Group 2_ Presentation 5 Myocardial Infarction

7/30/2019 Group 2_ Presentation 5 Myocardial Infarction

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Elrey Joseph Calitis, RN

Mae Anjneth Cuaton, RN

CARDIOVASCULARNURSING

(PRESENTATION 5)


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HEART ATTACK


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STATISTICS OF HEART ATTCK cases IN THEPHILIPPINES

Recent data from the National Statistics Office (NSO) showedthat 5 out of 10 deaths in the country were of cardiovascularcauses.

The NSO reported that 100,908 people died of heart diseases

in 2009. This accounted for 21 percent of all deaths in thecountry.(http://www.philstar.com/breaking-news/2012/07/09/826043/5-out-10-filipinos-die-heart-disease-nso)

(http://www.census.gov.ph/sites/default/files/attachments/ird/quickstat/January2013.pdf)


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STATISTICS OF HEART ATTCK cases IN THEUnited States

About 600,000 people die of heart disease in the UnitedStates every yearthats 1 in every 4 deaths.(http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_03.pdf)

Heart disease is the leading cause of death for both men and

women. More than half of the deaths due to heart disease in2009 were in men.

Every year about 715,000 Americans have a heart attack. Ofthese, 525,000 are a first heart attack and 190,000 happen inpeople who have already had a heartattack.(http://circ.ahajournals.org/content/125/1/e2.short?rss=1&amp%3bssource=mfr)


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What is heart attack?

A heart attack occurs when the blood flow that bringsoxygen to the heart muscle is severely reduced or cut offcompletely.

This happens because coronary arteries that supply the heart

muscle with blood flow can slowly become narrow from abuildup of fat, cholesterol and other substances that togetherare called plaque. This slow process is known

as atherosclerosis.


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..cont

When a plaque in a heart artery breaks, a blood clot forms aroundthe plaque. This blood clot can block the blood flow through theheart muscle. When the heart muscle is starved for oxygen and

nutrients, it is called ischemia. Myocardial ischemia, also called cardiac ischemia, can damage your

heart muscle, reducing its ability to pump efficiently. A sudden,severe blockage of a coronary artery may lead to a heart attack.


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What is silent ischemia?

Many Americans may have ischemic episodes without knowing it.These people have ischemia without pain silent ischemia. Theymay have a heart attack with no prior warning. People with anginaalso may have undiagnosed episodes of silent ischemia. In addition,

people who have had previous heart attacks or thosewith diabetes are especially at risk for developing silent ischemia.


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Clinical Classification of Myocardial Infarction

Spontaneous Myocardial Infarction (MI Type 1)

This is an event related to atherosclerotic plaque rupture, ulceration,fissuring, erosion, or dissection with resulting intraluminal thrombus

in one or more of the coronary arteries, leading to decreasedmyocardial blood flow or distal platelet emboli with ensuing myocytenecrosis. The patient may have underlying severe CAD but, onoccasion (5 to 20%), non-obstructive or no CAD may be found atangiography, particularly in women.


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Myocardial Infarction Secondary to an Ischemic Imbalance (MIType 2)

In instances of myocardial injury with necrosis, where a conditionother than CAD contributes to an imbalance between myocardialoxygen supply and/or demand, the term 'MI type 2' is employed Incritically ill patients, or in patients undergoing major (non-cardiac)surgery, elevated values of cardiac biomarkers may appear, due tothe direct toxic effects of endogenous or exogenous highcirculating catecholamine levels. Also coronary vasospasm and/orendothelial dysfunction have the potential to cause MI.


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Cardiac Death Due to Myocardial Infarction (MI Type 3) Patients who suffer cardiac death, with symptoms suggestive of

myocardial ischemia accompanied by presumed new ischemic ECG

changes or new LBBBbut without available biomarker valuesrepresent a challenging diagnostic group. These individuals may diebefore blood samples for biomarkers can be obtained, or beforeelevated cardiac biomarkers can be identified. If patients presentwith clinical features of myocardial ischemia, or with presumed newischemic ECG changes, they should be classified as having had afatal MI, even if cardiac biomarker evidence of MI is lacking.


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Myocardial Infarction Associated With RevascularizationProcedures (MI Types 4 and 5)

Periprocedural myocardial injury or infarction may occur at some

stages in the instrumentation of the heart that is required duringmechanical revascularization procedures, either by PCI or bycoronary artery bypass grafting (CABG). Elevated *cTn values maybe detected following these procedures, since various insults mayoccur that can lead to myocardial injury with necrosis. It is likely

that limitation of such injury is beneficial to the patient: however, athreshold for a worsening prognosis, related to an asymptomaticincrease of cardiac biomarker values in the absence of proceduralcomplications, is not well defined.Subcategories of PCI-related MIare connected to stent thrombosis and restenosis that may happen

after the primary procedure.


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MI is defined in pathology as myocardial cell death due toprolonged ischemia. After the onset of myocardial ischemia,histological cell death is not immediate, but takes a finite period of

time to developas little as 20 min

It takes several hours before myocardial necrosis can be identifiedby macroscopic or microscopic post-mortem examination. Completenecrosis of myocardial cells at risk requires at least 24 h, or longer,depending on the presence of collateral circulation to the ischemic

zone, persistent or intermittent coronary arterial occlusion, thesensitivity of the myocytes to ischemia, pre-conditioning, andindividual demand for oxygen and nutrients.


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American Heart AssociationPrevention of Heart Attack

Lifestyle Changes

Stop smoking

Choose good nutrition

Reduce bloodcholesterol

Total Cholesterol: Less than 200 mg/dLLDL (bad) Cholesterol:

If you're at low risk for heart disease: Less than 160 mg/dL If you're at intermediate risk for heart disease: Less than 130 mg/dL If you're at high risk for heart disease (including those with existing heart

disease or diabetes): Less than 100mg/dLHDL (good) Cholesterol: 40 mg/dL or higher for men and 50 mg/dL or higher forwomen

Triglycerides: Less than 150 mg/dL


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Lower Blood PressureYour goal is less than 120/80mmHg.

Be physically Active

Everyday

Research has shown that getting at least 30minutes of physical activity on 5 or more daysof the week can help lower blood pressure,lower cholesterol and keep your weight at ahealthy level

Aim for Healthy

Weight Manage diabetes

Reduce stress

Limit AlcoholDrinking too much alcohol can raise blood pressureand lead to heart failure or stroke. It can contributeto high triglycerides, produce irregular heartbeatsand affect cancer and other diseases.


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What to do if you see someone having aheart attack?

If you encounter someone who is unconsciousfrom a presumed heart attack, call for emergencymedical help. If you have received training inemergency procedures, begin cardiopulmonary

resuscitation (CPR). This helps deliver oxygen tothe body and brain.


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According to guidelines by the American Heart Association,regardless of whether you've been trained, you should beginCPR with chest compressions. Press down about 2 inches (5centimeters) on the person's chest for each compression at arate of about 100 a minute. If you've been trained in CPR,check the person's airway and deliver rescue breaths afterevery 30 compressions. If you haven't been trained, continuedoing only compressions until help arrives.


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Myocardial Infarction Classification based onECG tracings

1. Non-STEMI (Non- ST Elevation Myocardial Infarction)Non-ST elevation myocardial infarction (NSTEMI) is defined as condition wherethere is no ST elevation on ECG but with elevation of cardiac enzymes. On theother hand, unstable angina (UA) is not associated with ST elevation or cardiacenzymes elevation but with ECG ST or T wave changes coupled with typical

anginal pains

2. STEMI (ST Elevation Myocardial Infarction)

STEMI is defined as ST-segment elevation of greater than 0.1 mV in at leasttwo contiguous precordial or adjacent limb leads, a new left bundle branch

block, or a true posterior MI.


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Notes on Clinical Guidelines of Non-STEMI

1. Diagnosis and Risk Assessment2. ECG

3. TET

4. Biomarkers of Cardiac Injury

5. Risk Stratification6. General Recommendations on Initial Management

7. Medications

8. Invasive Procedures

9. Discharge Instructions


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Diagnosis and Risk Assessment: Patients with a high likelihood ofischemia due to CAD are at a greater risk of an untoward cardiacevent than are patients with a lower likelihood of CAD. Therefore,an assessment of the likelihood of CAD is the starting point for the

determination of prognosis in patients who present with symptomssuggestive of an ACS.

ECG: It IS STRONGLY RECOMMENDED that a 12 lead ECG be

obtained immediately within 10 minutes of ER presentation inpatients with ongoing chest discomfort


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TET (Treadmill Exercise Test): It IS NOT RECOMMENDED toperform stress test within 48 hours of the last chest pain

Biomarkers of Cardiac Injury: It IS STRONGLY RECOMMENDED thattroponin be measured in all patients with chest discomfort

consistent with ACS. In patients with negative cardiac markerswithin 6 hours of the onset of pain, another sample should bedrawn in the time frame 8-12 after symptom onset.

Risk Stratification: It IS RECOMMENDED for patients who present

with chest discomfort or other ischemic symptom to undergo earlyrisk stratification for risk of cardiovascular events (e.g. death or MI)based on an integration of the patients history, physicalexamination, ECG findings and result of cardiac biomarkers.


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Notes on Clinical Guidelines of Non-STEMI General Recommendations on Initial Management: It IS

RECOMMENDED that the following management strategies shouldbe instituted:

1. Bed rest with continuous ECG monitoring for ischemic and

arrhythmia detection in patients with ongoing rest pain.

2. Supplemental oxygen should be administered to patients withUA/ NSTEMI for patients with cyanosis or respiratory distress; fingerpulse oximetry or arterial blood gas determination to confirm

adequate arterial oxygen saturation (Sa02 greater than 90%) andcontinued need for supplemental oxygen in the presence ofhypoxemia


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Notes on Clinical Guidelines of Non-STEMI Medications:

1. Nitrates: It IS RECOMMENDED that nitrates (sublingual tablet or spray), followed byintravenous administration, be administered for the immediate relief of ischemic andassociated symptoms.

2. Beta Blockers: It IS RECOMMENDED that beta-blocker by oral or IV route beadministered if there is ongoing chest pain in the absence of contraindications.

3. Ca Channel Blockers: It MAY BE RECOMMENDED to use oral long-acting calciumantagonists for recurrent ischemia in the absence of contraindication and when beta-blockers and nitrates are maximally used.

4. ACE inhibitors and ARB: An ACE-I/ARB IS RECOMMENDED when hypertensionpersists despite treatment with nitroglycerin (NTG) and a beta -blocker in patients withLV systolic dysfunction or congestive heart failure (CHF), high risk chronic CAD, in postACS (with or without) diabetes, and in chronic kidney disease (CKD) unlesscontraindicated.

5. Morphine Sulfate: It IS RECOMMENDED that morphine sulfate be administeredintravenously when symptoms are not immediately relieved with NTG or when acutepulmonary congestion and/or severe agitation are present .

6. Aspirin: It IS STRONGLY RECOMMENDED that aspirin at initial dose of 160-325 mgnon-enteric formulation, followed by 80- 160 mg daily) be administered as soon aspossible after resentation and continued indefinitely.


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Notes on Clinical Guidelines of Non-STEMI Medications

7. ADP receptor antagonists (Clopidogrel, ticlopidine): It IS STRONGLY RECOMMENDED to startclopidogrel for:

1. Patients in whom an early non- interventional approach is planned in addition to ASA as soon aspossible on admission and administered for at least 1 month

2. Patients who are unable to take ASA because of hypersensitivity or major gastrointestinal

intolerance. 3. Patients in whom a PCI is planned and should be continued for at least 12 months in patients

who are not at high risk for bleeding.

It IS STRONGLY RECOMMENDED to discontinue clopidogrel for 5 to 7 days in patients whomelective CABG is planned.

8. Anticoagulants: It IS STRONGLY RECOMMENDED that anticoagulation with subcutaneousenoxaparine or intravenous unfractioned heparin (UFH) should be added to antiplatelet therapywith ASA and/or clopidogrel.

9. Fibrinolytic Therapy: It IS NOT RECOMMENDED to use intravenous fibrinolytic therapy inpatients with UA or in patients without acute ST-segment elevation, a true posterior MI, or apresumed new left bundle-branch block (LBBB)


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Notes on Clinical Guidelines of Non-STEMI Invasive Procedures:

It IS RECOMMENDED that an early invasive strategy (as early as possible up to 72hours) followed by revascularization (PCI or CABG) with

any of the following high-risk indicators:

a) Recurrent angina/ischemia at rest or with low-level activities despite intensive anti-ischemic therapy

b) Elevated cardiac biomarkers (TnT or TnI)

c) New or presumably new ST- segment depression

d) Intensive lipid- lowering therapy is strongly recommended by combining dietaryinterventions

with pharmacotherapy by statins, or combination with other lipid- lowering agents toreduce LDLc < 100 mg/dL and ideally reduced to 70 mg/dL.

e) Hemodynamic instability f) Sustained ventricular tachycardia

g) PCI within 6 months

h) Prior CABG

i) High-risk score (e.g., TIMI,GRACE)


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Discharge Instructions: It IS RECOMMENDED that the following specific instructionsshould be given:

a. Lifestyle modification that includes smoking cessation, achievement or maintenanceof optimal weight, daily exercise, and diet.

b. Daily exercise of 30 minutes or 5 days per week.

c. Consider referral of patients who are smokers to smoking cessation program orclinic and/or an out-patient cardiac rehabilitation program.

d. Intensive lipid- lowering therapy is strongly recommended by combining dietaryinterventions with pharmacotherapy using statins, or combining with other lipid-lowering agents to reduce LDLc < 100 mg/dL. Further reduction to less than 70 mg perdL may be recommended.

e. A fibrate or niacin if high- density lipoprotein (HDL) cholesterol is less than 40 mgper dL, occurring as an isolated

finding or in combination with other lipid abnormalities.

f. Hypertension control to a blood pressure of less than 140/90 mm Hg or less than130/80 mmHg if patient has diabetes or chronic kidney disease

g. Tight control of hyperglycemia in diabetes. Goal is HbA1c of less than 7%

h. Antiplatelet Agents/Anticoagulants


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Notes on Clinical Guidelines of STEMI1. Diagnosis and Risk Assessment

2. ECG

3. Initial Treatment

4. Medications

5. Invasive Procedures6. Hospital Management

7. Risk Stratification

8. Cardiac Rehabilitation

9. Hospital Discharge10. Exercise Testing


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Notes on Clinical Guidelines of STEMI

Diagnosis and Risk Assessment: It IS STRONGLY RECOMMENDED that a detailedhistory taking, physical examination and a 12 lead ECG be taken within 10 minutes ofarrival at the ER.

ECG: It IS RECOMMENDED that patients presenting with chest discomfort and ECGfinding of at least 0.1 mV ST segment elevation in two contiguous leads and withoutany contraindications should receive reperfusion therapy either primary PCI (in

hospitals with PCI capability) or with thrombolytics (in hospitals without PCI capability)

Initial Treatment: It IS RECOMMENDED that the following routine treatment measuresshould be administered to STEMI patients upon arrival at the ER (unless withcontraindication)

Supplemental oxygen during the first 6 hours

Aspirin 160 325 mg tablet (non

enteric coated, chewed)

Nitrates, sublingual or IV (contraindicated in patients with hypotension or those whotook sildenafil within 24 hrs)

Morphine 2-4 mg IV for relief of chest pain


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Notes on Clinical Guidelines of STEMI

Medications:

Thrombolysis or fibrinolytic therapy: STEMI patients presenting to a hospital withoutfacilities for primary percutaneous coronary intervention (PCI) IS RECOMMENDED toundergo immediate thrombolysis unless contraindicated with a door to needle time

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Group 2_ Presentation 5 Myocardial Infarction

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