This document provides information about myocardial infarction (MI) or heart attack. It defines MI as death of heart muscle cells due to lack of oxygen, usually caused by a blockage in the coronary arteries. It lists risk factors for MI such as smoking, diabetes, hypertension, and family history. It describes the signs and symptoms of MI, diagnostic tests including ECG and cardiac enzymes, types of MI, and treatments including thrombolytics, angioplasty, medications, and lifestyle changes to prevent future heart attacks. The nursing management of MI focuses on reducing pain, improving perfusion, preventing complications, health education, and calling for help if symptoms worsen.

1. MYOCARDIAL INFARCTION
PREPARED BY:
VINEETH. M
CLINICAL INSTRUCTOR
MOH KUWAIT

2. OBJECTIVES
At the end of the session the staff nurses should be
able to..
Define myocardial infarction
List down the risk factors of MI
Distinguish between STEMI & NSTEMI
State the clinical manifestation of MI
List down the complication of MI
Discuss the management of MI

3. ANATOMY AND PHYSIOLOGY OF
HEART
• Location of the heart
• Cardiovascular function
• Layers of the heart wall
• Chambers of heart

4. septum
Chordae tendanae

5. MYOCARDIAL THICKNESS AND FUNCTION
EPICARDIUM:
MYOCARDIUM:
• RESPONSIBLE FOR PUMPING
• BULK OF THE HEART CONSISTING MAINLY OF
CARDIAC MUSCLE
• ATRIA : THIN WALLED
• VENTRICLES :THICK WALLED
• LT VENTRICLE IS THICKER THAN THE RT
VENTRICLE.
ENDOCARDIUM

6. PHYSIOLOGIC CHARACTERISTICS OF
THE MYOCARDIUM
• AUTOMATICITY
• EXCITABILITY
• CONDUCTIVITY
• RHYTHMICITY
• CONTRACTILITY
• EXTENSIBILITY

7. Coronary Circulation
CORONARY ARTERIES
• THE CORONARY ARTERIES ARISE
FROM THE BASE OF THE AORTA AND
ACTIVELY DELIVER BLOOD ONLY WHEN
THE HEART IS RELAXED

9. HEART VALVES AND CIRCULATION OF
BLOOD

10. Pulmonary Circulation

11. Systemic Circulation

12. The conduction system

14. Definition
Myocardial infarction (MI) death of the cells of an area of
the heart muscle (myocardium) as a result of oxygen
deprivation, which in turn is caused by obstruction of
the blood supply commonly referred to as a “heart
attack”.

15. Definition cont…
When the heart muscle becomes ischemic, this often
causes chest pain. This is called angina pectoris.
If the ischemia lasts long enough, the heart muscle
that is not getting enough oxygen. This is called an
infarction. "Myocardial infarction" means "infarction
(muscle death) in the heart muscle."

16. Incidence
• Health data compiled from more than 190 countries show
heart disease remains the No. 1 global cause of death with
17.3 million deaths each year, according to “Heart Disease
and Stroke Statistics — 2015. -“American Heart
Association.”
• The number is expected to rise to more than 23.6 million by
2030, the report found.
• Evidence suggests that heart attacks are at least three times
more likely to occur in the morning hours especially
between 6AM and noon.

17. Risk factors
Modifiable
Life style:
-Smoking- 36% & other tobacco
use
-Obesity -20%
-Physical inactivity7- 12%
Diabetes
Hypertension
Hyperlipidemia/ dyslipidemia
Hypertriglyceridemia
Non modifiable
Age
Gender
Heredity/ Family
history.
Genetic

18. Risk factors cont..
Modifiable
Psychosocial factors:
low socioeconomic
status, social isolation,
and negative emotions
Stress
Poor oral hygiene
Type A personality.
No modifiable

19. Other risk factors
Sleep disorders such as snoring and sleep apnoea
Long-term exposure to noise
Cold weather
Infections:
Chlamydophilapneumoniae, influenza, Helicobacter pylori,
and Porphyromonas gingivalis
late consequence of Kawasaki disease.
Endometriosis in women under the age of 40
Pollutants and other toxic chemicals.

20. Etiology
Atherosclerosis
Narrowing of heart's blood vessels
Platelets and plaque block the blood
vessel completely.
Heart attack.

22. Degree of damage to the heart muscle
Ischemia
• outer most area, source of arrhythmias,
viable if no further infarction.
Injury
• viable tissue found between ischemic
and infracted areas
Infarction/necrosis
• center area, dead not viable tissue that
turn into scar.

23. SitesOfMyocardialInfarction
1. Anterior WallMI.
2. Posterior Wall MI.
3. Inferior WallMI.
4. Lateral wall MI.
5. Septal MI.
• Thesemay be appear with combination.

25. TypeOfMyocardialInfarction
STELEVATEDORTRANSMURALMI:NONSTELEVATEDOR
SUBENDOCARDIALMI:

26. Subendocardial AMI(non ST elevated)
Involves a small area in the sub endocardial wall
of the left ventricle, ventricular septum,
or papillary muscles.
The sub endocardial area is particularly
susceptible to ischemia.
On ECG, ST depression and T wave changes.

27. Transmural AMI(ST elevated)
Involves a major coronary artery.
It can be sub classified into anterior, posterior,
inferior, lateral, or septal.
Transmural infarcts extend through the whole
thickness of the heart muscle and are usually a result
of complete occlusion of the area's blood supply.
On ECG, ST elevation and Q waves are seen.

28. Killip classification

29. Predisposing factors
Premature, accelerated atherosclerosis
Progressive narrowing of the blood vessel Risk for excessive blood clot formation
Ischemia of the heart muscle Thromboembolism
Hypoxia
Necrosis
Aerobic to anaerobic metabolism
Lactic acid formation
Chest pain / Muscle spasm
Release of lysosomal enzyme
Altered depolarization
Altered repolarisation
Myocardial
infarction
myocardial contractility
cardiac output
Renal ischemia/Oliguria

30. Clinical manifestations

31. Clinical manifestations cont..
Anxiety and fear resulting in an increase in heart
rate, blood pressure and respiratory rate.
Disorientation , confusion, restlessness.
Fainting , marked weakness
Atypical symptoms: epigastric or
abdominal distress, dull aching or
tingling sensation, Shortness of breath,
extreme fatigue.
“Silent heart attacks" more common
in elderly people , women, and people
with diabetes

32. Diagnostic evaluation
1. History taking:
AnyRiskfactor abovementioned ispresent.
2. Clinicalfeature:
Symptoms:
 Prolong CardiacPain.Centralchest pain which takesseveral
minuets or prolong to develop,dull aching, constricting,
heavy
 Squeezingandcrushing radiates to both arm throat and
jaw andevenin backandepigastria andassociateswith
breathlessnessandprolong in duration aggravatesby
exertion and relieved by takingrest.
 Anxiety andfear of impendingdeath.

33. Signs:
• sign of sympatheticactivation:
– pallor ,sweating, tachycardia.
• Signof vagalactivation:
– vomiting ,bradycardia.
• Signof impaired myocardialfunction:
– -Hypotension ,oliguria ,cold peripheries,Narrow pulse
pressure,third heart sound,Quietfirst heart sound.
• Sign of tissuedamage:Fever.
• Signof complication:mitral regurgitation, Pericarditis

34. ECG in MI
Hyper acute state
Transmural
ischemia
Transmural
infarction
Infarction
established
Hyperacute
T START:
IMMEDIATELY
Elevation ST
START:
INMEDIATELY
Pathologcal
Q START:
6HRS-DAYS
Invertion
T START:6-
24 HRS
ENDS:

37. Diagnostic evaluation
Exercise tolerance test
Imaging
•Thallium scan
•Multi gated cardiac pool imaging scans
•Cardiac catheterization

39. MANAGEMENT OF
MI

40. MEDICAL MANAGEMENT
Goals for treatment of acute MI:-
a) Initiating prompt care.
b) Reducing pain.
c) Delivering successful treatment for the acute
pain and reperfusion of the myocardium.
d) Preventing complications.

41. INITIATING PROMPT CARE
Immediate assessment
 Elevation of bed
 Loosen tight clothing around neck
 Measure vital signs
 Measure oxygen saturation
 Obtain IV access
 12-lead ECG
 Perform brief history
 Obtain initial serum cardiac markers level

42. REDUCING PAIN
Immediate general treatment
 Oxygen at 3-4L/mt
 Aspirin 160-325mg
 Nitrates (sublingually)
 IV Morphine (if pain is not relieved by NTG)

43. REPERFUSION OF MYOCARDIUM
Thrombolytic therapy
 Patient with STEACS.
 Bundle branch block on 12-lead ECG.
 Patient with NSTEACS managed with antiplatelet
and anticoagulants.

44. Contd…
Thrombolytic therapy include:-
 Streptokinase (1.5 million)
 Alteplase (15mg bolus, 50mg over 30mts, 35mg over
60mts for a total dose of 100mg)
Along with this continues iv heparin is given to maintain
(aPTT)
Thrombolytic agent should be givens 30mts after MI
(Door to needle time)

45. Contd…
Percutaneous coronary interventions (PCI)
It refers to the group of procedures performed
through percutaneously to treat coronary lesions
It includes:-
 angioplasty
 Athrectomy
 Intercoronary stenting
It should be done with in 60mts after a cardiac event
(door to balloon time)

46. Contd…
CABG (coronary artery bypass graft)
CABG is a surgical procedure in which one or more
blocked coronary arteries are bypassed by a blood
vessel graft to restore normal blood flow to the
heart, with an intent to relieve angina and prevent
death

47. PREVENTING COMPLICATIONS
 Assessment
 Physical examinations
 12-lead ECG
 Hemodynamic monitoring

48. PHARMACOLOGICAL MANAGEMENT
 Aspirin – anti platelet effect
 Clopidrogel- antiplatelet
 Ticagrelor- platelet aggregation inhibitor
 Glycoprotein iib/iiia inhibitors
 Heparin – anticoagulant
 Nitrates
 Beta blockers
 ACE inhibitors

49. NURSING MANAGEMENT
Nursing diagnosis:-
Acute pain related to myocardial ischemia resulting from
coronary artery occlusion, an imbalance between
myocardial oxygen supply and demand.
Interventions:-
1. Assess patients description of chest discomfort
2. Assess BP, heart rate, rhythm and respiratory rate
3. Assess the skin for temperature and moistness
4. Obtain 12-lead ECG during chest comfort
5. Administer oxygen, nitrates, iv morphine or other
medication as ordered

50. Contd…
Nursing diagnosis:-
Ineffective tissue perfusion related to an imbalance between
myocardial oxygen supply and demand that manifested by
chest discomfort and dysrhythmias
Interventions:-
1. Keep the client on bed rest with a quite environment
2. Administer oxygen and antiarrhythmic and other
medications as ordered and continuously evaluating patient
condition.
3. Administer thrombolytic or send the patient for angioplasty
as ordered
4. Monitor ST segment

51. Contd…Nursing diagnosis:-
Decreased systemic tissue perfusion related to decrease in cardiac
output from arrhythmias and conducting disturbances.
Interventions:-
1. Decrease patient physical activity
2. Administer oxygen and antiarrhythmic and other medications
as ordered and continuously evaluating patient condition.
3. Assess for peripheral perfusion: by monitoring skin for
cyanosis, pallor, coolness, diaphoresis, and peripheral pulses
4. Check for cerebral perfusion: by checking mental
status(restlessness and decreased responsiveness)

52. Contd…
5. Auscultate for lung sounds:-by monitoring for
crackles
6. Auscultate for heart sounds:-note the presence of
gallop, murmur and increased or decreased heart rate.
7. Check for renal perfusion:-decreased urine output.
8. Monitor arterial blood gas analysis

53. Contd…
Nursing diagnosis:-
Impaired gas exchange related to decreased cardiac output as
evidenced by cyanosis, impaired capillary refill time, dyspnea
Interventions:-
1) Administer oxygen as ordered
2) Maintain ABG’s as ordered
3) Continue to assess the clients skin, capillary refill, and level
of consciousness every 2 to 4 hrs
4) Assess respiratory status for dyspnea and crackles
5) prepare for intubation and mechanical ventilation if hypoxia
increases.

54. HEALTH EDUCATION
Nurses should focus on:
 Pathophysiology of acute MI.
 Description of signs and symptoms such as pain.
pressure, or heaviness in chest.
 Notification of nurses of any changes in chest pain
intensity.
 Avoidance of the Valsalva maneuver.

55. Contd…
Health education focused on:-
 Home care
 Diet
 Physical activity
 Medications
 Lifestyle changes and prevention

56. Contd…
Home care
• Rest until doctor says it is okay to return to work or
other activities.
• Take all medicines are prescribed by your doctor
• Attend a cardiac rehabilitation program if
recommended by your doctor

57. Contd…
Diet
Eat a heart healthy diet:
• Limit your intake of fat, cholesterol and sodium.
Food such as ice cream, cheese, baked goods,
processed foods and red meat are not the best
choices.
• Increase intake of whole grains, fish, fruits,
vegetables and nuts.

58. Contd…
Physical activity
• At least 30mts of exercise daily, or at least 3-4 times
per week.
• Do not drive unless your doctor has given you
permission to do so.
• Ask your doctor when you may resume sexual
activity.

59. Contd…
medications
• Take your medicine as directed.
• Do not stop taking them without talking your
doctor.
• Report to your doctor regarding any side effects.
• Avoid over the counter medicine.
• Plan ahead for refills so you do not runout.

60. Contd…
Life style changes and prevention
• Get regular medical check-ups.
• Control blood pressure.
• Eat a healthful diet.
• Have a regular, low impact exercise programme.
• Maintain healthy weight.
• Manage stress through activities such as yoga,
meditation and counselling.

61. Contd…
Call for medical help right away If any of the following occurs
• Chest pain, which may feel like a crushing weight on your
chest.
• A sense of fullness, squeezing or pressure in the chest.
• Rapid, irregular heart beet.
• Pain, tingling or numbness in the left shoulder and arm, the
neck or jaw, or the right arm.
• Sweating, nausea or vomiting
• Indigestion or heartburn.
• Light headness, weakness, or fainting
• Shortness of breath
• Abdominal pain

62. So…….Be…safefrom Heart disease.
ThankYou.