ACUTE MYOCARDIAL INFARCTION (AMI)

Dr. R. Irabagon

Myocardial Infarction
Permanent destruction of the myocardium.
Usually caused:
by reduced blood flow in a coronary artery
due to rupture of an atherosclerotic plaque
subsequent occlusion of the artery by a thrombus.

Acute MI – Clinical Features

Effects of Ischemia, Injury, and Infarction on ECG
Clinical Manifestations and Diagnosis
Chest pain, other symptoms
ECG
Laboratory tests--biomarkers
CK-MB
Myoglobin
Troponin T or I

DX: ECG, Cardiac enzymes/proteins, Echo, HX & PE

Cardiac enzymes: a.
CKMB: increases 4-8 hours after MI, peaks after 24-36 H, returns to normal after 3 days
AST; increases 12-16 H, peaks after 24 hours, returns to normal after 3 days
LDH: peaks 3 days post MI, & persists for 4-7 days
Troponin I: Increases 2-4 H post MI, peaks 4-24 H post MI, Returns to normal after 1-3 weeks

Assessment findings:

CVS: chest pain or discomfort, palpitations. Heart sounds may include S3, S4 &
new onset of a murmur. Jugular vein distention, decreased/increased BP, ST
segment changes
RS: Dyspnea, tachypnea, crackles
GIT: n/v
GUT: decreased UO
SKIN: cold, clammy, diaphoretic, pale
Neurologic: Anxious, restless, HA, visual disturbance
Psychological: fear of impending death

Treatment of Acute MI
Obtain diagnostic tests including ECG within 10 minutes of admission to the ED.
Oxygen
Aspirin, nitroglycerin, morphine, beta-blockers
Angiotensin-converting enzyme inhibitor within 24 hours
Evaluate for percutaneous coronary intervention or thrombolytic therapy.
As indicated; IV heparin or LMWH, clopidogrel or ticlopidine, glycoprotein IIb/IIIa
inhibitor
Bed rest

Nursing Process: The Care of the Patient with ACS:

Diagnosis
Ineffective cardiac tissue perfusion
Risk for fluid imbalance
Risk for ineffective peripheral tissue perfusion
Death anxiety
Deficient knowledge

Collaborative Problems
Acute pulmonary edema
Heart failure
Cardiogenic shock
Dysrhythmias and cardiac arrest
Pericardial effusion and cardiac tamponade

Nursing Process: The Care of the Patient with ACS:

Planning
Goals include the relief of pain or ischemic signs and symptoms, prevention of
further myocardial damage, absence of respiratory dysfunction, maintenance
of or attainment of adequate tissue perfusion, reduced anxiety, adherence to
the self-care program, absence or early recognition of complications.

Percutaneous Coronary Intervention

Coronary Artery Bypass Grafts

Greater and lesser saphenous veins are commonly used for

bypass graft procedures.

Postoperative Care of the Cardiac Surgical Patient

Complications:

arrhythmia: most common cause of death in the first several hours following MI
myocardial rupture: a catastrophic complication within the 1st 4-7 days & may
result in death from cardiac tamponade
Mural thrombosis
Ventricular aneurysm: w/in 3- 6 months after MI

Electrocardiogram (ECG or EKG)

A graphic recording of electric potential generated by the heart.
The signals are detected by means of metal electrodes attached to the
extremities & chest wall & are then amplified and recorded by
electrocardiograph.
Indication:
To determine cardiac rate
To accurately define cardiac rhythm
To diagnose old or new myocardial infarction
To identify intra-cardiac conduction disturbances
To aid in the diagnosis of ischemic heart disease, pericarditis, myocarditis,
electrolyte abnormalities & pacemaker malfunction

Relationship of ECG Complex, Lead System, and Electrical

Impulse

ECG Electrode Placement

The 12 conventional ECG leads record the difference in potential between electrodes
placed on the surface of the body.
These leads are divided into two groups: six extremity (limb) leads and six chest
(precordial) leads.
The extremity leads record potentials transmitted onto the frontal plane, and the chest
leads record potentials transmitted onto the horizontal plane.
The six extremity leads are further subdivided into three bipolar leads (I, II, and III) and
three unipolar leads (aVR, aVL, and aVF). Each bipolar lead measures the difference
in potential between electrodes at two extremities: lead I = left arm-right arm voltages,
lead II = left leg-right arm, and lead III = left leg-left arm. The unipolar leads measure
the voltage (V) at one locus relative to an electrode (called the central terminal or
indifferent electrode) that has approximately zero potential. Thus, aVR = right arm,
aVL = left arm, and aVF = left leg (foot)
Together, the frontal and horizontal plane electrodes provide a three-dimensional
representation of cardiac electrical activity. Each lead can be likened to a
different camera angle "looking" at the same events¾atrial and ventricular
depolarization and repolarization¾from different spatial orientations
The electrocardiogram is ordinarily recorded on special graph paper which is
divided into 1-mm2 gridlike boxes . Since the ECG paper speed is generally 25
mm/s, the smallest (1 mm) horizontal divisions correspond to 0.04 s (40 ms),
with heavier lines at intervals of 0.20 s (200 ms). Vertically, the ECG graph
measures the amplitude of a given wave or deflection (1 mV = 10 mm with
standard calibration; the voltage criteria for hypertrophy mentioned below are
given in millimeters)

The ECG waveforms are labeled alphabetically

P wave, which represents atrial depolarization
QRS complex represents ventricular depolarization
ST-T-U complex (ST segment, T wave, and U wave) represents ventricular
repolarization
J point is the junction between the end of the QRS complex and the beginning of
the ST segment.
Atrial repolarization is usually too low in amplitude to be detected, but it may
become apparent in such conditions as acute pericarditis or atrial infarction.

Heart Rate
3 Possibilities
Bradycardia : <60 beats per minute
Normal Rate : 60-100 beats per minute
Tachycardia : > 100 beats per minute

Rate Analysis
Formula

Heart Rate= 1500/ #of small boxes

Or = 300/ # of big boxes

Short cut
If R to R interval > 5 big square: Bradycardia
If R to R interval between 3-5 big square: Normal Rate
If R to R interval < 3 big square: Tachycardia

Mnemonic
Heart Rate Determination
Normal Sinus Rhythm
Sinus Bradycardia
Sinus Tachycardia
Rhythm
Common Rhythm Interpretations:
 Sinus rhythm
Common supraventricular arrythmias:
Atrial fibrillation
Atrial flutter
Supraventricular tachycardia
Ventricular Arrhythmias
Premature Ventricular Contraction
Ventricular tachycardia
Ventricular fibrillation

Heart Blocks
First degree AV block
Second degree AV block Mobitz type 1 (wenckebach)
Second degree AV block mobitz type II
3rd degree AV block
Left or rigth bundle branch block( complete & incomplete)

Rhythm Analysis
Identify the P wave
Determine frm the configuration if this is a sinus P.
Check the relation of P wave to QRS
P wave is before QRS (Normal)
P wave is buried or after QRS (ex. SVT, complete HB)
Check PR interval (Normal PR interval: 0.12-020 sec)
Short PR (WPW syndrome)
Normal PR
Prolonged PR (1st degree or 2nd degree AV block)

Normal Sinus Rhythm

Check QRS duration (Normal QRS duration <0.10 sec)

Normal QRS
Wide QRS (bundle branch blocks
Check the relation of R-P & PP interval
Equal R-R & P-P interval (normal)
P-P interval shorter than R-R interval (complete heart block)
P-P interval longer than R-R interval (AV dissociation)

Normal Sinus Rhythm

Axis
Interpretation
Normal axis
Left axis deviation (LAD)
Right axis deviation (RAD)
Indeterminate axis
Analysis
(+) QRS deflection: Average QRS vector above the baseline in lead I or AVF.
(-) QRS deflection: Average QRS vector below the baseline in lead I or AVF
Differential Dx
Hypertrophy
No hypertrophy
LVH
RVH
Left atrial enlargement
Right atrial enlargement
combination
LVH
S wave in V1 + Rwave in V5 or V6: >35mm
Commonly used
43% sensitive, 97% specific
R in AVL > 11mm
11% sensitive, 100% specific

RVH
Right axis deviation
Lead V1: Rwave >Swave
Deep S wave in leads V5 & V6
ST depression & T wave inversion in V1 – V3
Myocardial Infarction: correspondence of specific ECG lead
ECG criteria for MI
ST elevation≥ 2mm in 2 or more chest lead (chest lead)
Or ≥1mm in 2 or more limb leads.
Q wave ≥ 0.04 sec (1 ml square)
Miscellaneous
Hypokalemia
U wave as tall or taller than the T wave at leads V2 & V3
Normal serum Potassium: 3.6-5.5 mEq/L
Hyperkalemia
Chest leads: T wave> 10mm in most leads, in limb leads,T wave > 5mm in most leads
Digitalis effect
Prolonged PR interval, scooping of ST segment, short QT interval
Hypocalcemia
Prolonged QT interval
Hypercalcemia
Shortened QT interval