MYOCARDIAL

INFARCTION
CONTENTS:
1. INTRODUCTION
2. DEFINITION
3. RISK FACTORS
4. ETIOPATHOPHYSIOLOGY
5. CLINICAL FEATURES
6. INVESTIGATION
7. MANAGEMENT
8. COMPLICATION
9. PREVENTIONS
10. ASSESMENT
 MYO CARDIAL -
INFARCTION

Muscle heart tissue death

because of lack of blood
supply in heart.
INTRODUCTION
 MYOCARDIAL INFRACTION (MI)

HEART ATTACK
In MI area of myocardium is permanently
destroyed.
Usually caused by reduced or decreased blood
flow in a coronary artery due to rupture of
atherosclerotic plaque and occlusion of artery by
thrombus.
DEFINITION
 Defined as necrosis of a portion
of the myocardium.
It is associated with acute
coronary syndrome.
RISK FACTORS
ETIOPATHOPHYSIOLOGY
MI refers to the process by which
myocardial tissue is destroyed in
regions of the heart that are
deprived of an adequate blood
supply because of reduced coronary
artery blood flow.
80-90% of all acute MI are
secondary to thrombus formation
When thrombus develops,
perfusion to the myocardium distal
to the occlusion is halted ,resulting
in necrosis.
Occlusion of one or more of these
blood vessels(coronary occlusion ) is
one of the major causes of myocardial
infarction.
The occlusion may result from the
formation of a clot that develops
suddenly when an athermanous plaque
ruptures through the sublayers of a
blood vessel, or when the narrow,
roughened inner lining of a scleroses
artery leads to complete thrombosis.
 The acute MI process takes time.
Cardiac cells can withstand in ischemic
condition for approximately 20 minutes
before cellular death begins.
 The earliest tissue to become ischemic is
the subendocardium (the innermost layer
of tissue in the cardiac muscle)
 If ischemia persists, it takes
approximately 4 to 6 hours for the entire
thickness if the heart muscle to become
necrosis.
CLINICAL
FEATURES
1 CARDIOVASCULAR
2 PULMONARY
3 GASTRO-INTESTINAL
4 GENITOURINARY
5 SKIN
6 NEUROLOGICAL SYMPTOMS
7 PSYCHOLOGICAL
1 CARDIOVASCULAR
Chest pain :occrus suddenly ,severe
immobilizing chest pain that not
relieved by rest ,position change, and
medications.
Increased jugular venous distention.
BP may elevated because of
sympathetic stimulation or decreased
BP because of decreased contractility ,
development of cardiogenic shock.
Decrease pulse rate
ST-segment and T-wave changes ,
ECG may show tachycardia ,
bradycardia , or dysrhythmias.
2 PULMONARY
Shortness of breath.
Dyspnea, tachypnea and crackles
if MI has caused pulmonary
congestion.
Pulmonary edema.
3 GASTRO-INTESTINAL
 nausea and vomiting.
4 GENITOURINARY

Decreased urinary output

5 SKIN
Cool, clammy, diaphoretic and pale
appearance.
6 NEUROLOGIC SYMPTOMS :
Anxiety, restlessness, light
headedness.
7. PSYCHOLOGICAL

Feeling depressed.
INVESTIGATION :
HISTORY
Electrocardiogram
Echocardiogram
LAB TEST (cardiac biomarker)
ECG (ELECTROCARDIOGRAM)
:
Assists in diagnosing of acute MI
Should be obtained within 10
minutes from the patient reports
chest pain (if possible)
TYPES OF ECG TO BE STUDIED
:
1 normal ECG
2 STEMI
3 Non-STEMI
ECHOCARDIOGRAM :

It’s a standard tool in the

management of patient with acute
MI. the role of echocardiography is
to location and extent of MI.
LAB TEST
Also called cardiac biomarkers
used to diagnose acute MI.
Creatine kinase MB (CK-MB ),
myoglobin and troponin T or I.
MANAGEMENT:
1 drug
2 surgical
3 physiotherapy
1 DRUG :
GOALS OF MEDICAL MANAGEMENT
Minimize myocardial damage and also
reducing myocardial oxygen demand and
increasing oxygen supply
Preserve myocardial function and
prevent complication
1 THROMBOLYTIC THERAPY
2 ANALGESICS
3 ANGIOTENSIN –
CONVERTING ENZYMES
INHIBITORS (ACE-
INHIBITORS)
SURGICAL MANAGEMENT

1. Coronary artery bypass graft

(CABG)
2. Precutaneous transluminal
coronary angiography (PTCA)
1 CABG
PCTA
3 PHYSICAL MANAGEMENT
CARDIAC
REHABILITATION
MONITORING BP
WHILE
CONTINUATION OF
EXERCISE
 COMPLICATION
1. Dysrhythmias (most common cause
after an MI in 80% of MI cases)
2. Acute pulmonary edema
3. Heart failure
4. Cardiogenic shock
5. Papillary muscle dysfunction
6. Pericarditis and cardiac tamponed.
PREVENTIONS FOR AVOIDING
CHANCES OF 2 ND HEART
ATTACK OR ANY FURTHER
COMPLICATIONS DUE TO
MYOCARDIAL INFRACTION:
PHYSIOTHERAPY
ASSESSMENT
DEMOGRAPHIC DATA
Personal details :
Name :
Age: 45 yrs or more
Gender: male > female
weight/height: obesity
occupation: sedentary lifestyle
 HISTORY :
1. Presenting condition: patient complains
of ;
Chest pain
Arm or back or neck or jaw discomfort
Difficulty in breathing
fatigue
Headache or dizziness
Feeling sick and general weakness
Nausea or vomiting
2. previous medical /surgical history :
patient when comes with severe
symptoms must had been gone through
anginal attack or gone through treatment
of PTCA or CABG or pacemaker
implantation .
3.drug history :
 morphine(2.5-5.0mg)i.v- for sudden relief of pain
& anxiety
Aspirin(162-325 mg)orally – prevention of
thrombus extension , embolism , venous thrombosis
i.v fluids – maintain blood volume & perfusion.
B-blocker –prophylactic i.v infusion to reduce
incidence of arrhythmia & mortality
Furosemide : reduce preload & pulmonary edema
Vasodilators :nitroglycerine for reduce venous
return and decrease work load
4. Family history : mostly present .
5. social history : may complains of inactivity
due to health issues
6. life style : sedentary lifestyle ,socially
involvement decrease
SUBJECTIVE ASSESSMENT :
1.breathlessness /dyspnea : according to NYHA grading
If ACUTE STAGE
-- grade 1 : no symptoms with ordinary activity ,breathlessness only
occurs with severe exertion.
If CHRONIC STAGE
-- GRADE 2 : symptoms with ordinary activity
-- GRADE 3 : symptoms with mild exertion
--GRADE 4 : SYMPTOMS AT REST
Dyspnea : is present . It can be initially acute dyspnea and later on
becomes functional dyspnea in severe stage
2. COUGH : may or may not be present .
Noctural coughing –older patients –cardiac complications

Cough complications : chronic cough – fractured ribs (cough

fractures) , hernia.
Stress incontinence (esp. women)
Syncope (men,smoker>women,nonsmoker)
Headache
Back pain
hematomas
3. sputum & hemoptysis : rarely present

4. wheeze :post surgical may be present if any cough

accumalation is present
5. CHEST PAIN : angina pectoris- dull , central ,
retrosternal gripping or band like sensation , may radiate
to arm , neck , jaw.
Pericarditis – pain similar to angina or pleurisy . sitting up
and leaning forward or lying on right side relieves pain.

6. pain assessment : VAS scale

OTHER SYMPTOMS:
 fever
Fatigue &weakness
Headache
Peripheral edema
FUNCTIONAL ABILITY AND
QUALITY OF LIFE
Ask about his/her ADL for getting proper idea about the
complains and helps in preparing the home planning
OBJECTIVE ASSESSMENT :
1. general observation : if patient is in ICU then;
Breathless ,o2 supplement, ventilator support ,

2. level of consciousness :
3. body built : obesity commonly present hampering
cardiac and respiratory function
BMI should be calculated.
4. observation on hands : sweaty hands with flapping
tremors irregularly .fingers may show nicotine staining
from smoking.
5. clubbing: loss of angle between nail bed and nail .
Sign of hypoxia -
6. observation of eyes : pallor (anemia)

7. cyanosis : central as well as peripheral, mild or none

8. jugular vein pressure : Elevated in chronic stage of
myocardial infarction

9. peripheral edema :present

10. observation of chest : altered if gone through previous
surgical procedures

11. chest shape : post surgical due to incisions gets altered

12. breathing pattern :cheyne stroke breathing

13. types of breathing :abdominal

14. chest movement : altered due to shallow breathing so

decrease in expansion but symmetrically equal
ON EXAMINATION :
1. vital measurement :
Body temperature : increase (fever)
Heart rate : increase,rapid ,irregular
Bp : tendency to fall 5 mmhg , postural hypotension
Respiratory rate : tachypnea
ON PALPATION
1. treachea : not altered
2. chest expansion : not altered
3. tenderness : may be present around operated site
4. tvf : altered post surgically due to ineffective coughing
ON PERCUSSION
Dull
Due to secretion accumalation after surgery.
ON AUSCULTATION
1. breath sound : abnormal post surgically if respiratory
functions are hampered

2. heart sounds : weak ,gallop rhythm ,murmur is present

INVESTIGATION :
1. x-ray
2. ECG :stemi and nstemi
3. CT Scan and MRI : show late enhancement in infracted
zone.
D/D
1. angina pectoris
2. acute pericarditis
3.aortic dissection
4. pulmonary embolism
MANAGEMENT :
1. surgical : ptca and cabg
2.drug : mentioned earlier
3. physiotherapy
4. home planning
CARDIAC REHABLILITATION
PHASE ONE :
DAY OF SURGERY : in ICU patient would be connected
to lines and monitors and ventilator support. He would
not be fully conscious because of effect of anaesthesia .
Visit patient 3-4 times a day and give relaxed
diaphragmatic breathing and gentle ankle-toe movement .
DAY 1
As patient weaned off the ventilator ,therapist gives assisted
coughing in sitting and passive and active exercise of upper limb
within pain free range. By preventing shoulder girdle movement
with causes pain due to operated site. During this period care is to
be taken that electrocardiogram is monitored
continuously and also through out the exercise program, and that
the heart
rate should not exceed 120/min.
Day 2:
Patient’s intravenous lines are removed. Repetition of the same
exercises as the previous day.
Day 3:
Patient is shifted out of the intensive care unit and to the ward if he
is declared stable by the attending physician. The previous exercises are
repeated and the patient is made to walk around the bed under supervision.
Sitting in chair with the back support is encouraged
Day 4
Shoulder girdle movements are performed within the pain free
range.
The patient is made to sit and stand in the right posture. Walking
distance
is increased within the ward under supervision of a
physiotherapist.
Day 5 and 6:
Stair climbing up to five steps is started under the supervision
of physiotherapist
Day 7:
The patient is asked to cover a longer distance, with increase in stride
length and cadence.
Day 8:
Patient is counseled in the cardiac rehabilitation department by a team
comprising of a psychologist, a physiotherapist, a dietician, a cardiologist and
a cardiothoracic surgeon.
Day 9 and 10:
Home exercise program is taught and patient is discharged after
suture removal. Ideally by now the patient should have achieved a metabolic
equivalent between two and three for progression to the second phase of
rehabilitation.
Phase Two
This is an out patient program which means that the patient has to be brought
to the department following his discharge until three months, thrice a week.
Exercises are given for thirty to forty five minutes checking the vital signs
periodically. A gradual warm up session for 5-10 minutes is given, followed
by static cycling, treadmill walking for up to half an hour.
A cool down program for 5 minutes is also given at the end of this session,
Phase Three
A detailed home exercise program is taught which is followed by
the patient
at home.
The rehabilitation program should monitor risk factors in post MI
patients
like hypertension, increased serum cholesterol levels, obesity and
coronary
atherosclerosis. Other habits like smoking and excessive drinking
should be
avoided.
Conclusion
It is increasingly being recognized that life after a bypass
surgery is more
effective only if delivered with proper rehabilitation back-
up to enhance the
speed of recovery and quality of life