Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Acute Myocardial infarction
Priya .M. Vincent & Padma Susan Mathew
ICCU
Definition
• Necrosis to cardiac muscle
due to acute occlusion of
coronary artery as a result
of plaque rupture and
thromb...
Coronary Atherosclerosis with Thrombus
Riskfactors
• Non-modifiable
– Age
– Race
– Sex
– Heredity
• Modifiable
– Smoking
– Hypertension
– Diabetes mellitus
– Hyp...
Understanding Myocardial Infarction
Change in the condition of plaque in the
coronary artery
Activation of platelets
Forma...
Contractility
Stimulation of the
sympathetic nervous system LV function
Preload Cardiac
Output
CVP
PCWP
LVEF
HR O...
Normal Myocardium:
Myocardial Infarction - Gross
Myocardial Infarction – 1st
week
Post-infarcted Myocardium- CS
2nd
week- Myocardial Infarction -
3d
MI 18-24 hours loss of nucleus,
contraction bands, coagulative necrosis
MI 3-4 days – Hemorrhage, inflammation
MI 1st
– 2nd
week– Granulation tissue
MI 2-
4 weeks - Resorption, fibrosis
MI > 4–6 weeks - Collagen Scar
Clinical features
Symptoms:
• Prolonged chest pain
• Profuse sweating
• Nausea & vomiting
• Breathlessness
• Anxiety
• Col...
Physical signs
• Pallor, sweating, vomiting
• Tachycardia / Bradycardia
• Hypotension, oliguria, cold periphery
• Narrow p...
Diagnostic measures
• ECG
• Lab Investigations
– Troponin I
– Troponin T
– CPK-MB
– CPK [Total]
– SGOT
– CBC & ESR
• X-Ray...
ECG Patterns
Coronary
Arteries
•Left Coronary A.
•L.A.Descending
•Left Circumflex
•Right Coronary A.
LCx
LAD
Area of myocardium
involved
Coronary artery supply Leads
Anterior Left coronary artery left anterior
descending branch
V2,...
Enzyme Normal value Onset Peak Return to
normal
Trop. I &
Trop T
<0.2 4-6hrs 24-36 hrs. 10-12days
CPK[Total] 21-232 hrs. 1...
Management
• Se e k im m e diate m e dicalatte ntio n
Medical Management
• Major goals:
– Management of the acute attack
– Prevention of complications
– Rehabilitation
1. Management of Acute attack
• History
• ECG
• IV access
• Routine blood investigations
• Continuous cardiac monitoring
•...
General Measures
• Pain control
• Aspirin
• Clopidogrel
• Nitrates
• Beta-adrenoreceptor blockers
• ACE inhibitors
• Bed r...
Patients with ischemic type discomfort
ECG
ST elevation ECG strongly suspicious for
ischemia ( ST depression, T
wave inver...
Thrombolysis
• Streptokinase
• Urokinase
• Tissue plasminogen activator (t-PA)
• Acylated plasminogen
streptokinase activa...
Criteria forthrombolysis in acute
MI
Indications:
• Chest pain
• ECG changes
• Time from onset of symptoms
<6 hrs. : most ...
Absolute contraindications
1. Active internal bleeding (excluding menses)
2. Suspected aortic dissection
3. Recent head tr...
Relative contraindications
• BP>180/110mmHg on at least 2 readings
• History of hypertension
• Active peptic ulcer
• Histo...
Protocol followed in ICCU
• Aspirin 150-325mg chewed, 75mg daily thereafter
• Clopidogrel 300mg stat & 75mg daily
• Pain r...
• Inj. NTG infusion x 24-48hrs. in LVF, large anti. MI
persistent pain
• β blockers to all patients unless contraindicated...
2. Prevention of complications
a. Dysrhythmias
b. Cardiogenic shock
c. Heart failure & pulmonary edema
d. Pulmonary emboli...
3. Rehabilitation
Overall goals
• Lead a productive life
• Remain within the limits of the heart’s ability to respond to
i...
Phase I (in hospital)
• Bed rest for 1 day with liquid diet
• When vital signs get stabilized, patient can move in bed
• P...
Phase II (Intermediate)
• If no complications, discharge at the end of one week
• Sexual intercourse after 4-8 weeks.
• St...
Phase – III (Long term)
• Periodic evaluation
Interventional Management
[PTCA] Percutaneous Transluminal Coronary Angioplasty
Coronary Artery Bypass Graft
Surgery [CABG]
Nursing Management
• Nursing Diagnosis:
– Acute chest pain related to myocardial ischemia resulting from coronary
artery o...
Thankyou
Acute mi
Upcoming SlideShare
Loading in …5
×

Acute mi

1,410 views

Published on

Published in: Health & Medicine
  • Be the first to comment

Acute mi

  1. 1. Acute Myocardial infarction Priya .M. Vincent & Padma Susan Mathew ICCU
  2. 2. Definition • Necrosis to cardiac muscle due to acute occlusion of coronary artery as a result of plaque rupture and thrombosis
  3. 3. Coronary Atherosclerosis with Thrombus
  4. 4. Riskfactors • Non-modifiable – Age – Race – Sex – Heredity • Modifiable – Smoking – Hypertension – Diabetes mellitus – Hyperlipidemia. – Obesity – Response to stress
  5. 5. Understanding Myocardial Infarction Change in the condition of plaque in the coronary artery Activation of platelets Formation of thrombus Ischemia of tissue in the region supplied by the artery Coronary blood supply < demand Myocardial cell death Contractility Stimulation of the sympathetic nervous system Altered repolarization of myocardium Release of lysosomal enzymes Anaerobic Glycolysis Myocardial irritability Dysrhythmia s ST seg. q wave CPK-MB LDH Lactic Acid production Angina
  6. 6. Contractility Stimulation of the sympathetic nervous system LV function Preload Cardiac Output CVP PCWP LVEF HR O2 NEED After load Vasoco nstricti on Continuation….
  7. 7. Normal Myocardium:
  8. 8. Myocardial Infarction - Gross
  9. 9. Myocardial Infarction – 1st week
  10. 10. Post-infarcted Myocardium- CS
  11. 11. 2nd week- Myocardial Infarction - 3d
  12. 12. MI 18-24 hours loss of nucleus, contraction bands, coagulative necrosis
  13. 13. MI 3-4 days – Hemorrhage, inflammation
  14. 14. MI 1st – 2nd week– Granulation tissue
  15. 15. MI 2- 4 weeks - Resorption, fibrosis
  16. 16. MI > 4–6 weeks - Collagen Scar
  17. 17. Clinical features Symptoms: • Prolonged chest pain • Profuse sweating • Nausea & vomiting • Breathlessness • Anxiety • Collapse / Syncope
  18. 18. Physical signs • Pallor, sweating, vomiting • Tachycardia / Bradycardia • Hypotension, oliguria, cold periphery • Narrow pulse pressure • Raised JVP in RVMI • Lung crepitation • 3rd and 4th heart sounds • Fever
  19. 19. Diagnostic measures • ECG • Lab Investigations – Troponin I – Troponin T – CPK-MB – CPK [Total] – SGOT – CBC & ESR • X-Ray Chest • Echocardiogram • Radioisotope studies - Stress Thallium - Rest Thallium - Multi-gated acquisition scan [MUGA] • Coronary Angiogram • MRI
  20. 20. ECG Patterns
  21. 21. Coronary Arteries •Left Coronary A. •L.A.Descending •Left Circumflex •Right Coronary A. LCx LAD
  22. 22. Area of myocardium involved Coronary artery supply Leads Anterior Left coronary artery left anterior descending branch V2,V3,V4 Posterior Right Coronary Artery V1 – V3 Inferior Right Coronary Artery II, III, avf Anteroseptel Left Coronary Artery left anterior descending branch V2 & V3 High lateral Circumflex artery, marginal branch or LCA I, aVL Apical Usually LCA, left anterior branch may be RCA, posterior descending branch V5 & V6
  23. 23. Enzyme Normal value Onset Peak Return to normal Trop. I & Trop T <0.2 4-6hrs 24-36 hrs. 10-12days CPK[Total] 21-232 hrs. 12-24 hrs. 3-5days CPK– MB <25 . 12-20 hrs. 42-48hrs. SGOT <40 6-12hrs. 24-48 hrs. ≥10days LDH 160 – 410 24hrs. 48-72 hrs. 7-10days
  24. 24. Management • Se e k im m e diate m e dicalatte ntio n
  25. 25. Medical Management • Major goals: – Management of the acute attack – Prevention of complications – Rehabilitation
  26. 26. 1. Management of Acute attack • History • ECG • IV access • Routine blood investigations • Continuous cardiac monitoring • Invasive monitoring
  27. 27. General Measures • Pain control • Aspirin • Clopidogrel • Nitrates • Beta-adrenoreceptor blockers • ACE inhibitors • Bed rest upto 48 hours • Soft diet • Stool softeners
  28. 28. Patients with ischemic type discomfort ECG ST elevation ECG strongly suspicious for ischemia ( ST depression, T wave inversion Non diagnostic ECG Eligible for thrombolytic therapy Thrombolytic therapy contraindicated Admit Initial antiischemic therapy or treat as unstable angina Thrombolytic therapy Primary PTCA Continue evaluation Obtain follow up serum cardiac marker levels ECHO Evidence of ischemic infarction Evidence of ischemic infarctionYes NoInitial reperfusion strategy if ST elevation develops Discharge
  29. 29. Thrombolysis • Streptokinase • Urokinase • Tissue plasminogen activator (t-PA) • Acylated plasminogen streptokinase activator complex (APSAC)
  30. 30. Criteria forthrombolysis in acute MI Indications: • Chest pain • ECG changes • Time from onset of symptoms <6 hrs. : most beneficial 6-12 hrs. : lesser but still important benefits >12 hrs. : diminishing benefits but may still be used in selected patients
  31. 31. Absolute contraindications 1. Active internal bleeding (excluding menses) 2. Suspected aortic dissection 3. Recent head trauma or known intracranial neoplasm 4. Hemorrhagic CVA 5. Major surgery or trauma < 2weeks.
  32. 32. Relative contraindications • BP>180/110mmHg on at least 2 readings • History of hypertension • Active peptic ulcer • History of CVA • Current use of anticoagulants • Prolonged or traumatic CPR • Diabetic hemorrhagic retinopathy • Pregnancy • Prior exposure to STK & APSAC
  33. 33. Protocol followed in ICCU • Aspirin 150-325mg chewed, 75mg daily thereafter • Clopidogrel 300mg stat & 75mg daily • Pain relief – Inj. Morphine 3mg + Inj. Phenergan 12.5mg slow IV – Inj. Pethedine 12.5mg IV in patients with asthma • O2 2-4 lit/min for 2-3 hrs. If saturation <95% continue beyond 3hours. • 2 IV access if the patient is for thrombolysis • Inj.Avil 2cc + Inj. Hydrocortisone 200mg+Inj. Ranitidine 50mg IV • Inj.Streptokinase 1.5million /15 lakhs units in 100ml NS over 1hr. • Inj. Heparin 60 units/kg bolus + 12units/kg/hr.infusion 4 hrs. after STK
  34. 34. • Inj. NTG infusion x 24-48hrs. in LVF, large anti. MI persistent pain • β blockers to all patients unless contraindicated Metoprolol 12.5mg – 25mg BD use carvedilol 3.125mg OD for anti. MI, LVF, previous MI • Statins if LDL >100mg/dL & TGL>150mg/dL • Stool softeners • Hypnotic – Lorazepam 1-2mg HS • NPO till pain relief Liquid diet x 12 hours. Semisolid diet thereafter, low fat,low cholesterol 1500 calories diet. • Pulse,BP ½ hourly till stable then hourly. • ECG 90 min,180 min after starting STK &daily thereafter till transfer out. • Consider IV beta-blockers in young patients with tachycardia,hypertension(Metoprolol 5mg 3 doses at 5min interval.
  35. 35. 2. Prevention of complications a. Dysrhythmias b. Cardiogenic shock c. Heart failure & pulmonary edema d. Pulmonary embolism e. Recurrent MI f. Complications due to necrosis of myocardium g. Pericarditis h. Dressler’s syndrome (late pericarditis)
  36. 36. 3. Rehabilitation Overall goals • Lead a productive life • Remain within the limits of the heart’s ability to respond to increase in activity and stress Sub goals • A programme of progressive physical activity • Health teaching • Help to accept the limitations • Aid the client in adjusting to changes in occupational goal • Change the psychological factors • Reduce risk factors
  37. 37. Phase I (in hospital) • Bed rest for 1 day with liquid diet • When vital signs get stabilized, patient can move in bed • Passive exercises • As strength is regained - sit on the side of the bed and dangle the feet. • Once transferred from CCU self-care activities are encouraged • Brief walks with supervision • Instruct regarding warning signs of over exertion • Client education
  38. 38. Phase II (Intermediate) • If no complications, discharge at the end of one week • Sexual intercourse after 4-8 weeks. • Stop smoking completely • Encourage frequent walks • Avoid strenuous activities • Monitored group programmes • Warm up and stretching exercises • Aspirin daily. • Return to work at the end of 8-9 wks. • Follow up in hospital between 8-9 wks.
  39. 39. Phase – III (Long term) • Periodic evaluation
  40. 40. Interventional Management [PTCA] Percutaneous Transluminal Coronary Angioplasty
  41. 41. Coronary Artery Bypass Graft Surgery [CABG]
  42. 42. Nursing Management • Nursing Diagnosis: – Acute chest pain related to myocardial ischemia resulting from coronary artery occlusion with loss/restriction of blood flow to an area of myocardium and necrosis of the myocardium. – Dysrhythmias related to electrical instability or irritability secondary to ischemic or infracted tissue. – Decreased cardiac output related to negative inotropic changes in the heart secondary to myocardial ischemia, injury or infarction. – Impaired gas exchange related to decreased cardiac output – Powerlessness related to hospital environment and anticipated life style changes – Fear & anxiety related to hospital admission and fear of death – Altered health maintenance related to MI and implications for life style changes.
  43. 43. Thankyou

×