1. CORE MEASURES
 Are a standardized set of quality measures identified by the Joint Commission in
association with the Centers for Disease Control, Centers for Medicare and
Medicaid Services,American Hospital Association and the Institute for Healthcare
Improvement, Joint Commission (2014).
 Core Measures are designed to improve overall patient care by using Evidence-Based
Practice to determine appropriate treatments to provide the best outcomes for
patients. Hospitals are held accountable by measuring their performance in these
core measure areas, Joint Commission (2014).
 According to the CDC, 715,000 Americans have heart attacks every year and heart
disease is the leading cause of death in the United States CDC (2014).
 MI can cause irreversible damage to the heart or sudden death and the odds of
surviving increase if clinician follow the time sensitive clinical guidelines outlines in
the core measures AHA (2014).

2. DISEASE PROCESS
 MI is caused by the slow but insidious buildup of plaque in the arteries over time.This
plaque can rupture and cause ischemia and infarction of the heart muscle.This leads to
cell death and necrosis of the affected tissue.The severity of the MI depends on which
vessel was occluded and the size of the infarct. Hyperglycemia may be present for the first
72 hours after MI and must be well controlled. It is associated with a high risk of death
Huether and McCance (2012).
 Incidence: the prevalence of MI is much higher in males and increases with age CDC
(2014).
 Risk factors: Diabetes, obesity, poor diet, physical inactivity and excessive alcohol use
CDC (2014).
 Healthcare cost: 108.9 Billion dollars for healthcare services, medications and lost
productivity CDC (2014).
 Morbidity and mortality: 715,000 American have a MI each year. For 525,000 this will be
their first heart attack. 190,000 will have already suffered a MI in the past. Heart disease
accounts for one out of every four deaths that occur CDC (2014).

3. ASSESSMENT OF PATIENTS WITH MI
 Patients with acute MI generally present with the onset of sudden severe
chest pain and may be accompanied by a sensation of pressure. Pain may also
be noted in the jaw, neck, back, shoulder or radiating down the left arm.
According to the American Heart Association, women may not experience
chest pressure but report vague symptoms such as dizziness, shortness of
breath, fatigue, upper abdominal pain or flu like symptoms. Some patients do
not experience any pain AHA (2014). Heart rate and blood pressure reading
may be elevated. The clinician may hear abnormal heart sounds, inspiratory
crackles and they may be diaphoretic with cool clammy skin. Nausea and
vomiting may also be present Huether and McCance (2012).
 Relevant medical history may include family history of heart disease, prior
history of CAD, hypertension, diabetes, current medications, dietary habits,
smoking, exercise habits, stress level and hyperlipidemia.

4. DIAGNOSTIC TESTS FOR MI
 Electrocardiogram to evaluate ST segment and presence of LBBB. ST depression
are signs of subendocardial ischemia and ST elevation is indicative of Transmural
infarction.The test also identifies the coronary artery that is involved
(Huether&McCance P.608)
 Serial biomarkers (troponin and troponinT) if serologic test show high levels
(troponin 1 >10 orT > 0.1) is indicative of acute myocardial infarction(Troponin test,
2012).
 CK-MB and LDH are less specific and may indicate other conditions.

5.  Asymptomatic individuals can go through stress testing, Radioisotope Thallium-201 or Stress echocardiography to
detect any coronary obstruction.
 Noninvasive coronary angiography using computed tomography, intravascular ultrasound and protein weighted magnetic
resonance imaging to evaluate coronary atherosclerotic(Huether&McCance P.602)
 Coronary angiography is invasive and used to determine the extent of CAD and whether percutaneous coronary
intervention (Angioplasty or Stent placement) or coronary artery bypass is needed.
 Another tool, the PhysicianTIMI Score can be used to determine mortality for patients with unstable angina and non-ST
elevation MI, using a scoring system based on:
Historical
 Age of patient
 >3 CAD risk factors
 Known CAD
 Use of ASA in the past 7 days
Presentation
 Presence of severe angina in less than 24hrs
 Elevated bio markers/ST deviation>0.5mm

6. TREATMENT MODALITIES
 ASA 162-325mg unless self administered
 EKG within 10 minutes of ER arrival
 Continuous Cardiac monitoring and vital signs
 IV access and use of MONA
 Repeat EKG every 10-30 minutes if symptoms continue with non
diagnostic ekg.
www.hcbi.hlm.nih.gov/pmc/articles

7. MEDICATION MANAGEMENT
 Vasodilators-Nitrogycerine, beta blockers
 Statins- Simvastatin, pravastin
 Anti-thrombolytics- unfractioned heparin,low molecular heparin
 Anti-platelets- plavix,ASA, Iib/IIIa glycoprotein inhibitor i.e ReoPro, Integrillin,
Aggrastat
 Analgesics-Morphine
 Stool Softeners- Colace

8. PROGNOSIS
 MI leading cause of sudden death
 Time is muscle(PCI <90 minutes)
 Irreversible heart muscle damage (CABG)
 Disturbance of cardiac rhythm
 Organic brain syndrome impaired blood flow
 Stroke secondary to detached clots
 Infection
(Huether&McCance p.609)

9. MYOCARDIAL INFARCTION
Prevention begins with Understanding risk factors

10. PATIENT TEACHING GUIDE POST MI
Patient teaching starts with understanding the learning style of each patient and
family.Teaching starts with the CCU nurse but needs to maintain
consistency as it is taught by the staff nurses, and home health nurses within
the care-planning, setting goals and objectives that are realistic.
Preparing the patient and family for “what to expect” in the course of recovery
and rehabilitation.This would also include cardiovascular anatomy and
physiology, s/s of Angina and MI, and further tests i.e. EKGs, angiograms.
 Parameters for activity including sexual activity , maximum heart rate, and to
stop when pain or shortness of breath occur.
 Patient should “listen to what the body is saying” to prevent overexertion
to have an uncomplicated recovery.
 Teach about cardiac diet i.e. low salt, and salt substitutes
Dirksen, Lewis Heitkemper

11. MI AS A CORE MEASURE
 Myocardial Infarction has evidence based practices (EBPs) that have been proven to increase
patient recovery time and survival rates.The Joint Commission (JC) has set these EBPs in the
Core Measures for Quality Care as a “starting point“ for improving patient outcomes
 Physician and Nursing staff will have an increased awareness of these EBPs when using the
Core Measures for Quality Care guidelines and this will increase their ability to provide
structured care that has demonstrated to improve patient outcomes.
 Aspirin at Arrival
 Aspirin Prescribed at Discharge
 ACE Inhibitor or Angiotensin Receptor Blocker
 (ARB) for LeftVentricular Systolic Dysfunction
 Adult Smoking Cessation Advice/Counseling
 Beta-Blocker Prescribed at Discharge
 Beta-Blocker at Arrival
 Fibrinolytic Therapy Received within 30 Minutes of Hospital Arrival
 Primary Percutaneous Coronary Intervention (PCI) within 90 Minutes of Hospital Arrival
 AMI 30-day Mortality Stellaris Health

12. NURSING ROLE
 Initially it is the nurses role to quickly recognize the signs and symptoms of an MI and call for
emergency assistance (Code Blue)
 Provide the appropriate immediate interventions: IV access x 2, oxygen, nitroglycerin, aspirin,
and morphine if no relief provided.
 Obtain cardiac enzyme markers, electrolytes, and chest x-ray
 Obtain a 12 lead EKG to determine if it is a STEMI: complete occlusion of a coronary vessel
characterized by elevation of the ST segment- this establishes the “door to balloon time” need
for Cardiac catheterization (PCI) the window is 90 minutes.
 Delay in PCI related to rural settings with no Cath Lab available, patients may be treated with
fibrinolytics within 30 minutes, such as tenecteplase,streptokinase,Activase or Retevase.
Administration of these drugs, limits the progression of the MI by dissolving the thrombus in
the coronary artery and restoring blood flow to the ischemic myocardium. Good medical
history needed prior to using.
 NSTEMI: incomplete occlusion of a coronary vessel and no ST-segment elevation- monitoring
and pharmacological interventions.
https://www.nursece.com/courses/80

13. NURSING ROLES
CONTINUED
 Continuous cardiac monitoring, note any changes in cardiac function, pain,
oxygenation, and respiratory distress
 Monitor patients treated with heparin or lovenox , and thrombolytics for bleeding
 Monitor patients for coronary reocclusion, symptoms such as chest pain, nausea,
diaphoresis, and ST segment elevation usually are similar to those experienced with
the original MI, and can occur within the first 24 hours following thrombolytic
therapy.
 Heart failure occurs when myocardial tissue is damaged and the ventricle no longer
works as an efficient pump, heart failure can rapidly decline into cardiogenic shock
and occurs when 40% or more of the myocardium has been affected by the
infarction.
 Reevaluate patients before during and after interventions to determine
if symptoms have become worse, remained the same or improved partially
or completely, this provides a guide on what treatments have worked and
what ones have not and can help with identifying improvements or
worsening of patient conditions and need for further interventions.
https://www.nursece.com/courses/80

14.  Core measures benefit both the patient and the
health care facility.
 Since the MI core measure is standardized,
hospitals are able to evaluate how well they are
caring for patients based on Scientific and
Evidenced Based Practice.
 Patients also can benefit by reviewing how well a
healthcare facility is practicing based on EBP.
 The end goal is to provide best patient outcomes
and reduce readmissions.
CONCLUSION
Georgia Regents medical center

15.  About Heart Attacks (2013, January 13). Retrieved February 26, 2014, fromThe American Heart Association:
http://www.heart.org/HEARTORG/Conditions/HeartAttack/AboutHeartAttacks/About-Heart-Attacks_UCM_002038_Article.jsp
 America’s Heart Disease Burden Retrieved February 26, 2014 From Centers for Disease Control and
Prevention: http://www.cdc.gov/heartdisease/facts.htm
 Cheryl Duksta, RN,ADN, M.Ed , JacquelynYounker, RN, MSN (2012). STEMI Alert! Rapid Response to Myocardial Infarction.
National Center of Continuing Education, Inc., Lakeway,Texas. Retrieved from https://www.nursece.com/courses/80
 Hospital core quality measures. (n.d.). Retrieved March 02, 2014, from GRHealth: http://www.grhealth.org/how-we-
compare/ContentPage.aspx?nd=2799
 Huether, S. E., & McCance, K. L. (2012). Understanding Pathophysiology. St. Louis: Elsevier Mosby.
 Joint Commission Core Measures Sets (2014, March 5). Retrieved February 26, 2014, from The Joint
Commission: http://www.jointcommission.org/core_measure_sets.aspx
 Lewis, S.M., Heitkemper, M.M., & Dirksen, S.R. (2000). Medical Surgical Nursing (5th ed.). St. Louis, Mo.: Mosby , Inc.
 Montana cardiac initiative. (2013,August 15). Retrieved from Montana.Gov: http://cardiac.mt.gov/
 Stellaris-Core-Measure-Education-Templete- August-2012. Retrieved 2/28/14 from: https://www.wphospital.org/.../SHN-Core-
Measure-Education.aspx
 Troponin test. (2012, January 11). Retrieved from Medline plus: http://www.nlm.nih.gov/medlineplus/ency/article/007452.htm
 Understand your risk of heart attack. (2014, February 4). Retrieved February 27, 2014, from American heart association:
http://www.heart.org/HEARTORG/Conditions/HeartAttack/UnderstandYourRiskofHeartAttack/Understand-Your-Risk-of-Heart-
Attack_UCM_002040_Article.jsp
REFERENCES