MIOCARDIAL INFARCTION • Cardiac Output (CO): The volume of blood

the heart pumps per minute.

o Formula: CO = Stroke Volume
Anatomy of the Heart (SV) × Heart Rate (HR)

• Location: In the mediastinum, with 2/3 of o Normal Range: 5 L/min at rest.

the heart located to the left of the midline. o Stroke Volume (SV): 70 mL of

• Apex: Positioned just above the diaphragm. blood ejected per beat.

• Base: Lies at the level of the 3rd rib.

• Heart Layers: Blood Pressure (BP)
1. Epicardium (outer layer)
• Systolic BP: The pressure in arteries during
2. Myocardium (middle muscle
ventricular contraction.
layer)
• Diastolic BP: The pressure in arteries during
3. Endocardium (inner layer)
ventricular relaxation.
• Valves:
• Layers:
1. Atrioventricular (S1): Located at
o Epicardium
the apex of the heart, responsible
o Myocardium
for the “lub” sound.
o Endocardium
2. Semilunar (S2): Located at the
• Valves:
base, responsible for the “dub”
o Atrioventricular (S1): Located at the
sound.
apex.
• Coronary Arteries: Supply the heart muscle
o Semilunar (S2): Located at the base.
with blood.

Cardiac Cycle
Cardiac Cycle and Physiology
• Systole: Contraction to pump blood out.
• Cardiac Cycle: Describes the events
• Diastole: Relaxation to fill the heart
between one heartbeat and the next,
chambers with blood.
involving both contraction (systole) and
• Blood Pressure: Increases during systole,
relaxation (diastole) of the heart.
decreases during diastole.
o Systole: Heart muscles contract to
pump blood out of the chambers.
o Diastole: Heart muscles relax to
allow the chambers to fill with
blood.
Cardiac Output ECG Components:

• Formula: Cardiac Output = Stroke Volume • P wave: Atrial contraction.

(SV) × Heart Rate (HR) • QRS complex: Ventricular contraction.
• Normal Range: 5 L/min at rest, increases • T wave: Ventricular recovery.
during exercise.

Electrophysiology of the Heart

• Sinoatrial (SA) Node: Dominant

pacemaker, 60-100 BPM.
• Atrioventricular (AV) Node: Back-up
pacemaker, 40-60 BPM.
• Purkinje Fibers: Spread impulses
throughout ventricles, 20-40 BPM.

MYOCARDIAL INFARCTION (MI)

The continuum from angina to myocardial infarction (MI) is acute coronary syndrome. Manifestations of
acute coronary syndrome are due to an imbalance between myocardial oxygen supply and demand.

When blood flow to the heart is compromised, ischemia causes chest pain. Anginal pain is often described
as a tight squeezing, heavy pressure, or constricting feeling in the chest. The pain can radiate to the jaw, neck, or
arm. Pain unrelieved by rest or nitroglycerin and lasting for more than 15 min differentiates an MI from angina.
 Females and older adults do not always experience manifestations typically associated with angina or MI.
The area of infarction in clients experiencing a myocardial infarction (MI) develops over minutes to hours. Early
recognition and treatment of an acute MI is essential to prevent death.

Research shows improved outcomes following an MI in clients treated with aspirin, betablockers, and
angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.

An abrupt interruption of oxygen to the heart muscle produces myocardial ischemia. Ischemia can lead to
tissue necrosis (infarction) if blood supply and oxygen are not restored. Ischemia is reversible. An infarction
results in permanent damage. When the cardiac muscle suffers ischemic injury, cardiac enzymes are released into
the bloodstream, providing specific markers of MI.

PATHOPHYSIOLOGY

Atherosclerosis triggers coronary artery spasm

Decrease or complete blockage of blood flow

Tissue damage triggers platelet aggregation causing a complete arterial obstruction

Ischemia beyond 20 minutes to several hours can cause irreversible cellular death (necrosis)

MI CLASSIFICATION

MIs are classified based on:

• Affected area of the heart: anterior, lateral, inferior, or posterior

• ECG changes produced: ST elevation myocardial infarction (STEMI) vs. non-ST elevation
myocardial infarction (NSTEMI)
MI CATEGORIES: hypertension, diabetes mellitus, hypercholesterolemia, elevated homocysteine, and highly
sensitive C reactive protein (hs-CRP)

o Transmural MI: Full thickness hypercholesterolemia, elevated damage of the myocardium. (from
endocardium to epicardium) AKA Q-wave MI
o Non-Transmural MI: Partial thickness damage. Affects only part of the myocardium. AKA non Q-wave
MI. ST depression and T wave inversion may be seen.
✓ T-wave inversion is an indicator of ischemic damage to myocardium. Typically, few changes to P
waves occur during or after an MI, whereas Q-wave changes with no change in the ST or T wave
indicate an old MI.

RISK FACTORS: • Metabolic disorders (diabetes mellitus,

hyperthyroidism)
o Non-modifiable: Age, genetics.
• Methamphetamine or cocaine use
o Modifiable: Hypertension, smoking,
obesity. • Stress (with ineffective coping skills)

• Male sex or postmenopausal clients • An increased risk of coronary artery disease

exists for older adult clients who are
• Ethnic background
physically inactive, have one or more chronic
• Sedentary lifestyle
diseases (hypertension, heart failure, and
• Hypertension
diabetes mellitus), or have lifestyle habits
• Tobacco use
(smoking and diet) that contribute to
• Hyperlipidemia
atherosclerosis. Atherosclerotic changes
• Obesity
related to aging predispose the heart to poor
• Excessive alcohol consumption
blood perfusion and oxygen delivery.
 • Incidence of cardiac disease increases with • Chest pain: substernal or precordial Can
age, especially in the presence of radiate down the shoulder or arm, or present
hypertension, diabetes mellitus, as jaw pain Can be described as a crushing or
hypercholesterolemia, elevated aching pressure
homocysteine, and highly sensitive C • Nausea
reactive protein (hs-CRP) • Dizziness
• Females can experience atypical angina,
which is characterized by pain between the
shoulders, ache in the jaw, or sensation of
choking with exertion.

PHYSICAL ASSESSMENT FINDINGS

• Pallor, and cool, clammy skin

• Tachycardia and heart palpitations
• Tachypnea and shortness of breath
• Diaphoresis
EXPECTED FINDINGS • Vomiting
• Decreased level of consciousness
• Anxiety, feeling of impending doom

LABORATORY TESTS infarction, peak at 24 hrs., return to

normal after 48 hrs.
Cardiac enzymes released with cardiac muscle
• Troponin I or T: Any positive value indicates
injury:
damage to cardiac tissue and should be
• Myoglobin: Earliest marker of injury to reported.
cardiac or skeletal muscle. Levels no longer o Troponin I: Levels no longer evident
evident after 24 hr. after 7 to 10 days.
• Creatine kinase-MB: Peaks around o Troponin T: Levels no longer evident
o 24hr after onset of chest pain. Levels after 10 to 14 days.
no longer evident after 3 days.
o CK-MB can detect reinfarction after
initial MI: levels increased 4 hrs. after
CARDIOVASCULAR DIAGNOSTIC AND 2. Stress test Also known as exercise
THERAPEUTIC PROCEDURES electrocardiography: Client tolerance of
activity is tested using a treadmill, bicycle, or
medication to evaluate response to increased
1. Electrocardiogram (ECG): Recording of heart rate.
electrical activity of the heart over time 3. Radionuclide Imaging: A small amount of

Nursing actions radioactive material such as thallium or

technetium is injected into a patient’s vein.
• Assess for changes on serial ECGs.
The radioactive material travels to the
• Angina:
patient’s heart muscle and pictures are taken
o ST depression and/or T-wave inversion
with a special camera to obtain a three-
indicates presence of ischemia.
dimensional image.
• MI:
• Thalium scan
o T-wave inversion indicates ischemia;
o Assesses for ischemia or necrosis.
o ST-segment elevation indicates injury;
Radioisotopes cannot reach areas with
o Abnormal Q-wave indicates necrosis.
decreased or absent perfusion, and the
The appearance of abnormal Q waves is another areas appear as “cold spots.”
indication of MI. Q waves develop within 1 to 3 days
Client education: Avoid smoking and consuming
because there is no depolarization current conducted
caffeinated beverages 4hr prior to the procedure.
from necrotic tissue (Urden et al., 2019).
These can affect the test.

4. Cardiac catheterization
• A coronary angiogram, also called a cardiac
catheterization, is an invasive diagnostic
procedure used to evaluate the presence and
degree of coronary artery blockage.
• Angiography involves the insertion of a
catheter into a femoral (sometimes a brachial)
vessel and threading it into the right or left
side of the heart. Coronary artery narrowing
and occlusions are identified by the injection
of contrast media under fluoroscopy.
Nursing actions: 1. Oxygen therapy- 2-4Lpm
2. Sublingual nitroglycerin therapy
• Ensure the client understands the procedure
3. Adequate analgesia (with morphine sulfate or
prior to signing informed consent.
Meperidine)
• Ensure that the client remains NPO 8hr prior
4. Aspirin, 160 to 325 mg orally
to procedure.
5. 12-lead electrocardiogram (ECG) should be
• Assess for iodine/shellfish allergy (contrast
performed
media).
6. Immediate reperfusion therapy, either by
thrombolytic or primary percutaneous

MEDICAL MANAGEMENT OF MI transluminal coronary angioplasty (PTCA)

Primary focus/ Goal: The patient with suspected MI should

immediately receive supplemental oxygen, aspirin,
✓ Relieve chest pain
nitroglycerin, and morphine. Morphine sulphate
✓ Reduce the extent of myocardial damage
reduces preload and decreases workload of the heart,
✓ Maintain cardiovascular stability
along with increased oxygen from oxygen therapy
✓ Decrease cardiac workload
and bed rest. With decreased cardiac demand, this
✓ Prevent complications
provides the best chance of decreasing cardiac
• STEMI first priority: emergent reperfusion damage.
via percutaneous coronary intervention (e.g.
catheterization)/thrombolysis
o Very time sensitive THE FIRST 24 HOURS
• NSTEMI: reperfusion via percutaneous
1. Continuous ECG and serum cardiac markers.
coronary intervention (not thrombolysis)
2. The patient's physical activities should be
o Less time sensitive than in STEMI
limited for at least 12 hours, and pain and/or
anxiety should be minimized with
appropriate analgesics.
INITIAL RECOGNITION AND
3. Although the use of prophylactic
MANAGEMENT IN THE EMERGENCY
antiarrhythmic agents in the first 24 hours of
DEPARTMENT
hospitalization is not recommended,
The initial evaluation of the patient ideally should Atropine, Lidocaine, transcutaneous pacing
be accomplished within 10 minutes of his or her patches or a transvenous pacemaker, a
arrival in the ED; certainly, no more than 20 minutes defibrillator, and epinephrine should be
should elapse before an assessment is made. immediately available.
 4. When primary PTCA is performed, high- Nursing actions:
dose of intravenous heparin is
• Use to treat angina and help control blood
recommended.
pressure.
5. Aspirin, 160 to 325 mg daily, initially given
• Use cautiously with other antihypertensive
in the ED, should be continued indefinitely.
medications.
6. The patient with evolving acute MI should
• Monitor for orthostatic hypotension.
receive early intravenous β-adrenergic
• Ensure the client has not taken a
blocker therapy, followed by oral therapy,
phosphodiesterase inhibitor for erectile
provided that there is no contraindication.
dysfunction within 24 to 48hr, as severe
7. ACE inhibitor should be initiated within
hypotension can result.
hours of hospitalization, provided that the
patient does not have hypotension or a Client education for chest pain
contraindication.
• Stop activity and rest.
• Place a nitroglycerin tablet under the tongue
to dissolve (quick absorption).
AFTER FIRST 24 HOURS
• If pain is unrelieved in 5 min, call 911 or be
1. Indefinitely with a β-adrenergic blocker driven to an emergency department.
2. ACE inhibitor for at least 6 weeks.
• Up to two more doses of nitroglycerin can be
3. Nitroglycerin should be infused
taken at 5-min intervals.
intravenously for 24 to 48 hours, and
• Headache is a common adverse effect of this
magnesium sulfate should be given as needed
medication.
to replete magnesium deficits for 24 hours.
• Change positions slowly.
4. Angiography and PTCA >procedure that uses
a special dye & x ray to see how blood flows
through the arteries in your heart ➢ Analgesics: Morphine sulfate is an opioid
5. Continue Aspirin 160 to 325 mg/day. analgesic used to treat moderate to severe
pain. Analgesics act on the mu and kappa
receptors that help alleviate pain. Activation
MEDICATIONS
of these receptors produces analgesia (pain
➢ Vasodilators: Nitroglycerin prevents relief), respiratory depression, euphoria,
coronary artery vasospasm and reduces sedation, and decreases in myocardial oxygen
preload and afterload, decreasing myocardial consumption and gastrointestinal (GI)
oxygen demand. motility. Use cautiously with clients who
 have asthma or emphysema due to the risk of Nursing actions:
respiratory depression.
• Beta-blockers can cause bradycardia and
Nursing actions: hypotension. Hold the medication if the
apical pulse rate is less than 60/min, and
• For the client having chest pain, assess pain
notify the provider.
every 5 to 15 min.
• Avoid giving to clients who have asthma.
• Watch for manifestations of respiratory
Cardio selective beta blockers (which affect
depression, especially in older adults. If
only beta1 receptors), such as metoprolol, are
respirations are less than 12/min, stop
preferred because they minimize the effects
medication, and notify the provider
on the respiratory system.
immediately.
• Use with caution in clients who have heart
• Monitor vital signs for hypotension and
failure.
decreased respirations.
• Monitor for decreased level of consciousness,
• Assess for nausea and vomiting.
crackles in the lungs, and chest discomfort.
Client education
Client education
• If nausea and vomiting persist, notify a nurse.
• Change positions slowly.
• If a PCA pump is prescribed, the client is the
• Notify the provider immediately of shortness
only person who should push the medication
of breath, edema, weight gain, or cough.
administration button. The safety lockout
mechanism on the PCA pump prevents
overdosing of the medication.
➢ Thrombolytic agents
• Alteplase and reteplase are used to break
up blood clots.
➢ Beta-blockers
• Thrombolytic agents have similar adverse
• Metoprolol has antidysrhythmic and
effects and contraindications as
antihypertensive properties that decrease
anticoagulants.
the imbalance between myocardial
• For best results, give within 6hr of
oxygen supply and demand by reducing
infarction.
afterload and slowing heart rate.
• In an acute MI, beta-blockers decrease Nursing actions:
infarct size and improve short- and long-
• Assess for contraindications (active bleeding,
term survival rates.
peptic ulcer disease, history of stroke, recent
trauma).
 • Monitor for effects of bleeding (mental status Client education
changes, hematuria).
• There is risk for bruising and bleeding
• Monitor bleeding times: PT, aPTT, INR,
while on this medication.
fibrinogen levels, and CBC.
• If aspirin is prescribed, choose the
• Monitor for the same adverse effects as
entericcoated form and take with food to
anticoagulants (thrombocytopenia, anemia,
minimize GI upset.
hemorrhage).
• Report ringing in the ears.
• Administer streptokinase slowly to prevent
hypotension.

Client education ➢ Anticoagulants: Heparin and enoxaparin are

used to prevent clots from becoming larger or
• There is a risk for bruising and bleeding while
other clots from forming.
on this medication.
Nursing actions:

• Assess for contraindications (active bleeding,

➢ Antiplatelet agents
peptic ulcer disease, history of stroke, recent
• Aspirin and clopidogrel prevent
trauma).
platelets from forming together,
• Monitor platelet levels and bleeding times:
which can produce arterial clotting.
PT, aPTT, INR, and CBC.
• Aspirin prevents vasoconstriction.
• Monitor for adverse effects of anticoagulants
Due to this and antiplatelet effects, it
(thrombocytopenia, anemia, hemorrhage).
should be administered with
nitroglycerin at the onset of chest Client education

pain. • There is risk for bruising and bleeding while

• Antiplatelet agents can cause GI on this medication.
upset.

Nursing actions: ➢ Glycoprotein IIB-IIIA inhibitors

• Eptifibatide is used to prevent binding
• Use cautiously with clients who have a
of fibrinogen to platelets, in turn
history of GI ulcers.
blocking platelet aggregation. It
• Tinnitus (ringing in the ears) can be a
inhibits platelet function.
manifestation of aspirin toxicity.
• In combination with aspirin therapy,
IIB/IIIA inhibitors are standard
therapy.
 • IV administration of glycoprotein procedure for circulatory support during
(GP) IIb/IIIa agents, such as weaning from CPB. Because the IABP can be
abciximab or eptifibatide, is indicated inserted percutaneously via the femoral
for hospitalized patients with unstable artery, it can be inserted in an interventional
angina and as adjunct therapy for PCI. area such as the cardiac catheterization
• This medication can cause active laboratory or the ICU when necessary. An
bleeding. IABP reduces left ventricular workload and
increases delivery of oxygen to the
Nursing actions:
myocardium, thereby increasing cardiac
• Monitor platelet levels. output and systemic perfusion. An IABP

Client education cannot be effective without partial ventricular

function.
• Report evidence of bleeding during
medication therapy.

Interprofessional care

• Pain management services can be consulted if

pain persists or is uncontrolled.
• Cardiac rehabilitation care can be consulted if
the client has prolonged weakness and needs
assistance with increasing level of activity.
• Nutritional services can be consulted for diet
modification to promote food choices low in
• Percutaneous transluminal coronary
sodium and saturated fat.
angioplasty (PTCA)

In percutaneous transluminal coronary

THERAPEUTIC PROCEDURES angioplasty (PTCA), a balloon-tipped catheter is
used to open blocked coronary vessels and resolve
• INTRA-AORTIC BALLOON PUMP (IABP)
ischemia. It is used in patients with angina and as an
An intraaortic balloon pump (IABP) is a left
intervention for ACS. Catheter based interventions
ventricular supportive device used to assist a
can also be used to open blocked CABGs (see later
patient with prolonged myocardial ischemia,
discussion). The purpose of PTCA is to improve
reversible left ventricular failure, or
blood flow within a coronary artery by compressing
cardiogenic shock. The IABP can be inserted
the atheroma.
in the OR in conjunction with an open-heart
SURGICAL PROCEDURES: CORONARY • Ventricular assist device
ARTERY REVASCULARIZATION
Mechanical pump that's used to support heart
• Bypass graft (also known as CABG) function and blood flow in people who have
weakened hearts. The device takes blood from a
A healthy artery or vein from the body is
lower chamber of the heart and helps pump it to the
connected, or grafted, to the blocked coronary artery.
body and vital organs, just as a healthy heart would.
The grafted artery or vein bypasses (that is, goes
around) the blocked portion of the coronary artery.
This creates a new path for oxygen-rich blood to flow
to the heart.

For a patient to be considered for CABG, the

coronary arteries to be bypassed must have at least a
70% occlusion, or at least a 50% occlusion in the left
main coronary artery.
Client education o Monitor ABG, cardiac enzymes,
electrolytes and CBC
• Cardiac rehabilitation should be consulted for
o Maintain IV flow rate and assess insertion
a specific exercise program related to the
site
heart.
o Assume position as tolerated: semi to high
• Nutritional services, such as a dietitian, can be
fowler’s
consulted for diet modification or weight
o Schedule adequate rest periods and limit
management.
visiting time
• Monitor and report findings of infection
o Administer stool softener as ordered;
(fever, incisional drainage, redness).
avoid valsalva response.
• Avoid straining, strenuous exercise, or
emotional stress when possible. Nursing diagnoses

• Regarding response to chest pain: follow • Acute Pain

instructions on use of sublingual • Anxiety and Fear
nitroglycerin.
• Decreased cardiac output
• Consider smoking cessation, if applicable.
• Ineffective family coping
• Remain active and to exercise regularly
• Ineffective tissue perfusion
Nursing management
Expected outcomes
• Instruct to report all chest pain; Administer
• Decrease pain scale
pain medication as ordered.
• Verbalize reduced anxiety and fear
• Encourage verbalization of fears and
• Demonstrate no signs of bleeding
concerns.
• Maintain adequate cardiac output
• Explain the need for frequent monitoring of
vital signs and potential bleeding.
• If needed, prepare for intubation and
mechanical ventilation.
• Discuss continuing cardiac care and
rehabilitation.
o Place patient on cardiac monitor
o Report any changes in mental status
o Monitor hemodynamic status
o Administer oxygen, continuous oximetry