Analgesics

The analgesic of choice for acute MI is morphine administered in IV boluses to reduce pain and
anxiety. It
also reduces preload and afterload, which decreases the workload of the heart and relaxes bronchioles
to
enhance oxygenation. The cardiovascular response to morphine is monitored carefully, particularly
the
blood pressure, which can decrease, and the respiratory rate, which can be depressed. Because
morphine decreases the sensation of pain, ST-segment changes may be a better indicator of
subsequent
ischemia than reported pain.
Angiotensin-Converting Enzyme Inhibitors

Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensin I to

angiotensin II.
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. Use of ACE inhibitors in patients after MI
decreases mortality rates and prevents remodeling of myocardial cells that is associated with the onset
of
heart failure. It is important to ensure that a patient is not hypotensive, hyponatremic, hypovolemic, or
hyperkalemic before administering ACE inhibitors. Blood pressure, urine output, and serum sodium,
potassium, and creatinine levels need to be monitored closely.
Thrombolytics
Thrombolytics are used to treat some patients with acute MI. These agents are administered IV
according to a specific protocol (Chart 28-8). The purpose of thrombolytics is to dissolve (ie, lyse) the
thrombus in a coronary artery (thrombolysis), allowing blood to flow through the coronary artery
again
(reperfusion), minimizing the size of the infarction and preserving ventricular function. Thrombolytics
can
be used as first-line therapy in facilities that lack the resources to perform PCIs (Boden, Eagle &
Granger,
2007). However, although thrombolytics may dissolve the thrombus, they do not affect the underlying
atherosclerotic lesion. The patient may be referred for a cardiac catheterization and other invasive
interventions. Thrombolytics dissolve all clots, not just the one in the coronary artery. Thus, they
should
not be used if the patient has formed a protective clot elsewhere, such as after major surgery or
hemorrhagic stroke. Because thrombolytics reduce the patient’s ability to form a clot, the patient is at
risk
for bleeding. Thrombolytics should not be used if the patient is bleeding or has a bleeding disorder.
All
patients who receive thrombolytic therapy are placed on bleeding precautions to minimize the risk for
bleeding. This means minimizing the number of punctures for inserting IV lines, avoiding IM
injections,
preventing tissue trauma, and applying pressure for longer than usual after any puncture.
To be effective, thrombolytics must be administered as early as possible after the onset of symptoms
that
indicate an acute MI, generally within 3 to 6 hours. They are given to patients with ECG evidence of
acute
MI. The selected thrombolytic agent should be initiated within 30 minutes of presentation to the
hospital
(ISCI, 2006a). This is called door-to-needle time, and hospitals monitor their ability to administer the
thrombolytic agent within the recommended time period as an indicator of quality of care.
The thrombolytic agents used most often are alteplase (Activase) and reteplase (r-PA, TNKase).
Alteplase is a tissue plasminogen activator (t-PA) that activates the plasminogen present on a blood
clot.
An IV bolus dose is given and followed by an infusion. Aspirin and unfractionated heparin or LMWH
may
be used with t-PA to prevent another clot from forming at the site of the lesion. Reteplase, a newer
recombinant thrombolytic, is similar to alteplase and has similar effects. It is administered in two
bolus
doses, followed by a heparin infusion.
Emergent Percutaneous Coronary Intervention
The patient with STEMI may be taken directly to the cardiac catheterization laboratory for an
immediate
PCI. The procedure is used to open the occluded coronary artery and promote reperfusion to the area
that has been deprived of oxygen. Superior outcomes have been reported with use of PCI compared to
thrombolytics (Antman, et al., 2007).
Early PCI has been shown to be effective in patients of all ages, including those older than 75 years
(Chart 28-9). PCI may also be indicated in patients with unstable angina and NSTEMI who are at high
risk
due to persistent ischemia (King, Smith, Hirshfeld, et al., 2007). The procedure treats the underlying
atherosclerotic lesion. Because the duration of oxygen deprivation is directly related to the number of
myocardial cells that die, the time from the patient’s arrival in the emergency department to the time
PCI
is performed should be less than 60 minutes. This is frequently referred to as door-to-balloon time. A
cardiac catheterization laboratory and staff must be available if an emergent PCI is to be performed
within
this short time. The nursing care related to PCI is presented later in this chapter.
Cardiac Rehabilitation
After the patient with an MI is free of symptoms, an active rehabilitation program is initiated. Cardiac
rehabilitation is an important continuing care program for patients with CAD that targets risk
reduction by
means of education, individual and group support, and physical activity. It is considered to be an
important part of continuing care for patients with CAD (Thomas, King, Lui, et al., 2007). Most
insurance
programs, including Medicare, cover the cost of cardiac rehabilitation, although not all patients who
are
candidates for cardiac rehabilitation services participate in these programs.
The goals of rehabilitation for the patient who has had an MI are to extend life and improve the
quality of
life. The immediate objectives are to limit the effects and progression of atherosclerosis, return the
patient
to work and preillness lifestyle, enhance the psychosocial and vocational status of the patient, and
prevent another cardiac event. These objectives are accomplished by encouraging physical activity
and
physical conditioning, educating the patient and family, and providing counseling and behavioral
interventions.
Throughout all phases of rehabilitation, the goals of activity and exercise tolerance are achieved
through
gradual physical conditioning. Cardiac efficiency is achieved when work and activities of daily living
can
be performed at a lower heart rate and lower blood pressure, thereby reducing the heart’s oxygen
requirements and reducing cardiac workload. Physical conditioning is achieved gradually over time.
It is not unusual for patients to “overdo it” in an attempt to achieve their goals too rapidly. Patients are
observed for chest pain, dyspnea, weakness, fatigue, and palpitations and instructed to stop exercise if
any of these occur. In a monitored program, they are also monitored for an increase in heart rate
above
the target heart rate, an increase in systolic or diastolic blood pressure of more than 20 mm Hg, a
decrease in systolic blood pressure, onset or worsening of dysrhythmias, or ST-segment changes on
the
ECG.
The target heart rate during hospitalization is an increase of less than 10% from the resting heart rate,
or
120 bpm. Following discharge, the target heart rate is based on the patient’s stress test results,
medications, and overall condition. Oxygen saturation may also be assessed through pulse oximetry to
ensure that it remains higher than 93%. If signs or symptoms occur, the patient is instructed to slow
down
or stop exercising. If the patient is exercising in an unmonitored program, he or she is cautioned to
cease
activity immediately if signs or symptoms occur and to seek appropriate medical attention. Patients
who
are able to walk at 3 to 4 miles/h can usually resume sexual activities. They should be well rested and
in
a familiar setting, wait at least 1 hour after eating or drinking alcohol, and use a comfortable position.
Sexual dysfunction or cardiac symptoms should be reported to the health care provider.
Phases of Cardiac Rehabilitation
Cardiac rehabilitation programs are categorized in three phases. Phase I begins with the diagnosis of
atherosclerosis, which may occur when the patient is admitted to the hospital for ACS (eg, unstable
angina or acute MI). Because of today’s brief hospital stays, mobilization occurs earlier and patient
teaching focuses on the essentials of self-care, rather than instituting behavioral changes for risk
reduction. Research has shown that the low-level activities and initial education for the patient and
family
improve patient outcomes (Flynn, Cafarelli, Petrakos, et al., 2007). Priorities for in-hospital teaching
include the signs and symptoms that indicate the need to call 911 (seek emergency assistance), the
medication regimen, rest–activity balance, and follow-up appointments with the physician. The
patient is
reassured that although CAD is a lifelong disease and must be treated as such, most patients can
resume a normal life after an MI. This positive approach while in the hospital helps motivate and
teach the
patient to continue the education and lifestyle changes that are usually needed after discharge. The
amount of activity recommended at discharge depends on the age of the patient, his or her condition
before the cardiac event, the extent of the disease, the course of the hospital stay, and the development
of any complications.
Phase II occurs after the patient has been discharged. The patient attends sessions three times a week
for 4 to 6 weeks but may continue for as long as 6 months. This outpatient program consists of
supervised, often ECG-monitored, exercise training that is individualized based on the results of an
exercise stress test. Support and guidance related to the treatment of the disease and teaching and
counseling related to lifestyle modification for risk factor reduction are a part of this phase. Short-
term and
long-range goals are collaboratively determined based on the patient’s needs. At each session, the
patient is assessed for the effectiveness of and adherence to the treatment. To prevent complications
and
another hospitalization, the cardiac rehabilitation staff alerts the referring physician to any problems.
Outpatient cardiac rehabilitation programs are designed to encourage patients and families to support
each other. Programs may offer support sessions for spouses and significant others while the patients
exercise. The programs involve group educational sessions for both patients and families that are
given
by cardiologists, exercise physiologists, dietitians, nurses, and other health care professionals. These
sessions may take place outside a traditional classroom setting. For instance, a dietitian may take a
group of patients to a grocery store to examine labels and meat selections or to a restaurant to discuss
menu offerings for a “heart-healthy” diet.
Phase III is a long-term outpatient program that focuses on maintaining cardiovascular stability and
long-
term conditioning. The patient is usually self-directed during this phase and does not require a
supervised
program, although it may be offered. The goals of each phase build on the accomplishments of the
previous phase.