Concept Map for Anterior Myocardial Infarction

I. INTRODUCTION AND OBJECTIVES

A myocardial infarction or heart attack is a deadly medical emergency where the
heart muscle begins to die because there isn’t enough blood flow. The lack of blood
flow can occur because of many different factors but is usually caused by a blockage
in one or more of the heart’s arteries. When a heart attack happens, blood flow to a
part of your heart stops or is far below normal, which causes that part of your heart
muscle to die. When a part of your heart can’t pump because it’s dying from lack of
blood flow, it can disrupt the pumping sequence for the entire heart. That reduces or
even stops blood flow to the rest of your body, which can be deadly if it isn’t
corrected quickly.
According to research submitted to PubMed on 2020, globally, an estimate of
126 million individuals or 1,655 per 100,000 are affected by IHD which is
approximately 1.71% of the world’s population. There has been a total of nine million
deaths tallied that was caused by IHD. Men were more commonly affected than
women, and incidence typically started in the fourth decade and increased with age.
The global prevalence of IHD is rising. It is estimated that the current prevalence
rate of 1,655 per 100,000 population is expected to exceed 1,845 by the year 2030.
Eastern European countries are sustaining the highest prevalence.
Incidence of cardiovascular diseases (CVD) in the Philippines based on the
Philippine Heart Association survey among hospital-based population showed
hypertension as the highest (38.6%), followed by stroke (30%), coronary artery
disease (CAD) (17.5%), and heart failure (10.4%). Based on Philippine FNRI data,
the prevalence of coronary, cerebrovascular, and peripheral arterial diseases were
1.1%, 0.9%, and 1.0%, respectively. Cardiovascular risk factor prevalence was the
following: diabetes at 3.9%, dyslipidemia at 72%, smoking at 31%, obesity at 4.9%
(BMI), and 10.2% and 65.6% by waist-hip ratio in men and women, respectively.
Bohol tallied 1,428 cases for cardiovascular diseases with a rate of 115.3.
The objectives of this case analysis are to supply information that creates
understanding for the readers about anterior myocardial infarction. This case
analysis also displays clinical presentations of the information about myocardial
infarction. Another object of this case analysis is for the readers or audience to
become actively engaged in the issues and problems posed in the case, to explain
the assessments, and to propose workable solutions may it be medically of
pharmacologically.
II. PATHOPHYSIOLOGY AND MANAGEMENT

ETIOLOGY - Myocardial infarctions (MIs) result from an acute thrombus that obstructs an atherosclerotic coronary
artery. Plaque rupture and erosion are the major triggers for coronary thrombosis. Following plaque erosion or
rupture, platelet activation and aggregation, coagulation pathway activation, and endothelial vasoconstriction occur,
leading to coronary thrombosis and occlusion. Risks include age, sex, family history, male-pattern baldness, smoking,
hypertension, diabetes, obesity, and psychosocial stress.

SIGNS AND SYMPTOMS – Fatigue, Chest Discomfort (often radiates

up to the neck, shoulder, jaw, and down to the left arm, described as
PATHPHYSIOLOGY - Myocardial infarction is
a substernal pressure sensation), Malaise, Tachycardic, irregular
usually due to thrombotic occlusion of a
pulse, hypotension for right ventricular MI, hypertension for
coronary vessel caused by rupture of a
ventricular dysfunction, elevated respiratory rate, coughing with
vulnerable plaque. Ischemia induces profound
frothy sputum, wheezing, anxiety, lightheadedness, nausea, and
metabolic and ionic perturbations in the
shortness of breath.
affected myocardium and causes rapid
depression of systolic function. Severe loss of
the ability of the heart muscle cell to contract
can be observed as early as within 60 seconds. DIAGNOSTIC TEST/
Persistence of oxygen deprivation to the EVALUATION TOOLS –
myocardium through the cessation of blood Cardiac MANAGEMENT – Administration
Biomarkers/Enzymes, of SL nitroglycerin, Aspirin,
supply will lead to irreversible myocardial injury
Troponin Levels, CBC, Nitrates, Analgesia, PCI, O2
within 20 to 40 minutes and up to several hours, Therapy.
depending on several factors including the Comprehensive
existing metabolic state of the body and Metabolic Panel, Lipid
presence of coronary collateral blood flow. Profile, ECG, Cardiac
Imaging.
 IF NOT TREATED IF TREATED

MEDICAL SURGICAL NURSING MANAGEMENT

PROGNOSIS - During a heart
attack, blood flow to the heart
stops due to a blockage in a
coronary artery. These are the
arteries that carry blood to the
heart. If a person does not receive
immediate treatment, this lack of
blood flow can cause damage to
the heart. Complications arising
from this situation include
Arrhythmias, Cardiogenic shock,
and Heart failure. The longer a
heart attack is left untreated, the
more damage that occurs and the
worse the outcome becomes.
 Monitor and document characteristic of pain, noting verbal
reports, nonverbal cues (moaning, crying, grimacing, restlessness,
diaphoresis, clutching of chest) and BP or heart rate changes.
 Obtain full description of pain from patient including location,
intensity (using scale of 0–10), duration, characteristics (dull,
crushing, described as “like an elephant in my chest”), and
radiation. Assist patient to quantify pain by comparing it to other
experiences.
 Review history of previous angina, anginal equivalent, or MI pain.
Discuss family history if pertinent.
 Instruct patient to report pain immediately. Provide quiet
environment, calm activities, and comfort measures. Approach
patient calmly and confidently.
 Instruct patient to do relaxation techniques: deep and slow
breathing, distraction behaviours, visualization, guided imagery.
Assist as needed.
 Check vital signs before and after narcotic medication.
 Administer supplemental oxygen by means of nasal cannula or
face mask, as indicated.
 Administer anticoagulant medication, Enoxaparin Na as per
doctor’s order.
 Administer vasodilator, ISMN as per doctor’s order.
 Administer NSAID, ASA as per doctor’s order.
 Administer anti-anginal medication, ISDN as per doctor’s order.
 Administer analgesic, Paracetamol as per doctor’s order.
 Administer laxative, Lactulose as per doctor’s order.
 Perform percutaneous coronary intervention if patient’s condition

PROGNOSIS - Better prognosis is associated with the following factors:

Successful early reperfusion (ST-elevation MI [STEMI] goals: patient arrival to
fibrinolysis infusion within 30 minutes OR patient arrival to percutaneous
coronary intervention [PCI] within 90 minutes) Preserved left ventricular
function Short-term and long-term treatment with beta-blockers, aspirin, and
angiotensin-converting enzyme (ACE) inhibitors

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. Plaque rupture and
erosion are the major triggers for coronary thrombosis. Following plaque erosion or
rupture, platelet activation and aggregation, coagulation pathway activation, and
endothelial vasoconstriction occur, leading to coronary thrombosis and occlusion. Within
the coronary vasculature, flow dynamics and endothelial shear stress are implicated in
the pathogenesis of vulnerable plaque formation. A large body of evidence indicates
that in numerous cases, culprit lesions are stenoses of less than 70% and are located
proximally within the coronary tree. Coronary atherosclerosis is especially prominent
near branching points of vessels. Culprit lesions that are particularly prone to rupture
are atheroma containing abundant macrophages, a large lipid-rich core surrounded by a
thinned fibrous cap.

Nonmodifiable risk factors for atherosclerosis include the following: age, sex,
family history of premature coronary heart disease, male-pattern baldness. Modifiable
risk factors for atherosclerosis include the following: smoking or other tobacco use,
hypercholesterolemia, and hypertriglyceridemia, including inherited lipoprotein disorders
dyslipidemia, diabetes mellitus, hypertension, obesity (abdominal obesity), psychosocial
stress, sedentary lifestyle and/or lack of exercise, reduced consumption of fruits and
vegetables, poor oral hygiene, type a personality elevated homocysteine level,
presence of peripheral vascular disease. MI can also occur for causes other than
atherosclerosis. In addition, MI can result from hypoxia due to carbon monoxide
poisoning or acute pulmonary disorders. Although rare, pediatric coronary artery
disease may be seen with Marfan syndrome, Kawasaki disease, Takayasu arteritis,
progeria, and cystic medial necrosis. Acute MI is rare in childhood and adolescence.
Although adults acquire coronary artery disease from lifelong deposition of atheroma
and plaque, which causes coronary artery spasm and thrombosis, children with acute
MI usually have either an acute inflammatory condition of the coronary arteries or an
anomalous origin of the left coronary artery. Intrauterine MI also does occur, often in
association with coronary artery stenosis.

The signs and symptoms of MI are fatigue, chest discomfort (often radiates up to
the neck, shoulder, jaw, and down to the left arm, described as a substernal pressure
sensation), malaise, tachycardic, irregular pulse, hypotension for right ventricular mi,
hypertension for ventricular dysfunction, elevated respiratory rate, coughing with frothy
sputum, wheezing, anxiety, lightheadedness, nausea, and shortness of breath. the
diagnostic test that will confirm MI are Cardiac Biomarkers/Enzymes, Troponin Levels,
CBC, Comprehensive Metabolic Panel, Lipid Profile, ECG, Cardiac Imaging. The
managements that can alleviate these signs and symptoms are administration of SL
nitroglycerin, aspirin, nitrates, analgesia, PCI, O2 therapy.

During a heart attack, blood flow to the heart stops due to a blockage in a
coronary artery. These are the arteries that carry blood to the heart. If a person does not
receive immediate treatment, this lack of blood flow can cause damage to the heart.
Complications arising from this situation include Arrhythmias, Cardiogenic shock, and
Heart failure. The longer a heart attack is left untreated, the more damage that occurs
and the worse the outcome becomes.

These are the pharmacologic, medical, and nursing interventions. Monitor and
document characteristic of pain, noting verbal reports, nonverbal cues (moaning, crying,
grimacing, restlessness, diaphoresis, clutching of chest) and BP or heart rate changes.
Obtain full description of pain from patient including location, intensity (using scale of 0–
10), duration, characteristics (dull, crushing, described as “like an elephant in my
chest”), and radiation. Assist patient to quantify pain by comparing it to other
experiences. Review history of previous angina, anginal equivalent, or MI pain. Discuss
family history if pertinent. Instruct patient to report pain immediately. Provide quiet
environment, calm activities, and comfort measures. Approach patient calmly and
confidently. Instruct patient to do relaxation techniques: deep and slow breathing,
distraction behaviours, visualization, guided imagery. Assist as needed. Check vital
signs before and after narcotic medication. Administer supplemental oxygen by
means of nasal cannula or face mask, as indicated. Administer anticoagulant
medication, Enoxaparin Na as per doctor’s order. Administer vasodilator, ISMN as per
doctor’s order. Administer NSAID, ASA as per doctor’s order. Administer anti-anginal
medication, ISDN as per doctor’s order. Administer analgesic, Paracetamol as per
doctor’s order. Administer laxative, Lactulose as per doctor’s order. Perform
percutaneous coronary intervention if patient’s condition worsens.

Better prognosis is associated with the following factors: Successful early

reperfusion (ST-elevation MI [STEMI] goals: patient arrival to fibrinolysis infusion within
30 minutes OR patient arrival to percutaneous coronary intervention [PCI] within 90
minutes) Preserved left ventricular function Short-term and long-term treatment with
beta-blockers, aspirin, and angiotensin-converting enzyme (ACE) inhibitors
III. DISCHARGE PLANNING
Patients with active symptoms of acute coronary syndrome (ACS) should
be instructed to call emergency services, and they should be transported by
emergency medical services personnel, not by themselves, family, or friends.
Patients should be instructed to go to the emergency department immediately if
the suspected ACS symptoms last longer than 20 minutes at rest or are
associated with near syncope/syncope or hemodynamic instability. If nitroglycerin
is prescribed to a patient with suspected ACS, the patient should be instructed to
 take a dose if symptoms arise. If no relief is experienced 5 minutes after the first
dose, the patient should contact emergency services. If relief is experienced
within 5 minutes of the first nitroglycerin dose, repeated doses can be given
every 5 minutes for a maximum of 3 doses total. If by then the symptoms have
not yet fully resolved, the patient, a family member, or a caregiver should contact
emergency services. Diet plays an important role in the development of coronary
artery disease (CAD). Educate post–myocardial infarction (MI) patients about the
role of a low-cholesterol and low-salt diet. A dietitian should see and evaluate all
patients prior to discharge from the hospital. Additionally, emphasis on exercise
training should be made, because current evidence demonstrates that cardiac
rehabilitation after MI results in lower rates of recurrent cardiovascular events. All
patients should be educated regarding the critical role of smoking in the
development of CAD. Smoking cessation classes should be offered to help
patients avoid smoking after their MI.
IV. RELATED NURSING THEORY
This case analysis is supported by Dorothea E. Orem’s theory
which is Self-care Deficit Nursing theory. The central philosophy of the Self-Care
Deficit Nursing Theory is that all patients want to care for themselves, and they
can recover more quickly and holistically by performing their own self-care as
much as they’re able. This theory is particularly used in rehabilitation and primary
care or other settings in which patients are encouraged to be independent.
Dorothea Orem’s Self-Care Deficit Nursing Theory is that it can
easily be applied to a variety of nursing situations and patients. The generality of
its principles and concepts makes it easily adaptable to different settings, and
nurses and patients can work together to ensure that the patients receive the
best care possible but are also able to care for themselves.
V. REVIEW OF RELATED LITERATURE
A. Acute Myocardial Infarction
Author: Oren J. Mechanic; Michael Gavin; Shamai A. Grossman
Acute myocardial infarctions are one of the leading causes of
death in the developed world, with prevalence approaching three million
people worldwide, with more than one million deaths in the United States
annually. This activity reviews the presentation, evaluation, and
management of patients with acute myocardial infarctions and highlights
the role of the interprofessional team in caring for these patients.
Objectives:
 Describe the difference in time to peak and duration between
troponin, creatine kinase MB, and LDH.
 Describe how to evaluate a patient who presents with diaphoresis
and chest pain that radiates to bilateral arms.
 Describe the difference in management between ST-elevation
myocardial infarction, non-ST-elevation myocardial infarction, and
unstable angina.
 Review how interprofessional team strategies to improve care
interprofessional team coordination for patients with acute
myocardial infarctions.
B. Epidemiology of Myocardial Infarction
Author: Joshua Chadwick Jayaraj, Karapet Davatyan, S.S. Subramanian
and Jemmi Priya
Abstract: Coronary heart disease (CHD) is the leading cause of morbidity
and mortality throughout the world. The most common form of CHD is the
myocardial infarction. It is responsible for over 15% of mortality each
year, among most people suffering from non-ST-segment elevation
myocardial infarction (NSTEMI) than ST-segment elevation myocardial
infarction (STEMI). The prevalence of myocardial infarction (MI) is higher
in men in all age-specific groups than women. Although the incidence of
MI is decreased in the industrialized nations partly because of improved
 health systems and implementation of effective public health strategies,
nevertheless the rates are surging in the developing countries such as
South Asia, parts of Latin America, and Eastern Europe. The modifiable
risk factors represent over 90% of the risk for acute MI. The risk factors
such as dyslipidemia, smoking, psychosocial stressors, diabetes mellitus,
hypertension, obesity, alcohol consumption, physical inactivity, and a diet
low in fruits and vegetables were strongly associated with acute MI.
C. The Process of Care-seeking for Myocardial Infarction Among Patients
with Diabetes
Author: Ängerud, Karin Hellström RN, MSc; Brulin, Christine RNT, PhD;
Eliasson, Mats MD, PhD; Näslund, Ulf MD, PhD; Hörnsten, Åsa RN, PhD
Abstract:
Background: People with diabetes have a higher risk for myocardial
infarction (MI) than do people without diabetes. It is extremely important
that patients with MI seek medical care as soon as possible after
symptom onset because the shorter the time from symptom onset to
treatment, the better the prognosis.
Objective: The aim of this study was to explore how people with diabetes
experience the onset of MI and how they decide to seek care.
Methods: We interviewed 15 patients with diabetes, 7 men and 8 women,
seeking care for MI. They were interviewed 1 to 5 days after their
admission to hospital. Five of the participants had had a previous MI; 5
were being treated with insulin; 5, with a combination of insulin and oral
antidiabetic agents; and 5, with oral agents only. Data were analyzed
according to grounded theory.
Results: The core category that emerged, “becoming ready to act,”
incorporated the related categories of perceiving symptoms, becoming
aware of illness, feeling endangered, and acting on illness experience.
Our results suggest that responses in each of the categories affect the
care-seeking process and could be barriers or facilitators in timely care-
seeking. Many participants did not see themselves as susceptible to MI
and MI was not expressed as a complication of diabetes.
Conclusions: Patients with diabetes engaged in a complex care-seeking
process, including several delaying barriers, when they experienced
symptoms of an MI. Education for patients with diabetes should include
discussions about their increased risk of MI, the range of individual
variation in symptoms and onset of MI, and the best course of action,
when possible, symptoms of MI occur.
D. Global Epidemiology of Ischemic Heart Disease: Results from the Global
Burden of Disease Study
Author: Moien Ab Khan, Muhammad Jawad Hashim, Halla Mustafa, May
Yousif Baniyas, Shaikha Khalid Buti Mohamad Al Suwaidi, Rana
AlKatheeri, Fatmah Mohamed Khalfan Alblooshi, Meera Eisa Ali Hassan
Almatrooshi, Mariam Eisa Hazeem Alzaabi, Reem Saif Al Darmaki,
Shamsa Nasser Ali Hussain Lootah
Abstract:
Ischemic heart disease (IHD) is a leading cause of death
worldwide. Also referred to as coronary artery disease (CAD) and
atherosclerotic cardiovascular disease (ACD), it manifests clinically as
myocardial infarction and ischemic cardiomyopathy. This study aims to
evaluate the epidemiological trends of IHD globally. Methods The most
up-to-date epidemiological data from the Global Burden of Disease (GBD)
dataset were analyzed. GBD collates data from a large number of
sources, including research studies, hospital registries, and government
reports. This dataset includes annual figures from 1990 to 2017 for IHD in
all countries and regions. We analyzed the incidence, prevalence, and
disability-adjusted life years (DALY) for IHD. Forecasting for the next two
decades was conducted using the Statistical Package for the Social
 Sciences (SPSS) Time Series Modeler (IBM Corp., Armonk, NY). Results
Our study estimated that globally, IHD affects around 126 million
individuals (1,655 per 100,000), which is approximately 1.72% of the
world's population. Nine million deaths were caused by IHD globally. Men
were more commonly affected than women, and incidence typically
started in the fourth decade and increased with age. The global
prevalence of IHD is rising. We estimated that the current prevalence rate
of 1,655 per 100,000 population is expected to exceed 1,845 by the year
2030. Eastern European countries are sustaining the highest prevalence.
Age-standardized rates, which remove the effect of population changes
over time, have decreased in many regions. Conclusions IHD is the
number one cause of death, disability, and human suffering globally. Age-
adjusted rates show a promising decrease. However, health systems
must manage an increasing number of cases due to population aging.

VI. REFERENCES
 Oren J. Mechanic; Michael Gavin; Shamai A. Grossman, O. J. M. M. G. S. A. G.
(2021). Acute Myocardial Infarction. Acute Myocardial Infarction. Published.
https://www.ncbi.nlm.nih.gov/books/NBK459269/
 Joshua Chadwick Jayaraj, Karapet Davatyan, S.S. Subramanian And Jemmi Priya,
J. C. J. K. D. S. S. S. J. P. (2018). B.Epidemiology of Myocardial Infarction.
B.Epidemiology of Myocardial Infarction. Published.
https://www.intechopen.com/chapters/59778
 C.The Process Of Care-seeking For Myocardial Infarction Among Patients With
Diabetes, C. T. P. C.-M. I. A. P. D. (2018). C.The Process of Care-seeking for
Myocardial Infarction Among Patients with Diabetes. C.The Process of Care-
Seeking for Myocardial Infarction Among Patients with Diabetes. Published.
https://doi.org/10.1097/JCN.0000000000000195
 Moien Ab Khan, Muhammad Jawad Hashim, Halla Mustafa, May Yousif
Baniyas, Shaikha Khalid Buti Mohamad Al Suwaidi, Rana AlKatheeri, Fatmah
Mohamed Khalfan Alblooshi, Meera Eisa Ali Hassan Almatrooshi, Mariam Eisa
Hazeem Alzaabi, Reem Saif Al Darmaki, Shamsa Nasser Ali Hussain Lootah, M.
A. K. M. J. H. H. M. M. Y. B. S. K. B. M. A. S. R. A. K. F. M. K. A. M. E. A. H.
A. M. E. H. A. R. S. A. D. S. N. A. H. L. (2020). D.Global Epidemiology of
Ischemic Heart Disease: Results from the Global Burden of Disease Study.
D.Global Epidemiology of Ischemic Heart Disease: Results from the Global
Burden of Disease Study. Published. https://pubmed.ncbi.nlm.nih.gov/32742886/