs, procedures und uII oLIer uspecLs oI cure prIor Lo deIIvery.
O ProvIde boLI menLuI und pIysIcuI ucLIvILIes LIuL ure wILIIn LIe puLIenL`s
ubIIILy.
O DIscuss cIunges wILI LIe puLIenLJIumIIy beIore mukIng LIem (room cIunges,
Increuses In ucLIvILy Ior eumpIe).
O Use ucLIve IIsLenIng LecInIques wIen LIe puLIenL Is descrIbIng IeeIIngs oI
sudness, Ioss, guIIL or unger.
O ncouruge LIe puLIenL Lo descrIbe prevIous IIIe sLressors und Iow IeJsIe
coped wILI LIose sLressors In LIe pusL.
O Be supporLIve.
O Use sysLemuLIc desensILIzuLIon wIen InLroducIng new peopIe, pIuces, LesL or
procedures (Ieur oI new LIIngs dImInIsIes wILI repeuLed eposure).
O ReIer Ior counseIIng us needed.
PuLIenLJ¡umIIy ducuLIon:
O TeucI puLIenLJIumIIy copIng LecInIques sucI us probIem soIvIng.
O Huve LIe puLIenLJIumIIy descrIbe LIe probIem or cuuse oI LIeIr InubIIILy Lo
cope.
O IsL LIe udvunLuges und dIsudvunLuges oI LIe sILuuLIon us weII us possIbIe
opLIons.
O ProvIde LIe puLIenLJIumIIy wILI IILeruLure ubouL sILuuLIons (LesL procedures Ior
eumpIe) oI LIe sLressor (II LIe sLressor Is IdenLIIIubIe).
O TeucI reIuuLIon LecInIques.
O ProvIde InIormuLIon ubouL communILy resources.
pecLed uLcomes:
O ¡mproved copIng ubIIILIes
O ¡mproved decIsIon mukIng
O ¡mproved ¡mpuIse seII conLroI
O ¡mproved InIormuLIon processIng
O AbIIILy Lo eIIecLIveIy purLIcIpuLe In cure
Additionul NANÐA Norsing Ðiugnoses Ior Considerution:
O AILeruLIon In breuLIIng puLLern
O AILeruLIon In nuLrILIon
O ¡IuId voIume overIoud
O AILeruLIon In mobIIILy
O KnowIedge deIIcIL
Curdiuc #ehubilitution:
TIe gouIs oI curdIuc reIub ure Lo provIde u medIcuIIy supervIsed progrum (posL
dIscIurge) LIuL Is uImed uL ImprovIng LIe puLIenLs overuII pIysIcuI und menLuI
ubIIILIes wIIIe sLubIIIzIng, sIowIng or even reversIng LIe progressIon oI curdIovuscuIur
dIseuse. TIe IoIIowIng componenLs ure purL oI u good curdIuc reIubIIILuLIon progrum:
O Proper counseIIng und supporL so LIe puLIenL Ius u beLLer undersLundIng oI
IIsJIer dIseuse process.
O TIe deveIopmenL oI u puLIenL specIIIc eercIse pIun (even gerIuLrIc puLIenLs
wILI coronury dIseuseJIeurL IuIIure Iuve been Iound Lo beneIIL Irom eercIse).
O DIeLury consuILuLIon Lo IeIp educuLe LIe puLIenL LIe ImporLunce oI IoIIowIng u
Iow sodIum, Iow IuL dIeL. DIeL pIunnIngJsIoppIng sIouId uIso be u purL oI LIIs
educuLIon.
O ducuLIon und supporL Lo modIIy rIsk IucLors sucI us cIgureLLe smokIng, IIgI
bIood pressure, dIubeLes, IIgI cIoIesLeroI, pIysIcuI InucLIvILy und obesILy.
O TeucI LIe ImporLunce oI IImILIng or uvoIdIng uIcoIoI InLuke (An uveruge oI one
Lo Lwo drInks per duy Ior men und one drInk per duy Ior women. A drInk Is
one 1z oz. beer, q oz. oI wIne, 1.¸ oz. oI 8o-prooI spIrILs, or 1 oz. oI 1oo-prooI
spIrILs.) TIIs umounL oI uIcoIoI Is consIdered Lo be ¨drInkIng In moderuLIon¨.
O VocuLIonuIJsocIuI educuLIon In LIe uLLempL Lo reLurn LIe puLIenL Lo work und
normuI ucLIvILIes.
O SuppIyIng InIormuLIon ubouL pIysIcuI IImILuLIons (ecessIve eercIse, seuuI
ucLIvILy Ior eumpIe).
O ducuLIonJcounseIIng regurdIng prescrIpLIon medIcuLIon und LIe ImporLunce
oI sLIckIng Lo LIe rouLIne us weII us reporLIng sIde eIIecLs.
O moLIonuIJspIrILuuI supporL us needed.
Note: Lonç term success oj the pretention oj c secondcrç MI is dependcnt on the
pctient hctinç c çood understcndinç oj the role he,she plcçs cjter dischcrçe.
Without complicnce uith cll trectment cnd rehcbilitction intertentions (in
combinction), pctients is ct çrect risl oj hctinç c second MI.

#eIerences
AckIey, B., J & udwIg, G., B. (zooq). NursIng dIugnosIs Iundbook: A guIde Lo
pIunnIng cure. (6LI ed.). Mosby; SL. ouIs MIssourI

AmerIcun HeurL AssocIuLIon (zoo;). TIe IeurL oI dIubeLes. ReLrIeved on JuIy q, zoo;
uL:
szmw.comJIeurLoIdIubeLesJInde.ILmI

AmerIcun HeurL AssocIuLIon (zoo;). PerIormunce meusures. ReLrIeved on JuIy q,
zoo; uL:
umerIcunIeurL.orgJpresenLer.jILmI?IdenLIIIer=¸o1zqoq

AmerIcun HeurL AssocIuLIon (zoo;). HeurL und sLroke encycIopedIu. ReLrIeved on
JuIy q, zoo; uL:
umerIcunIeurL.orgJpresenLer.jILmI?IdenLIIIer=¸ooqzq;o

AmerIcun HeurL AssocIuLIon (zoo;). user ungIopIusLy. ReLrIeved on JuIy q, zoo; uL:
umerIcunIeurL.orgJpresenLer.jILmI?IdenLIIIer=qqq6

AmerIcun MedIcuI NeLwork (zoo;). AcuLe myocurdIuI InIurcLIon. ReLrIeved on JuIy
¸, zoo; uL:
ILLp:JJwww.IeuILI.umJcurdIoJmoreJucuLe_myocurdIuI_InIurcLIonJ

Bujzer. C. M.D. (zooz). AcuLe myocurdIuI InIurcLIon. ReLrIeved on JuIy q, zoo; uL:
cIeveIundcIInIcmeded.comJdIseusemunugemenLJcurdIoIogyJucuLemIJucuLemI.ILm

Druke-MeIunder, S. (zooq). Cuse sLudIes In crILIcuI cure nursIng: A guIde Ior
uppIIcuLIon und revIew (¸rd ed.). Suunders, PIIIudeIpIIu

SIsks, J., ., M.A. (zoo;). ncycIopedIu oI nursIng und uIIIed IeuILI: CurdIuc
cuLIeLerIzuLIon. ReLrIeved on JuIy ;, zoo; uL:
IeuILI.enoLes.comJnursIng-encycIopedIuJcurdIuc-cuLIeLerIzuLIonJprInL

SperLus, J., A., MD, MPH, eL. uI. (zoo¸). AmerIcun CoIIege oI CurdIoIogy und
AmerIcun HeurL AssocIuLIon MeLIodoIogy Ior LIe SeIecLIon und CreuLIon oI
PerIormunce Meusures Ior "uunLIIyIng LIe "uuIILy oI CurdIovuscuIur Cure. ReLrIeved
on JuIy q, zoo; uL:
cIrc.uIujournuIs.orgJcgIJconLenLJIuIIJ111J1¸J1;o¸

WebMD. (zoo;). cerpLs Irom myocurdIuI InIurcLIon: AcuLe. ReLrIeved on JuIy ¸,
zoo; uL:
emedIcIne.comJrudIoJbynumeJmyocurdIuI-InIurcL-ucuLe.ILm

Wbat is a myocardial infarction?
Myocardial inIarction (MI) means that part oI the heart muscle suddenly loses its blood
supply. Without prompt treatment, this can lead to damage to the aIIected part oI the heart.
An MI is usually caused by a blood clot in a heart (coronary) artery that Iorms over a patch oI
atheroma (Iatty deposit). See separate leaIlet called ´Myocardial Infarction´ which discusses
MI in more detail.
Wbat can I do to belp after baving a myocardial infarction?
Following an MI, there are things that you can do to reduce the risk oI Iurther heart problems.
Everyone is diIIerent and individual circumstances will vary. You should discuss with a
doctor or nurse what is -08t for you. This leaIlet aims to complement any advice that you may
receive.
Smoking
II you smoke, giving up smoking is the single most eIIective way to reduce your risk oI
having a Iurther MI. The chemicals in cigarette smoke aIIect the arteries. II you stop
smoking, your risk oI a Iurther MI is roughly halved compared to the risk iI you continue to
smoke. Angina is also more likely to develop in smokers.

II you Iind it hard to give up smoking then seek help Irom your doctor, practice nurse or
pharmacist. They can give help and can advise on the use oI nicotine replacement therapy
(nicotine gum, etc) or other treatments that can help you to stop smoking. Separate leaIlets
give more details about smoking and ways that help you to stop smoking.
Diet
Changes in diet can make a big diIIerence. Studies suggest that people who eat a healthy diet
may halve their chance oI a Iurther MI compared to those who do not eat healthily. See
separate leaIlet called ´H0althy Eating´ Ior more details.

BrieIly:
O Lat at |east f|ve port|ons of a var|ety of fru|t and vegetab|es each dayŦ 1hey are rlch ln
vlLamlns and mlneralsŦ 1hese can be freshţ frozen or drledŦ
O o not eat much saturated fatŦ lL ls noL [usL abouL Lhe totol fot conLenL of Lhe dleLţ buL also
Lhe type of fot ln Lhe dleLŦ 1ry Lo avold eaLlng foods LhaL are hlgh ln saLuraLed faLŦ loods LhaL
are hlgh ln saLuraLed faL lnclude meaL plesţ sausagesţ buLLerţ creamţ hard cheeseţ cakesţ
blsculLs and foods LhaL conLaln coconuL or palm ollŦ LaLlng foods LhaL are hlgh ln unsaLuraLed
faL can help Lo reduce your cholesLerol levelŦ loods hlgh ln unsaLuraLed faL lnclude olly flsh
(such as herrlngţ mackerelţ sardlneţ salmon)ţ avocadosţ nuLs and seedsţ sunflowerţ rapeseed
and ollve ollŦ
O educe you sa|t |ntakeŦ Many foods conLaln hldden salLŦ Lowerlng your salL lnLake can
reduce your rlsk of anoLher Ml and also oLher cardlovascular dlseasesŦ
Alcohol
A little alcohol may be beneIicial. People who drink one glass oI wine per day, or about halI
a pint oI beer per day, may have less risk oI heart disease compared to those who do not drink
at all. It is probably the alcohol rather than anything else in the drink that is the active
ingredient. The exact way this works is not clear. Alcohol may aIIect the way atheroma is
Iormed.

However, drinking too much alcohol can be harmIul. Men should drink no more than 21 units
per week (and no more than Iour units in any one day). Women should drink no more than 14
units per week (and no more than three units in any one day). One unit is about halI a pint oI
normal strength beer, or two thirds oI a small glass oI wine, or one small pub measure oI
spirits. See separate leaIlet called ´Alcohol and S0n8i-l0 Drinking´ Ior more details.
A Mediterranean diet
Eating a Mediterranean style diet is thought to be one oI the best ways to reduce the risk oI
having an MI. This type oI diet is, in eIIect, a summary oI the advice above. That is - meals
with poultry rather than red meat, lots oI wholegrain pasta and breads and plenty oI Iruit,
vegetables, olive oil, oil-rich Iish, accompanied by a small glass oI wine or beer.
holesterol
Cholesterol is involved in the Iormation oI atheroma. Eating a healthy diet (described above)
will help to lower cholesterol. In addition, most people who have an MI are advised to take a
statin drug to lower the cholesterol level. Statins work by reducing the amount oI cholesterol
that is made in your liver.

In general, the lower the cholesterol level, the better. See separate leaIlet called ´Chol08t0rol´
Ior more details.
Physical activity and exercise
Normal physical activity and regular exercise is advised Ior most people who have had an
MI. You should try and be physically active, Ior example take the stairs whenever possible,
walk to the shops and wash your car. In the past, some people thought that exercise 'put a
strain on the heart' and was bad. However, quite the opposite is true Ior most people who
recover Irom an MI. Physical activity and regular exercise is good Ior the heart. Indeed,
regular exercise is one oI the main parts oI cardiac (heart) rehabilitation programmes that are
popular aIter having an MI (as discussed later). Regular exercise is a major way to reduce the
risk oI having a Iurther MI.

However, beIore starting regular exercise, get the go-ahead Irom your doctor. This is because
strenuous exercise in c0rtain 8ituation8 may not be advised. For example, some people with
heart valve problems may not be advised to exercise. However, these people are the
exception, and Ior most people who have had an MI, exercise is beneIicial.

Following an MI, once you get the go-ahead, it is best to gradually build up the level oI
activity and exercise that you do. For the Iirst week or so, try simply to go Ior a short walk
each day. Everyone is diIIerent and the length oI the walk depends on how Iit you were to
start with. For some people, at Iirst it may simply be a walk to the end oI the garden and
back, Ior others a walk to the end oI the road and Ior others a bit Iurther.

You can then gradually build up the distance oI your walking over time. A reasonable goal by
about six weeks aIter having an MI is to aim to walk Ior 20-30 minutes each day. However,
the amount oI exercise that some people can do will be limited because oI other medical
problems. For example, some people develop angina which may limit the intensity oI
exercise that can be done. Others have other unrelated medical problems that limit exercise
ability, or are too Irail to exercise.

Regarding liIting and sudden bursts oI strenuous eIIort. As a rule, normal manual work is
Iine, however, you should not do anything that makes you need to hold your breath. For
example, liIting very heavy objects when you would need to 'grit your teeth' and hold your
breath.

In most cases, aIter about 6-8 weeks Iollowing an MI the advice about exercise is the same as
applies to anyone else to gain health beneIits. That is, aim to build up to do at least 20-30
minutes oI moderate exercise on most days (at least Iive days per week) to the extent oI
getting slightly short oI breath with your exercise. See separate leaIlet called ´Phy8ical
Activity for H0alth´ Ior more details.
Weight
II you are obese or overweight then reducing your weight gradually will reduce your risk oI a
Iuture MI. II you Iind it diIIicult to lose weight then see your practice nurse Ior
encouragement and advice. See separate leaIlets called ´O-08ity and Ov0rw0ight´ and ´W0ight
R0duction - How to Lo80 W0ight´ Ior more details.
Blood Pressure
It is important to have your blood pressure checked regularly. High blood pressure is a major
risk Iactor Ior heart disease. Normal blood pressure is less than 140/90 mmHg. II you are
being treated Ior high blood pressure, the usual target is to reduce blood pressure in someone
who has had an MI to below 130/80. In some cases this Iigure may vary depending on
whether or not you have other conditions, Ior example kidney disease.

LiIestyle Iactors can help to lower blood pressure such as eating a healthy diet, exercise,
losing weight iI you are overweight and not eating much salt.

Medication is advised iI your blood pressure remains persistently high. See separate leaIlet
called ´High Blood Pr088ur0 (Hyp0rt0n8ion)´ Ior more details.
Diabetes
II you have diabetes then good control oI your blood sugar level and also your blood pressure
will help to reduce the risk oI a Iurther MI. See separate leaIlets called ´Dia-0t08 - Typ0 1´ and
´Dia-0t08 - Typ0 2´ Ior more details.
Wbat medication is usual following a myocardial infarction?
Medication aIter an MI is discussed more Iully in another leaIlet called ´Myocardial
Infarction - M0dication´. BrieIly, the Iollowing Iour drugs are commonly prescribed:
O splrln reduces Lhe ƌsLlcklnessƌ of bloodţ whlch reduces Lhe rlsk of blood cloLs formlngŦ
Clopldogrel ls an alLernaLlve Lo asplrln whlch helps Lo prevenL blood cloLsŦ lL ls usually used ln
people who are noL able Lo Lake asplrlnŦ lL may be glven wlLh asplrln ln some casesŦ
O beLaŴblocker slows Lhe hearL raLe and reduces Lhe rlsk of abnormal hearL rhyLhmsŦ
O n CL (angloLensln converLlng enzyme lnhlblLor) reduces Lhe rlsk of developlng hearL
fallure and furLher MlŦ
O sLaLln reduces Lhe cholesLerol level (as dlscussed above)Ŧ
Although the Iour drugs above are commonly advised, treatments may vary depending on
other Iactors such as whether you have complications or other diseases.
etting back to normal
AIter having an MI, it is natural to wonder iI there are any 'dos and don'ts'. In the past, well-
meaning but bad advice to 'rest and take it easy Irom now on' caused some people to become
over-anxious about their hearts. Some people gave up their jobs, hobbies, and any activity
that caused exertion Ior Iear oI 'straining the heart'. However, quite the opposite is true Ior
most people who recover Irom an MI. Regular exercise and getting back to normal is usually
advised.
Work issues
Following an MI, most people can go back to work within 2-3 months. However, each person
is diIIerent. For example, some people who have a small MI and Ieel well go back sooner. On
the other hand, some people with ongoing symptoms or complications such as angina or heart
Iailure may take longer to go back or may not be able to go back to work.

Some people have wrong belieIs about work aIter an MI. For example, some people wrongly
believe that work-related stress was the cause oI their MI and they need to 'take things easy'
Irom now on. However, as explained, an increase in activity is oIten preIerable aIter an MI
rather than 'taking it easy'. Some people believe that a physical job will be ruled out. Again,
this is usually not the case provided that you Ieel well in yourselI. Indeed, physical jobs are
oIten better Ior the heart than oIIice jobs. For many people, returning to work is an important
part oI regaining quality oI liIe.

A possible sensible approach is:
O eL Lhe goŴahead from your docLor abouL when you should reLurn Lo workŦ
O 1henţ a phased reLurn Lo work may be besL lf your employer ls agreeableŦ lor exampleť
4 LarL wlLh alLernaLe half daysţ and bulld up Lo your normal rouLlne over 2Ŵ3 weeksŦ
4 LarL wlLh llghL or less challenglng duLles aL flrsLŦ
4 lnclude addlLlonal resL perlods lf Llredness ls a problemŦ
Understandably, some people consider early retirement Iollowing an MI, as the Iuture may be
uncertain. However, it is very important that you make such a decision Ior the right reasons
and not based on Iear or wrong belieIs about your heart.
Driving and flying issues
You should not drive Ior at least Iour weeks aIter an MI, provided you have made a
satisIactory recovery (and your insurance company is notiIied). However, iI driving causes
angina, you should not drive until the angina is well controlled. PCV and HGV rules are
stricter and Iurther assessment is required.

You can usually Ily as a passenger within two to three weeks oI a MI, as long as you have no
complications. This means that, Ior example:
O ou have reLurned Lo your usual dally acLlvlLlesŦ
O our condlLlon ls sLableŦ
O ou donƌL have any sympLomsţ or your sympLoms are conLrolledŦ
It is usually sensible to check with your travel operator, airline and travel insurance company
beIore you Ily.
Stress, anxiety and relaxation
It is commonly believed that 'stress' can cause an MI. However, medical research has Iailed to
show this and the conclusion is that stress does not cause an MI. However, being stressed and
anxious can make you Ieel generally unwell in yourselI.

Some people have unIounded concerns and wrong belieIs about MI which can cause
symptoms oI anxiety. Don't be aIraid oI talking to your doctor iI you have concerns about
your health. Alternatively, ring the helpline oI the British Heart Foundation Ior advice (see
below). They will give correct up-to-date advice (which may be very diIIerent to the 'old
wives tales' that sometimes get passed around).

Many people who become anxious beneIit Irom learning to positively relax. See separate
leaIlet called ´R0laxation Ex0rci808´ which may help as it goes through the two main ways to
positively relax. That is, muscular exercises and deep breathing exercises. There is also
another leaIlet called ´Str088 - Tip8 on How to Avoid It´. You can also buy relaxation tapes and
CDs to help you learn to relax. Also, you should tell your doctor iI you Ieel that you have
become over anxious as there are other treatments Ior anxiety that may help.
Sex issues
Some people worry about resuming sex. For a Iew weeks it is probably best avoided. II you
are able to walk without discomIort, then a return to sexual relationships should not cause any
problems. II sex causes angina (chest pains) then tell your doctor.

Some men Iind that they have problems getting or maintaining an erection (erectile
dysIunction) aIter having a MI. These problems can be caused by emotional stress or by
medication such as beta-blockers. However, impotence can also have other causes. Speak to
your GP who can check what is causing your problems and advise you on treatment. Various
treatments (including medication) are now very eIIective Ior the treatment oI erectile
dysIunction.
ardiac rehabilitation
You may be advised to attend a cardiac rehabilitation programme. Not every area has this
Iacility, but these courses are becoming more widely available on the NHS. They are staIIed
by nurses, physiotherapists, and other health proIessionals. They aim to provide advice and
help on exercise, diet, stress, and getting back to work and normal liIe Iollowing an MI. It is
also useIul to mix with others who are going through the same experience. Studies have
shown that cardiac rehabilitation helps to reduce the risk oI having another MI and improves
general wellbeing.
Immunisation
You should have the annual inIluenza jab and be immunised against the pneumococcal
bacterium.
ome otber general points
O 1ell your docLor lf you geL anglna followlng an MlŦ (nglna ls a paln ln Lhe chesL LhaL comes
on when you exerclse such as when walklng brlsklyŦ lL ls due Lo narrowlng of Lhe coronary
arLerlesŦ ee separaLe leafleL called ƌ°–°oƌ for more deLallsŦ) lurLher LreaLmenL may be
neededŦ
O 1ell your docLor lf you geL breaLhlessţ become more Llred Lhan usualţ or noLlce your feeL
swelllngŦ 1hese sympLoms may lndlcaLe a degree of hearL fallure (Lhe hearL muscle noL
pumplng as well as normal)Ŧ 1hls can ofLen be helped wlLh medlcaLlonŦ ee separaLe leafleL
called ƌeott loloteƌ for more deLallsŦ
O epresslon ls common afLer an Mlţ ofLen made worse by unfounded concernsŦ galnţ Lell
your docLor lf you Lhlnk you are depressedŦ 1reaLmenL for depresslon ofLen works well and
can lmprove your quallLy of llfeŦ
Some thoughts to remember:
O MosL people who have an Ml make a full recoveryŦ
O ln many casesţ only a small parL of Lhe hearL muscle ls damagedŦ 1he resL of Lhe hearL
muscle remalns undamaged and ln many cases easlly manages Lo do Lhe work neededŦ
O MosL people who have a [ob should be able Lo geL back Lo work and do Lhelr normal [ob
afLer havlng an MlŦ
O n Ml ofLen causes people Lo revlew and change Lhelr dleL and llfesLyleŦ ome people
acLually become flLLer and healLhler afLer Lhey have an MlŦ
O gradual lncrease ln physlcal acLlvlLy ls good for Lhe hearL afLer an MlŦ (s one exampleţ Lhe
famous explorer lr 8anulph llennes had an Ml ln 2003 and even had a cardlac arresLŦ !usL a
few monLhs laLer he was Lralnlng for seven maraLhons ln seven conLlnenLs ln seven daysŦ
Þerhaps Lhls ls a blL excesslve Ŵ buL lL shows lL can be doneŦ)
O lor some peopleţ Lhe blggesL cause of dlsablllLy followlng an Ml ls noL Lhelr hearLţ buL
unfounded worrles and anxleLy oboot Lhelr hearLŦ 1ry Lo learn Lo poslLlvely relaxţ and Lalk Lo
your docLor lf you have any concernsŦ
urtber sources of information and belp
British Heart Foundation
Greater London House, 180 Hampstead Road, London, NW1 7AW
Tel (Heart Help Line): 0300 330 3311 Web: www.bhI.org.uk
HEART UK (the Hyperlipidaemia Education and Atherosclerosis Research
Trust UK)
7 North Road, Maidenhead, Berkshire SL6 1PE
Tel (Helpline): 0845 450 5988 Web: www.heartuk.org.uk
British ardiac Patients Association
15 Abbey Road, Bingham, Notts, NG13 8EE
Tel (Helpline): 01223 846845 Web: www.bcpa.co.uk
eferences
O econdary prevenLlon ln prlmary and secondary care for paLlenLs followlng a myocardlal
lnfarcLlonţ nlCL Cllnlcal uldellne (2007)
O cuLe coronary syndromesţ ln (2007)
O Myocardlal lnfarcLlon Ŵ secondary prevenLlonţ Cllnlcal knowledge ummarles (!anuary 2008)
O lannuzzl Þţ 1emporelll ÞLţ Marchloll 8ţ eL alŤ lobal secondary prevenLlon sLraLegles Lo llmlL
evenL recurrence afLer myocardlal rch lnLern MedŦ 2008 nov 10Ť168(20)ť2194Ŵ204Ŧ
żabsLracLŽ
O
O » Publication »
O PENGAMATAN FIBRINOGEN PADA PENYAKIT JANTUNG KORONER DAN
IMA DI RSJHK Author : Nurlaily Syamsuddin, Senin, 06 Agustus 2007 00:00:00
Bagian Kardiologi FKUI/RSJHK Berbagai tulisan terdahulu melaporkan bahwa
terdapat hubungan langsung dan bermakna antara nilai Iibrinogen dalam darah dengan
kekerapan PJK serta maniIestasi klinis penyakit jantung iskemik akut (IMA) di
kemudian hari. Disimpulkan bahwa Iibrinogen dapat dimasukkan sebagai Iaktor
resiko dan Iaktor prediktor untuk PJK dan IMA. Tujuan penelitian adalah untuk
mengamati penyebaran Iibrinogen terhadap berbagai Iaktor yang diperkirakan dapat
memberikan gambaran mengenai hubungan Iibrinogen dengan kejadian ataupun
maniIestasi klinis PJK dan IMA, disamping mengamati penyebaran dan hubungan
Iibrinogen dengan beberapa Iaktor tertentu di dalam darah. Telah dilakukan penelitian
studi kasus retrospektiI terhadap 133 penderita PJK dan 76 penderita IMA. Seluruh
kasus terdiri dari laki-laki, berumur 29-72 tahun. Dilakukan pemeriksaan darah
dengan metode Clauss pada semua kasus. Selanjutnya diamati dan diteliti nilai
Iibrinogen rata-rata serta hubungannya dengan berbagai Iaktor yang diteliti. Faktor
yang diteliti adalah kelompok umur, waktu tiba di RS, kliasiIikasi kelas angina
pektoris, berbagai Iaktor resiko PJK, gambaran angiograIi koroner dan beberapa
Iaktor di dalam darah. Ditemukan bahwa nilai rata-rata Iibrinogen pada kelompok
PJK adalah 322,6 mg/dl dan kelompok IMA 274,9 mg/dl. Pada kelompok IMA
ditemukan peninggian Iibrinogen yang bermakna pada kelompok umur diatas 45
tahun, sedangkan pada kelompok PJK tidak ditemukan perbedaan menurut pembagian
umur. Pada kelompok PJK ditemukan nilai rata-rata Iibrinogen tertinggi pada
kelompok dengan Iaktor resiko merokok yaitu 340,9 mg/dl, diikuti dengan kelompok
DM yaitu 340,1 mg/dl dan kelompok dengan Iaktor resiko riwayat PJK dalam
keluarga yaitu 331,1 mg/dl. Sedangkan pada kelompok IMA ditemukan peninggian
Iibrinogen yang bermakna pada kelompok dengan Iaktor resiko DM dibanding
kelompok IMA ditemukan tanpa DM. Menurut gambaran klinis pada kelompok PJK
ditemukan peninggian Iibrinogen yang bermakna pada kelompok angina pektoris
kelas IV dibanding dengan kelompok angina pektoris kelas I, II, dan III. Tidak
ditemukan perbedaan bermakna penyebaran Iibrinogen berdasarkan waktu untuk RS
dan jumlah pembuluh darah koroner yang stenosis. Dari pemeriksaan laboratorium
ditemukan korelasi positiI antara penyebaran Iibrinogen dengan LED dan hitung
lekosit pada kelompok PJK, sedangkan pada kelompok IMA ditemukan korelasi
positiI dengan jumlah trombosit dan korelasi negatiI dengan LDL dan albumin.
Terlihat peninggian Iibrinogen pada kelompok dengan Iaktor resiko merokok. DM
dan riwayat keluarga PJK serta terdapatnya peninggian Iibrinogen yang bermakna
pada kelompok angina pektoris kelas IV, dengan demikian dapat disimpulkan bahwa
hasil pengamatan ini sangat mendukung pendapat terdahulu yang mengemukakan
bahwa Iibrinogen merupakan Iaktor resiko dan prediktor

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