nursing perspective of myocardial infarction

1. MYOCARDIAL INFARCTION
ASRAF HUSSAIN
MBBS,MD
DM RESIDENT (CARDIOLOGY)

2. "Nurses are the heart of healthcare." –
Donna Wilk Cardillo

3. Agenda
• MYOCARDIAL INFARCTION- DEFINITION/CLASSIFICATION
• DIAGNOSIS
• PREVENTION
• MANAGEMENT OF ACUTE MI
• LONG TERM THERAPY
• NURSING PERSPECTIVES
• QUESTION/ANSWER
• QUIZ

4. • Myocardial infarction (MI), refers to tissue death (infarction) of the heart muscle
(myocardium) caused by ischemia, the lack of oxygen delivery to myocardial
tissue.
• It is a type of acute coronary syndrome, which describes symptoms related to
blood flow to the heart.
• The spectrum of ACS includes unstable angina, non-ST-segment elevation MI,
and ST-segment elevation MI.
• Unlike the other type of acute coronary syndrome, unstable angina, a
myocardial infarction occurs when there is cell death, which can be estimated by
measuring by a blood test for biomarkers (the cardiac protein troponin).
• When there is evidence of an MI, it may be classified as an ST elevation
myocardial infarction (STEMI) or Non-ST elevation myocardial infarction (NSTEMI)
based on the results of an ECG.

6. Classification
• MI can be sub categorized by anatomy and clinical diagnostic
information.
• Anatomic
• -Transmural.
• -Sub endocardial.
• Diagonostic
• -ST elavations (STEMI)
• -Non ST elavations (NSTEMI)

7. Fourth universal definition of MI

9. • “Time is muscle”; this is the reflection of the urgency of appropriate
treatments to improve patient outcome.
• Each year in the United States, nearly 1 million people have acute
MIs.
• One fourth of the people with the disease die of MI.
• Half of the people who die with acute MI never reach the hospital.

10. Mechanism and causes
• Most frequent cause is rupture of athero sclerotic lesion within coronary wall
with subsequent spasm and thrombus formation
• Coronary artery vasospasm
• Ventricular hypertrophy
• Hypoxia
• Coronary artery emboli
• Cocaine
• Coronary anomalies
• Aortic dissection
• Pediatrics Kawasaki disease, Takayasu arteritis
• Increased myocardial demand

11. Diffrential diagnosis

12. Intrathoracic Sources
• Heart - ACS, stable angina, pericarditis, myocarditis, pericardial
effusion/tamponade, valvular disease, coronary dissection, coronary
spasm, endocarditis
• Aorta - aortic dissection, aortic aneurysm
• Lungs - pulmonary embolism, pneumothorax, pneumonia,
pleurisy/pleuritis, foreign body aspiration, asthma, COPD
• Chest wall - contusion, costochondritis, rib fracture

13. Extraathoracic causes
• Abdominal source - cholecystitis, hepatitis, gastritis, peptic ulcer
disease, pancreatitis, nephrolithiasis
• Skin - herpes zoster
• Psychiatric - anxiety, panic attack, stress reaction
• Toxidrome - sympathomimetic use, cocaine

14. 4-2-1 rule
• 4 heart related: ACS, aortic dissection, pericarditis/myocarditis,
pericardial effusion/tamponade
• 2 lung related: PE and pneumothorax
• 1 esophageal related : esophageal perforation.
• Remembering the 4-2-1 rule will help you consider the main
intrathoracic chest pain emergencies in each patient.

17. Signs and symptoms
• Chest pain - described as a sensation of tightness, pressure, or
squeezing. Pain radiates most often to the left arm, but may also
radiate to the lower jaw, neck, right arm, back, and upper abdomen.
• The pain associated with MI is usually diffuse, does not change with
position, and lasts for more than 20 minutes
• Levine's sign, in which a person localizes the chest pain by clenching
one or both fists over their sternum
• Typically, chest pain because of ischemia, be it unstable angina or
myocardial infarction, lessens with the use of nitroglycerin, but
nitroglycerin may also relieve chest pain arising from non-cardiac
causes

18. • Sweating, nausea or vomiting, and fainting. Dizziness or
lightheadedness
• In women, the most common symptoms of myocardial infarction
include shortness of breath, weakness, and fatigue
• Shortness of breath , weakness, palpitations, and abnormalities
in heart rate or blood pressure
• Loss of consciousness , cardiogenic shock, and sudden death

19. • "Silent" myocardial infarctions can happen without any symptoms at
all.
• More common in the elderly, females, in those with diabetes
mellitus and after heart transplantation.

20. Prevention
• Primary prevention (To prevent a myocardial infarction )
• Lifestyle
• 150 minutes of moderate or 75 minutes of vigorous intensity aerobic exercise a
week. Keeping a healthy weight, drinking alcohol within the recommended limits,
and quitting smoking
• Dietary modifications: reducing unhealthy diets (excessive salt, saturated fat, and trans-
fat)
• Blood pressure, body mass index and waist circumference check and balance
• Medication
• Statins
• Aspirin
• Antidaibetics
• Antihypertensives

21. • Secondary prevention(after first episode of MI)
• Smoking cessation, exercise, healthy diet, low in saturated fat and low
in cholesterol, drinking alcohol within recommended limits, healthy weight.
Exercise is recommended to start gradually after 1–2 weeks.
• Medications
• Aspirin is continued indefinitely, as well as another antiplatelet agent such
as clopidogrel or ticagrelor ("dual antiplatelet therapy" or DAPT) for up to
twelve months
• Beta blocker such as metoprolol or carvedilol is recommended to be
started within 24 hours, provided there is no acute heart failure or heart
block.

22. • ACE inhibitor therapy should be started within 24 hours and
continued indefinitely at the highest tolerated dose. Those who
cannot tolerate ACE inhibitors may be treated with an angiotensin II
receptor antagonist.
• Statin therapy
• Aldosterone antagonists (spironolactone or eplerenone) may be used
if there is evidence of left ventricular dysfunction after an MI, ideally
after beginning treatment with an ACE inhibitor
• A defibrillator, an electric device connected to the heart and surgically
inserted under

23. Assessment and diagnostic findings
• Patient history. The patient history includes the description of the
presenting symptoms, the history of previous cardiac and other
illnesses, and the family history of heart diseases.
• ECG. ST elevation signifying ischemia; peaked upright or inverted T
wave indicating injury; development of Q waves signifying prolonged
ischemia or necrosis.
• Cardiac enzymes and isoenzymes. CPK-MB, LDH, Troponins. Troponin
I (cTnI) and troponin T (cTnT), Myoglobin

30. • Findings suggestive of NSTEMI include transient ST elevation, ST
depression, or new T wave inversions.
• ECG should be repeated at predetermined intervals or if symptoms
return.
• Cardiac troponin is the cardiac biomarker of choice.

32. • Chest x-ray. May be normal or show an enlarged cardiac shadow
suggestive of HF or ventricular aneurysm.
• Two-dimensional echocardiogram.
• Nuclear imaging studies: Persantine or Thallium. Evaluates
myocardial blood flow and status of myocardial cells, e.g.,
location/extent of acute/previous MI.
• Cardiac blood imaging/MUGA. Evaluates specific and general
ventricular performance, regional wall motion, and ejection fraction.
• Technetium. Accumulates in ischemic cells, outlining necrotic area(s).

33. • Electrolytes. Imbalances of sodium and potassium can alter conduction
and compromise contractility.
• WBC. Leukocytosis (10,000–20,000) usually appears on the second day
after MI because of the inflammatory process.
• ESR. Rises on second or third day after MI, indicating inflammatory
response.
• Chemistry profiles. May be abnormal, depending on acute/chronic
abnormal organ function/perfusion.
• ABGs/pulse oximetry. May indicate hypoxia or acute/chronic lung disease
processes.
• Lipids (total lipids, HDL, LDL, VLDL, total cholesterol, triglycerides,
phospholipids). Elevations may reflect arteriosclerosis as a cause for
coronary narrowing or spasm.

34. • Coronary angiography. Visualizes narrowing/occlusion of coronary
arteries
• Digital subtraction angiography (DSA). Technique used to visualize
status of arterial bypass grafts and to detect peripheral artery disease.
• Magnetic resonance imaging (MRI). Allows visualization of blood
flow, cardiac chambers or intraventricular septum, valves, vascular
lesions, plaque formations, areas of necrosis/infarction, and blood
clots.
• Exercise stress test. Determines cardiovascular response to activity
(often done in conjunction with thallium imaging in the recovery
phase).

35. Management
• Treatment aims to preserve as much heart muscle as possible, and to
prevent further complications.
• Treatment depends on whether the myocardial infarction is a STEMI or
NSTEMI.
• Treatment in general aims to unblock blood vessels, reduce blood clot
enlargement, reduce ischemia, and modify risk factors with the aim of
preventing future MIs.
• In addition, the main treatment for myocardial infarctions with ECG
evidence of ST elevation (STEMI) include thrombolysis or percutaneous
coronary intervention, although PCI is also ideally conducted within 1–3
days for NSTEMI.

36. • Pain
• Nitroglycerine,Morphine or other opioid medications.
• Antithrombotics
• Aspirin, P2Y12 inhibitors such as clopidogrel, prasugrel and ticagrelor
• Heparins
• inhibitors of the platelet glycoprotein αIIbβ3a receptor such
as eptifibatide or tirofiban

37. • Angiogram
• Primary percutaneous coronary intervention (PCI) is the treatment of
choice for STEMI
• Some recommend it is also done in NSTEMI within 1–3 days,
particularly when considered
• Coronary artery bypass grafting is only considered when the affected
area of heart muscle is large, and PCI is unsuitable, for example with
difficult cardiac anatomy.

38. • Fibrinolysis
• If PCI cannot be performed within 90 to 120 minutes in STEMI then
fibrinolysis, preferably within 30 minutes of arrival to hospital, is
recommended.
• If a person has had symptoms for 12 to 24 hours evidence for effectiveness
of thrombolysis is less and if they have had symptoms for more than 24
hours it is not recommended
• Medications include tissue plasminogen activator, reteplase, streptokinase,
and tenecteplase.
• Thrombolysis is not recommended in situations associated with a active
bleeding, past strokes or bleeds into the brain, or severe hypertension.

39. • Rehabilitation and exercise
• It should start soon after discharge from the hospital.
• The program may include lifestyle advice, exercise, social support, as
well as recommendations about driving, flying, sports participation,
stress management, and sexual intercourse.
• Returning to sexual activity after myocardial infarction is a major
concern for most patients, and is an important area to be discussed in
the provision of holistic care.

40. Prognosis
• Varies greatly depending on the extent and location of the affected heart
muscle, and the development and management of complications.
• Prognosis is worse with older age and social isolation. Anterior infarcts,
persistent ventricular tachycardia or fibrillation, development of heart
blocks, and left ventricular impairment are all associated with poorer
prognosis.
• Without treatment, about a quarter of those affected by MI die within
minutes and about forty percent within the first month.
• In those who have a STEMI in the United States, between 5 and 6 percent
die before leaving the hospital and 7 to 18 percent die within a year.
• It is unusual for babies to experience a myocardial infarction, but when
they do, about half die.

42. Complications

45. Nursing perspectives
• The nursing management involved in MI is critical and systematic, and
efficiency is needed to implement the care for a patient with MI.

47. Assessment
• One of the most important aspects of care of the patient with MI is the
assessment.
• Assess for chest pain not relieved by rest or medications.
• Monitor vital signs, especially the blood pressure and pulse rate.
• Assess for presence of shortness of breath, dyspnea, tachypnea, and crackles.
• Assess for nausea and vomiting.
• Assess for decreased urinary output.
• Assess for the history of illnesses.
• Perform a precise and complete physical assessment to detect complications and
changes in the patient’s status.
• Assess IV sites frequently.

48. • Diagnosis
• Based on the clinical manifestations, history, and diagnostic
assessment data, major nursing diagnoses may include.
• Ineffective cardiac tissue perfusion related to reduced coronary
blood flow.
• Risk for ineffective peripheral tissue perfusion related to decreased
cardiac output from left ventricular dysfunction.
• Deficient knowledge related to post-MI self-care.

49. Planning and goal
• To establish a plan of care, the focus should be on the following:
• Relief of pain or ischemic signs and symptoms.
• Prevention of myocardial damage.
• Absence of respiratory dysfunction.
• Maintenance or attainment of adequate tissue perfusion.
• Reduced anxiety.
• Absence or early detection of complications.
• Chest pain absent/controlled.
• Heart rate/rhythm sufficient to sustain adequate cardiac output/tissue perfusion.
• Achievement of activity level sufficient for basic self-care.
• Anxiety reduced/managed.
• Disease process, treatment plan, and prognosis understood.
• Plan in place to meet needs after discharge.

50. Priorities
• Relieve pain, anxiety.
• Reduce myocardial workload.
• Prevent/detect and assist in treatment of life-threatening
dysrhythmias or complications.
• Promote cardiac health, self-care.

51. Nursing interventions
• Nursing interventions should be anchored on the goals in the nursing care plan.
• Administer oxygen along with medication therapy to assist with relief of
symptoms.
• Encourage bed rest with the back rest elevated to help decrease chest discomfort
and dyspnea.
• Encourage changing of positions frequently to help keep fluid from pooling in the
bases of the lungs.
• Check skin temperature and peripheral pulses frequently to monitor tissue
perfusion.
• Provide information in an honest and supportive manner.
• Monitor the patient closely for changes in cardiac rate and rhythm, heart sounds,
blood pressure, chest pain, respiratory status, urinary output, changes in skin
color, and laboratory values.

52. Evaluation
• After the implementation of the interventions within the time
specified, the nurse should check if:
There is an absence of pain or ischemic signs and symptoms.
Myocardial damage is prevented.
Absence of respiratory dysfunction.
Adequate tissue perfusion maintained.
Anxiety is reduced.

53. Discharge and homecare guidelines
• The most effective way to increase the probability that the patient will
implement a self-care regimen after discharge is to identify the patient’s
priorities.
• Education. This is one of the priorities that the nurse must teach the
patient about heart-healthy living.
• Home care. The home care nurse assists the patient with scheduling and
keeping up with the follow-up appointments and with adhering to the
prescribed cardiac rehabilitation management.
• Follow-up monitoring. The patient may need reminders about follow-up
monitoring including periodic laboratory testing and ECGs, as well as
general health screening.
• Adherence. The nurse should also monitor the patient’s adherence to
dietary restrictions and prescribed medications.

54. Documentation guidelines
• To ensure that every action documented is an action done, documentation
must be secured. The following should be documented:
Individual findings.
Vital signs, cardiac rhythm, presence of dysrhythmias.
Plan of care and those involved in planning.
Teaching plan.
Response to interventions, teaching, and actions performed.
Attainment or progress towards desired outcomes.
Modifications to plan of care.

56. My assessment

58. 1. Which of the following is the most common symptom of
myocardial infarction (MI)?
• A. Chest pain
B. Dyspnea
C. Edema
D. Palpitations

59. 2. An intravenous analgesic frequently administered to relieve chest
pain associated with MI is:
• A. Meperidine hydrochloride
B. Hydromorphone hydrochloride
C. Morphine sulfate
D. Codeine sulfate

60. 3. The classic ECG changes that occur with an MI include all of the
following except:
• A. An absent P wave
B. An abnormal Q wave
C. T-wave inversion
D. ST segment elevation

61. 4. Which of the following statements about myocardial infarction pain
is incorrect?
• A. It is relieved by rest and inactivity.
B. It is substernal in location.
C. It is sudden in onset and prolonged in duration.
D. It is viselike and radiates to the shoulders and arms.

62. 5. Myocardial cell damage can be reflected by high levels of cardiac
enzymes. The cardiac-specific isoenzyme is:
• A. Alkaline phosphatase
B. Creatine kinase (CK-MB)
C. Myoglobin
D. Troponin

63. 6.You're educating a patient about the causes of a myocardial infarction.
Which statement by the patient indicates they misunderstood your teaching
and requires you to re-educate them?
A. Coronary artery dissection can happen spontaneously and occurs
more in men.
B. The most common cause of a myocardial infarction is a coronary
spasm from illicit drug use or hypertension.
C. Patients who have coronary artery disease are at high risk for
developing a myocardial infarction.
D. Both A and B are incorrect.
•1.

64. 7. You note in the patient's chart that the patient recently had a myocardial
infarction due to a blockage in the left coronary artery. You know that which
of the following is true about this type of blockage?*
• A. A blockage in the left coronary artery causes the least amount of
damage to the heart muscle.
• B. Left coronary artery blockages can cause anterior wall death which
affects the left ventricle.
• C. Left coronary artery blockage can cause posterior wall death which
affects the right ventricle.
• D. The left anterior descending artery is least likely to be affected by
coronary artery disease.

65. 8. A patient is 36 hours status post a myocardial infarction. The patient
is starting to complain of chest pain when they lay flat or cough. You
note on auscultation of the heart a grating, harsh sound. What
complication is this patient mostly likely suffering from?
• A. Cardiac dissection
• B. Ventricular septum rupture
• C. Mitral valve prolapse
• D. Pericarditis

66. 9. A patient is complaining of chest pain. You obtain a 12-lead EKG and
see ST elevation in leads II, III, AVF. What area of the heart does this
represent?
• A. Lateral
• B. Septal
• C. Anterior
• D. Inferior

67. 10. On an EKG, the lateral view of the heart is represented with leads?*
• A. V1, V2, V3
• B. II, II, AVF
• C. I, AVL, V5, V6
• D. V1, V2, V6

68. 11. On an EKG, the lateral view of the heart is represented with leads?
• A. V1, V2, V3
• B. II, II, AVF
• C. I, AVL, V5, V6
• D. V1, V2, V6

69. 12. A patient is admitted with chest pain to the ER. The patient has
been in the ER for 5 hours and is being admitted to your unit for
overnight observation. From the options below, what is the most
IMPORTANT information to know about this patient at this time?
• A. Troponin result and when the next troponin level is due to be
collected
• B. Diet status
• C. Last consumption of caffeine
• D. CK result and when the next CK level is due to be collected

70. 13. A patient is complaining of chest pain. On the bedside cardiac monitor you observe pronounce
T-wave inversion. You obtain the patient's vital signs and find the following: Blood pressure 190/98,
HR 110, oxygen saturation 96% on room air, and respiratory rate 20. Select-all-that-apply in regards
to the MOST IMPORTANT nursing interventions you will provide based on the patient’s current
status:
• A. Obtain a 12-lead EKG
• B. Place the patient in supine position
• C. Assess urinary output
• D. Administer Nitroglycerin sublingual as ordered per protocol
• E. Collect cardiac enzymes as ordered per protocol
• F. Encourage patient to cough and deep breath
• G. Administer Morphine IV as ordered per protocol
• H. Place patient on oxygen via nasal cannula
• I. No interventions are needed at this time

71. 14. In regards to the patient in the previous question, after administering the
first dose of Nitroglycerin sublingual the patient's blood pressure is now
68/48. The patient is still having chest pain and T-wave inversion on the
cardiac monitor. What is your next nursing intervention?
• A. Hold further doses of Nitroglycerin and notify the doctor immediately
for further orders.
• B. Administer Morphine IV and place the patient in reverse Trendelenburg
position.
• C. Administer Nitroglycerin and monitor the patient’s blood pressure.
• D. All the options are incorrect.

72. 15. Which of the following EKG changes are abnormal findings that may
indicate ischemia or injury to the cardiac muscle found on a 12-lead
EKG? SELECT-ALL-THAT-APPLY:
• A. Lengthening p-waves
• B. ST-segment elevation
• C. T-wave inversion
• D. Tall t-waves
• E. QT interval narrowing
• F. ST-segment depression

73. • Thank you