Myocardial Ischemia Myocardial ischemia occurs when blood flow to the heart muscle is decreased by a partial or complete blockage

e of the heart's arteries (coronary arteries). The decrease in blood flow reduces The heart's oxygen supply. Myocardial ischemia, also called cardiac ischemia, can damage heart muscles, reducing its ability to pump efficiently. A sudden, severe blockage of a coronary artery may lead to a heart attack. Myocardial ischemia may also cause serious abnormal heart rhythms. Anatomy and Physiology The major vessels of the coronary circulation are the left main coronary that divides into left anterior descending and circumflex branches, and the right main coronary artery. The left and right coronary arteries originate at the base of the aorta from openings called the coronary ostia located behind the aortic valve leaflets. These vessels supply oxygen and nutrients to the heart. The left and right coronary arteries and their branches lie on the surface of the heart, and therefore are sometimes referred to as the epicardial coronary vessels. These vessels distribute blood flow to different regions of the heart muscle. When the vessels are not diseased, they have a low vascular resistance relative to their more distal and smaller branches that comprise the microvascular network. As in all vascular beds, it is the small arteries and arterioles in the microcirculation that are the primary sites of vascular resistance, and therefore the primary site for regulation of blood flow. The arterioles branch into numerous capillaries that lie adjacent to the cardiac myocytes. A high capillary-to-cardiomyocyte ratio and short diffusion distances ensure adequate oxygen delivery to the myocytes and removal of metabolic waste products from the cells (e.g., CO2 and H+). Capillary blood flow enters venules that join together to form cardiac veins that drain into the coronary sinus located on the posterior side of the heart, which drains into the right atrium. There are also anterior cardiac veins and thebesian veins drain directly into the cardiac chambers. In the presence of coronary artery disease, coronary blood flow may be reduced. This will increase oxygen extraction from the coronary blood and decrease the venous oxygen content. This leads to tissue hypoxia and angina. If the lack of blood flow is due to a fixed stenotic lesion in the coronary artery (because of atherosclerosis), blood flow can be improved within that vessel by placing a stent within the vessel to expand the lumen, using an intracoronary angioplasty balloon to stretch the vessel open, or bypassing the diseased vessel with a vascular graft. If the insufficient blood flow is caused by a blood clot (thrombosis), a thrombolytic drug that dissolves clots may be administered. Anti-platelet drugs and aspirin are commonly used to prevent the reoccurrence of clots. If the reduced flow is due to coronary vasospasm, then coronary vasodilators can be given (e.g., nitrodilators, calcium-channel blockers) to reverse and prevent vasospasm.

Pathology
Predisposing Factors: Atherosclerosis Blood Clot Coronary Artery Spasm Risk Factors: Smoking Diabetes High blood pressure High blood cholesterol or triglyceride levels Lack of physical activity Obesity Family history

Narrowing or Blockage of the coronary artery/arteries

Signs and Symptoms: Angina pectoris Neck or jaw pain Shoulder or arm pain Clammy skin Shortness of breath Nausea

Not enough blood flow to the heart muscle

If left untreated, parts of the heart that did not get enough oxygen can be permanently damaged.

Medications: Antiplatelet and Anticoagulant Medications Nitroglycerin Beta-Adrenergic Blockers Cholesterol-lowering medications Calcium channel blockers ACE inhibitors Ranolazine (Ranexa)

Medical Procedure: Angioplasty and Stenting Coronary Artery Bypass Surgery

Complications: Heart attack Irregular heart rhythm Heart failure

Death

Recuperation

Diagnostics Electrocardiogram (ECG). Certain abnormalities in the heart's electrical activity may indicate myocardial ischemia. Blood tests. Certain heart enzymes slowly leak out into the blood if the heart has been damaged. Cardiac CT scan. CT scans can determine if there is a coronary artery calcification a sign of coronary atherosclerosis. The heart arteries can also be seen using CT scanning (CT coronary angiogram). Echocardiogram. An echocardiogram can help identify whether an area of the heart has been damaged and isn't pumping normally. Nuclear scan. This test helps identify blood flow problems to the heart. Small amounts of radioactive material are injected into the bloodstream. Special cameras can detect the radioactive material as it flows through the heart and lungs. Areas of reduced blood flow to the heart muscle through which less of the radioactive material flows appear as dark spots on the scan. Coronary angiography. Coronary angiography uses X-ray imaging to examine the inside of the heart's blood vessels. During coronary angiography, a type of dye that's visible by Xray machine is injected into the blood vessels of the heart. The X-ray machine rapidly takes a series of images (angiograms), offering a detailed look at the inside of the blood vessels. Stress test. A stress test can reveal problems within the heart that might not be noticeable otherwise. It can be particularly useful in diagnosing silent ischemia Holter monitoring. A Holter monitor test is usually performed if an electrocardiogram isn't able to give a health care provider enough information about the heart's condition or if there is suspected silent myocardial ischemia Medical Procedures Angioplasty and Stenting (Percutaneous Coronary Intervention or PCI) a long, thin tube (catheter) is inserted into the narrowed part of the artery. A wire with a tiny, deflated balloon is passed through the catheter to the narrowed area. The balloon is inflated to widen the artery, and then a small wire mesh coil (stent) is usually inserted to keep the artery open. Some stents slowly release medication to help keep the artery open. This procedure improves blood flow in the heart, reducing or eliminating myocardial ischemia. Coronary Artery Bypass Surgery a vessel from another part of the body is grafted to bypass blocked coronary arteries. This allows blood to flow around the blocked or narrowed coronary artery.

Nursing Management Adiminister oxygen therapy via nasal cannula at 2-4Lpm Asess vital signs frequently as long as the patient is experiencing pain and other symptoms of ischemia Elevate head Deep breathing exercises Change positions frequently Encourage to rest until pain free and hemodynamically stable Check peripheral pulses regularly Alleviate anxiety Ensure quiet environment Prevent sleep interuptions Teach relaxations techniques such as music therapy Provide spiritual support Report any changes on vitals signs, ECG and laboratory results promptly