MEDICAL AND SURGICAL MANAGEMENT OF ACUTE MYOCARDIAL INFARCTION

Medical management
The goal of medical management is to
1. Minimize myocardial damage
2. Preserve myocardial function and prevent
complications
- Minimizing myocardial damage is also
reducing myocardial oxygen demand and
increasing oxygen supply.

MANAGEMENT
- preserve cardiac muscle fibers
- Vital signs
- Iv assess
- ECG
- Biomarkers

INITIAL MANAGEMENT
M- Morphine
O- oxygen
N-Nitrates
A- Antiplatelets

EMERGENT PERCUTANEOUS CORONARY

INTERVENTION (PCI)
- PCI may be used to open the occluded
coronary artery in an acute MI and promote
reperfusion to the area that has been deprived
of oxygen.
- PCI performed should be less than 90
minutes.
- Usually PCI with the placement of stent will be performed
- Complications- dissection of coronary artery
- Cardiac tamponade
- Restenosis
- Hematoma formation at the site

Thrombolytic therapy/fibrinolytic therapy

The purpose of thrombolytics is to dissolve and lyse the thrombus in a coronary artery
(thrombolysis), allowing blood to flow through the coronary artery again (reperfusion),
minimizing the size of the infarction, and preserving ventricular function.
Thrombolytics are usually administered through IV, although some may also be given
directly into the coronary artery in cardiac catheterization.

Thrombolytics should not be used if the patient is bleeding or has bleeding disorders.
To be effective, thrombolytics must be
administered as early as possible after the onset of symptoms that indicate an acute MI,
generally within 3 to 6 hours.

Indications
- Chest pain for longer than 20 minutes,
unrelieved by nitroglycerin
- ST-segment elevation in at least two leads that
- face the same area of the heart
- Less than 24 hours from onset of pain

Absolute Contraindications
- Active bleeding
- Known bleeding disorder
- History of hemorrhagic stroke
- History of intracranial vessel malformation
- Recent major surgery or trauma

Relative contraindications
- Active peptic ulcer disease
- Pregnancy
- Stroke more than 3 months back
- Uncontrolled hypertension

Start within 30 minutes ( door-to-needle time)

Common thrombolytics
 1st generation
 Streptokinase
 Urokinase
 2nd generation
 alteplase ( tPA)
 reteplase
 Anistreplase

Nursing considerations
Minimize the number of times the patient's skin is punctured.
Avoid intramuscular injections.
Draw blood for laboratory tests when starting the IV line.
Monitor for acute dysrhythmias, hypotension, and allergic reaction.
Monitor for reperfusion: resolution of angina or
acute ST-segment changes.
Check for signs and symptoms of bleeding.

Pharmacologic management
- Analgesics
morphine sulfate
decreases preload and afterload
reduce anxiety
- Nitrates
IV nitroglycerin
- ACE inhibitors
increases the left ventricular function
prevent ventricular remodeling
- Beta-adrenergic blockers
decreases the contractility and myocardial
oxygen demand
• Cholesterol lowering agents
• Stool softeners

SURGICAL MANAGEMENT
- CORONARY ARTERY BYPASS GRAFT(CABG)
Construction of new conduits between aorta
or other major arteries with help of CPB machine
Indications
Triple vessel disease
60% occlusion of LAD
Fails medical management

Grafts used
Internal mammary artery
Great saphenous vein
Inferior epigastric artery
Radial artery

Nursing management for a patient with acute MI

- Achieving a balance between myocardial oxygen supply and demand.
- These are achieved via oxygen administration and medication (Nitroglycerin)
- Prevention of complications
- Continuous monitoring of cardiac functions
- Continuous ECG monitoring
- Hemodynamic monitoring
- Monitor and record intake and urine output
- Closely monitor and prevent complications associated with MI particularly dysrhythmia
and cardiogenic shock
- Provide emotional and psychological support
- Explain and provide adequate information and knowledge about disease condition and
treatment process.

Risk factors modification

Daily fat intake less than 309 % of total calories
Maintenance of serum cholesterol level
• Maintain LDL levels less than 70 mg/dl
• Stop smoking and reduce daily salt intake
Control Hypertension and diabetes
Increase physical activity and reduce weight.