1. Acute Myocardial infarction
Priya .M. Vincent & Padma Susan Mathew
ICCU

2. Definition
• Necrosis to cardiac muscle
due to acute occlusion of
coronary artery as a result
of plaque rupture and
thrombosis

3. Coronary Atherosclerosis with Thrombus

4. Riskfactors
• Non-modifiable
– Age
– Race
– Sex
– Heredity
• Modifiable
– Smoking
– Hypertension
– Diabetes mellitus
– Hyperlipidemia.
– Obesity
– Response to stress

5. Understanding Myocardial Infarction
Change in the condition of plaque in the
coronary artery
Activation of platelets
Formation of thrombus
Ischemia of tissue in the region
supplied by the artery
Coronary blood supply
< demand
Myocardial cell death
Contractility
Stimulation of the
sympathetic nervous system
Altered
repolarization of
myocardium
Release of lysosomal
enzymes
Anaerobic
Glycolysis
Myocardial
irritability
Dysrhythmia
s
ST seg.
q wave
CPK-MB
LDH
Lactic Acid
production
Angina

6. Contractility
Stimulation of the
sympathetic nervous system LV function
Preload Cardiac
Output
CVP
PCWP
LVEF
HR O2 NEED After load
Vasoco
nstricti
on
Continuation….

7. Normal Myocardium:

8. Myocardial Infarction - Gross

9. Myocardial Infarction – 1st
week

10. Post-infarcted Myocardium- CS

11. 2nd
week- Myocardial Infarction -
3d

12. MI 18-24 hours loss of nucleus,
contraction bands, coagulative necrosis

13. MI 3-4 days – Hemorrhage, inflammation

14. MI 1st
– 2nd
week– Granulation tissue

15. MI 2-
4 weeks - Resorption, fibrosis

16. MI > 4–6 weeks - Collagen Scar

17. Clinical features
Symptoms:
• Prolonged chest pain
• Profuse sweating
• Nausea & vomiting
• Breathlessness
• Anxiety
• Collapse / Syncope

19. Physical signs
• Pallor, sweating, vomiting
• Tachycardia / Bradycardia
• Hypotension, oliguria, cold periphery
• Narrow pulse pressure
• Raised JVP in RVMI
• Lung crepitation
• 3rd
and 4th
heart sounds
• Fever

20. Diagnostic measures
• ECG
• Lab Investigations
– Troponin I
– Troponin T
– CPK-MB
– CPK [Total]
– SGOT
– CBC & ESR
• X-Ray Chest
• Echocardiogram
• Radioisotope studies
- Stress Thallium
- Rest Thallium
- Multi-gated acquisition scan [MUGA]
• Coronary Angiogram
• MRI

21. ECG Patterns

22. Coronary
Arteries
•Left Coronary A.
•L.A.Descending
•Left Circumflex
•Right Coronary A.
LCx
LAD

23. Area of myocardium
involved
Coronary artery supply Leads
Anterior Left coronary artery left anterior
descending branch
V2,V3,V4
Posterior Right Coronary Artery V1 – V3
Inferior Right Coronary Artery II, III, avf
Anteroseptel Left Coronary Artery left anterior
descending branch
V2 & V3
High lateral Circumflex artery, marginal branch or
LCA
I, aVL
Apical Usually LCA, left anterior branch may
be RCA, posterior descending
branch
V5 & V6

24. Enzyme Normal value Onset Peak Return to
normal
Trop. I &
Trop T
<0.2 4-6hrs 24-36 hrs. 10-12days
CPK[Total] 21-232 hrs. 12-24 hrs. 3-5days
CPK– MB <25 . 12-20 hrs. 42-48hrs.
SGOT <40 6-12hrs. 24-48 hrs. ≥10days
LDH 160 – 410 24hrs. 48-72 hrs. 7-10days

25. Management
• Se e k im m e diate m e dicalatte ntio n

26. Medical Management
• Major goals:
– Management of the acute attack
– Prevention of complications
– Rehabilitation

27. 1. Management of Acute attack
• History
• ECG
• IV access
• Routine blood investigations
• Continuous cardiac monitoring
• Invasive monitoring

28. General Measures
• Pain control
• Aspirin
• Clopidogrel
• Nitrates
• Beta-adrenoreceptor blockers
• ACE inhibitors
• Bed rest upto 48 hours
• Soft diet
• Stool softeners

29. Patients with ischemic type discomfort
ECG
ST elevation ECG strongly suspicious for
ischemia ( ST depression, T
wave inversion
Non diagnostic ECG
Eligible for
thrombolytic
therapy
Thrombolytic
therapy
contraindicated
Admit
Initial antiischemic
therapy or treat as
unstable angina
Thrombolytic
therapy
Primary PTCA
Continue
evaluation
Obtain follow up
serum cardiac
marker levels
ECHO
Evidence of
ischemic infarction
Evidence of
ischemic infarctionYes
NoInitial reperfusion strategy if ST
elevation develops Discharge

30. Thrombolysis
• Streptokinase
• Urokinase
• Tissue plasminogen activator (t-PA)
• Acylated plasminogen
streptokinase activator complex
(APSAC)

31. Criteria forthrombolysis in acute
MI
Indications:
• Chest pain
• ECG changes
• Time from onset of symptoms
<6 hrs. : most beneficial
6-12 hrs. : lesser but still important benefits
>12 hrs. : diminishing benefits but may still
be used in selected patients

32. Absolute contraindications
1. Active internal bleeding (excluding menses)
2. Suspected aortic dissection
3. Recent head trauma or known intracranial
neoplasm
4. Hemorrhagic CVA
5. Major surgery or trauma < 2weeks.

33. Relative contraindications
• BP>180/110mmHg on at least 2 readings
• History of hypertension
• Active peptic ulcer
• History of CVA
• Current use of anticoagulants
• Prolonged or traumatic CPR
• Diabetic hemorrhagic retinopathy
• Pregnancy
• Prior exposure to STK & APSAC

34. Protocol followed in ICCU
• Aspirin 150-325mg chewed, 75mg daily thereafter
• Clopidogrel 300mg stat & 75mg daily
• Pain relief
– Inj. Morphine 3mg + Inj. Phenergan 12.5mg slow IV
– Inj. Pethedine 12.5mg IV in patients with asthma
• O2 2-4 lit/min for 2-3 hrs. If saturation <95% continue
beyond 3hours.
• 2 IV access if the patient is for thrombolysis
• Inj.Avil 2cc + Inj. Hydrocortisone 200mg+Inj. Ranitidine
50mg IV
• Inj.Streptokinase 1.5million /15 lakhs units in 100ml NS over
1hr.
• Inj. Heparin 60 units/kg bolus + 12units/kg/hr.infusion 4 hrs.
after STK

35. • Inj. NTG infusion x 24-48hrs. in LVF, large anti. MI
persistent pain
• β blockers to all patients unless contraindicated
Metoprolol 12.5mg – 25mg BD
use carvedilol 3.125mg OD for anti. MI, LVF, previous MI
• Statins if LDL >100mg/dL & TGL>150mg/dL
• Stool softeners
• Hypnotic – Lorazepam 1-2mg HS
• NPO till pain relief
Liquid diet x 12 hours.
Semisolid diet thereafter, low fat,low cholesterol 1500
calories diet.
• Pulse,BP ½ hourly till stable then hourly.
• ECG 90 min,180 min after starting STK &daily thereafter till
transfer out.
• Consider IV beta-blockers in young patients with
tachycardia,hypertension(Metoprolol 5mg 3 doses at 5min
interval.

36. 2. Prevention of complications
a. Dysrhythmias
b. Cardiogenic shock
c. Heart failure & pulmonary edema
d. Pulmonary embolism
e. Recurrent MI
f. Complications due to necrosis of myocardium
g. Pericarditis
h. Dressler’s syndrome (late pericarditis)

37. 3. Rehabilitation
Overall goals
• Lead a productive life
• Remain within the limits of the heart’s ability to respond to
increase in activity and stress
Sub goals
• A programme of progressive physical activity
• Health teaching
• Help to accept the limitations
• Aid the client in adjusting to changes in occupational goal
• Change the psychological factors
• Reduce risk factors

38. Phase I (in hospital)
• Bed rest for 1 day with liquid diet
• When vital signs get stabilized, patient can move in bed
• Passive exercises
• As strength is regained - sit on the side of the bed and
dangle the feet.
• Once transferred from CCU self-care activities are
encouraged
• Brief walks with supervision
• Instruct regarding warning signs of over exertion
• Client education

39. Phase II (Intermediate)
• If no complications, discharge at the end of one week
• Sexual intercourse after 4-8 weeks.
• Stop smoking completely
• Encourage frequent walks
• Avoid strenuous activities
• Monitored group programmes
• Warm up and stretching exercises
• Aspirin daily.
• Return to work at the end of 8-9 wks.
• Follow up in hospital between 8-9 wks.

40. Phase – III (Long term)
• Periodic evaluation

41. Interventional Management
[PTCA] Percutaneous Transluminal Coronary Angioplasty

42. Coronary Artery Bypass Graft
Surgery [CABG]

43. Nursing Management
• Nursing Diagnosis:
– Acute chest pain related to myocardial ischemia resulting from coronary
artery occlusion with loss/restriction of blood flow to an area of
myocardium and necrosis of the myocardium.
– Dysrhythmias related to electrical instability or irritability secondary to
ischemic or infracted tissue.
– Decreased cardiac output related to negative inotropic changes in the
heart secondary to myocardial ischemia, injury or infarction.
– Impaired gas exchange related to decreased cardiac output
– Powerlessness related to hospital environment and anticipated life style
changes
– Fear & anxiety related to hospital admission and fear of death
– Altered health maintenance related to MI and implications for life style
changes.

44. Thankyou