2016 1

Oleh: Ns. Cipto Susilo, S. Pd., S. Kep., M. Kep

FIKES UNMUH JEMBER By. Ns. Cipto, M. Kep - FIKES UMJ

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 Anatomy

of coronary artery  Coronary artery disease : atherosclerosis  Progression of CAD  IMA  Diagnosing IMA  IMA Treatment

By. Ns. Cipto, M. Kep - FIKES UMJ

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Coronary

arteries branch off at base of aorta & supply blood to the electrical conduction system & myocardium. 3

main arteries:

• RCA • LCA • Circumflex


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•

Left main coronary artery (LCA) - Left anterior descending artery (LAD) >descends toward the anterior wall & apex of LV > supplies LV, ventricular septum, chordae, papillary muscle & RV - Left circumflex artery (LXA) > descends toward the lateral wall of LV & apex > supplies LA, lateral & posterior LV surfaces *45% supplies SA node


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 ACS / SKA) • Kegawatan pada pembuluh darah koroner yang

bersifat progresif • Sering terjadi perubahan secara tiba-tiba dari keadaan stabil menjadi keadaan tidak stabil atau akut. • Berdasarkan pada luasnya presentasi klinis maka SKA mengacu adanya segmen ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI) serta unstable angina (UA) atau angina pektoris tidak stabil (APTS), By. Ns. Cipto, M. Kep - FIKES UMJ

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Pembentukan lesi aterosklerotik yang semakin kompleks


Ruptur plak

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Chest Pain


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The cardiovascular continuum of events ACS Coronary Thrombosis

Arrhythmia and Loss of Muscle

Myocardial Ischemia

Remodeling

Ventricular Dilatation

CAD Atherosclerosis

Risk Factors (DYSLIPIDEMIA , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)

Congestive Heart Failure End-stage Heart Disease Adapted from Dzau et al. Am Heart J. 1991;121:1244-126310


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 Mayor 1.Hiperlipidemia 2.Hipertensi 3.Merokok 4.Diabetes 5.Obesitas 6.Diet tinggi lemak jenuh, kalori  Minor 1.Inaktifitas fisik 2.Pola kepribadian tipe A (emosional, agresif, ambisius, kompetitif). 3.Stress psikologis berlebihan.

1. Usia > 40 tahun 2. Jenis kelamin : insiden pada pria, sedangkan pada wanita meningkat setelah menopause 3. Hereditas 4. Ras : lebih tinggi insiden pada kulit hitam.

( Christian , 2012 ) By. Ns. Cipto, M. Kep - FIKES UMJ

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DIABETES


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  

   

Sifat :Berat/ Panas (burning) ; Masuk angin, Sesak,”maag” Lokasi: Di dada kiri/tengah tidak bisa ditunjuk Penjalaran : ke bahu/lengan, leher, dagu, belakang,epigastrium Lama : 5-30’ Pencetus :aktifitas/stres/dingin Berkurang: Nitrat/Istirahat Tidak khas: Pingsan/kejang/tidak sadar/berdebar

ESC guidelines for SAP 2006 By. Ns. Cipto, M. Kep - FIKES UMJ ESC AMI1/22/2016 ST elevation guidelines 200816

Organ type

Spesific example

Comment

Cardiovasculer

Dissection of the aorta

Usually abrupt onset, radiating to the back, may produced ECG change mimicking STEMI, and widened mediastinum on chest radiograph may provide the clue of the diagnosis

Pericarditis

Patient often feel fluey/unwell. Pain usually worse on lying flat and when leaning forward. Pain is also worsened by inspiration. Widespread ST elevation on ECG may cause confusion with STEMI

Costocondritis

Pain result from inflamation of costal cartilage. Usually localised tenderness over the affected area

Musculoskeletal

Reffered pain from neck or thorax

Common in golfers of following heavy lifting. Try rotating the thorax to see if this prodiced the pain


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Organ Type

Specific Example

Comment

Gastroesophageal

Reflux Disease

Usually describe as burning with relation to food. However, cardiac pain can mimic this. Rapid relief with antacida may be suggestive

Aesophageal spasm

Often distinguishable from cardiac pain-usually a diagnosis exclution may be eased by GTN

Peptic ulcer disease

Pain may be originated from below the diafragm. Epigastric tenderness is suggest an intrabdominal cause. However remember that MI can also present with abdominal symtom

Abdominal


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Acute Coronary Syndrome ST Segment Elevation

Non-ST Segment Elevation

Unstable Angina Pectoris

Non-Q-wave Q-wave Acute Myocardial Infarction By. Ns. Cipto, M. Kep - FIKES UMJ

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Unstable Angina

NSTEMI

Non occlusive thrombus

Occluding thrombus sufficient to cause tissue damage & mild myocardial necrosis

Non specific ECG Normal cardiac enzymes

STEMI Complete thrombus occlusion ST elevations on ECG or new LBBB

ST depression +/T wave inversion on ECG

Elevated cardiac enzymes

Elevated cardiac enzymes

More severe symptoms


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Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG ST elevation or new or presumably new LBBB strongly suspicious for injury

ST-depression or dynamic T-wave inversion strongly suspicious for injury

Normal or nondiagnostic changes in ST-segment or Twaves

Start adjunctive treatment

Start adjunctive treatment

Develops high or intermediate risk criteria or troponin-positive

Time from onset of symptoms

 12 hrs

Admit to monitored bed Assess risk status

Monitored bed in ED

 12 hours

- Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) - ACE-I/ARB within 24 h of symptom onset) - Statin

- High risk: early invasive strategy - Continue ASA, heparin, ACE-I, statin

Develops high or intermediate risk criteria or troponin-positive

No evidence of ischemia and MI: discharge with follow-up Ns. Cipto, M. Kep - FIKES UMJ 1/22/2016 2005 AHA-ILCOR Guidelines for By. CPR and ECC. Circulation 2005;112 (Suppl):IV-90

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Serum Troponin Low risk <0.06µg/dl Medium risk 0.06-0.18µg/dl High risk >0.18 µg/dl

5 Month risk of death or MI 4.3% 10.5% 16.1%


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Low risk Medium risk High risk

Number of risk factors 0/1 2 3 4

14 day event rate 4.7 % 8.3% 13.2% 19.9%

5 6/7 By. Ns. Cipto, M. Kep - FIKES UMJ

26.2% 40.9% 1/22/2016

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GAMBAR EKG NON STEMI


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Anterior STEMI

By. Ns. Cipto, M. Kep - FIKES UMJ 1/22/2016 ECG demonstrates large

anterior infarction 32

 Troponin

T/Troponin I

 CKMB


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 Sadar-Koma  TD: Hypertensi-Normal-Hypoptensi  HR: Regular-irregular/

Bradycardia-

Tachycardia pulseless  RR: Tachypnea-apnea  Cor: Regular-iregular, murmur, gallop  Pulmo: Normal-Rales- wheezing  Ext: dingin/hangat, edema+/-, etc.


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1. 2. 3. 4. 5.

6. 7. 8.

Get regular medical checkups Control your blood pressure Check your cholesterol Don’t smoke Exercise regularly Maintain a healthy weight Healthy diet Manage stress


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Pra rumah sakit

Di ruang Emergency

Secara umum


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 Cepat

(time responsif), obati penyebab  buka sumbatan  Terlambat: Fatal  Monitor ketat tanda vital sejak awal  Antisipasi dini tanda tanda perburukan dan komplikasi


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 Atasi

keadaan kegawat daruratan : asistol, apneu, syock, lung edema, gagal jantung dll.  Terapi reperfusi : PCI, Fibrinolitik, heparin  Antiischemic  Turunkan oksigen demand : Bed rest total, pendekatan psikologis, dll  Terapi komorbid; hipertensi, DM, dll


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 Sumbatan

total15-30 menit tanpa kolateral IMA  Reperfusion  selamatkan miorkard  Kematian1 bulan: 25-30% 4-6% dengan reperfusi (PCI, fibrinolytic, antithombotic)

ESC AMI1/22/2016 ST elevation By. Ns. Cipto, M. Kep - FIKES UMJ

guidelines 2008

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 Keluhan

berhubungan dengan fungsi dan beban jantung, deteksi dini komplikasi  Monitor tanda vital, saturasi, perfusi, EKG, intake- output, balance. dll  Kalau perlu ukur CVP, arteri line dll  Laboratorium : Enzyme jantung, analisa gas darah, fungsi ginjal, elektrolit, komorbid (infeksi, dm, dll)


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 

1. Decreased Cardiac Output

7. Fluid Volume Excess

2. Impaired Tissue Perfusion

8. Imbalanced Nutrition, Less Than Body Requirements

3. Ineffective Airway Clearance

4. Ineffective Breathing Pattern 5. Impaired Gas Exchange

6. Acute Pain

9. Activity Intolerance 10. Self-Care Deficit 11. Anxiety 12. Knowledge Deficit


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 Turunkan

kebutuhan dan bebang jantung misalnya istirahat fisik dan mental, kondisi hangat, tenang, rasa aman, pemilihan diet : NGT atau bantuan makanan, dilarang mengejan, atasi febris, rasa sakit atau sesak dll  Bantu fungsi jantung: Inotropic, IABP (intra aortic balloon pump), anti iskemik, dll  Atasi komorbid/komplikasi: hipertensi, DM, infeksi, gagal jantung, gangguan ginjal, dll  Atasi kekurangan atau kelebihan cairan, kalori, oksigen, PH, elektrolit, dll By. Ns. Cipto, M. Kep - FIKES UMJ

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Rehabilitatif 







Tahap 1: dimulai segera setelah terjadi episode penyakit (CVCU). Tahap 2: Terjadi pada saat pasien akan pulang. Pada tahap kedua ini perawat dapat membantu pasien ke arah pencapaian tujuan untuk hidup mandiri, penyesuaian perilaku sesuai dengan kondisi. Tahap 3: dimulai saat pasien pulang kerumah dan berlangsung selama massa pemulihan (bekerja atau kembali ke aktivitasb biasa). Tahap 4: Di fokuskan pada penyesuaian jangka panjang dan pada pemulihan stabilitas kardiovaskuler


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Engkau tak dapat meraih ilmu kecuali dengan enam hal yaitu cerdas, selalu ingin tahu, tabah, punya bekal dalam menuntut ilmu, bimbingan dari guru dan dalam waktu yang lama. ( Ali bin Abi Thalib ) Orang yang keluar rumah untuk menuntut lmu akan berada di jalan Alloh hnga ia pulang kembali By. Ns. Cipto, M. Kep - FIKES UMJ

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1. 2.

3.

4.

5.

6.

7.

8.

Overbaugh, K.J (2009). ACUTE CORONARY SYNDROME AJN , May Vol. 109, No. 5 Alawi A. Alsheikh-Ali, Georgios D. K, Ethan M. B, Lau, J, Stanley Ip. (2010). The Vulnerable Atherosclerotic Plaque: Scope of the Literature. Annals of Internal Medicine. Sept; 153 (6) :387-395.. Anderson, J. L., Adams, C. D., Antman, E. M Bridges, C. R., Califf, R.M., et al. (2011). ACC/AHA Practice Guideline, 2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non– ST-Elevation Myocardial Infarction. Circulation: 123: e426-e579. Doi:10/1161/CIR.0b013e318121bb8b. Coven, D.L. (2012). Acute Coronary Syndrome, Madscape, http://emedicine. medscape. com /article/1910735-overview#showall John, P., Higgins, M.D., Higgins, J.A. (2003). Elevation of cardiac troponin I indicates more than myocardial ischemia, Medicine, University of Oklahoma, St. John Medical Center, Tulsa, Okla.Clin Invest Med. 26(3): 133-47. Karo-Karo, S., Rahajoe, A. U., Sulistyo, S., & Kosasih, A. (2012). Buku Panduan: Kursus Bantuan Hidup Jantung Lanjut, Jakarta. PERKI. Zafari, A. M & Yang, E. H. (2012). Myocardial Infarction, www. emedicine. medscape. com. Parsonage, W.A., Cullen, L. & Younger, J. F. (2013). Clinical Focus: The approach to patient with possible cardiac pain, doi:10.5694/mja12.11171. MJA. 198: 606-610. By. Ns. Cipto, M. Kep - FIKES UMJ 1/22/2016

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Wassalam...... Semoga Bermanfaat

2016 1

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