for educational purpose only..

1. Acute Myocardial Infarction
Is the medical term for an event commonly known as a heart attack. An MI occurs when
blood stops flowing properly to a part of the heart, and the heart muscle is injured because it is
not receiving enough oxygen. Usually this is because one of the coronary arteries that supplies
blood to the heart develops a blockage due to an unstable buildup of white blood cells,
cholesterol and fat. The event is called "acute" if it is sudden and serious.
Myocardial infarction occurs when myocardial ischemia, a diminished blood supply to
the heart, exceeds a critical threshold and overwhelms myocardial cellular repair mechanisms
designed to maintain normal operating function and homeostasis. Ischemia at this critical
threshold level for an extended period results in irreversible myocardial cell damage or death.
S/Sx:
A person having an acute MI usually has sudden chest pain that is felt behind the breast
bone and sometimes travels to the left arm or the left side of the neck.
Additionally, the person may have shortness of breath, sweating, nausea, vomiting,
abnormal heartbeats, and anxiety.
Women experience fewer of these symptoms than men, but usually have shortness of
breath, weakness, a feeling of indigestion, and fatigue. In many cases, in some estimates as high
as 64%, the person does not have chest pain or other symptoms. These are called "silent"
myocardial infarctions.
Important risk factors
Important risk factors are previous cardiovascular disease, old age, tobacco smoking,
high blood levels of certain lipids (low-density lipoprotein cholesterol, triglycerides) and low
levels of high density lipoprotein (HDL) cholesterol, diabetes, high blood pressure, lack of
physical activity, obesity, chronic kidney disease, excessive alcohol consumption, and the use of
cocaine and amphetamines.
Dx:
The main way to determine if a person has had a myocardial infarction are
electrocardiograms (ECGs) that trace the electrical signals in the heart and testing the blood for
substances associated with damage to the heart muscle. Common blood tests are troponin and
creatine kinase (CK-MB). ECG testing is used to differentiate between two types of myocardial
infarctions based on the shape of the tracing. An ST section of the tracing higher than the
baseline is called an ST elevation MI (STEMI) which usually requires more aggressive
treatment.
A cardiac troponin rise accompanied by either typical symptoms, pathological Q waves,
ST elevation or depression, or coronary intervention is diagnostic of MI.
WHO criteria formulated in 1979 have classically been used to diagnose MI; a patient is
diagnosed with MI if two (probable) or three (definite) of the following criteria are satisfied:
Clinical history of ischaemic type chest pain lasting for more than 20 minutes
Changes in serial ECG tracings
Rise and fall of serum cardiac biomarkers
At autopsy, a pathologist can diagnose an MI based on anatomopathological findings.

2. Tx:
Immediate treatments for a suspected MI include aspirin, which prevents further blood
from clotting, and sometimes nitroglycerin to treat chest pain and oxygen.
STEMI is treated by restoring circulation to the heart, called reperfusion therapy, and
typical methods are angioplasty, where the arteries are pushed open, and thrombolysis, where the
blockage is removed using medications. Non-ST elevation myocardial infarction (NSTEMI) may
be managed with medication, although angioplasty may be required if the person is considered to
be at high risk. People, who have multiple blockages of their coronary arteries, particularly if
they also have diabetes, may also be treated with bypass surgery (CABG). Ischemic heart
disease, which includes MI, angina, and heart failure when it happens after MI, was the leading
cause of death for both men and women worldwide in 2011.
Pharma Tx:
Mgt:
An MI requires immediate medical attention. Treatment attempts to save as much viable heart
muscle as possible and to prevent further complications, hence the phrase "time is
muscle". Oxygen, aspirin, and nitroglycerin may be administered. Morphine was classically used
if nitroglycerin was not effective; however, it may increase mortality in the setting of NSTEMI.
Reviews of high flow oxygen in myocardial infarction found increased mortality and infarct size,
calling into question the recommendation about its routine use. Other analgesics such as nitrous
oxide are of unknown benefit. An MI requires immediate medical attention. Treatment attempts
to save as much viable heart muscle as possible and to prevent further complications, hence the
phrase "time is muscle". Oxygen, aspirin, and nitroglycerin may be administered. Morphine was
classically used if nitroglycerin was not effective; however, it may increase mortality in the
setting of NSTEMI. Reviews of high flow oxygen in myocardial infarction found increased
mortality and infarct size, calling into question the recommendation about its routine use. Other
analgesics such as nitrous oxide are of unknown benefit.
Non pharma:
Diet and Nutrition
Controlling the amount of salt in the diet (<2,000mg) is relevant in patients with advanced HF4,8
and a fluid restriction of
1,500–2,000ml should be advised to advanced HF patients.
It should also be advised that salt substitutes must be used with caution, as they may contain potassium. In large quantities,
in combination with an angiotensin-converting enzyme (ACE) inhibitor, they may lead to hyperkalaemia.
Rest and Exercise
Traditionally, patients with HF have been instructed not to exercise in order to avoid
deterioration. More recently, physical rest is only advised in acute HF or destabilisation of
chronic HF. the patient should be encouraged to, and advised how to, carry out daily physical
and leisure-time activities that do not induce symptoms, in order to prevent muscle de-
conditioning. In earlier days HF was described as a contraindication for exercise training.
Improve Symptom Recognition and Related Self-care Behaviour

3. In order to make patients recognise deterioration and take relevant action in case of
exacerbation, patients and partners need information on HF symptoms.4,8,10 Patients are
advised to weigh on a regular basis (once a day to twice a week) and, in case of a sudden
unexpected weight gain of more than 2kg in three days, to take appropriate action. Patients
are also encouraged to monitor other HF symptoms or note unexpected changes in the
health status. They need to be aware how serious these symptoms can be and what
appropriate actions are.
Other Lifestyle Changes and Other Therapies4,8,10
 Smoking should always be discouraged.
 Pneumococcal and influenza immunisation may reduce the incidence of respiratory
infections that may worsen HF.
 Continuous positive airway pressure (CPAP) to improve daily functional capacity and quality
of life may be used in patients with HF and obstructive sleep apnea.
 Non-pharmacologic techniques for stress reduction may be considered as a useful adjunct
for reducing anxiety in patients with HF.
Nsg Dx:
1. Decreased Cardiac Output
related to:
changes in the frequency of heart rhythm.
2. Impaired Tissue Perfusion
related to:
decrease in cardiac output.
3. Ineffective Airway Clearance
related to:
accumulation of secretions.
4. Ineffective Breathing Pattern
related to:
lung development is not optimal.
5. Impaired Gas Exchange
related to:
pulmonary edema.
6. Acute Pain

4. relate to:
increase in lactic acid.
7. Fluid Volume Excess
related to:
retention of sodium and water.
8. Imbalanced Nutrition, Less Than Body Requirements
related to:
Inadequate intake.
9. Activity Intolerance
relate to:
imbalance between myocardial oxygen supply and needs.
10. Self-Care Deficit
related to:
physical weakness.
11. Anxiety
related to:
ncaman death.
Acute (Chest)Pain r/tmyocardialischemia resultingfrom coronaryartery
occlusionwithloss/restriction of blood flow to anarea of themyocardium andnecrosis of
themyocardium
1. assesscharacteristics of chest pain, includinglocation, duration,quality,
intensity,presence of radiation,precipitating andalleviating factors, andas associatedsymptoms,
have clientrate pain on a scale of 1-10 and documentfindings in nurse’snotes.2. obtain history of
previous cardiac painand familial history of cardiac problems.3. assess respirations,BP and heart
rate witheach episodes of chestpain.4. maintain bedrestduring pain, withposition of
comfort,maintain relaxingenvironment topromote calmness.5. prepare for theadministration of
medications, andmonitor response todrug therapy. Notifyphysician if pain doesnot abate
ctivityIntolerancer/t cardiacdysfunction,changes inoxygensupply andconsumptionasevidencedby
shortnessof breath.
1.monitor heart rate,rhythm, respirationsand blood pressure forabnormalities.
Notifyphysician of significantchanges in VS.2. Identify causativefactors leading tointolerance of
activity.3. encourage patient toassist with planningactivities, with restperiods as necessary.4.
instruct patient inenergy conservationtechniques.5. assist with active orpassive ROM exercisesat
least QID.6. turn patient at leastevery 2 hours, and prn.7. instruct patient inisometric and
breathingexercises.8. providepatient/family withexercise regimen, withwritten
instructions.DEPENDENT:1.Assisst patient withambulation, as ordered,with
progressiveincreases as patient’stolerance permits

5. Nursing Interventions: Myocardial Infarction
Administer analgesics as ordered.
Organize patient care and activities to allow periods of uninterrupted rest.
Provide a clear liquid diet until nausea subsides.
Provide stool softener to prevent straining during defecation.
Assist with range of motion exercises.
Provide emotional support, and help reduce stress and anxiety.
Assess and record the patient’s severity, location, type, and duration of pain.
Check his blood pressure after giving nitroglycerin, especially during first dose.
Thoroughly explain the medication and treatment regimen.
Review dietary restriction with the patient.
Advise the patient about appropriate responses to new or recurrent symptoms.
Stress the need to stop smoking.
Discharge planning
Medicines management plan
Consider starting guideline-recommended medicines
in hospital before discharge.1,2
Provide all patients with a written medicines
management plan which includes:
a list of all medicines
the dose and plan for any required dose titration
intended duration of therapy
the purpose and potential benefits of therapy
potential adverse effects of each medicines
schedule for follow-up and monitoring

6. access to consumer medicine information.
provide smoking-cessation advice and
support to all patients who smoke
Smoking is one of the most significant risk factors
for cardiovascular disease, including myocardial
infarction (MI).
Stopping smoking is associated with a substantial
reduction in risk of all-cause mortality among
patients with coronary heart disease.
Adherence to therapy improves survival
Patients discontinuing their medicines after an MI is
common, often soon after discharge.13 Minimise this by:
Educating patients about their medicines. This is likely
to improve their understanding and knowledge and
thus adherence.14
Starting patients on secondary preventive therapies
and lifestyle changes before they leave hospital.
This significantly improves long-term adherence.7
Involving family members in educational efforts.
Smoking cessation, weight loss and increased
physical activity are enhanced by enlisting the
support of family members.3
Communicating risk of future cardiovascular events.
A complete list of medicines. Document why guideline
medicines have not been prescribed and alternative
medicine(s) used.
Any changes to medicines being taken at admission.
A plan for required dose titration (include who
is responsible).
Recommendations for monitoring and management
of medicine-related adverse effects.
Treatment goals including blood pressure, blood
lipid levels, weight, HbA1c.
Referral for cardiac rehabilitation.
Advice given on lifestyle modifications (e.g. smoking
cessation as applicable).
Recommendations for use of dose-administration aids,
carer support and referral for a Home Medicines Review.
Psychological and social support
 Patients should be offered basic stress management advice and may not
need more complex treatment such as cognitive behavioural therapy.

7. However, one study found that six components of psychological
intervention - usual care, educational, behavioural, cognitive, relaxation and
support - offered positive benefits in terms of clinical outcomes.[
17]
 Partners and carers should be involved if this is in accordance with the
patient's wishes.
 Patients with anxiety or depression should be managed according to the
appropriate NICE guidance.
ase 1: the initial stage following MI or cardiac event
 Assessment of a patient's physical/psychological condition.
 Assessment of risk factors, eg diet, smoking, exercise, lipid profile.
 Reassurance and correction of any misconceptions.
 Education.
 Initial mobilisation.
 Plan for discharge.
Phase 2: the post-discharge stage
The early discharge period is the time at which the patient is the most
vulnerable and psychological distress at this stage is a predictor of poor
outcome and increased use of hospital services independent of the
physical damage to the heart.[
19]
Patients should be screened for anxiety
and depression at this stage and should be treated with suitable non-
cardiotoxic antidepressants if appropriate.
Support groupse
 British Heart Foundation
 Chest, Heart and Stroke Northern Ireland
Find support near you ▶
Phase 3: structured exercise and rehabilitation
Graded exercise is a vital component of cardiac rehabilitation, although it
does not alter morbidity and mortality rates if offered in isolation. Aerobic
low-to-moderate intensity exercise will be suitable for most patients who
have been assessed as low-to-moderate risk. This form of exercise

8. programme may generally be undertaken either at home or under
supervision in the community, eg graded exercise programmes in leisure
centres where staff have received basic life support training. One meta-
analysis confirmed that light-to-moderate exercise in a group setting
offered the greatest benefit in terms of improved quality of
life.[
20]
Exercise training for high-risk patients would normally be carried
out in a hospital or other suitable venue able to provide facilities and staff
trained in resuscitation should this prove necessary.
Graded exercise should be accompanied at this stage by other
interventions tailored to meet the individual patient's requirements.
Lifestyle changes should be encouraged and supported where
appropriate, eg weight reduction, smoking cessation, retraining with a
view to returning to work. This is likely to be accompanied by education
concerning the cardiac condition and the reasons why changes in
lifestyle might be desirable.
Phase 4: long-term maintenance
In order to be effective, physical activity and changes in lifestyle need to
be maintained for the long-term.
A protocol which allows for the regular review of all patients with
ischaemic heart disease and/or heart failure by the primary care team is
desirable.[
1]
Long-term review will permit continued support of lifestyle
changes in addition to assessment of drug therapy, and physical and
psychological wellbeing, and will allow early intervention, where
required, in all areas.