Acute Myocardial InfarctionIs 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 factorsImportant 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 minutesChanges in serial ECG tracingsRise and fall of serum cardiac biomarkersAt autopsy, a pathologist can diagnose an MI based on anatomopathological findings.

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 NutritionControlling 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 ExerciseTraditionally, 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

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 Outputrelated to:changes in the frequency of heart rhythm.

2. Impaired Tissue Perfusionrelated to:decrease in cardiac output.

3. Ineffective Airway Clearancerelated to:accumulation of secretions.

4. Ineffective Breathing Patternrelated to:lung development is not optimal.

5. Impaired Gas Exchangerelated to:pulmonary edema.

6. Acute Pain

relate to:increase in lactic acid.

7. Fluid Volume Excessrelated to:retention of sodium and water.

8. Imbalanced Nutrition, Less Than Body Requirementsrelated to:Inadequate intake.

9. Activity Intolerancerelate to:imbalance between myocardial oxygen supply and needs.

10. Self-Care Deficitrelated to:physical weakness.

11. Anxietyrelated 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

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 planConsider starting guideline-recommended medicines in hospital before discharge.1,2Provide 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

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 survivalPatients 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. 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 stageThe 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.

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Phase 3: structured exercise and rehabilitationGraded 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 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 maintenanceIn 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.