ACUTE MYOCARDIAL INFARCTION

Classifications
Definition • MI’s can be subcategorized by anatomy and clinical diagnostic information.
• Otherwise know as heart attack Anatomic
• An MI occurs when there is a diminished blood supply to the heart which • Transmural and Subendocardial
leads to myocardial cell damage and ischemia.
• Contractile function stops in the necrotic areas of the heart. Diagnostic
• Ischemia usually occurs due to blockage of the coronary vessels. • ST elevations (STEMI) and non ST elevations (NSTEMI).
• This blockage is often the result of thrombus that is superimposed on an
ulcerated or unstable atherosclerotic plaque formation in the coronary artery. Risk Factors
• MI’s are described by the area of occurrence. • The presence of any risk factor is associated with doubling the risk of an
• Anterior, Inferior, Lateral or Posterior. MI.
Non Modifiable
• Age
• Gender
• Family history

Modifiable
• Smoking
• Diabetes Control • Hypertension
• Hyperlipidemia
• Obesity
• Physical Inactivity

Smoking
• Tobacco use increases the risk of coronary artery disease two to six times
more than non smokers.
• Nicotine increases platelet thrombus adhesion and vessel inflammation.

Diabetes & Hypertension

• Diabetes not only increases the rate of atherosclerotic formation in
vascular vessels but also at an earlier age.
• The constant stress of high blood pressure has been associated with the • S- Severity of pain
increased rate of plaque formation. • T- Timing
• Shearing Stress and inflammation of endothelial lining begins the process.

Hyperlipidemia
• Elevated levels of cholesterol, LDL’s or
triglycerides are associated with the
increased risk of coronary plaque
formation and MI.
• Almost 50% of the population has
some form of dyslipidemia.

Obesity and Physical Inactivity

• Mortality rate from CAD is higher in those who are obese.
• Some evidence shows that those who carry their weight in their abdomen
have a higher incidence of CAD
• Physically inactive people have lower HDL levels with higher LDL levels
and an increase in clot formation.

Signs and Symptoms

• Signs and symptoms are unique to each individual patient. 2. Nausea and Vomiting
• Ranging from no symptoms to sudden cardiac arrest. • Not everyone will experience this.
• Vomiting results as a reflex from severe pain.
1. Chest Pain • Vasovagal reflexes initiated from area of ischemia.
• The most common initial manifestation is chest pain or discomfort.
• This is not relieved by rest, position change or nitrate administration. 3. Sympathetic Nervous System Stimulation
• Pain is described by heaviness, pressure, fullness and crushing sensation. • During an MI increased catecholamines
• Not everyone experiences this sensation.l are released.
PQRST assessment for chest pain • This results in diaphoresis and vasoconstriction of peripheral blood vessels.
• P- Precipitating events • “Cool Sweat” with a temperature increase during the first 24 hours.
• Q- Quality of pain
• R- Radiation of pain
4. Cardiovascular Changes Investigation- Serum Cardiac Markers
• Initially the BP and pulse may be elevated. • Myocardial cells produce certain proteins and enzymes associated with
• Later, BP will drop due to decreased cardiac output. cellular functions.
• Urine output will decrease • When cell death occurs, these cellular enzymes are released into the blood
• Lung sounds will change to crackles stream.
• Jugular veins may become distended and have obvious pulsations. • CPK and troponin

Within the first 10 minutes upon arrival to the hospital: CPK

• Check vital signs and evaluate oxygen saturation • Creatine Phosphokinase
• Establish IV access • Begin to rise 3 to 12 hours after acute MI. • Peak in 24 hours
• Obtain and review 12-lead ECG • Return to normal in 2 to 3 days
• Take a brief focused history and perform a physical exam
• Obtain blood samples to evaluate initial cardiac markers, electrolytes and Troponin
coagulation • Myocardial muscle protein released into circulation after injury.
• These are highly specific indicators of MI.
Diagnostics • Troponin rises quickly like CK but will continue to stay elevated for 2
• After collecting patient health history, a series of ECG’s should be taken to weeks.
rule out or confirm MI. • Myoglobin-lacks cardiac specificity.
• 12 lead ECG can help to distinguish between ST-elevation MI ’ s and
Non-ST-elevation MI’s. Treatment Options
• The immediate goal for any acute MI is to restore normal coronary blood
flow to vessels and salvage myocardium.
• There are a variety of medical and medicinal therapies to treat an MI.

General Treatment for the MI patient

1. MONA
• Morphine
• Oxygen
• Nitroglycerin
• Aspirin
2. Fibrinolytic Therapy Long Term Care
• Indicated for patients with STEMI MI’s. • Smoking Cessation and lifestyle modifications.
• Should be given within 12 hours of symptom onset. • Aspirin, Beta Blockers and Clopidogrel will be indefinite.
• Fibrinolytics will break down clots found within the vessles • Lipid lowering medication along with diet modifications.
• Contraindications: post op surgical patients, history of hemorrhagic stroke,
ulcer disease, pregnancy, etc.

Myocardial infarction
Nursing process
Assessment
• A careful history
• Description of symptoms (chest pain, palpitation, dyspnea, syncope or
sweating). Each symptom must be evaluated with regard to time, duration,
precipitating & relieving factors. In addition complete physical assessment
for:
*Level of consciousness
*Heart sounds
*Peripheral pulses
*Lung sound

3. Cardiac Catheterization Nursing diagnosis

• A diagnostic angiography which includes angioplasty and possible stenting. – Chest pain related to reduced coronary blood flow.
• Performed by an interventional cardiologist with a cardiac surgeon on stand – High risk for breathing pattern ineffective related to fluid overload
by. – Anxiety related to fear from death
• Percutaneous procedure through the femoral or brachial artery. – High risk for tissue perfusion alteration related to decreased cardiac output
– Health maintenance alteration related to no adherence to therapeutic
4. Coronary artery bypass graft regimen
• Surgical treatment where saphenous vein is harvested from the lower leg
and used to bypass the occluded vessels. Nursing Management of MI
• Nursing interventions for a patient with acute MI focus on:
– Achieving a balance between myocardial oxygen supply and demand: This
means that in the acute phase, there is a need to increase myocardial oxygen
supply by oxygen administration to prevent tissue hypoxia. Myocardial
oxygen supply can be enhanced by the administration of coronary artery
vasodilators (nitroglycerin).
– Prevention of complications: Nurses need to apply cardiac monitoring of
patient to detect early ventricular dysrhythmias. In addition, nurses should
continue to assess for signs of ischemic pain.

– Health education: Nurses should focus on:

• Pathophysiology of acute MI.
• Description of signs and symptoms such as pain. pressure, or heaviness in
chest.
• Notification of nurses of any changes in chest pain intensity.
• Avoidance of the Valsalva maneuver.
• Risk factors modification, including:
– Daily fat intake < 30% of total calories.
– Maintain serum cholesterol level < 200 mg/dL. – Maintain LDL
cholesterol to < 70 mg/dL.
– Stop smoking and reduce daily salt intake.
– Control hypertension and diabetes mellitus.
– Increase physical activity and reduce weight
– Health education (Continued...): Nurses should focus on:
• Medication teaching: indications and side effects.
• Follow-up care after discharge.