2. Learning Outcomes
At the end of the lecture, student will be able to:
Define acute myocardial infarction (AMI).
State the etiology of AMI.
Explain the pathophysiology of AMI
State the clinical manifestations of AMI.
State the diagnostic tests that helps to confirmed the
AMI.
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3. Cont. Learning Outcomes
At the end of the lecture, student will be able to:
Explain the treatment and management for AMI.
Explain the nursing management for patient with
AMI.
Provide health teaching on preventive measures to
patients prior to discharge.
3
7. Acute Myocardial Infarction (AMI)
Also called a heart attack.
Defines as myocardial cell death due to
prolonged ischemia.
(Malaysian Heart Assoc, 2019).
Myocardial injury is myocardial cell death due to
non ischemic causes.
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8. Cont..
AMI is diagnosed by the rise and/fall in cardiac
troponins with at lease one value > 99 percentile
with accompanied with at lease one of the following:
clinical history consistent with chest pain of
ischemic origin
ECG changes
imaging evidence of new loss of variable
myocardium
identification of an intracoronary (IC) thrombus
by angioplasty
(Malaysian Heart Assoc, 2019).
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9. Cont.
The main cause of AMI ---> sudden blockage
in the coronary artery ---> due to formation of
blood clot (thrombus) ---> causing irreversible
damage (necrosis) to the heart muscle.
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13. Pathogenesis of MI
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Myocardial necrosis begins within 20-30 minutes, mostly
starting at the sub-endocardial region (less perfuse, high
intramural pressure.
Infarct reaches its full size within 3-6 hrs; during this
period, lysis of the thrombus by streptokinase or tPA
(tissue plasminogen activator), may limit the size of the
infarct.
14. Etiology & Risk Factors
Most heart attack results from atherosclerosis
Family history CAD
Hypercholesterolemia
↑LDL ↓HDL
↑BP
Obesity
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18. Cont.
Fever
Nausea & vomiting ---> results from
vasovagus reflexes.
Crackles sound, peripheral edema & hepatic
enlargement ---> indicates cardiac failure.
Cardiac vascular manifestations:
elevated BP and HR
BP may drop as decreased co and urinary output.
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19. Diagnostic Tests
Clinical history consistent chest pain of ischemic
origin.
Serum Troponin I or T
Serum CK-MB (cretinine kinase-myocardial band)
12-lead ECG (ST-T wave elevated by greater than
1 mm or > in two continuous leads ---> MI)
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20. Cont.
Echocardiogram
Serum potassium, magnesium & calcium
(imbalances & acidosis may cause change in
conduction & contractile).
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23. Pre-Hospital Management
Patient with suspected ST segment elevation
MI (STEMI), should be given soluble or
chewable 300 mg aspirin and 300 mg
clopidogrel.
These patient should be rapidly transported to
the hospital for early initiation of reperfusion
strategies.
DO NOT BRING TO A CLINIC
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24. Treatment & Management
The goals of medical management are to:
minimize myocardial damage, preserve myocardial
function and prevent complications lethal
dysrhythmias and cardiogenic shock:
1) Reperfusion – use of the percutaneous coronary
intervention (PCI) or thrombolytic medications.
2) Reduce myocardial oxygen demand & increase
oxygen supply with medications, oxygen therapy
& bed rest.
3) Coronary artery bypass or minimally invasive direct
coronary bypass (MIDCAB)
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25. Cont..
Pharmacological Therapy
Nitrates (nitroglycerin) to increase oxygen supply
Anticoagulants (aspirin, heparin)
Analgesics (morphine sulfate)
Angiotensin-converting enzyme inhibitors
Beta blocker initially & a prescription to continue its
use after hospital discharge
Thrombolytics (tPA, Activase) and reteplase (rPA,
TNKase) ---> must be administered after the onset of
symptoms, generally within 3-6hours
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28. Contraindication for Thrombolytic
Therapy
Active Bleeding
Known bleeding disorder
History of hemorrhagic stroke
Recent major surgery or trauma
Uncontrolled hypertension, CVA
Pregnancy
30. Complications Post STEMI
Important complications following STEMI:
Arrhythmias
Heart failure due to extensive myocardial damage or
mechanical complications.
Chest pain post STEMI may be due to:
reinfarction / recurrent MI
post infarct angina
pericarditis
non cardiac causes such as gastritis (epigastric pain)
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31. Nursing Management
Obtain baseline data on current status for
comparison with ongoing status include:
history of chest pain or discomfort,
dyspnea,
palpitations,
unusual fatigue,
faintness (syncope) or
diaphoresis.
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32. Cont..
1. Perform a complete physical assessment
---> for detecting complications & any change in
status. The examination include:
Assess level of consciousness
Evaluate chest pain (most important clinical
finding).
Assess heart sound to detect an early sign of
impending LVF.
Measure BP to determine response to pain &
treatment.
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33. Cont..
Note narrowed pulse pressure after MI, suggesting
ineffective ventricular contraction.
Assess bowel movement. Serve laxative to prevent
straining.
Observe urinary output and check for edema; an
early sign of cardiogenic shock in hypotension with
oliguria.
Examine IV lines and sites frequently.
2. Maintain CRIB
3. Assist in ADLs
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34. Nursing Diagnoses
1) Ineffective cardiac tissue perfusion related to
reduced coronary blood flow.
2) Risk for imbalanced fluid volume.
3) Risk for ineffective peripheral tissue perfusion
related to decreased cardiac output from left
ventricular dysfunction.
4) Death anxiety.
5) Deficient knowledge about post acute coronary
syndrome self-care.
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35. Nursing Interventions
Relieve sign & symptoms of ischemia.
Administer oxygen to reduce pain associated with
low levels of circulating oxygen.
Assess vital signs frequently to detect
hemodynamic changes.
Position patient of Fowler’s position or put on
cardiac bed to decrease chest discomfort and
dyspnea.
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36. Cont…
Improving Respiratory Function
Assess respiratory function to detect an early
signs of complications.
Monitor fluid volume status to prevent
overloading the heart and lungs.
Encourage patient to perform deep breathing
exercise and change position often to prevent
pooling fluid in lungs bases.
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37. Cont…
Promoting Adequate Tissue Perfusion
Maintain patient on bed rest
rest to reduce myocardial oxygen consumption.
Check skin temperature and peripheral pulses
frequently
determine adequate tissue perfusion.
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38. Cont…
Reduce Anxiety
Develop a therapeutic relationship with patient.
Allow patient to express feelings.
Provide information to the patient and family in an
honest and supportive manner.
Ensure a quiet environment, prevent interruptions that
disturb sleep.
Use a caring and appropriate touch, relaxation
technique, and use humor.
Provide spiritual support consistent with patient’s
beliefs.
Provide divertional therapy.
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39. Health Teaching
Compliance with prescribed medication.
Adhere to the prescribed cardiac rehabilitation
regimen.
Assist patient with scheduling & keeping follow up
appointments for monitoring, laboratory test, ECG
and general health screening.
Advise family member to assist patient in adhere to
restrictions dietary advice.
Instruct patient to monitor for sign of complications
and seek for medical attention immediately.
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40. Cont.
Advice patient to change life styles:
Stop smoking and alcohol intake
Regular exercise as advised at lease 3 times a
week (cardio-exercise).
Diet modifications
Stress management
Maintain ideal body weight
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41. References
Amsterdam EA, Wenger NK, Brindis RG, et al. (2014).
AHA/ACC guideline for the management of patients with
non–ST-elevation acute coronary syndromes. J Am Coll
Cardiol. 2014;64(24):e139- 228. [PMID:25260718]
Basavanthappa. B.T. (2015). Medical Surgical Nursing (3rd ed.).
New Delhi: Jaypee.
Black, J. M., & Hawks, J. H. (2011). Medical Surgical Nursing.
(8th ed.). St. Louis, UK: Saunders.
Ignatavicius, D. D., & Workman, M. L. (2016). Medical-Surgical
Nursing: Patient-Centered Collaboration Care. (8th ed.).
Singapore: Elsevier.
https://www.malaysianheart.org/files/5cb6bf193304e.pdf
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Early management of STEMI is directed at:
Pain relief – analgesic & oxygen therapy
Establishing early reperfusion – use of Percutaneous Coronary Intervention (PCI) or thrombolytic medications
Treatment of complications