Acute Coronary Syndrome: MI

Myocardial Infarction: Medical Surgical Nursing

1. Myocardial Infarction/ Acute Coronary Syndrome By, Shristi Shrestha Medical Surgical Nursing, Ms. Shristi Shrestha

2. Learning Objectives At the end of the seminar participants will be able to: Define MI/ACS Discuss the epidemiology of MI/ACS State the causes & risk factors Name the types of MI Describe the pathophysiology List the clinical manifestations Medical Surgical Nursing, Ms. Shristi Shrestha

3. Learning Objectives At the end of the seminar participants will be able to: State the diagnostic measures list the complications of MI Describe the Management Explain the Nursing Management Discuss the preventive strategy for MI Medical Surgical Nursing, Ms. Shristi Shrestha

4. Does Myocardial Infarction and Acute Coronary Syndrome means same? Acute coronary syndromes, or “heart attacks,” include unstable angina and acute myocardial infarction.  Medical Surgical Nursing, Ms. Shristi Shrestha

5. Acute Coronary syndrome (ACS) When patient comes with ischemic discomfort, he or she is considered to have acute coronary syndrome (ACS). Medical Surgical Nursing, Ms. Shristi Shrestha

6. Unstable Angina (UA) New onset angina of less than two months duration Angina of increasing severity, frequency, duration Angina that occurs at rest that lasts >20 mintues Chest pain within two weeks of previous MI In UA, there is no biomarker evidence of myocardial necrosis Medical Surgical Nursing, Ms. Shristi Shrestha

7. Myocardial Infarction (MI) MI is the manifestation of prolonged ischemic event.   refers to the process by which areas of myocardial cells are permanently destroyed by the rapid development of myocardial necrosis. Medical Surgical Nursing, Ms. Shristi Shrestha

8. Non ST Elevation MI In NSTEMI, there is persistent (>20 minutes) chest pain along with the biomarker evidence of myocardial necrosis . It is mostly due to partial occlusion. Medical Surgical Nursing, Ms. Shristi Shrestha

9. ST Elevation MI Commonly occurs due to complete occlusion of coronary artery by thrombus. Pathological diagnosis of MI requires evidence of myocardial cell death caused by ischemia. Medical Surgical Nursing, Ms. Shristi Shrestha

10. Classically, a diagnosis of MI is made when 2 out of 3 following criteria are fulfilled (WHO criteria): Chest pain : classical chest pain or atypical chest pain. ECG changes suggestive of MI : pathological Q waves, ST elevation and T wave inversion. Increase in cardiac markers : cardiac troponins, CPK-MB Medical Surgical Nursing, Ms. Shristi Shrestha

11. Universal Definition of Acute MI Detection of a rise and/or fall in cardiac biomarker values with at least one of the following: Symptoms of ischemia New or presumed new significant ST segment, T wave changes or new LBB. Pathological Q waves Imaging evidence Identification of an intracoronary thrombus by angiography. Medical Surgical Nursing, Ms. Shristi Shrestha

12. Epidemiology Medical Surgical Nursing, Ms. Shristi Shrestha

13. Epidemiology Medical Surgical Nursing, Ms. Shristi Shrestha

14. Medical Surgical Nursing, Ms. Shristi Shrestha

15. Risk Factors Medical Surgical Nursing, Ms. Shristi Shrestha

16. Causes Occlusion of coronary artery with atheromatous plaque Plaque rupture/erosion with thrombus formation Medical Surgical Nursing, Ms. Shristi Shrestha

17. Classification proposed by the third universal definition of myocardial infarction Medical Surgical Nursing, Ms. Shristi Shrestha

18. Normal Coronary Supply Medical Surgical Nursing, Ms. Shristi Shrestha

19. Pathophysiology of MI Medical Surgical Nursing, Ms. Shristi Shrestha

20. Pathophysiology of MI Medical Surgical Nursing, Ms. Shristi Shrestha

21. Pathophysiology of MI Medical Surgical Nursing, Ms. Shristi Shrestha

22. Pathophysiology of MI Medical Surgical Nursing, Ms. Shristi Shrestha

23. Clinical Manifestations Medical Surgical Nursing, Ms. Shristi Shrestha

24. Medical Surgical Nursing, Ms. Shristi Shrestha

25. "Silent" myocardial infarctions can happen without any symptoms at all Such silent myocardial infarctions represent between 22 and 64% of all infarctions, and are more common in the  elderly in those with diabetes mellitus and after heart transplantation .   Medical Surgical Nursing, Ms. Shristi Shrestha

26. Diagnosis Medical Surgical Nursing, Ms. Shristi Shrestha

27. Clinical Presentation Pain Retrosternal chest pain, described as tightness, pressure, squeezing and heaviness Radiating to jaw, neck, arms, back & epigastrium Physical Examination Restless, anxious, sweating, vomiting Distended neck veins Medical Surgical Nursing, Ms. Shristi Shrestha

28. 12-Lead ECG Medical Surgical Nursing, Ms. Shristi Shrestha

29. Classic changes in ECG are: Medical Surgical Nursing, Ms. Shristi Shrestha

30. High-risk unstable angina (UA) or NSTEMI (non-ST-segment elevation myocardial infarction) Definition:  Ischemic ST-segment depression of 0.5 mm (0.5 mV) or greater   -OR-   Dynamic T wave inversion with pain or discomfort. Medical Surgical Nursing, Ms. Shristi Shrestha

31. T wave inversion Medical Surgical Nursing, Ms. Shristi Shrestha

32. STEMI (ST-segment elevation myocardial infarction) Definition:  ST segment elevation greater than 1 mm (0.1 mV) in 2 or more contiguous precordial leads or 2 or more adjacent limb leads  - OR-   New or presumed new left bundle branch block Medical Surgical Nursing, Ms. Shristi Shrestha

33. STEMI- Specific ECG Changes Medical Surgical Nursing, Ms. Shristi Shrestha

34. Abnormal Q wave Medical Surgical Nursing, Ms. Shristi Shrestha

35. Localization of MI on ECG Medical Surgical Nursing, Ms. Shristi Shrestha

36. MI LEADS COLOR ARTERY INFERIOR II, III, aVF BLUE RCA SEPTAL VI , V2 GREEN LAD ANTERIOR V3, V4 YELOW LAD LATERAL I, aVL , V5, V6 RED CIRC Medical Surgical Nursing, Ms. Shristi Shrestha

37. What part of the heart is affected ? II, III, aVF = Inferior Wall I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 Medical Surgical Nursing, Ms. Shristi Shrestha

38. What part of the heart is affected ? V3 , and V4 = Anterior Wall MI I II III V1 V2 V3 V4 V5 V6 aVR aVL aVF Medical Surgical Nursing, Ms. Shristi Shrestha

39. What part of the heart is affected ? V1, and V2 = Septal Wall MI I II III V1 V2 V3 V4 V5 V6 aVR aVL aVF Medical Surgical Nursing, Ms. Shristi Shrestha

40. Which part of the heart is affected ? I, aVL , V5 and V6: Lateral wall of left ventricle I II III V1 V2 V3 V4 V5 V6 aVR aVL aVF Medical Surgical Nursing, Ms. Shristi Shrestha

41. Cardiac Biomarkers Medical Surgical Nursing, Ms. Shristi Shrestha

42. Diagnostic Measures Others investigations Complete blood count ESR also rises within 3 days and remain elevated for several weeks. Leukocytes peaks in 2-4 days and return to normal within 1 week. Medical Surgical Nursing, Ms. Shristi Shrestha

43. Diagnostic Measures Echocardiography shows regional wall motion abnormality which suggests ischemic or infracted myocardium. LV function, RV infarction, ventricular aneurysm, pericardial effusion, LV thrombus. Medical Surgical Nursing, Ms. Shristi Shrestha

44. Diagnostic Measures Chest X-ray Helps to rule out other causes of chest pain, also to look for pulmonary edema and cardiac size. Coronary Angiography a “road-map” for guiding the angioplasty procedure. Medical Surgical Nursing, Ms. Shristi Shrestha

45. Diagnostic Measures Medical Surgical Nursing, Ms. Shristi Shrestha

46. Management Medical Surgical Nursing, Ms. Shristi Shrestha

47. Emergency Treatment Monitor and support ABCs (airway, breathing, and circulation ). Be prepared to administer CPR if the need arises. Watch for it . Obtain 12 lead ECG Establish IV access . Look for risk factors for ACS Medical Surgical Nursing, Ms. Shristi Shrestha

48. Emergency Treatment O 2 via Face mask @ 4-5 liters/min to maintain SPO2 >90%. Morphine 2.5-5 mg IV stat. Nitrates (Sub lingual) up to three 0.4 mg tablets can be administered 5 minutes apart . Aspirin 300 mg stat, to be chewed and swallowed. Medical Surgical Nursing, Ms. Shristi Shrestha

49. Emergency Treatment Complete bed rest ECG monitoring Clopidogrel 300-600 mg PO stat. Statin: Atorvastatin 80 mg/ Rosuvastatin 40 mg PO Medical Surgical Nursing, Ms. Shristi Shrestha

50. Emergency Management For refractory chest pain, IV NTG can be given, starting dose 5-19 mcg/min and dose titrated according to response . Beta blockers: Metoprolol 5 mg IV every 5 minutes, up to 3 doses. Nil per oral for initial 6 hours Medical Surgical Nursing, Ms. Shristi Shrestha

51. ACS Algorithm Medical Surgical Nursing, Ms. Shristi Shrestha

52. Medical Surgical Nursing, Ms. Shristi Shrestha

53. Medical Surgical Nursing, Ms. Shristi Shrestha

54. Definitive Management Management is based on the results of the ECG . Confirm how much time has passed since the onset of symptoms . If less than 12 hours has elapsed: Develop a reperfusion strategy based on the patient's and the hospital's criteria. Unless impossible, the patient should be taken to the cardiac catheterization laboratory for PCI Medical Surgical Nursing, Ms. Shristi Shrestha

55. Adjunctive Therapies ACE inhibitors/angiotensin receptor blocker (ARB) within 24 hours of symptom onset Unfractioned Heparin: Loading dose- 60 units/kg (maximum 5000 U); maintenance- 14 units/kg (maximum 1000U/h). target aPTT - 1.5-2 of normal (50-70 seconds ) Enoxaparin (low molecular weigh heparin) 1mg/kg body weigh SC 12hrly Medical Surgical Nursing, Ms. Shristi Shrestha

56. Reperfusion Therapy Prompt and effective reperfusion therapy is the cornerstone for treatment of STEMI Primary Percutaneous Coronary Intervention (PPCI) Fibrinolytics Balloon angioplasty Strptokinase Alteplase Reteplase Tenecteplase Placement of intracoronary stent: Bare-metal stent (BMS) Drug-eluting stent (DES ) Bio-absorbable stent (BAS) Medical Surgical Nursing, Ms. Shristi Shrestha

57. Timing to Reperfusion Therapy Treatment Recommended Time for Initiation of Treatment PCI Door-to-balloon time < 90 min Fibrinolytic agents Door-to-needle time < 30 min Medical Surgical Nursing, Ms. Shristi Shrestha

58. Percutaneous Coronary Intervention P ercutaneous transluminal coronary angioplasty ( PTCA) F irst performed by Andreas Gruentzig in 1977 with fixed wire ballon catheter. The term PCI now encompasses the broad array of ballons , stents and adjuctive devices. Medical Surgical Nursing, Ms. Shristi Shrestha

59. Indications For Primary PCI Indications COR Ischemic symptoms <12 hours   I Ischemic Symptoms <12 hours and contraindication to fibrinolytic therapy   I Cardiogenic shock or acute severe heart failure   I Evidence of ongoing ischemia 12 to 24 hours after symptom onset   IIa Medical Surgical Nursing, Ms. Shristi Shrestha

60. Percutaneous Coronary Intervention Coronary devices: Balloon angioplasty Coronary atherectomy Thrombectomy and aspiration devices Embolic protection devices Distal embolic filters Medical Surgical Nursing, Ms. Shristi Shrestha

61. Balloon Angioplasty extends the coronary lumen by stretching and tearing the atherosclerotic plaque Medical Surgical Nursing, Ms. Shristi Shrestha

62. Bare Metal Stents (BMS) It is a vascular stent without a coating Previous stents were made of stainless steel, nowadays BMS is made of cobalt chromium alloy . U sed in 10-30% of patients undergoing PCI. Medical Surgical Nursing, Ms. Shristi Shrestha

63. Drug Eluting Stents (DES) Provides sustained local delivery of an anti-proliferative agent at the site of vessel wall injury Medical Surgical Nursing, Ms. Shristi Shrestha

64. Bio-Absorbable Stents (BAS) BAS will resorb and be benignly cleared from the body, leaving no permanent implant. Medical Surgical Nursing, Ms. Shristi Shrestha

65. Complications of PCI Prioperative mortality: <0.1 % Perioperative myocardial infarction: <3 % Thrombotic occlusion: 1-3 % Restenosis: 10-30% BMS, 5-15 % in DES Emergent CABG for unsuccessful procedure: <1% Medical Surgical Nursing, Ms. Shristi Shrestha

66. Fibrinolytic Therapy Indications COR Ischemic symptoms <12 hours   I Evidence of ongoing ischemia 12 to 24 hours after symptom onset and a large area of myocardium at risk or hemodynamic instability.   IIa Fibrinolytic therapy   also known as thrombolytic therapy works by dissolving clots  Indication for fibrinolysis when there is >120 min delay from FMC to primary PCI. Medical Surgical Nursing, Ms. Shristi Shrestha

67. Streptokinase Dose : 1.5 million unit in 100 ml NS IV over 30-60 minutes. 12 lead ECG should be taken at the start, in between and at the end of the therapy. Medical Surgical Nursing, Ms. Shristi Shrestha

68. Tenecteplase Dose : Single IV weight based bolus (30 mg for weight <60 kg; 35 mg for 60-69 kg; 40 mg for 70-79 kg; 45 mg for 80-89kg and 50 mg for ≥90 kg) Medical Surgical Nursing, Ms. Shristi Shrestha

69. Indicator of successful thrombolysis (at 90 minutes) Decrease and disappearance of chest pain Decrease in ST elevation by 50% Appearance of rrythmias i.e. idioventricular rhythm Medical Surgical Nursing, Ms. Shristi Shrestha

70. Coronary Artery Bypass Graft S urgical procedure in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the heart. Medical Surgical Nursing, Ms. Shristi Shrestha

71. Coronary Artery Bypass Grafting Indications COR Urgent CABG in STEMI and coronary anatomy not amenable to PCI, cardiogenic shock, sever HF   I The technical goal of bypass surgery is to achieve complete revascularization by grafting all coronary arteries of sufficient proximal stenosis. Medical Surgical Nursing, Ms. Shristi Shrestha

72. Coronary Artery Bypass Graft Common Bypass grafts Left internal mammary artery (LMA) Radial artery Right internal mammary artery (RIMA) Saphenous vein Medical Surgical Nursing, Ms. Shristi Shrestha

73. Complications of MI Medical Surgical Nursing, Ms. Shristi Shrestha

74. Complications of MI Medical Surgical Nursing, Ms. Shristi Shrestha

75. Complications of MI Medical Surgical Nursing, Ms. Shristi Shrestha

76. Complications of MI Medical Surgical Nursing, Ms. Shristi Shrestha

77. Presentation and outcome of patients with acute coronary syndromes in eastern Nepal. Shreshta NR 1 ,  Basnet S ,  Bhandari R ,  Acharia P ,  Karki P ,  Pilgrim T ,  Meier B ,  Urban P . RESULTS: A total of 153 patients with ACS were admitted in 2008: 58 with ST elevation myocardial infarction (STEMI) (38%), 28 with non-ST elevation myocardial infarction (NSTEMI) (18%) and 67 with unstable angina (UA) (44%) . 40% of patients with STEMI presented within 12 hours of symptom onset. Most patients presented late and 33% of them presented after 2 days or more. Over half the patients were not literate. Due to the unavailability of percutaneous coronary intervention (PCI) at the centre , thrombolysis with Streptokinase was considered for patients presenting with STEMI up to 24 hours after symptom onset. However, due to financial constraints, only 53% of patients in this broadened time window actually received thrombolytic treatment. The in-hospital mortality was 14% for all patients with ACS, and 17% for the patients with STEMI. Medical Surgical Nursing, Ms. Shristi Shrestha

78. Nursing Management Medical Surgical Nursing, Ms. Shristi Shrestha

79. Nursing Diagnosis Acute pain related to tissue ischemia as verbalized by patient. Anxiety related to fear of death changing health status . Activity intolerance related to Imbalance between myocardial oxygen supply and demand as evidenced by generalized weakness. Risk for ineffective air exchange related to fluid overload. Risk for ineffective tissue perfusion related to decrease cardiac output. Medical Surgical Nursing, Ms. Shristi Shrestha

80. Nursing Intervention RELIEVING PAIN AND ISCHEMIA. Asses for chest discomfort including location, duration and factors that affect it. Asses for nausea, diaphoresis, unusual fatigue, change in blood pressure, loss of consciousness, decrease in urine output. Obtain 12 lead ECG Administer oxygen, drugs as prescribed. Ensure physical rest : use of bedside commode, back rest, tolerated diet, stool softner . Medical Surgical Nursing, Ms. Shristi Shrestha

81. Nursing Interventions REDUCING ANXIETY. Assess the patient’s and family level of anxiety and coping mechanism. Allow the patient to express anxiety and fearby showing genuine interest, facilitating communication, answering question. Use of flexible visiting hour. Medical Surgical Nursing, Ms. Shristi Shrestha

82. Nursing Interventions PROMOTING ADEQUATE TISSUE PERFUSION. Assess for hypotension, tachycardia, activity intolerance, reduced urine output, cool, moist ,cyanotic extremities. Limiting the patient to bed or chair during initial phase of treatment. Check skin temperature and peripheral pulses. Oxygen administration. Medical Surgical Nursing, Ms. Shristi Shrestha

83. Gradual Mobilisation Medical Surgical Nursing, Ms. Shristi Shrestha

84. Gradual Mobilisation Medical Surgical Nursing, Ms. Shristi Shrestha

85. Nursing Consideration in STK Continue cardiac monitoring Measure platelet count, APTT, PT, before therapy is intiated . Slowly start the STK Anaphylactic reaction may occur, adminster hydrocortisone and chlorpheniramine . Reperfusion arrhythmias like idioventricular rhytm /VPCs usually donot require treatment. Medical Surgical Nursing, Ms. Shristi Shrestha

86. Nursing Consideration in PCI Medical Surgical Nursing, Ms. Shristi Shrestha

87. Prognosis Poorer prognosis is associated with the following: Delayed or unsuccessful reperfusion Unpreserved LV function, persistent ventricular arrhythmias, bundle branch block, high enzyme level. Advanced age. Medical Surgical Nursing, Ms. Shristi Shrestha

88. Prevention Medical Surgical Nursing, Ms. Shristi Shrestha

89. Prevention Medical Surgical Nursing, Ms. Shristi Shrestha

90. Medical Surgical Nursing, Ms. Shristi Shrestha

91. References Acute Coronary Syndromes Algorithm. Dec 12, 2017.Available from: https :// www.acls.net/acute-coronary-syndromes-algorithm.htm Smeltzer C .S, Hinkle L. J, Bare G. B, Cheever H. K. Brunner and Suddarth's Textbook of Medical Surgical Nursing.12th ed , New Delhi: Wolters Kluwer (India) Pvt.Ltd ; 2011.Vol. 2. Black JM, Hawks H. JK. Medical Surgical Nursing. 8th edition. Philadelphia: Elsevier Publication; 2012. Medical Surgical Nursing, Ms. Shristi Shrestha

92. References Adhikari CM. Trends and in- hospital mortality of Acute Coronary Syndrome at Shahid Gangalal National Heart Centre, Kathmandu, Nepal during 2001-2012. Journal of Advances in Internal Medicine 2014;03(01):23-26. Available from: http://www.aimjournal.org/downloads/Adhikari_CM_JAIM_Volume03_Number01_2014_23_26.pdf Laudari S et al.Acute coronary syndrome in the young Nepalese population with their angiographic characteristics . Journal of College of Medical Sciences-Nepal, Vol-13, No 2, Apr-June 017 .Available from:https :// www.nepjol.info/index.php/JCMSN/article/viewFile/17147/14446 Medical Surgical Nursing, Ms. Shristi Shrestha

93. THANK YOU SO MUCH Medical Surgical Nursing, Ms. Shristi Shrestha