Medication notes for MI class

You are responsible for the medications that are listed under Myocardial
Infarction on the grid on page 49 of your workbook. These notes are a synopsis
of what was discussed in class. All of the information from the notes are derived
from the group work you produced during the class and from the drug reference
books you used (Lehne or your drug handbook).
I advise you to read the pages that are listed on the myocardial infarction
page (page 259) from your workbook.

Heparin:
Action:
 PREVENTS clot formation
 Suppresses coagulation by inactivating antithrombin  inactivates factor
Xa & thrombin
 Inactivation of thrombin & factor Xa  suppresses formation of fibrin
 Fibrin is the framework for clots that originate in the VENOUS system ie.
DVT  used in prevention of DVTs
Therapeutic uses:
 Low dose therapy (5000u): prevention of DVTs post surgery
 High dose therapy: used to treat pulmonary embolism, evolving stroke
 MI clients:
1. used post PTCA since the procedure causes trauma to vessels &
risk of thrombus formation and re-occlusion is high
2. used post thrombolytic therapy (only alteplase & reteplase) to
reduce the risk of re-occlusion
Adverse effects:
 hemorrhage
 heparin-induced thrombocytopenia:
1. decrease in platelet counts (thrombocytopenia) but increase in
thrombotic events
 2. immune-mediated, meaning it is an immune reaction from the
patient’s own body
3. 1-3% of patients develop this problem
 hypersensitivity reactions (allergy):
1. heparin is extracted from animal tissues
2. evidenced by allergic reactions: chills, fevers, development of
uticaria (hives)
Nursing Implications:
 can be administered using deep SC, intermittent IV or continuous IV
administration
 observe clients closely for signs of bleeding:
1. monitor for increase in HR, quality thready, decrease in BP
2. assess for hematuria, blood in stool
3. assess skin for development of ecchymosis, petechiae, hematomas
4. assess for lumbar pain (adrenal hemorrhage), pelvic pain (ovarian
hemorrhage)
 monitor for allergic reactions
 educate client to:
1. use soft toothbrush, decrease gingival bleeding
2. use of electric razor when shaving
3. call for help when getting out of bed or when ambulating, minimize risk
of bumping into furniture or hospital equipment
Laboratory Monitoring: APTT versus INR
 lab monitoring for clients on heparin: APTT (Lehne) but at some hospitals
(MUHC, for example), physicians use INR
 both these lab tests allow physicians to adjust heparin doses accordingly
 these lab results measure bleeding time; the time it takes for the client’s
blood to form a clot
 the goal when on heparin (or any anticoagulant therapy) is to prevent clots
from forming but not to the point where your client is spontaneously
bleeding
  if the lab values indicate that the bleeding time is too long (ie client is
taking too long to form a clot), the heparin dosage will DECREASE
 if lab values indicate that the bleeding time is too short (ie client forms a
clot in a short period of time), then the heparin dosage will INCREASE
 APTT: activated partial thromboplastin time: actually measures the time (in
seconds) of formation of thromboplastin
 In order to measure any coagulation studies (APTT), laboratories use
reagents however there are many different types of reagents, the results
will vary between laboratories (and even within the same lab, if the lab
decides to change their reagents)
 INR results correct for the variability that exists between the different
reagents
 INR: a ratio between client’s prothrombin time (time In seconds to make
prothrombin) and the laboratory’s normal average of the prothrombin time
(PT)
 Target INR=2.0-3.0  recommended for prophylaxis of DVT or prevention
of further clotting in MIs

Coumadin (warfarin)
Action:
 Suppresses coagulation by acting as an antagonist to vitamin K
 Four (4) clotting factors need vitamin K for their synthesis
 Suppression of Vitamin K  suppression of the four (4) clotting factors 
anticoagulant effect
Therapeutic Uses:
 Long term prophylaxis (prevention) of thrombus (clots)
 Prevention of VENOUS thrombosis and pulmonary embolism
 Reduce the risk of recurrent MIs and TIAs (transient ischemic attacks)
Adverse effects:
 Hemorrhage: major complication of coumadin therapy
 Fetal hemorrhage if used during pregnancy
 Nursing Implications:
 Monitor for bleeding
 Review points under heparin
 Verify that vitamin K (antidote for warfarin overdose) is available on the
department
Important to note the specific drug interactions that occurs with coumadin

Streptokinase
Action:
 Dissolve thrombin by producing an enzyme that digests the fibrin network
of clots
Therapeutic Uses:
 Used to dissolve thrombosis
 Treatment of acute coronary thrombosis (acute MI)
 DVT
 Massive pulmonary emboli
Adverse Effects:
 Bleeding, particularly intercranial hemorrhage (ICH)
 Hypotension: 1-10% of patients unrelated to bleeding or allergic reactions
 Fever
 Allergic reactions: due to medication derived from bacteria (streptococcus)
Nursing Implications:
 Assess areas of possible hemorrhage: recent wounds, incision sites, IV
puncture sites and sites where invasive procedures have been performed
 Apply pressure dressing to areas of bleeding
 Avoid SC or IM injections
 Minimize invasive procedures

Magnesium
Action (for MI patients):
  Protects myocardium by decreasing platelet aggregation
 Increases coronary blood flow
 Lowers the risk of ventricular dysrhythmias
 Reduces cardiac afterload
Note: Magnesium has demonstrated decreased mortality in small research
studies. Another large research study has demonstrated the OPPOSITE and
increased the risk of death from CHF or cardiogenic shock. Due to the
inconsistent results of the studies, the use of magnesium has not been
recommended as a routine treatment for MI clients (Lehne ppg 570).

Lidocaine:
Action:
 Blocks cardiac Na channels slows conduction in the atria, ventricles and
Purkinje system
 Reduces automaticity in ventricles and Purkinje system (unknown
mechanism)
 Acclerates repolarization
Therapeutic Uses:
 Treat ventricular dysrhythmias associated with acute MI
Nursing Implications:
 To treat dysrhythmias, lidocaine is given IV and in a monitored setting with
constant EKG monitoring
Note: In the past, lidocaine was used PROPHYLACTICALLY to prevent the
occurrence of dysrhythmias. However, this practice is no longer recommended.
Lidocaine is used to TREAT serious ventricular dysrhythmias when they occur.

Atorvastatin
Therapeutic actions
 Lowers LDL cholesterol (bad cholesterol)
 Increases HDL cholesterol (good cholesterol)
 CAD or MI clients:
 1. promote plaque stability
2. reduce inflammation to the plaque site
3. enhance ability for blood vessels to dilate
4. reduce the risk of thrombosis formation (decreases platelet
aggregation, suppression of thrombin)
Uses:
 primary prevention of coronary events
Note: research has shown that clients with pre-existing coronary heart disease
(MI or angina), statins reduce the risk of death from cardiac causes. Other
studies have demonstrated that treatment should include people at high risk of
developing these cardiac events.
Adverse effects:
 patients may develop headache, rash or GI disturbances (flatulence,
abdominal pain, cramps)  mild effects
 hepatotoxicity: as evidenced by increase in liver enzymes (blood tests) 
rare
 myopathy

Other medications that are used in the treatment of MI

Many of these medications have been discussed in other classes (angina, pain,
immobility, hypertension). You should already know these classifications however
these medications are used in the context of a patient suffering an acute MI.
Please consider this while you are researching your medications.

Morphine:
 narcotic analgesic
 used for clients with an acute MI for:
1. decreases cardiac workload by venodilation (dilation of vessels)
2. decreases cardiac O2 consumption by lowering HR
 3. reduces anxiety and fear which decreases cardiac workload and
O2 consumption
Colace:
 stool softener
 used to prevent constipation in clients with acute MI:
1. avoid straining which increases intrathoracic pressure which
increases workload (and O2 consumption) of heart
2. vasovagal reaction may occur as a result of straining (patient may
experience severe bradycardia)
Nitroglycerin:
 vasodilator by acting on the smooth muscle
 increases O2 supply to myocardium
 increases collateral blood flow to ischemic regions of the heart
 limits infarct size and improves left ventricular function
 helps reduce chest pain
Aspirin:
 NSAIDs
 Protection against MI from the inhibition of COX-1  decreases platelet
aggregation
 Works in synergy with thrombolytic agents
 Clients experiencing an MI: will take 325mg (initial dose is crushed &
chewed, to release the medication into the body)
 325mg initial dose  decreased to 81mg/day, reduces risk of stroke,
reinfarction
Beta blocker:
 used to decrease HR & myocardial contractility
 decreases workload on heart
 decreases infarct size
ACE inhibitor:
 prevents ventricular re-modeling
 slows progression of heart failure