Document: Cardiovascular Emergency

(1)

Cardiovascular Emergency

Ns. Ryan Budiyanto,Skep

INTENSIVE & ACUTE CARDIOVASCULAR CARE UNIT NATIONAL CARDIOVASCULAR CENTER HARAPAN KITA

[email protected]

(2)

Outline

Blood stops causing damage or death to the heart muscle

• Introduction

• Background/epidemiology

• Definition

• Etiology

• Pathophysiology

• Classification

• Complication

• Management

(3)

• Every 40 seconds,

someone in the United States has a heart attack

• More than half of the deaths due to heart disease in 2015 were in men

• Heart disease costs the United States about $200 billion each year

CDC. (2015). Heart Attack Facts & Statistics. Retrieved from http://www.cdc.gov/heartdisease/heart_attack.htm

[email protected]

(4)

Introduction

Ischemic heart disease is the single most common cause of death and its frequency is increasing.

now accounts for almost 1.8 million annual deaths, or 20% of all deaths in Europe, large variations between countries ¹ .

Myocardial infarction (MI) can be recognized by clinical features, including electrocardiographic (ECG) findings, elevated values of biochemical markers (biomarkers) of myocardial necrosis, and by imaging, or may be defined by pathology ² .

1. Ibanez, B.,et al. (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal, 39(2), 119–

177.

[email protected]

(5)

Epidemiology

• The relative incidences of STEMI and NSTEMI are decreasing and increasing, respectively

¹

• European STEMI registry is found in Sweden, STEMI was 58 per 100 000 per year in 2015. ¹

• incidence rates from the USA decreased from 133 per 100 000 in 1999 to 50 per 100 000 in 2008 ¹ .

• consistent pattern for STEMI to be relatively more common in younger than in older people, and more common in men than in women ¹ . NSTEMI remained constant or increased slightly

• JACS Registry (2014-2015) Total amount 3015 patients with acute coronary syndrome, which 1024 patients had STEMI ² .

• 2007, the ACS mortality was 6.6% and decreased to 4.1% in 2009 ³ .

• 2016, In hospital mortality of non-reperfused patients with STEMI was significantly higher than patients with STEMI receiving primary PCI or fibrinolytic therapy (9.1% vs 3.2% vs 3.8%, p<0.001 ² .

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

2. Dharma, S., et al (2016). BMJ Open, 6(8), e012193.

3. Dharma, S., et al (2012). Netherlands Heart Journal, 20(6), 254–259. [email protected]

(6)

Classification of ACS

ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation:European Heart Journal, 2011

(7)

The Universal Definition

• AMI should be used when there is evidence of myocardial infarction in clinical setting consistent with acute myocardial ischemia.

Thygesen, K., et al. (2012). Third universal definition of myocardial infarction. Circulation, 126(16), 2020–2035. https://doi.org/10.1161/CIR.0b013e31826e1058

[email protected]

(8)

Etiology

• Atherosclerosis is the disease primarily responsible for most acute coronary syndrome. Approximately 90% of myocardial infarctions (MIs) result from an acute thrombus

• Non modifiable risk:

• Age

• Sex

• Family history of premature coronary heart disease

• Male-pattern baldness

(9)

Modifiable risk

• Smoking or other tobacco use

• Hypercholesterolemia and hypertriglyceridemia, including inherited lipoprotein disorders

• Dyslipidemia

• Diabetes mellitus

• Hypertension

• Obesity (abdominal obesity)

• Psychosocial stress

• Sedentary lifestyle and/or lack of exercise

• Reduced consumption of fruits and vegetables

• Type A personality

• Elevated homocysteine levels

• Presence of peripheral vascular disease

Zafari, A. M. (2018). Myocardial Infarction: Practice Essentials, Background, Definitions. Retrieved from https://emedicine.medscape.com/article/155919-overview

[email protected]

(10)

Pathophysiology

(11)

[email protected]

(12)

Classification

(13)

Sign and Symptoms

• Chest Pain > 20 minutes

• Chest Discomfort

• Anxiety

• Nausea with/Wo Vomitting

• Shortness of breath

• Profuse sweating

• Fullness, indigestion or choking feeling

Zafari, A. M. (2018). Myocardial Infarction: Practice Essentials, Background, Definitions. Retrieved from

https://emedicine.medscape.com/article/155919

[email protected]

(14)

Suggestive Clinical Symptoms

Fadil, M. (2013). Pre Hospital and Initial Management of Acute Coronary Syndrome

(15)

Diagnosis

Roffi, M., et al. (2016). 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal, 37(3), 267–315. https://doi.org/10.1093/eurheartj/ehv320

[email protected]

(16)

Diagnostic tools

✓ Physical examination

✓ Electrocardiogram

✓ Biomarkers

✓ Imaging

• Non-invasive imaging techniques

• Invasive imaging (CAG)

(17)

Acute pain in Myocardial infarct

Gaúcha De Enfermagem, R., Maria, S., Santos, J. Dos, Leite De Araújo, T., Cavalcante, T. F., Miguel, N., & Neto, G. (2015). Acute pain in myocardial infarction: analysis of concept, 36(3), 102–8. https://doi.org/10.1590/1983-1447.2015.03.51203

[email protected]

(18)

ECG Criteria

• ST-segment elevation at the J point in two contiguous leads

• ≥0.25 mV in men below the age of 40 years,

• ≥0.2 mV in men over the age of 40 years, or ≥0.15 mV in women in leads V2–V3 and/or ≥0.1 mV in other leads

• Advisable to record right precordial leads (V3R and V4R) seeking

• ST elevation identify concomitant right ventricular

1. Thygesen, K., et al. (2012). Third universal definition of myocardial infarction. Circulation, 126(16), 2020–2035. https://doi.org/10.1161/CIR.0b013e31826e1058

2. Ibanez, B., et al. (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal, 39(2), 119–177.

https://doi.org/10.1093/eurheartj/ehx393

[email protected]

(19)

Cardiac biomarker

• Troponins are more specific

and sensitive than the

traditional cardiac enzymes such as creatine kinase (CK), its

isoenzyme MB (CK-MB), and myoglobin.

• Elevation of cardiac troponins reflects myocardial cellular damage

Cardiac-Biomarkers. (n.d.). Retrieved from http://www.cardiac-biomarkers.com/

ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation:European Heart Journal, 2011

[email protected]

(20)

Biomarker detection of myocardial injury

1. Thygesen, K., et al. (2012). Third universal definition of myocardial infarction. Circulation, 126(16), 2020–2035.

https://doi.org/10.1161/CIR.0b013e31826e1058

(21)

Chest X ray

• Determine Acute heart failure

• Cardiac abnormality

[email protected]

(22)

Coronary Angiography

Fadil, M. (2013). Pre Hospital and Initial Management of Acute Coronary Syndrome

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Complications

• Myocardial dysfunction

• Heart failure

• Arrhythmias

• Mechanical complication

• Pericarditis/ pericardial effusion

Ibanez, B., et al. (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal, 39(2), 119–177. https://doi.org/10.1093/eurheartj/ehx393

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What is the new in 2017 version?

Management

(25)

Principle of ACS management

[email protected]

Fadil, M. (2013). Pre Hospital and Initial Management of Acute Coronary Syndrome

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Pre-hospital logistics of care

(27)

Reperfusion Therapy

[email protected]

(28)

Periprocedural Pharmacotherapy

(29)

Fibrinolytic therapy

Fibrinolysis Strategy is Preferred

• When Time To PCI > 12 Hour.

• The Goal to inject lytic bolus is

< 10 minutes after STEMI diagnosis

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(30)

Contraindication of fibrinolytic Therapy

Absolute

• Previous Intracranial haemmorage

• Ischemic stroke in the preceding 6 months

• Central nervous system damage or neoplasma or arteriovenous malformation

• GIT bleeding within the past month

• Known Bleeding disorder (excluded menses)

• Aortic Dissection

• Non-compressible puncture in the past 24 H(

Liver Biopsy, Lumbar Puncture)

Relative

• Transient ischemic attack in the preceding 6 months

• Oral Anticoagulant therapy

• Pregnancy or within 1 Week post partum

• Refractory Hypertension (SBP>180 and/or CBP >110 mmHg)

• Advanced Liver disease

• Infective Endocardities

• Active peptic ulcer

• Prolonged or traumatic resuscitation

Adapted from Ibanez, B., et al. (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal, 39(2), 119–177. https://doi.org/10.1093/eurheartj/ehx393

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Nursing Management

Priorities

• Relieve pain, anxiety.

• Reduce myocardial workload.

• Prevent/detect and assist in treatment of life-threatening dysrhythmias or complications.

• Promote cardiac health, self-care.

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Guidelines for management

• Assess : chest pain,

• Monitor : dysrhythmia

• ECG within 10 minutes

• IV access / Blood draw

• Oxygen/ medication

• Chest X ray

Medication

M : Morphine O : Oxygen N : Nitrate A : Aspirin

CO : Clopidogrel

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(34)

Primary Assessment

Medical Cardiac Arrest

• D: Danger

• R: response

• C: Circulation

• A: Airway

• B : Breathing

• D : danger

• R : Response

• A : Airway

• B : Breathing

• C : Circulation

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Secondary Survey

Goal is To obtain detailed history

History O: onset

P : Provocation Q: Quality

R : radiation S : Severity T : Timing

S: sign and symptoms A: Alergies

M : Medication P: past Medication L : Last Meal

E : even prior

Vital Signs BP, HR, RR, Temp, SpO2 GCS, 12 Lead ECG

Physical Examination Head to Toe Complete assessment

Queensland Goverment. (2015). Clinical Practice Procedures: Assessment/Primary and secondary survey,

(October

[email protected]

(36)

Nursing management

Triage and first assessment

• Physical Assessment

• Vital sign

• history, past medication

• 12 lead ECG within 10 minutes

• Cardiac Biomarker Blood is drawn on arrival of the patient in hospital and the results should be available within 60 min

Best Practice Recommendation

All nursing stations are

equipped with the following minimum equipment:

• 12-Lead ECG,

• Cardiac monitors,

• Defibrillators.

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

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Possible Nursing Diagnosis

• Acute pain related to myocardial ischemia

• Ineffective tissue perfusion (cardiac) related to myocardial injury and potential pulmonary congestion

• Anxiety related to perceived or actual threat of death, pain, possible lifestyle changes

• Ineffective therapeutic regimen management related to lack of knowledge of risk factors, disease process, rehabilitation, home activities, and medications

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(38)

Nursing Intervention

Diagnosis NIC in Acute Cardiac Care

Acute pain related to myocardial ischemia

Cardiac Care: Acute

• Evaluate chest pain

• Monitor effectiveness of oxygen therapy

• Administer medications to relieve/prevent pain and ischemia to decrease anxiety and cardiac workload.

• Obtain 12-lead ECG during pain episode

• Monitor cardiac rhythm and rate and trends in blood pressure and hemodynamic parameters

Ineffective tissue perfusion (cardiac)

related to myocardial injury and potential pulmonary congestion

Monitor vital signs frequently to determine baseline and ongoing changes.

• Monitor for cardiac dysrhythmias,

• Monitor respiratory status for symptoms of heart failure

• Monitor fluid balance

• Arrange exercise and rest periods

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Diagnosis NIC in Acute Cardiac Care Anxiety related to perceived or actual

threat of death, pain, possible lifestyle changes

Observe for verbal and nonverbal signs of anxiety.

• Identify level of anxiety

• Use a calm, reassuring approach so as not to increase patient’s anxiety.

• Instruct patient in use of relaxation techniques (e.g., relaxation breathing, imagery)

• Encourage family to stay with patient to provide comfort.

• Encourage verbalization of feelings, perceptions, and fears to decrease anxiety and stress.

• Provide factual information concerning diagnosis, treatment, and prognosis to decrease fear of the unknown

Ineffective therapeutic regimen

management related to lack of knowledge of risk factors, disease process,

rehabilitation, home activities, and medications

Teaching: Disease Process

• Appraise the patient’s current level of knowledge

• Explain the pathophysiology of the disease

• Discuss lifestyle

• Refer the patient to local community agencies/support groups Teaching: Prescribed Medication •

Instruct the patient on the purpose and action of each medication.

• Instruct the patient on the dosage, route, and duration of each

medication

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Nursing Role

Critical Point During Acute Phase

Assess Action MONITOR Evaluate/

Review

These Should not delayed reperfusion treatment

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Relief of pain, breathlessness, and anxiety

Morphine

• Act : Pain killer

• Dose 3-5 mg IV/SC

• Nurse Consideration : Monitor for bradypnea,

intoxication. Routine used is not recommended

Nitates

• Action: Vasodilates, Dilates coronary arteries, Increases collateral blood flow

• Dose: 5 mg SL ,Give every 5

minutes for a total of 3 doses if

needed, IV rute are more effective.

• Nursing considerations :Assess pain and blood pressure after each dose

[email protected]

(42)

Relief of pain, breathlessness, and anxiety

ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation,2011

(43)

Double Anti-platelet

Aspirin

• Action: Decrease platelet aggregation

• Dose 160-300 mg chewed as soon as ACS is suspected

• Nursing considerations : Allergy

Clopidogrel

• Action : Inhibits platelet aggregation

• Dose : loading dose (300-600mg) followed by 75mg daily

• Nursing considerations : Allergy ,Bleeding, Discontinue steroids &

avoid NSAIDS

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Reperfusion

strategy in the Infarct Related Artery

[email protected] Ibanez, B., et al. (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal, 39(2), 119–177. https://doi.org/10.1093/eurheartj/ehx393

(46)

Long term Strategies

• Lifestyle intervention and risk factor control

• Smoking cessation

• Diet, alcohol, weight control

• Exercise based cardiac rehabilitation

• Resumption of activities

• Blood pressure control

• Adherence to treatment

(47)

Time Is muscle

Favourable outcome

[email protected]

(48)

Myocardial Infarct With Non-Obstructive coronary arteries

(49)

Conclusions

• The very early stages of STEMI are most vulnerable time,

when most sudden cardiac death occur.

• To minimize patient delay, it is recommended to increase

public awareness.

• Reducing of total ischemic time is a critical point

• Optimizing treatment of care should be based on

implementing of network

between hospital, with various level technologies linked by

prioritized and efficient ambulance service

• Nurses has an important role to provide high quality care,

minimizing delay, thereby improving clinical outcomes.

[email protected]

(50)

References

• Cardiac-Biomarkers. (n.d.). Retrieved from http://www.cardiac-biomarkers.com/

• CDC. (2015). Heart Attack Facts & Statistics. Retrieved from http://www.cdc.gov/heartdisease/heart_attack.htm

• Dharma, S., Andriantoro, H., Purnawan, I., Dakota, I., Basalamah, F., Hartono, B., … Rao, S. V. (2016). Characteristics, treatment and in-hospital outcomes of patients with STEMI in a metropolitan area of a developing country: an initial report of the extended Jakarta Acute Coronary Syndrome registry. BMJ Open, 6(8), e012193.

https://doi.org/10.1136/bmjopen-2016-012193

• Dharma, S., Juzar, D. A., Firdaus, I., Soerianata, S., Wardeh, A. J., & Jukema, J. W. (2012). Acute myocardial infarction system of care in the third world. Netherlands Heart Journal, 20(6), 254–259. https://doi.org/10.1007/s12471-012-0259-9

• Fadil, M. (2013). Pre Hospital and Initial Management of Acute Coronary Syndrome. Retrieved from https://cardiologyupdateunand.files.wordpress.com

• Gaúcha De Enfermagem, R., Maria, S., Santos, J. Dos, Leite De Araújo, T., Cavalcante, T. F., Miguel, N., & Neto, G. (2015). Acute pain in myocardial infarction: analysis of concept, 36(3), 102–8. https://doi.org/10.1590/1983-1447.2015.03.51203

• Hamm, C. W., Bassand, J.-P., Agewall, S., Bax, J., Boersma, E., Bueno, H., … Widimsky, P. (2011). ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting

without persistent ST-segment elevation of the European Society of Cardiology (ESC). European Heart Journal, 32(23), 2999–3054.

https://doi.org/10.1093/eurheartj/ehr236

• Ibanez, B., James, S., Agewall, S., Antunes, M. J., Bucciarelli-Ducci, C., Bueno, H., … Zeymer, U. (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal, 39(2), 119–177. https://doi.org/10.1093/eurheartj/ehx393

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

• Moloney, B. (2012). Nursing Management of Patients with Cardiovascular Disease Part II : Acute Myocardial Infarction. Retrieved from http://www.crudem.org/wp- content/uploads/2012/01/Nursing-Management-Patients-w-CVD-Part2_Myocardial-Infarction_English.pdf

• Queensland Goverment. (2015). Clinical Practice Procedures: Assessment/Primary and secondary survey, (October).

• Roffi, M., Patrono, C., Collet, J.-P., Mueller, C., Valgimigli, M., Andreotti, F., … Windecker, S. (2016). 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal, 37(3), 267–315. https://doi.org/10.1093/eurheartj/ehv320

• Thygesen, K., Alpert, J. S., Jaffe, A. S., Simoons, M. L., Chaitman, B. R., White, H. D., … Wagner, D. R. (2012). Third universal definition of myocardial infarction.

Circulation, 126(16), 2020–2035. https://doi.org/10.1161/CIR.0b013e31826e1058

• Zafari, A. M. (2018). Myocardial Infarction: Practice Essentials, Background, Definitions. Retrieved from https://emedicine.medscape.com/article/155919- overview?pa=tsgIZuFuw62Bw8Q6hyNbtlSeSjuZMO%2FBZt%2FW3mGLVJ8qdINVIg2s1NXhLEfE3uTJ43mU9jD%2B1DtnxY47OmyybA%3D%3D

(51)

Thank you

[email protected]

Document: Cardiovascular Emergency

Cardiovascular Emergency

Ns. Ryan Budiyanto,Skep

INTENSIVE & ACUTE CARDIOVASCULAR CARE UNIT NATIONAL CARDIOVASCULAR CENTER HARAPAN KITA

Outline

Blood stops causing damage or death to the heart muscle

• Introduction

• Background/epidemiology

• Definition

• Etiology

• Pathophysiology

• Classification

• Complication

• Management

• Every 40 seconds,

someone in the United States has a heart attack

• More than half of the deaths due to heart disease in 2015 were in men

• Heart disease costs the United States about $200 billion each year

CDC. (2015). Heart Attack Facts & Statistics. Retrieved from http://www.cdc.gov/heartdisease/heart_attack.htm

Introduction

Ischemic heart disease is the single most common cause of death and its frequency is increasing.

now accounts for almost 1.8 million annual deaths, or 20% of all deaths in Europe, large variations between countries 1 .

Myocardial infarction (MI) can be recognized by clinical features, including electrocardiographic (ECG) findings, elevated values of biochemical markers (biomarkers) of myocardial necrosis, and by imaging, or may be defined by pathology 2 .

Epidemiology

• The relative incidences of STEMI and NSTEMI are decreasing and increasing, respectively

• European STEMI registry is found in Sweden, STEMI was 58 per 100 000 per year in 2015. 1

• incidence rates from the USA decreased from 133 per 100 000 in 1999 to 50 per 100 000 in 2008 1 .

• consistent pattern for STEMI to be relatively more common in younger than in older people, and more common in men than in women 1 . NSTEMI remained constant or increased slightly

• JACS Registry (2014-2015) Total amount 3015 patients with acute coronary syndrome, which 1024 patients had STEMI 2 .

• 2007, the ACS mortality was 6.6% and decreased to 4.1% in 2009 3 .

• 2016, In hospital mortality of non-reperfused patients with STEMI was significantly higher than patients with STEMI receiving primary PCI or fibrinolytic therapy (9.1% vs 3.2% vs 3.8%, p<0.001 2 .

Classification of ACS

The Universal Definition

• AMI should be used when there is evidence of myocardial infarction in clinical setting consistent with acute myocardial ischemia.

Etiology

• Atherosclerosis is the disease primarily responsible for most acute coronary syndrome. Approximately 90% of myocardial infarctions (MIs) result from an acute thrombus

• Non modifiable risk:

• Age

• Sex

• Family history of premature coronary heart disease

• Male-pattern baldness

Modifiable risk

• Smoking or other tobacco use

• Hypercholesterolemia and hypertriglyceridemia, including inherited lipoprotein disorders

• Dyslipidemia

• Diabetes mellitus

• Hypertension

• Obesity (abdominal obesity)

• Psychosocial stress

• Sedentary lifestyle and/or lack of exercise

• Reduced consumption of fruits and vegetables

• Type A personality

• Elevated homocysteine levels

• Presence of peripheral vascular disease

Pathophysiology

Classification

Sign and Symptoms

• Chest Pain > 20 minutes

• Chest Discomfort

• Anxiety

• Nausea with/Wo Vomitting

• Shortness of breath

• Profuse sweating

• Fullness, indigestion or choking feeling

Zafari, A. M. (2018). Myocardial Infarction: Practice Essentials, Background, Definitions. Retrieved from

https://emedicine.medscape.com/article/155919

Suggestive Clinical Symptoms

Fadil, M. (2013). Pre Hospital and Initial Management of Acute Coronary Syndrome

Diagnosis

Diagnostic tools

✓ Physical examination

✓ Electrocardiogram

✓ Biomarkers

✓ Imaging

• Non-invasive imaging techniques

• Invasive imaging (CAG)

Acute pain in Myocardial infarct

ECG Criteria

• ST-segment elevation at the J point in two contiguous leads

• ≥0.25 mV in men below the age of 40 years,

now accounts for almost 1.8 million annual deaths, or 20% of all deaths in Europe, large variations between countries ¹ .

Myocardial infarction (MI) can be recognized by clinical features, including electrocardiographic (ECG) findings, elevated values of biochemical markers (biomarkers) of myocardial necrosis, and by imaging, or may be defined by pathology ² .

• European STEMI registry is found in Sweden, STEMI was 58 per 100 000 per year in 2015. ¹

• incidence rates from the USA decreased from 133 per 100 000 in 1999 to 50 per 100 000 in 2008 ¹ .

• consistent pattern for STEMI to be relatively more common in younger than in older people, and more common in men than in women ¹ . NSTEMI remained constant or increased slightly

• JACS Registry (2014-2015) Total amount 3015 patients with acute coronary syndrome, which 1024 patients had STEMI ² .

• 2007, the ACS mortality was 6.6% and decreased to 4.1% in 2009 ³ .

• 2016, In hospital mortality of non-reperfused patients with STEMI was significantly higher than patients with STEMI receiving primary PCI or fibrinolytic therapy (9.1% vs 3.2% vs 3.8%, p<0.001 ² .