1. The document defines myocardial infarction (MI) or heart attack as the irreversible damage of myocardial tissue caused by prolonged ischemia and hypoxia due to reduced blood flow in a coronary artery from atherosclerosis or blockage. 2. There are 5 types of MIs defined based on their cause. Signs and symptoms include chest pain and other indicators. Diagnosis involves ECG, cardiac marker tests, and other evaluations. 3. Treatment includes both pharmacological interventions like thrombolytics and aspirin as well as surgical procedures like angioplasty, stents and bypass surgery. Nursing management focuses on monitoring for complications, providing education and facilitating cardiac rehabilitation.

1. MYOCARDIAL
INFARCTION
KIRAN NAYYAR

3. INTRODUCTION
Acute myocardial infarction is the medical name for a
heart attack. A heart attack is a life-threatening condition
that occurs when blood flow to the heart muscle is
abruptly cut off, causing tissue damage. This is usually
the result of a blockage in one or more of the coronary
arteries. A blockage can develop due to a build up of
plaque, a substance mostly made of fat, cholesterol, and
cellular waste products.

4. Definition
MI is defined as a diseased condition which is caused by
reduced blood flow in a coronary artery due to atherosclerosis
and occlusion of an artery by an embolus or thrombus. MI or
heart attack is the irreversible damage of myocardial tissue
caused by prolonged ischemia and hypoxia.

6. MI is defined as death of a segment of heart
muscle which follows interruption of its blood
supply.
MI refers to the process by which myocardial
tissue is destroyed in region of the heart that are
deprived of an adequate blood supply because of a
reduced coronary blood flow.

7. TYPES OF MYOCARDIAL
INFARCTION

8. TYPE-1 Spontaneous MI
Type-2: MI secondary to an ischemic imbalance
Type-3: MI resulting in death when Biomarker
values are unavailable
Types-4: MI related to percutaneous coronary
intervention.
Type-5: MI related to CABG.

10. DEGREE OF DAMAGE

11. 1.Zone of
Necrosis
• Death of the heart muscle caused by
extensive and complete oxygen
deprivation, irreversible damage.
1.Zone of
Injury
• Region of the muscle surrounding
the area of necrosis, inflamed and
injury, but still visible if adequate
oxygenation can be restored.
1.Zone of
Ischemia
• Region of the heart
muscle surrounding
the area if injury,
which is ischemic and
viable and endangered
unless extension of
the infarction occurs.

12. CAUSES OF MI

13. High
blood
pressure
High
cholestero
l level,
High
triglyceri
de levels
High
blood
sugar
levels
Obesity

14. Smoking Age Family
history
Stress
Lack of
exercise
History of
preeclamp
sia

15. RISK
FACTORS
1.Non-
Modifiable
Risk Factors
1.Modifiable
Risk Factors

16. Family
history of
CAD
AGE Being
older
GENDER
being male
RACE

17. High
blood lipid
level
Smoking
hypertension
DM,
Obesity
Physical
inactivity
Lack of
estrogen
in women

18. PATHOPHYSIOLOGY

20. SIGN AND SYMPTOMS

22. C- Chest pain
R- Radiating pain chest, left arm, jaw, back
U- Unrelieved pain by rest or nitro-glycerine
S- Sweating
H-Hard to breath
I- Increased or irregular heart rate, increased BP, Indigestion
N- Nausea and Vomiting
G- Going to anxious
Painful condition with tightness, pressure or squeezing pain
in chest – 75% patients experience.

23. DIAGNOSTIC EVALUATION

24. HISTORY
 Patient with MI describe a heaviness, squeezing, choking or
something sensation.
 Patients often describe the sensation as “something sitting on
my chest”.
 The substernal pain can radiate to the neck, left arm, back, or
jaw.
 Associated finding on history include nausea and vomiting,
especially for the patient with an inferior wall MI.
PHYSICAL EXAMINATION

25. ECG: An ECG can be used to detect pattens of ischemia,
injury and infraction.
ECG changes
 ST segment elevation
 T wave inversion
 Appearance of wide deep Q waves

26. CARDIAC MARKERS
 CK-MB appears in the serum in 6 to 12 hours, peaks between
12 to 28 hours, and return to normal level in about 72 to 96
hours. Serial sampling are performed every 4 to 6 hours for the
first 24 to 24 hours after the onset of symptoms.
 Creatine Kinase Isoforms CK-MB1 is the isoforms found in
the plasma, and CK-MB2 is found in the tissues. In the patient
with an MI, the CK-MB2 level rises, resulting in a CK-MB2 to
CK-MB1 ratio greater than one.

27.  Myoglobin is an oxygen binding protein found in skeletal
and cardiac muscle. Myoglobin’s release from ischemic
muscle occurs earlier than the release of CK. The
myoglobin level can elevate within 1 to 2 hours of acute
MI and peaks within 3 to 15 hours. Because myoglobin
present in skeletal muscle, an elevated myoglobin level is
not specific for the diagnosis of MI.
 Troponin (troponin T and Troponin I) Troponin I level
rise in about 3 hours, peak at 14 to 18 hours and remain
elevated for 5 to 7 days. Troponin T level rise in 3 to 5
hours and remain elevated for 10 to 14 days.

28. MRI
Angiography
Chest X- ray

29. MANAGEMENT

30. Non-pharmacological
management
Medical management
Surgical management
Nursing management

32. 1. Oxygen therapy: Administered oxygen 3 litres by nasal cannula.
Oxygen therapy improves oxygenation to ischemic heart muscle or
improves myocardial oxygen supply.
2. Thrombolytic agent: agents such as urokinase, streptokinase and tissue
plasminogen activators are used to dissolve clots and allows blood flow
to the myocardium, administered IV.
3. Analgesic Therapy: Morphine is used to relieve pain
4. Vasodilators Therapy: Nitroglycrine
5. Angiotensin- Converting Enzymes Inhibitors: Captopril, enalapril.
6. Beta- Adrenergic Blocking Agents: Propenolol.
7. Calcium- Channel Blockers: Nifedipine.
8. Anticoagulant therapy: Heparin.

33. SURGICAL
MANAGEMENT

34.  Coronary artery bypass surgery
 Percutaneous Transluminal Coronary Angioplasty
 Coronary stent
 Atherectomy
 Transmyocardial laser revascularization

35. Percutaneous Transluminal Coronary Angioplasty (PTCA)
Percutaneous coronary angiography is minimal invasive procedure
blocked coronary arteries.
PURPOSE
The purpose of PTCA is to improve blood flow within a coronary
artery by compressing and cracking the atheroma.

36. PROCEDURE
 Hollow the catheter sheaths are inserted, usually in the
femoral artery, providing a conduit for the other catheters.
 The catheters are threaded through the femoral artery, up
through the aorta and into the coronary arteries.
 Angioplasty is performed using infected radiopaque
contrast agent to identify the location and extent of
blockage.
 A billion tipped catheter is passed through the sheath and
position over lesion.
 After insertion, the catheter is inflated with high pressure
of several second and then deflated.
 The pressure compresses and then cracks the atheroma.

37. CORONARY ARTERY STENT
A stent is a metal mesh placed in the coronary arteries that supply blood
to the heart to keep the arteries open in the treatment of coronary heart
disease. A stent reduce chest pain and improve the survivability in the
event of an acute myocardial infarction. Some stent are coated with
medications such as paclitaxel, which minimize the for plaque formation
of thrombus or scar tissue within the stent.
ATHERECTOMY
Atherectomy is an invasive interventional procedure that involves the
removal of the atheroma or plaque from a coronary artery by cutting,
shaving or grinding. It may be used in conjunction PTCA. Directional
atherectomy involves the use of catheter that remove the lesions and its
fragments.

38. POST PROCEDURE CARE
The nurses have to obtain a comprehensive report that include,
medication during the procedure, stent placed and their location, time of
last heparin dose. No of sticks required to place the sheath.
 Assessment of the sheath site for any bleeding
 Check the vital sign, site assessment and pedal pulse checks every 5
minutes until the sheath is removed.
 Elevate the head of the bed at 30 degree. If bleeding occur or any
presence of hematoma then lie the patient flat.
 Sterile gloves and mask to be worn during procedure.
 Fluid therapy during the procedure.

39. CORONARY ARTERY REVASCULARIZATION
CABG is a surgical procedure in which a blood vessel is grafted to an
occluded coronary artery so blood can flow beyond the occlusion.
A blood vessel commonly used for CABG is the greater saphenous
vein. Cephalic and basilica veins are also used. The vein is move from
the leg and grafted to ascending aorta and to coronary artery distal to
the lesion. Arterial graft are preferred over veins for CABG because
they do not develop atherosclerosis changes as quickly and remain
potent longer.

40. INDICATIONS
 Alleviation of angina that cannot be control with medications or
PCO.
 Treatment of left main coronary artery stenosis or multi vessel
CAD.
 Prevention and treatment of MI, dysrhythmias or heart failure.
 Treatment for complication from an unsuccessful PCI

41. TREATMENT ALGORITHM FOR MI

43. NURSING MANAGEMENT

44. 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

45. NURSING DIAGNOSIS
 Acute pain related to myocardial ischemia and decreased
myocardial oxygen supply.
 Decreased cardiac output related to decreased cardiac
contractility.
 Activity intolerance related to fatigue secondary to
insufficient oxygenation as evidenced by shortness of
breath, weakness.
 Anxiety related to chest pain, fear of death, threatening
environment.
 Knowledge deficit related to disease process, medications,
home activities.

46.  CARDIAC REHABILITATION
 Cardiac rehabilitation does not change your past, but it can help you improve your
heart’s future.
 Cardiac rehabilitation is a medically supervised program designed to improve your
cardiovascular health if you have experienced heart attack, heart failure, angioplasty or
heart surgery. Cardiac rehabilitation has three equally important parts:
 Exercise counselling and training: Exercise gets your heart pumping and entire
cardiovascular system working. Patient will learn how to get the body moving in ways
that promote heart heath.
 Education for heart-healthy living: A key element of cardiac rehab is educating:-
How can you manage your risk factors? Quit smoking? Make heart- healthy nutrition
choices?
 Counselling to reduce stress: Stress hurts yours heart. This part of cardiac rehab helps
you identify and tackle everyday sources of stress.

47. PHASES OF CARDIAC REHABILITATION
Phase I in hospital (3-5 days)
Phase II post discharge (2-6 weeks)
Phase III outpatient programme (6-12 weeks)
Phase IV long term maintenance in community

48. In Phase I: Acute MI, CABG, unstable heart failure.
 First 24-48 hours- breathing exercises.
 Simple arm and leg ROM exercises
 Limited self-care activities
 Over the next 2-3 days- sit out of bed
 Take short walks.
 Shower

49. In Phase II: By discharge patient should know sign and
symptoms of excessive exertion and rate level of exertion.
 Home exercise programme for first 6 weeks, mostly
walking.
 Contact and telephonic follow-ups with rehabilitation
services
In Phase III: Patient should be seen by physician or
cardiologist before exercising. Patient safety during
exercising very important. Assessment of heart rate and
BP at rest and during exercising, etc.
In Phase IV: Patient must be able to manage himself
regarding exercise. Community based instruction.

50. BIBLIOGRAPHY
 Brunner & Suddarth’s, “textbook of medical surgical nursing” 11th edition, published by
lippincort, page no. 1602-1617.
 Lemone Priscilla “medical surgical nursing” 4th edition, published by pearson, page no. 600-620.
 Ansari Javed “a textbook of medical surgical nursing-1” PV published, page no. 869-883.
 http://www.scribed.com
 http://en.m.wikipedia.com
 http://nurseslabs.com
 http://www.healthxchange.sg.com
 https://www.healthline.com/health/acute-myocardial-infarction#risk-factors
 https://nurseslabs.com/myocardial-infarction/

51. SUMMARY
Today we have done:-

52. RECAPULIZATION
Define MI?
Explain the risk factor of MI?
Describe the nursing management of MI?

53. ASSIGNMENT
Explain the management of patient first 48 hours after MI?