A 55-year-old male smoker and alcoholic presented with chest pain and was diagnosed with a myocardial infarction based on electrocardiogram and cardiac enzyme changes. He received treatment including aspirin, nitroglycerin, morphine, and streptokinase thrombolysis and was admitted to the intensive care unit. Nursing care focused on monitoring, providing pain relief, and health teaching prior to discharge.

2. •CASE PRESENTATION
•ACUTE MYOCARDIAL INFARCTION
•Definition
•Etiology
•Pathophysiology
•Clinical features
•Diagnosis
•Management
•Complication
•Nursing care

3. Case :
55 yr/M
alcoholic and smoker
Presented with: pain in Left side of chest since 5 am
radiating to lt. shoulder and back

4. O/E GCS fair
P-76
BP 130/84
S/E : WNL
Inv: Hb- 12.9 TLC-6700
BLOOD SUGAR Random 146
Urine normal
Urea-25
Creatinine -0.9
CKMB 28
Trop T - negative
ECG:
Chest x ray: WNL
Pt was prescribed tab. Pantocid and syp Digene
And was send for TMT from ECHS empanelled hospital

5. At around 5 pm the same evening he came back with
severe chest pain following TMT
2 episodes of vomiting
excessive sweating
and TMT positive for provocation
Pt was admitted to ICU and was investigated:
pulse : 97
BP: 110/72mm hg
resp:26
Chest : B/L basal crepts +
CVS
CNS WNL
P/A

6. Inv: Trop T : positive
CKMB : 98 ---- 110 next morning
SGOT : 140
SGPT: 72
ECG: Q waves in lead 2, 3, aVf, V1- V2

7. Management
Inj LMWH : 1 mg / kg SC BD
Inj NTG infusion : 5 mcg/ min till pain free
Atorvastatin : 40 mg stat and OD
Clopidogrel : 75 mg BD
Ecosprin 1 stat and OD
Beta blocker: Metaprolol : 12.5 mg BD
Thrombolysed using Streptokinase

8. DIAGNOSIS:

9. Myocardial Infarction

10. DEFINITION:-
Myocardial Infarction ,
Commonly known as HEART ATTACK
is the rapid development of myocardial necrosis by a
critical imbalance between oxygen supply and demand
to the myocardium

11. Classification
• Acute coronary syndromes include
ST-elevation MI (STEMI)
Non ST-elevation MI ( NSTEMI)
Unstable Angina

12. Classification
• Anatomic or morphologic
Transmural= Full thickness
Non-transmural= Partial thickness
• ECG
Q wave MI
Non Q wave MI
Does not distinguish transmural from a non-
transmural MI as determined by pathology

13. Risk Factors
• Smoking
• Family history
• Hypertension
• Diabetes mellitus
• Elevated triglycerides and cholesterol levels
• Obesity
• Sedentary lifestyle
• Aging
• Stress
• Men more than women (but women are increasing)

14. Causes
• Athrosclerosis (90%)
• Constriction or spasm of the coronary artery
• Coronary artery embolus
• Coronary artery thrombus

15. Pathophysiology
• 90% - coronary artery thrombosis
• 10% - vasospasm
• Irreversible cell death occurs within 20-40
minutes of cessation of blood flow
• Wavefront of cellular death proceeds from
endocardium to epicardium

16. FIGURE 25-1 Determinants of myocardial oxygen supply and
demand.

17. Pathophysiology
• Wavefront produces zones
– Zone of necrosis
– Zone of injury
– Zone of ischemia
• Amount of damage/necrosis depends on
duration of occlusion, which artery is blocked,
degree of collateral blood flow

18. Zones of Ischemia Injury and Infarction with
Transmural and Subendocardial Infarction

19. Clinical Presentation
• Chest pain
• Associated signs/symptoms
• Physical examination

20. Clinical Presentation
Chest pain
• Approximately 80% experience chest pain
• Pain is similar to angina, but usually more
severe, lasting greater than 30 minutes, not
relieved by NTG or rest

21. Rough diagram of pain zones
(Dark red = most typical (light red = other possible area)
area)

22. Clinical Presentation
Associated Symptoms/Signs
• Nausea/Vomiting – irritation to
diaphragm/vagal stimulation
• Profound weakness, cold perspiration, sense
of doom
• Dizziness
• Palpitations
• Dyspnea

23. Physical Examination
• Anxious, restless
• Skin may be cool, clammy, pale
• HR – Tachy or Brady
• Pulse changes – Decreased
quality, irregularities
• Blood pressure – Elevated or Lowered
• Heart sounds – S3, S4, Systolic
murmur, pericardial friction rub
• Signs of LV dysfunction –
congestion, peripheral hypoperfusion

24. Diagnostic ECG
• 12 lead ECG over several days shows changes
in 75% of patients
• Initially only 24-60% present with changes
• Diagnosis may be difficult with previous
infarctions

26. Diagnosis: ECG
• Zone of Ischemia
– T wave inversion
– T wave inverts in leads facing ischemic zone and
are upright in leads on opposite side of the heart
– Usually symmetrical shape

27. Diagnosis: ECG
• Zone of Injury
– ST segment elevation
– ST segment elevation seen in leads facing
injury zone
– ST segment depression in opposite leads
– Elevation is 1mm or greater in two contiguous
leads
– ST elevation in multiple leads is suggestive of
pericarditis

28. Diagnosis: ECG
• Zone of Infarction – Q waves
– Dead tissue does not depolarize
– Q wave criteria
• >0.03 seconds wide
• Depth is at least 25% height of total QRS

29. Acute MI: ECG Changes

30. Diagnosis
• Progression of ECG changes in typical
Q wave MI
– ST segment elevation is usually seen first
– T wave inversion occurs within hours and
may be present for months to life
– Q wave appears within hours. Usually
permanently

31. Evolution of Myocardial Infarction
Lead
V1
Normal ST Segment T Wave Q Wave Old MI
Elevation Inversion Development
(minutes to hours) (hours) (hours to days)
II
Normal ST Segment T Wave Q Wave Old MI
Elevation Inversion Development
(minutes to hours) (hours) (hours to days)

33. Region Leads
Inferior wall II , III , aVF
Anterior wall V2 – V5
Lateral wall I , aVL , V6
Posterior wall V1
Rt. Ventricular V1R – V6R

34. Anatomical Leads
L
A
I L

35. Acute Anterior MI

36. Acute Inferior MI

37. Acute Posterior MI

38. Cardiac Biomarkers
• AMI damages cell membranes, releasing
chemicals into plasma within 30-60 minutes
• The height and duration of these changes
usually correlates with the size of AMI if
allowed to run full course

39. Diagnosis:
Cardiac Biomarkers
• Traditional biomarkers
• CK (CPK) – creatinine phosphokinase
– Composed of 3 isoenzymes: MB, MM, BB
– CK-MB is very sensitive to myocardial injury

40. Diagnosis:
Cardiac Biomarkers
• Traditional biomarkers
• LDH – lactic dehydrogenase
– Consists of 5 isoenzymes; LDH 1 being most
reliable for myocardial damage
– Increase in LDH 1 occurs after CK elevation

41. Diagnosis:
Cardiac Biomarkers
• Newer biochemical markers
• Myoglobin
– Found in both heart and skeletal muscles; rises
within 2 hours, not specific to exclude skeletal
damage
• Troponin
– Structural protein only found in cardiac muscle
– Negative if 0 - .6mg/ml; positive if 1.5ng/ml or
greater

42. Acute MI: Serum Markers
First Peak Duration
Detectable
Troponin I 2-4 hrs 10-24 hrs 5-10 days
Troponin T 2-4 hrs 10-24 hrs 5-14 days
CK-MB 3-4 hrs 10-24 hrs 2-4 days

43. Acute MI: Serum Markers

44. Chest X-Ray
• Chest radiography may provide clues to an
alternative diagnosis ( aortic dissection or
pneumothorax)
• Chest radiography also reveals complications
of myocardial infarction such as heart failure

45. MANAGEMENT:-

46. Collaborative Management
Goals of Therapy
• Re-establish supply and demand balance
• Limit infarction size
• Relieve pain
• Prevent/treat complications
• Identify and manage risk factors

47. Initial Management in ED
• Initial evaluation with 12-lead ECG in < 10 minutes
• BP, HR monitoring
• IV access
• Draw blood for serum cardiac markers magnesium,
hematology, lipid profile panel

48. Acute Therapies
• Recommended in first 10 minutes of AMI
(“MONA”)
–Oxygen
–Nitroglycerin
–Aspirin
– Morphine

49. Oxygen
• 4-6 liters per nasal cannula to maintain oxygen
saturation >90%

50. Aspirin
• Action
– Inhibits platelet aggregation
• Indication
– Routinely recommended at earliest opportunity
for all pts with chest pain suspected to be of
ischemic etiology
• Dose
– 160-325 mg/day (chewable or rectal)

51. Nitroglycerin
• Actions • Dose
– Dilate coronary arteries – SL 0.5 mg every 3 min
– Venodilator at low doses – Initiate IV rate at 5-10
– Arteriodilator at higher mcg/min, increasing
every 5-10min by
doses 5mcg increments until
– Decreases pain of ischemia pain relieved or SBP
• Indications <100
– Routine in AMI • Contraindications
– With right ventricular
– Suspected ischemic
MI
– Unstable angina – Sinus bradycardia <50
– To reduce BP with AMI bpm

52. Morphine
• Actions • Dose
– Dilates arteries – 2-4mg increments every
– Analgesic 5-10 minutes until pain
– Decreases anxiety relieved or BP falls
– Venodilator • Contraindications
• Indications – SBP <90
– Continuing pain, not – hypovolemia
relieved by NTG
– Acute pulmonary edema

53. ACE Inhibitors
• Actions • Guidelines for initiation
– Reduces preload & – Give within 12-24 hours
afterload – Monitor closely for
– Reduces infarct hypotension
expansion – Monitor increase in
creatinine level

54. Beta Blockers
• Reduces mortality rates • Indications
by 20-25% when initiated – All patients without
days to weeks after AMI contraindication to B
• Reduces myocardial Blockers should be
treated within 12
demand hours of onset of AMI
– Decreases automaticity. • Contraindications
arrhythmias
– Bradycardia or
– Decreases HTN presence of AV block
– Decreases contractility – Hypotension
– Pulmonary edema
– Hx of bronchospastic
disease

55. Calcium Channel Blockers
• Not recommended as standard first-line
therapy
• May be used for significant hypertension or
refractory ischemia

56. Thrombolysis
• Benefit greatest if therapy initiated early
• Highly significant reduction in mortality
• Benefits patients irrespective of age, gender,
and comorbid conditions
• Slightly increased risk of intracerebral
hemorrhage

57. Thrombolysis
Candidates
• Time to therapy 3-6 hours or less
• Acute ST-segment elevation
• Symptoms consistent with acute MI
• Patients without ST-segment elevation should
not receive thrombolytic therapy

58. Thrombolytic Therapy
Contraindications
• Active bleeding
• Recent major surgery
• Stroke within 2 months
• Markedly elevated blood pressure
• Significant bleeding diathesis

59. Thrombolytic Agents
• Nonspecific agents deplete coagulation factors
A. Streptokinase
B. Urokinase
C.Anistreplase
• Specific agents do not deplete coagulation factors
A. Alteplase (tPA)
B. Reteplase

60. Primary PTCA
• Alternative to thrombolytic therapy if
performed in a timely fashion by skilled
individuals in high-volume centers
• Reperfusion strategy in patients with risk of
bleeding contraindications to thrombolytic
therapy

61. PTCA/Stent
• Clinical Indications
– Stable & unstable angina
– Evidence of myocardial ischemia upon treadmill
testing
– Acute MI

63. CABG
• Indications
– Critical coronary artery obstruction or multiple
ischemic sites
– Emergent when hemodynamically unstable as
result of dissecting artery during PTCA

64. CABG

65. Complications of MI
Mechanical Electrical
• Acute MR • Brady arrythmias
• RV infarction • Tachy arrythmias
• Ventricular septal
rupture
• LV thrombus
• Pericarditis

66. Post MI Prognosis
• Left ventricular ejection fraction
• Number of diseased coronary arteries
• Presence of spontaneous/inducible ischemia
• Presence and extent of ventricular ectopy

67. Nursing Management
 Start a IV line and blood samples to be taken as
per icu protocol of cardiac patient.
 Administer oxygen to relieve dyspnea and
prevent arrhythmias.
 Provide bed rest with semi fowler’s position to
decrease cardiac output.
 Moniter ECG and hemodynamic procedures.
 Tablet Aspirin 160-320 mg is given(to chew).
• Asprin alone – reduced mortality 23%
• Asprin with thrombolysis – reduced mortality
42%

68. Contd.
Nursing Management
 Tab sorbitrate 10mg sublingually to be given.
 Injection morphine 3mg iv can be given ,and .1mg/kg
and total 15mg can be given.
 NTG drip .5 microgram through infusion pump to be
given.
 Injection streptokinase - 1.5 million units dissolved in
200ml of normal saline over 30-40 minutes.
 Maintain quiet environment.
 Anti coagulant as advised.
 Stool softeners to be given.
 Anxiety to be relieved.

69. HEALTH TEACHING ON DISCHARGE
• Patients to take regular medications.
• Dietary restrictions—low sodium diet,low
cholesterol,avoidance of caffine.
• Risk factors to be explained.
• Modifications in life style.
• Need to report the following symptoms :-
increased persistent chest
pain, dyspnea, weakness, fatigue, persistent
palpitation.
• Regular visit to physician as advised.