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Acute Myocardial Infarction


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If not a thrombolytic candidate, person may have:
*angioplasty (ask if allergic to iodine; check BUN/Cr because dye is nephrotoxic)
*Directional coronary atherectomy
*laser ablation
*bypass surgery
Successful reperfusion is evidenced by:
*EKG ST segment and T wave "back to normal"
*relief of chest pain
*presence of reperfusion dysrhythmias (PVC's)
*cardiac enzymes decrease
Once in ER (AMI)
*4 D's - door, data, decision, drug
*O2, ECG monitor, IV, draw labs, obtain 12 lead EKG
*tx pain with IV morphine (helps < afterload, cuts pain)
Emergency treatment of person experiencing AMI
*call 911
*chew an ASA (mortality <23%)
*most people experiencing AMI don't think this is what AMI should feel like
Not all persons are candidates for thrombolytic therapy
*hx of CVA
*recent surgery
*person already on anticoagulants
*complications include: bleeding, allergic reaction and stroke
EKG findings
*bradycardia or tachycardia
*ventricular ectopy (PVC's)
*ST segment changes(depression - subendocardial MI; elevation - acute MI)
*T wave inversion
*presence of Q wave
Laboratory Findings of AMI
*creatinine kinase-MB (^3-4 hrs, >6%)
*myoglobin (^ 2hrs, >90ng/ml)
*cardiac troponin T (^3-5 hrs, >1/5 ng/ml)
*cardiac troponin I (^ 3 hrs, >0.1 - 0.2 ng/ml)
Pharmalogical Treatment of AMI
*anti-ischemic therapy
*nitroglycerin IV
*Beta blockade
Assessment of persons experiencing AMI
*chest pain not releived by NTG SL
*pain may be present in neck, jaw, back, epigastium or arms
*diaphoresis, restlessness, pallor, nausea, vomiting, SOB
*s/s low CO
Caring for person undergoing angiography
*before angiography: check allergies; distal pulses, and prep groin site
*after angiography: check for bleeding, pulses, reperfusion dysrhythmias, kidneys, neuro changes and flat for at least 4 hours
*a balloon tipped catheter is introduced into femoral artery to thrombosed vessel. The balloon is filled, compressing plaque and restoring flow
*an arterial sheath is left in place after procedure in case they have to emergently re-open vessel
*consent for open heart surgery is signed in case vessel can't be opened or if accidentally torn
*risk: bleeding, MI, tearing vessel
Anti-thrombotic Therapy (AMI)
*ASA, Heparin (help clot be not as strong)
*thrombolytic (streptokinase, urokinase, t-PA, anisoylated plasminogen streptikinase activator complex (APSAC), urokinase plasminogen activator and reteplase
*after thrombolytic given, person maintained with Heparin or a glycoproetin II/II inhibitor (abciximab)
*small self expandable or balloon expandable tubing is set in narrowed region to physically maintain vessel open
*person must be on anti-platelet meds
*thrombus vessel dissection and bleeding are complication
Directional Coronary Atherectomy
*rotating blade that shaves off plaque and deposits in the nose cone of the housing
*complications include embolus, vessel occlusion, perforation or spasm
Laser Ablation
*vaporize plaque, usually used right after a PCTA to fully remove plaque
*complications include vessel dissection, occlusion, perforation and embolism
Coronary Artery Bypass Grafting
*traditional, minimally invasive or "octopus" approach
*internal mammary artery or radial artery best choice for graft
*can also use saphnous, xenograft (pic), cadaver or synthetic grafting
If person has diffuse CHD and severe angina they might try
*trans-myocardial revascularization (TMR) or percutaneous myocardial revascularization (PMR)
*using short bursts of laser beams them "burn" holes in the myocardium to allow blood to enter the channels to feed the heart oxygenated blood
After initial treatment, the person may have
*stool softeners
*ace inhibitors
*should start cardiac rehab
Mortality from AMI increases with
*old age (>80 yrs have 60% mortality)
*evidence of other diseases (COPD, DM)
*anterior MI (30% mortality)
*hypotension (systolic BP <55mmHG on admission has a 60% mortality)
Risk factors for CHD
*age *gender *cigarette smoke *HTN
*^cholesterol (^240mg/dl)
*low HDL (^35mg/dl desired)
*^LDL (< 130mg/dl desired)
*diabetes *stress *homocysteine *menopause
*obesity *physical inactivity
*pain *impaired tissue perfusion *dysrhythmias
*decreased CO *impaired gas exchange
*risk for bleeding *powerlessness *anxiety/fear
*activity intolerance *heart failure
*fluid volume excess *skin breakdown
*potential for infection *knowledge deficit

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