Myocardial Infarction

-Limited blood supply to the myocardial tissue causing DEATH OR NECROS

-Characterized by an acute onset of myocardial ischemia that results in myocardial death (i.e., MI) if
definitive interventions do not occur promptly.

Causes

Blockage in coronary artery due to coronary artery disease or coronary spasm like drug abuse (cocaine),
and uncontrolled hypertension so what happens is the coronary constricts therefore no blood supply
causing death. Damage to artery due to coronary artery dissection results to tear in inner layer “tunica
intima” causes leakage in tunica media causing limitation to size of coronary artery, causing constriction
or restricted blood flow

Anaphy

These coronary artery branch off from aorta which receives rich oxygenated blood from lungs then they
supply the heart muscle a fresh blood para mag function properly

Right coronary artery supplies RIGHT ATRIUM AND VENTRICLE

Right marginal- supplies RIGHT ventricle and septum

LEFT CORONARY ARTERY- supplies LEFT side of heart

LEFT CIRCUMFLEX- supplies LEFT atrium and ventricle (branches of into arius, around heart) pos

LEFT ANTERIOR DESCENDING- COMMON SITE OF BLOCKAGE – supplies most of artery, right ventricle,
left ventri, septum- can cause worse damage (anterior wall MI)
Before we proceed to assessment, we must know the process of the disease.

So MI happens when the patient is exposed or there’s presence of risk factors like what Ms. Sirbough
said which is the acronyms SSODA and other factors like high intake of cholesterol and uncontrolled
hypertension, so if these factors are present, the patient may be at risk for myocardial infarction due to
damage to artery wall, so the ldl which is the bad cholesterol will stick to the artery and they will build
up eventually, causing blockage to blood flow so as a result, the remaining or the following path will not
receive blood supply, causing death. Another reason for MI is when these plaques, these build up
cholesterol ay nag burst or nag rupture, the body will thought na may sira ang artery wall so as a
response, magpapadala sya ng platelets to repair the rupture, so may plaque na nga, may platelets pang
pumunta, so maboblock din ang daluyan ng dugo, leading to MI.

For the signs and symptoms na maaassess natin sa patient are the following, so if the patient complains
my chest “ACHES” she may be suffering MI. A stands for anxiety, pag nahihirapan huminga, sumasakit
dibdib, magkakaron na ng anxiety si patient, kung ano ano na naiisp nya na siguro “mamamatay na sya”
dahil di makahinga, next is c for chest pain, dahil naiimpede ang flow, yung pressure sa heart tumataas
dahil cinocompensate ng body yung “walang blood supply” sa heart, so pump sya ng pump causing chest
pain or angina, and if may chest pain at tumataas ang pressure, maglelead to sa hypertension, and
elevated heart rate dahil nga pump nang pump, and mapapansin din natin kay patient na nagssweat sya
ng malamig, diaphoretic sya, gaya nga ng sabi ni ma’am Regie, kaya nyang basain ang kama, due to
severe pain na nararamdaman nya. And also since may chest pain si patient it is accompanied by pain
radiating sa left arm, shoulder, back and jaw, suspect that she is having MI. another thing na
mapapansin natin sa patient is the levines sign wherein it is identified as holding a clenched fist over the
chest, as seen in the picture, so pag nakita natin si patient na may levines sign, she may be having MI.

To diabetic patients, they may undergo silent MI kung saan wala silang mararamdaman na pain due to
diabetic neuropathy, means damage ang kanilang nerves kaya di nila alam nag MMI na pala sila,
nababalewala lang nila.

So to confirm these assessments, these signs and symptoms, the doctor will or may order ECG and Lab
test.

In ECG or electrocardiogram, it records electrical signal from the heart. So walang bonggang preparation
prior to the procedure, no withholding of food and medication, dapat lang ay tanggalin ang nga metals
like jewelry and mag shave para sa mabubuhok na pt kasi hindi mag sstick properly sa skin yung
electrodes. So the procedure of this ay tatanggalin damit ni pt, ilalagay ang electrodes sa chest and limbs
and irerecprd ang activity ng heart as it contracts through electrocardiograph and this procedure last for
abt 5-10 mns lang. The result na makikita natin if positive talaga sa MI is merong ST elevation. To read
ECG, merong P Q R S T, and sa ST segment ng ecg, nag elevate sya, as seen in the picture means there is
total blockage sa all layers ng heart. Pag naman ST depression, or bumaba yung line, ibig sabihin lang
non may infarction sa one layer ng heart sa subendocardial layer.

Lab test- sa lab test, these identifies enzymes na supposed to be hindi sila present sa blood, so
narerelease ang mga cardiac biomakers or enzymes na to kapag may cardiac damage. So ang specific
dito or ang gold standard biomaker ay pag merong troponin na nadetect (I & T) sa blood dahil specific
lang ito sa cardiac muscle. So once nag present si pt ng chest pain or any ther symptoms of MI, draw ng
blood, at the first hour, the result may be negative, but draw again after 3-4 hours of onset of s/sx dahil
ang peak onset or mag eelavate lanh ito around 3 hours, so repeat the test to really confirm MI.

Another enzymes na elevated ay creatin kinase MB at ang onset nya ay around 3 hours post injury and
last is the myoglobin wherein ito yung unang narerelease omce may problem sa heart but hindi sya
specific sa cardiac muscle kaya need further test kasi it includes skeletal muscles din.

Treatment

Anticoagulants commonly known as blood tinners are often given to make Blood less viscous ( warfarin)
(anti thrombotics + antiplatelets)

Antithrombotics- prevent formation of clot wherein it dissolve clots to improve flow, bcs as we
discussed a while a go, arteries may become block, so there’s rupture of a plaque, then all clotting factor
will form causing thrombus resulting to more problem dahil mas binoblock nya daluyan ng blood.
Monitor international normalized ratio and partial thromboplastin time to measure how long it takes for
clot to form.

Lovenox- subq- monitor for bleeding (gums, stools, urine, bp low increase hr)

Heparin- drip- monitor for bleeding too, watch platelet level bcs once dropped it is called heparin induced
thrombocytopenia (HIT) – less than 150k and if happens, papachange ng doctor ang meds to argatroban
or angiomax

Collect ptt partial thromboplastin time

n- 25-35 sec

Antiplatelets- works by decreasing platelet aggregation and thrombus formation

Aspirin- low dose- decreases clot forming, 2-4 tab 80 mg

Watch for GI bleeding

Plavix- if cant take aspirin-, thrombotic compli- thrombocytopenia purpura (ttp) – clots form in blood
vessel, decrease blood flow to vital organs – mani- decrease platelet, neuro changes, renal failure, fevrr,
anemia, bruising)

If for surgery- inform dx bcs it takes a while for the body to clear plavix up to 5-7 days

M- MORPHINE – for chest pain (not releive by nitroglycerin) IV route- watch for hypotension and respi
depression

NITRATES-nitroglycerin- given ointment, sublingual, iv, transdernal patch – treatment for angina as it
promotes the dilation of blood vessels and improves flow. It vasodilates coronary arteries and this
causes increase blood flow to the heart so if may schemia, bigay nitro to open up coronary arteries so
that blood can get to myocytes that are being deprive of nutrients. Monitor bp bcs it can cause massive
drop in bp, assess chest pain, ekg side effect- headache- dahil may vasodilation, lahat ng blood
nagpupump sa head, flushing and dizzy

NITRATE- given every 5 mns for 3 times if di narelieve, dalhin na sa ospi.

ACE INHIBITOR – ANGIOTENSIN converting enzymes inhibitors- “pril” medication – lisinopril,- blocks
conversion of angiotensin 1 to 2 which causes vasidilation and drops in bp for it lowers blood pressure
and reducing the strain on the heart muscles. Side effect – dry nagging cough, increase potassium level(-
it decreases aldosterone in the body which causes body to retain k+ and excrete sodium) hyperkalemia

BETA BLOCKERS- “coreg, lopressor” – “lol meds” – decreases worklpad on heart so it helps the heart
pump more effectively which causes slow hr, lower bp, so dapat monitor lalo na sa diabetic px bcs it
masks the symptoms of Hypoglycemia which includes tachycardia, hence sa beta blockers di magkakaron
tachycardia or sweating so monitor blood sugar closely,

Asthma- causes bronchospasm

Don’t take with grape fruit juice bcs it decreases beta blocker absorption)

ARBS- ANGIOTENSIN RECEPTOR BLOCKERS-“sartan” losartan- same with ace inhibitor wherein it blocks
angiotensin 2 then you get vasodilation, but in arbs you don’t get dry nagging cough,

CHOLESTEROL LOWERING MEDICATIONS- “statins” – px has high cholesterol level develop MI due to
aterosclerostic and plaque rupture- works by lowering ldl which is bad cholesterol, total cholesterol,
triglyceride and helps increase hdl which is good cholesterol wherein ang work in hdl is to detached ldl.

Educate px that it doesn’t replace diet snd exercise--- notify md if may muscle pain, monitor cpk level to
check if may muscle damage and monitor liver function bcs it works by lowering cholesterol so dapat
nagwowork properly ang liver

CALCIUM CHANNEL BLOCKERS – Norvasc, cardizem

used to lower blood pressure. They work by preventing calcium from entering the cells of the heart and
arteries. Calcium causes the heart and arteries to squeeze (contract) more strongly. By blocking calcium,
calcium channel blockers allow blood vessels to relax and open.

to stop transport of calcium to myocardium muscle and smooth muscle so whenever this happens you
get vasodilation of coronary artery that sets on the heart that feeds blood supply.

Monitor hr and hypotension and educate px since maraming blood flow, it may cause hyperplasia of
gums or enlargement of gums so dapat may good oral hygiene while taking calcium channel blocker

Diet
Low sodium- help lower blood pressure

Low fat- to prevent build up of cholesterol

Low sugar – to prevent blood making viscous