Myocardial infarction (MI )

Myocardial infarction (MI)

•The irreversible
necrosis of heart muscle
secondary to prolonged
ischemia (insufficient
tissue oxygenation )
 MI refers to a dynamic process by which one or more
regions of the heart experience a severe and prolong
decrease in O2 supply because of insufficient
coronary blood flow.

 Subsequently , necrosis or “death” to the myocardial

tissue occurs.

 The onset of the MI process may be sudden or

gradual and the progression of the event to
completion takes approximately 3-6 hours.

 MI is one manifestation of acute coronary syndrome.

CONT….
• In MI
–An area of the myocardium is
permanently destroyed
–Area of infarction develops over
minutes to hours
–Terminal stage of coronary artery
diseases
Cont….
• Causes
– Rupture of the atherosclerotic plaque
or formation of thrombus
– Coronary artery spasm
– Coronary A. embolism
MI – various classification
• A/C to myocardium damage
– ST elevation MI (STEMI) -full thickness
– Non ST elevation MI (NSTEMI)
• A/C to location
– Anterior,Inferior ,Posterior or Lateral MI
• A/C to time
– Evolving, Acute, Old
 Clinical features
• Chest pain (anginal) –
severe,steady,substernal,crushing or sqeezing nature,
not relieved by rest or GTN ,continues for more than
15 min.
• May radiate to arm,shoulders,neck back and jaw(Left
side)
• Shortness of breath/dyspnea
• Nausea & vomiting
• Anxiety ,restless
• Cool , pale, and moist skin,diaphoresis
• Tachycardia /bradycardia/palpitation
• Hypertension/hypotension
 DIAGNOSIS
• Patient Hx – P/H of heart disease, risk
factors……
• Electrocardiogram
– ST elevation
– T inversion
– Q wave
Location of the infarction is determined by
the leads in which the ischemic changes are
seen
ECG :- assess electrical activity of the heart
Cont….

• Laboratory Tests
– Cardiac enzymes and biomarkers
• The release of cellular contents into
the circulation when myocardial cells
die
• Level increase when myocardial
damage
Cont…
• Creatine Kinase (CK)
– CK-MM (skeletal muscle)
– CK-BB (brain tissue)
– CK-MB (heart muscle)
• Cardiac specific
Cont…
• Troponin
– A protein found in the myocardium
– Three types C, I & T
– Troponins I & T - specific for cardiac
muscle
– Level increase in acute MI
Cont…
• Echocardiogram
– Used to evaluate ventricular function
– EX:- wall movement and the ejection
fraction
– To identify muscle dysfunction
• Other investigations
 Elevated C reactive protein (CPR) and
lipoprotein due to inflammation in the
coronary arteries.
 Abnormal coagulation studies –(PT / PTT)
 Elevated WBC count and ESR due to
inflammatory process involved in heart
muscle cell damage.
 Radiologic imaging
to recognition of areas of decrease perfusion.
 Complications
• Cardiac arrhythmias –> cardiac arrest
– Ventricular fibrillation (VF), ventricular
tachycardia (VT), heart block
• Cardiogenic shock
• Acute pulmonary edema
• Heart failure
• Re infarction
Cont….
• Pericarditis
• Cardiac rupture
• Ventricular mural thrombus
• Ventricular aneurysm
• Psychiatric problem - depression
VF

VT

HEART
BLOCK
 Medical Management
• Goal
–To minimize myocardial damage
–Preserve myocardial function
–Prevent complications

–When treating acute myocardial

infarction
“TIME IS MUSCLES”
Mx
• Bed rest
• O2 therapy(to increase oxygenation to ischemic
heart muscle)
• Take 12 lead ECG- within 10 min.
• Pain control
– Morphine 5-10 mg - IM/ slow IV
– Nitroglycerin
• Setup IV line take blood for Ix-cardiac markers
• Monitor ECG, SaO2, BP
• Plan reperfusion therapy – thrombolytic
/PCI(percutaneous coronary intervention)
Drugs Therapy for MI
• Analgesics
– Morphine - IV bolus
• Reduce pain and anxiety
• Reduces heart work load
• Relaxes bronchioles
• Side effect – respiratory depression
Cont….
• Thrombolytics agents
– Dissolve the thrombus in a coronary
artery (thrombolysis)
– Allow blood flow again (reperfusion)
– Drugs
• Streptokinase
• Tissue plasminogen activator (t-PA)
Cont….
• Other drugs
– Antiplatletes -Aspirin /Clopidogrel
to halt platelet aggregation
– Beta blockers –Atenolol,metapralol
– ACE inhibitors – Captopril
– Anticoagulant – Heparin,Enoxaparin
to reestablish blood flow in coronary vessels by
dissolving thrombus.
– Antiarrhythmics- Lidocaine (Xylocaine)
decrease the ventricular irritability that occurs after
MI
 Surgical intervention
• Percutaneous Coronary Interventions
– Coronary angioplasty
– Coronary stenting
– Athrectomy
• Emergency CABG surgery (coronary
artery bypass graft)
 Nursing Assessment
 Gather information regarding the patient’s chest pain.
– Nature & intensity
– Onset & duration
– Location & radiation
– Precipitating & aggravating factors
 Assess for other symptoms associated with the pain
-diaphoresis
-facial pallor
-dyspnea
-rigid posture
-extreme weakness
-confusion
 Evaluate cognitive , behavioral and emotional
status.
 Question patient about prior health status
and emphasis on current medications ,
allergies, fainting attacks , alcohol use.
 Analyze information of contraindications for
thrombolytic therapy.
 Gather information about presence or
absence of cardiac risk factors.
 Identify patient’s social support system and
potential care givers.
 Identify significant others’ reaction to the
crisis situation.
 Nursing Diagnoses
o Acute pain related to O2 supply and demand
imbalance.
o Anxiety related to chest pain , fear of death,
threatening environment.
o Decreased cardiac out put related to impaired
contractility.
o Activity intolerance related to insufficient
oxygenation to perform activities of daily
living, deconditioning effects of bed rest.
o Risk for injury (bleeding) related to
dissolution of protective clots.
o Ineffective tissue perfusion (myocardial )
related to coronary restenosis , extension of
infarction.
o Ineffective coping related to threats to self
esteem , disruption of sleep rest pattern , lack
of significant support system and change in
life style.
 Nursing Interventions
• Reducing pain
-handle patient carefully while providing initial
care.
-maintain O2 saturation greater than 95%
-offer support and reassurance to patient that
relief of pain is a priority.
-administer sublingual nitroglycerin as directed.
(recheck BP, PR , RR before and 5-10 mins after
dose)
-administer opioids as prescribed
Eg: Morphine to reduce Ht rate , RR, BP,
muscle tension , anxiety. Use caution for COPD ,
hypotension or dehydration.
- Give IV nitroglycerin as prescribed(monitor
BP continuously)
- Frequently review chest pain , discomfort
and epigastric distress.
• Reducing anxiety
- assess etiologies for anxiety
- assess patient for hypo perfusion &administer
O2 as prescribed. Notify physician
immediately.
- Document all assessment findings ,
interventions & responses.
- Explain to patient & family – reason for
hospitalization, diagnostic test , therapies
administered, equipment, procedures & need
for frequent assessment , nursing & medical
regimen , visiting hours , limit visitors
-observe for autonomic signs of anxiety
(eg: increase HR , BP,RR) and administer anti-
anxiety agents as prescribed.
- Maintain consistency of care.
- Offer back massage for relaxation , reduce
muscle tension and anxiety.
• Maintain hemodynamic stability
- Monitor BP every 2 hours or as directed.
- Evaluate heart rate and heart sounds every
2-4 hours or as directed.
- Monitor respiration & lung fields every 2-4
hours or as prescribed (auscultate normal or
abnormal breath sounds , observe for
dyspnea, tachypnea , frothy pink sputum ,
orthopnea)
- Note presence of jugular vein distention and
engorgement (to estimate right atrial
pressure)
- Evaluate major arterial pulses (weak or plus
less laterals indicates low cardiac out put or
dysrhythmias)
- Take body temp. every 4 hours or as directed
(most pt. develop increased temp. within 24-
48 hours due to tissue necrosis)
- Monitor skin color and temperature
(cool ,clammy skin and pallor associated
cardiac output)
- Be alert to change in mental status eg:
confusion , restlessness , disorientation
- Evaluate urine out put (30ml/h) decrease in
volume reflects a decrease in renal blood
flow
- Monitor for life threatening dysrhythmias
(common within 24 hours following
infarction)
• Increasing activity tolerance
*promote rest with early gradual increase in
mobilization.
- Minimize environmental noise.
- Provide a comfortable environment temp.
- Avoid unnecessary interruptions and
procedures.
- Include rest periods after activity.
- Discuss with patient and family the purpose of
limited activity and visitors.
- Promote useful diversional activities for
patient eg: reading , listening to music etc.
- Encourage frequent position changes while in
bed.
*Assist patient with prescribed activities .
- assist pt. to rise slowly from a supine position
to minimize orthostatic hypotension related
to medication.

- Encourage activity and passive range of

motion exercises as directed while on bed
rest.
- Implement a step by step program for
progressive activity as directed.
• Preventing bleeding
- Take vital signs every 15 mins during infusion
of thrombolytic agent and then hourly.
- Observe hematomas or skin break down
specially in potential pressure areas such as
sacrum , back , elbows , ankles.
- Be alert to verbal complications of back pain
indicative of possible retroperitoneal
bleeding.
- Apply manual pressure or pressure dressing if
bleeding occurs.
- Observe for blood in stool , emesis , urine
and sputum.
-Avoid IM injections.
-Caution patient about vigorous tooth brushing, oral
suctioning, hair combing or shaving.
-Avoid trauma to patient by minimizing frequent
handling of patient.
-Monitor laboratory values; PT, INR, PTT, hematocrit,
Hb%
-Check for blood type & cross match
-Administer antacids or GI prophylaxis to prevent
stress ulcers.
-Implement emergency interventions as directed, in
the event of bleeding
-Monitor for changes in mental status & headache
-Avoid use of automatic BP device above puncture
sites or hematoma.
• Maintaining tissue perfusion
-Observe for persistent or recurrence of signs
& symptoms of ischemia, including chest pain,
diaphoresis, hypotension & report
immediately.
• Administer O2 as directed.
• Prepare patient for possible emergency
procedures (cardiac catheterization, bypass
surgery, thrombolytic therapy, intra aortic
balloon pump.
• Strengthening coping abilities
-Listen carefully to patient & family
-Assist patient to establish positive attitude
towards illness
-Promote restful sleep & be alert to signs &
symptoms of sleep deprivation.
 Patient Education and Health Maintenance

• Inform the patient & family about what has happened to

patient’s heart
• Instruct patient on how to judge the body’s response to
activity
• Design an individualizes activity progression program for
patient as directed
• Tell patient that sexual relations may be resumed on advise
of physician, usually after exercise tolerance is assessed.
• Advise eating 3-4 small meals per day rather than large,
heavy meals. Rest for 1 hour after meals.
• Advise limiting caffeine & alcohol intake
• Driving must be cleared with the physician at a
follow up visit.
• Teach patient about medication regimen &
adverse effects.
• Instruct the patient to notify health care provider
when the following symptoms appear;
-Shortness of breath
-Unusual fatigue
-Swelling of feet & ankles
-Fainting, dizziness
-Very slow or rapid heart beat
• Assist patient to reduce risk of another MI, by risk
factor modification.