Coronary Artery Disease

MYOCARDIAL INFARCTION
 Case scenario
A 46-year- old man is brought to the
emergency department after
experiencing crushing substernal chest
pain, which was unrelieved by rest or
nitroglycerin. He is pale, cool, clammy,
and diaphoretic. He complains of
inability to take a deep breath and
nausea. His blood pressure is 105/80
mmhg, heart rate 92bpm and
respirations 28 per minute.
 Diagnostic Procedures
• Cardiac Marker Studies
• Cardiac Enzyme Analysis (CPK and CPK-M)
• Lactic Dehydrogenase (LDH)
• Troponin I
• Myoglobin
• Imaging Studies
• Echocardiography
• MRI (Magnetic Resonance Imaging)
• Transesophageal Echocardiograph
• Chest X-ray
• Cardiac Catheterization and Angiography
• Digital Subtraction Angiography
 Cardiac Marker Studies
Cardiac Enzyme Analysis (CPK and
CPK-M)

-The CPK isoenzymes test measures the

different forms of creatine phosphokinase
(CPK) in the blood. CPK is an enzyme
found mainly in the heart, brain, and
skeletal muscle.
 Cardiac Enzyme Analysis
(CPK and CPK-M)
CPK: Male- 55-170 U/L; 50- 325 mu./ml
Female- 30-135U/L; 50-250 mu./ml

Highly sensitive, specific and cost effective, accurate

indication of Myocardial Infarction

-Onset:5-6hrs
-Considerations: Factors that can affect test results include
cardiac catheterization, intramuscular injections, recent
surgery, and vigorous and prolonged exercise or
immobilization. Isoenzyme testing for specific conditions
is about 90% accurate.
 Lactic Dehydrogenase (LDH)
LDH is a blood test that measures the amount of
lactate dehydrogenase (LDH).

-Onset:12hrs, Peak:48hrs
Return to Normal: 10-14 days
NV: 100-225 mu./ml

*LDH1 most sensitive indicator of Myocardial

Infarction
 Troponin I

Troponin is released during MI from the

cytosolic pool of the myocytes. Its subsequent
release is prolonged with degradation of actin
and myosin filaments. The troponin test can be
used as a test of several different heart disorders,
including myocardial infarction.
• detectable in 3-4hrs
• Peak: 4-24hrs
• remains elevated for 1-3wks
 Myoglobin

Myoglobin tests are done to evaluate a

person who has symptoms of a heart
attack (myocardial infarction) or other
muscle damage.
• rises in 1-3hrs
• Peak: 4-12hrs
• Normal by 12-24hrs; also elevated in renal
and musculoskeletal disease.
 Myoglobin

Preparation:
This test requires 5 ml of blood. Collection of the sample
takes only a few minutes. A urine myoglobin test requires
1 ml of urine collected into a urine collection cup.

Aftercare:
Discomfort or bruising may occur at the puncture site or
the person may feel dizzy or faint. Pressure to the
puncture site until the bleeding stops reduces bruising.
Warm packs to the puncture site relieve discomfort.
 Imaging Studies
Echocardiography
-uses sound waves to produce an image of the
heart
-uses ultrasound to assess cardiac structure and
mobility

*instruct the patient to remain still, in supine

position.
*Head of Bed is elevated to 15 degrees to 20
degrees (greater than 20 degrees-orthopnea)
 Magnetic Resonance Imaging (MRI)

-detect and define

between healthy and
diseased tissues.
-use strong magnetic field
and waves.
-can actually show the
heart beating and blood
flowing.
Magnetic Resonance Imaging (MRI)
Pre-procedural tee:
• secure consent,
procedure will last 45-
60min.
• remove all metals
• clients with
pacemaakers,
prosthetic valves/
implanted clips or
wires are not eligible.
• assess if the patient is
claustrophobic, it
makes a loud, knocking
noise.
 Transesophageal Echocardiograph
-allows ultrasonic imaging of the valves, cardiac
structures and great vessels via esophagus.
Transesophageal Echocardiography

Pre-procedural Tee:
• NPO(4-6hrs)
• Remove dentures and other oral prosthetics
• Assess for the history of esophageal surgery or
allergy to anesthetics.
• Keep suction and resuscitation equipment
available.
• Topical spray anesthesia is administered to
depress gag reflex.
• Place client in chin-to-chest position to facilitate
endoscope.
 Transesophageal Echocardiograph

Post-procedural Tee:
• NPO until gag reflex returns
• Place in lateral or semi-fowlers position
• Throat lozenges to relieve sore throat
soreness
• Observe for laryngeal edema, cardiac
dysrrhythmias, pharyngeal bleeding and
hypoxia
 Chest X-ray

To determine overall size and

configuration of the heart and
size of the cardiac chambers.
 Cardiac Catheterization and
Angiography
Purpose:
• evaluate function
• measure heart chamber pressures
• measure Oxygen Saturation
• Biopsy
• Performing electrophysiologic studies

Complication:
• Acute hemorrhage
• Transient Arrhythmias
• Nausea and Vomitting
Cardiac Catheterization and
Angiography
 Cardiac Catheterization and Angiography
Before the Procedure:
• NPO (6-8hrs)
• Mild IV or oral sedative will be given; local anesthesia to
the insertion site.
• Warm, light headedness or nausea will be felt after the
contrast medium is injected.
• cough or breathe deeply as instructed during the test
• metallic taste
After the procedure:
• Dye will be eliminated
• Supine for several hours; report chest pain
• Femoral: leg straight 12hrs or as ordered. Head elevation
not more than 30 degrees.
• Brachial: arm straight for at least 24hrs or as ordered
• Check insertion site- weak or absent pulse indicates
embolus
 Digital Subtraction Angiography

-a type of fluoroscopy technique used in

interventional radiology to clearly visualize
blood vessels in a bony or dense soft tissue
environment. Images are produced using
contrast medium by subtracting a pre-contrast
image or the mask from later images, once the
contrast medium has been introduced into a
structure.

After the DSA:

-the individual needs to lie still for about 6 hours to
prevent bleeding.
Digital Subtraction Angiography
 Patient Management

Medical management
• Immediate assessment
• 12 lead ECG stat! ,10min
• Measure Oxygen and saturation
• Obtain initial serum cardiac cardiac marker level
• Evaluate initiate electrolyte and coagulation
studies
• Chest x-ray within 30mins.
 IMMEDIATE GENERAL
TREATMENT
1. Morphine- Drug of choice as analgesic for episodes of M.I
ACTION- Cardiac workload to decrease body’s demand for oxygen
- dilates bronchioles to enhance oxygenation
- given if pain is unrelieved by Nitroglycerin
- Monitor B.P may cause unexpected Hypotension

2. Oxygen at 4 LPM via facemask

3. Nitroglycerin (Nitrates)- sublingual or spray (0.3- 0.4mg) for 3

times@ 5 mins. Interval
ACTION: - decrease myocardial oxygen consumption
Contraindications: Hypotension, Bradycardia <60 bpm

4. Aspirin- 160-325 mg (initially)

 Additional Adjunctive Therapies
• Beta blockers-
-reduces myocardial oxygen consumption by blocking B-
Adrenergic sympathetic stimulation in the heart
NURSING CONSIDERATIONS:
Monitor BP, ECG, HR, never discontinue abruptly
• Thrombolytics
– Heparin
– Enoxaparin (Lovenox

Available bedside Meds as Antidote:

1. Aminocaproic Acids
2. Protamine Sulfate
3. Vitamin K (Aqua Mephyton)
Nursing Consideration for Thrombolytics
Regimen:
• Minimize the number of times the patient’s skin
is punctured
• Avoid I.M injections as much as possible
• Check for signs and symptoms of bleeding-
epistaxis, rashes, petichiae, gingical bleeding
• Apply direct pressure @ puncture sites
• Assess coagulation profile prior to
administration
• Monitor and watch out for decrease BP, increase
heart rate and decrease hemoglobin and
hematocrit profile.
 Additional Adjunctive Therapies
ACE Inhibitors
ACTION- promotes vasodilation and diuresis by decreasing
preload and decreasing afterload= decrease cardiac workload

NURSING MANAGEMENT
ASSESSMENT
• Renal fluid, electrolyte
• Monitor baseline date: ECG, BP, HR, RR
• Evaluate liver function
• Monitor and watch out for hypotension, hypovolemia,
Hyperkalemia
• Prior to initiation of ACE inhibitors, hyperkalemia is first
corrected
• Not given when potassium is 5.0 mEq/L
• Weigh patient daily to report rapid weight gain and assess for
feet and hand edema.
 SURGICAL APPROACH FOR M.I:

2. PTCA- Percutaneous Transluminal

Coronary Angioplasty

2. CABG- Coronary Artery Bypass Grafting

NURSING MANAGEMENT IN GENERAL
FOR M.I PATIENTS:
• Initiate an I.V line
• limit hydration
• Oxygenation, keep patient in high fowlers o fowler’s
position
• Keep patient well rested
• Monitor ECG ad hemodynamic procedure
• Assess urine output of 4
• Monitor patient oxygen saturation
• Watch out for crackles, cough, increased RR and edema
• INSTITUTE DIET: low salt, low fat- no caffeine added
• Give stool softener- prevents Valsalva Maneuver
NURSING MANAGEMENT IN GENERAL
FOR M.I PATIENTS:

Health Teaching about:

• Ways of controlling cholesterol
abnormalities through dietary measures
and physical activity
• Cessation of smoking
• Managing hypertension
• Controlling DM
 Prepared by:

ANTOLIN, RANDOLPH O.
CERRERA, CHRISTINE JANE D.
CUACHIN, ROSEMARIE
CAGUIOA, MARIVIC
ENGNAN, MARY JHANE D.
FALLEJO, JESSICA MARIE P.
PERMEJO, NESSIE A.

Thank you! God Bless Us…