Bahir Dar university
College of medicine and other health science
Department of adult health nursing
Seminar presentation on; myocardial infarction
Submitted to; yeshaneh S.(msc,Asst.prof)
By Dagmawit Zewdu
10/28/2021 1
Myocardial
infarction
10/28/2021 2
Presentation outline
Definition
Pathophysiology
Etiology
Sign and symptom
Management
Complication
prognosis
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Objective
oTo explain definition of myocardial infarction
oTo highlight epidemiology and prognosis of MI
oTo discuses clinical manifestation and diagnosis of MI
oTo discuses evidence-based management
oApply nursing intervention
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Definition
Myocardial infarction ; Refers to the process by
which areas of myocardial cells in the heart are
permanently destroyed ( ECS guideline 2018)
ooccurs because of sustained ischemia, causing
irreversible myocardial cell death (necrosis).
Coronary occlusion, heart attack, and MI are terms
used synonymously, but the preferred term is MI
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Cont.….
Acute myocardial infarction can be divided in to
two categories based on the ECG presentation ,
Non-ST-segment elevation MI (NSTEMI);
Clinical symptoms suggestive of ACS with elevated
cardiac biomarkers (troponin); with or without ECG
changes indicative of cardiac ischemia
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Cont..
ST-segment elevation MI (STEMI); ACS
symptoms with elevated cardiac biomarkers
(troponin); ECG shows persistent ST elevation
(Anderson et al, 2013)
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Epidemiology
oglobally, IHD affects around 126 million individuals
(1,655 per 100,000), which is approximately 1.72%
of the world’s population.
oNine million deaths were caused by IHD globally.
oMen were more commonly affected than women,
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Epidemiology Cont.…
oAnd incidence typically started in the fourth
decade and increased with age.
oestimated that the current prevalence rate of 1,655
per 100,000 population is expected to exceed 1,845
by the year 2030.(Khan MA, Hashim MJ, 2020)
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Epidemiology Cont..
The death rate related to acute MI is approximately
three times higher in men than in women. It is more
frequent in black patients compared to white
patients,(Lloyd-Jones D, Adams RJ, 2010)
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Etiology
oThe etiology of acute myocardial infarction is
decreased coronary blood flow.
oDecreased coronary blood flow is multifactorial
oThe available oxygen supply cannot meet oxygen
demand, resulting in cardiac ischemia..
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Etiology
Atherosclerosis; is the disease primarily
responsible for most acute coronary
syndrome (ACS) cases.
Approximately 90 % of myocardial
infarctions (MIs) result from an acute
thrombus that obstructs an atherosclerotic
coronary artery.(Mechanic OJ, Grossman 2020)
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Modifiable risk factors
oModifiable risk factors account for 90% (men) and 94% (female) of myocardial
infarctions.
oSmoking or other tobacco oPsychosocial stress
use oSedentary lifestyle
oHypercholesterolemia and and/or
hypertriglyceridemia, olack of exercise
oDyslipidemia oReduced
oDiabetes mellitus
oObesity consumption of fruits
o (Maziar Zafari, et and vegetables
al 2019) oHypertension
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Non modifiable risk factors
Age
Sex
Family history of premature coronary heart
disease
(Maziar Zafari, et al 2019
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Pathophysiology
surface of an atherosclerotic plaque becomes disrupted
(exposing its contents to the blood)
A mural thrombus forms at the site of plaque disruption
After an initial platelet monolayer forms at the site of the
disrupted plaque, various agonists (collagen, ADP,
epinephrine, serotonin) promote platelet activation.
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Pathophysiology
the involved coronary artery becomes occluded
there is no blood flow to the myocardium distal to the
blockage, resulting in necrosis.
Contractile function of the heart stops in the necrotic
area
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Cont.…
oThe acute MI process takes time.
oCardiac cells can withstand ischemic conditions for
approximately 20 minutes before cell death begins.
oThe earliest tissue to become ischemic is the
subendocardial( the innermost layer of tissue in the
cardiac muscle). (Harrison 20th edition 2019)
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Cont..
oIf ischemia persists, it takes approximately 4 to 6 hours
for the entire thickness of the heart muscle to become
necrosed.
oIf the thrombus is not completely blocking the artery, the
time to complete necrosis may be as long as 12 hours.
(Oren J. Shamai A 2020)
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Cont..
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Clinical manifestation
In up to one-half of cases, a precipitating factor
appears to be present before MI,
such as-; vigorous physical exercise,
emotional stress, or
a medical or surgical illness.
.
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Cont.…
oChest Pain is the most common
presenting complaint.
o The pain is deep and visceral.
othe pain involves the central portion of
the chest and/or the epigastrium, and,
on occasion, it radiates to the arms.
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Cont.…
oCan be characterized as heavy, squeezing, and
crushing, although, occasionally, it is described as
stabbing or burning.
oIt is similar in character to the discomfort of angina
pectoris.
oThe pain continues despite rest and medication.
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Cont.…
ois usually more severe and lasts longer.
However, pain is not uniformly present in patients
with MI.
The proportion of painless MIs is greater in patients
with diabetes mellitus, women and it increases with
age.
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Cont.…
It is often accompanied by weakness, sweating,
nausea, vomiting, anxiety, and a sense of impending doom.
pale, cool, clammy skin
Shortness of breath
Un explained hypotension
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Cont..
A systemic review and meta ethnography showed
that; Women's experiences and interpretation of
body symptoms during myocardial infarction vary.
Most commonly women do not initially recognize
their body symptoms as being severe and life
threatening.
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Cont..
Therefore, the women chose to wait or self-
medicate before consulting others. (Rikke Madsen
andRegner Birkelund;2016 )
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Cont.…
A review on of symptoms frequency among myocardial
infarction patients showed as follow
Sami Ahmed Bilal1, Mohammad Abdallah
Alhakamy2, 2019
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Diagnostic
Patient history; family history, previous illness
Cardiac bio markers(lab finding); Released from
necrotic myocardial cells should be assessed
Cardiac troponins; a review on biomarker in acute
myocardial infarction states that; CTn are specific,
sensitive, and the preferred markers of myocardial
necrosis.
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Cont.…
oblood levels increase within 2–4 hours after acute
myocardial damage .
oBlood cTn levels are high for 2–3 weeks.
oTnI remains the gold standard for the diagnosis of AMI
o(Suleyman Aydin, Kader Ugur, 2019)
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Cont..
A retrospective chohort
study showed that;
Mortality increases with
elevated admission troponin
levels, regardless of baseline
clinical risk.(Brett L. Wanamaker,
MD1; Milan M. 2019)
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Cont.…
oCK-MB; relatively is a less sensitive alternative and
nonspecific but used for follow up b/c decline within 72 hrs
while troponins stay up to 10 days.
Another limitation of CK-MB is that it cannot detect minor
myocardial damage,
Suleyman Aydin, Kader Ugur, et al 2019)
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Cont..
Myoglobin:-a heme protein that helps to transport
oxygen.
The myoglobin level starts to increase within 1 to
3hr and .it will rapidly excreted within 24 hr
. It is a sensitive marker for AMI but has no
specificity.
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(Maziar Zafari et al,2019)
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Cont..
ECG; , total occlusion of an epicardial coronary artery
produces ST-segment and Q wave elevation
The ECG is highly specific for MI (95% to 97%), yet not
sensitive (approximately 30%).
repeat ECG testing can increase ECG sensitivity.
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Cardiac imaging
Echocardiograph; it is used to assess wall motion,
degree of valve abnormality, ischemic mitral
regurgitation (MR), and presence of cardiac
tamponade. (Mechanic OJ, Grossman SA 2020).
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Management
Goal
◦ To minimize myocardial damage
◦ To preserve myocardial function
◦ To prevent complications
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Management in Emergency
Recognition of symptoms by the patient and prompt seeking
of medical attention
Obtain 12-lead electrocardiogram to be read within 10
minutes.
Obtain laboratory blood specimens of cardiac biomarkers,
the patient should have intravenous access
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Cont..
Aspirin is essential in the management of patients
with suspected MI and is effective across the entire
spectrum of acute coronary syndromes
Require Immediate chawed of 162 mg-325mg.
This measure should be followed by daily oral
administration of aspirin in a dose of 75–162 mg.
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Cont.…
when hypoxemia is present, O2 should be administered by
nasal prongs or face mask (2–4 L/min) for the first 6–12 h
after infarction; (ESC 2018 guideline )
meta-analysis of randomized controlled trait showed that ,
oxygen inhalation did not benefit patients with AMI with
normal oxygen saturation. (Wen-Feng Lia, Yu-Qing H 2018)
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Managing discomfort
Sublingual nitro-glycerine can be given safely to
most patients with MI.
Up to three doses of 0.4 mg should be administered
at about 5-min intervals.
In addition to diminishing or abolishing chest
discomfort,
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Cont..
It also decreasing myocardial oxygen demand and
increasing myocardial oxygen supply
Therapy with nitrates should be avoided in patients
who present with low systolic arterial pressure (<90
mmHg)
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Cont..
Morphine is a very effective analgesic for the pain
associated with MI.
it may also reduce sympathetically mediated
arteriolar and venous constriction, and the resulting
venous pooling may reduce cardiac output and
arterial pressure. (ESC guideline et al 2018)
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Reperfusion therapy
Reperfusion strategies
Mechanical Pharmacological
reperfusion reperfusion
Primary pre cutaneous
fibrinolytics
coronary intervention
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Reperfusion therapy
PCI
oIts recommended that the use of PCI for patient
with acute MI who can undergo the procedure in
timely manner (within 120 minutes or less ) by
persons skilled in the procedure.
.
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Cont..
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Cont.…
meta-analysis of RCT reveals; PCI prevents death,
cardiac death, and MI in patients with unstable CAD.
For patients with stable CAD, PCI shows no
evidence of an effect on any of these outcomes. (
Liza Chacko , James P. 2020)
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Cont..
Fibrinolysis
for the management of MI recommended that the
use of fibrinolytics within 12 hr
For who cannot receive primary percutaneous
coronary intervention within 120 min of first
medical contact.
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Cont.…
It can be considered up to 24 hour after symptoms
•streptokiness;1.5 million units over 30 to 60
minutes
•retaples;10 unit over two min then repeat 10 unit
bolus at 30 min.
•Ateples and tenecteplas can also be given.(.(PG Thrane,
SD Kristensen, et al 2019)
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Cont..
RCT of 16 year follow up relieved; The benefit of
pPCI over fibrinolysis .
pPCI reduced the composite endpoint of death or
rehospitalization for MI, reduced cardiac mortality, and
delayed average time to a main event by approximately
1 year.(PG Thrane, SD Kristensen, et al 2019)
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Pharmacology therapy
Beta blockers; intravenous beta blockers are also
useful in the control of the pain of MI.
These drugs control pain effectively in some
patients, presumably by diminishing myocardial O2
demand and hence ischemia(ESC guideline 2018)
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Cont..
A chocrain review indicates that beta-blockers for suspected
or diagnosed acute myocardial infarction probably reduce
the short-term risk of a reinfarction and the long-term risk of
all-cause mortality and cardiovascular mortality.
Nevertheless, it is most likely that betablockers have little or
no effect on the short-term risk of all-cause mortality and
cardiovascular mortality. (afi S, Sethi NJ, Nielsen EE, 2019)
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Cont.
Angiotensin-Converting Enzyme Inhibitors (ACE-I).
ACEI prevent the conversion of angiotensinI to
angiotensinII.
In the absence of angiotensin II, the blood pressure
decreases and the kidneys excrete sodium and fluid
(diuresis), decreasing the oxygen demand of the heart
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Management during
hospitalization
Activity ; patients with STEMI should be kept at bed rest
for the first 6–12 h.
In the absence of hypotension and other complications, by
the second or third day, patients typically are ambulating in
their room with increasing duration and frequency, and they
may shower or stand at the sink to bathe.
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Cont.…
A Cochrane review shows that exercise-based CR
provide important benefits by reducing cardiovascular
mortality and hospitalization(and associated
healthcare costs)
also improving HRQL in younger men who have
suffered MI or are post-revascularisation. (Anderson
L, Thompson DR 2016)
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Complication
An overview on myocardial infarction complication showed
that;
Arrhythmias (commonest cause of
death in the first hours of MI) About
90%
Pericarditis ; The incidence of
early pericarditis after MI is
approximately 10%,
Cardiac rapture-Cardiac
rupture occurs in
approximately 5% of patients,
has a high mortality,
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Cont.…
Acute conduction system abnormality
Pump failure
Mitral regurgitation
Ventricular septal defect
Left ventricular aneurysm
(Ashok K Kondur, Pawan Hari 2014)
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Prognosis
Acute myocardial infarction (MI) is associated
with a 30% mortality rate; about 50% of the deaths
occur prior to arrival at the hospital.
An additional 5-10% of survivors die within the
first year after their myocardial infarction.
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Cont..
Approximately half of all patients with an MI are
re-hospitalized within 1 year of their index event.
Overall, prognosis is highly variable and depends
largely on the extent of the infarct, the residual left
ventricular function, and whether the patient
underwent revascularization. (Maziar Zafari,
Maziar Zafari 2019)
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Nursing diagnosis
1,Acute pain related to coronary occlusion AEB change in pulse, BP and facial
grimacing.
2, activity intolerance related to Imbalance between myocardial oxygen
supply and demand AEB Generalized weakness and Changes in skin
color/moisture
3,anxity related to acute onset of pain AEB fear attitude and Uncertainty,
4, risk for decreased cardia output related to Changes in rate, rhythm,
electrical conduction
5, risk for impaired tissue perfusion related to Reduction/interruption of
blood flow,
6, deficit knowledge related to Lack of information/misunderstanding of
medical condition AEB Questions; statement of misconception
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Nursing intervention
oProvide analgesic
oMaintain physical and psychological rest
oMonitoring vital sign
oRecord intake and output record to identify a negative balance
oWeighing the patient daily
oProviding general counseling and education
oSodium restriction
oEncouraging regular exercise
oAvoidance of excessive fluid intake, alcohol, and smoking.
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(Berg DD, Wiviott SD, Braunwald E, Guo J, Im K, Kashani A, Gibson CM, Cannon CP, Morrow DA, Bhatt DL,
Mega JL, O'Donoghue ML, Antman EM, Newby LK, Sabatine MS, Giugliano RP. Modes and timing of death in
66 252 patients with non-ST-segment elevation acute coronary syndromes enrolled in 14 TIMI trials. Eur.
Heart J. 2018 Nov 07;39(42):3810-3820. [PMC free article] [PubMed] [Reference list]
[Updated 2020 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK459269/
(Mechanic OJ, Grossman 2020)SA. Acute Myocardial Infarction. [Updated 2020 Aug 11]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK459269/
M. Rayner, “Cardiovascular disease in Europe 2015: epidemiological update,” European Heart Journal, vol.
36, no. 40, pp. 2673-2674, 2015. View at: Publisher Site | Google Scholar
Brant LCC, Marino BCA 2019, Passaglia LG, Ribeiro ALP. Implementing myocardial infarction systems of
care in low/middle-income countries. Heart. 2019 Jan;105(1):20-26. [PubMed] [Reference list]
Aydin S, Ugur K, Aydin S, Sahin İ, Yardim M. Biomarkers in acute myocardial infarction: current perspectives.
Vasc Health Risk Manag. 2019;15:1-10. Published 2019 Jan 17. doi:10.2147/VHRM.S166157
Khan MA, Hashim MJ, Mustafa H, et al. Global Epidemiology of Ischemic Heart Disease: Results from the
Global Burden of Disease Study. Cureus. 2020;12(7):e9349. Published 2020 Jul 23. doi:10.7759/cureus.9349
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