Myocardial Infarction

Myocardial Infarction Courtney Horine& Melissa Roy

Introduction • According to the American Heart Association (AHA), approximately every 34 seconds a person suffers from a heart attack in the United States (AHA, 2012). • The number one leading cause of death in the world in 2011 was ischemic heart disease, taking over 7 million lives (World Health Organization, 2013). • Objective: We are going to explore the different treatment plans for MI as recommended by The Joint Commission and proven effective by evidence-based practice.

Pathophysiology of Acute Coronary Syndrome • Acute coronary syndrome (ACS) is an umbrella term for issues such as angina, myocardial ischemia, and myocardial infarction. It is often diagnosed secondary to coronary artery disease (CAD) • Buildup of plaque in the lumen of the coronary artery restricts blood flow and oxygen to the myocardium. • Complete blockage of the artery results in myocardial infarction (MI). • An occlusion in the right coronary artery results in ischemia of the inferior wall of the left ventricle, inferior septum, papillary muscle, and the right ventricle. • An occlusion in the left coronary artery results in ischemia to over 70% of the left ventricle. (Osborne, Wraa, Watson, & Hollerand, 2013)

Clinical Presentation Pathophysiology • new onset or change in previous pattern of angina • pain in mid to lower sternal areas of the chest • pain may radiate to arms, back, neck, and jaw • diaphoresis • shortness of breath • general weakness • Depending on extent of ischemia patient may also experience nausea, vomiting, dyspnea, fainting, or feeling of impending doom. • In women, pain is more generalized, and patients often complain of overwhelming fatigue, weakness, and sleep disturbances. (Osborne, Wraa, Watson, & Hollerand, 2013)

Risk Factors Pathophysiology Non-Modifiable • Age • Family history • Gender Modifiable • Tobacco • Obesity • Sedentary lifestyle • Diet • Hostility/Stress • Medications • Substance abuse • Anabolic steroids Modifiable Perhaps… • Diabetes Mellitus • Hypertension (Osborne, Wraa, Watson, & Hollerand, 2013)

Diagnosis Pathophysiology • Laboratory tests • Triponin, Creatine kinase, and Myoglobin • Twelve-lead EKG • A 12 lead ECG is used to evaluate changes in electrical activity of the heart. While all components are important, the ST segment is the major focus when evaluating damage from MI. Diagnostic criteria call for a change in ST segment and T wave in at least 2 contiguous leads. For an inferior wall MI, an ECG would have to have at least a 1mm elevated ST segment in two of three specific leads (p. 951). (Osborne, Wraa, Watson, & Hollerand, 2013)

Treatment Pathophysiology • Initial treatment upon arrival: • M– morphine is given to relieve chest pain • O-- oxygenation • N– nitroglycerin to promote vasodilation in blocked artery • A– aspirin to decrease platelet aggregation • Implementation of CORE measures for acute MI from the Joint Commission • Angioplasty • Coronary Artery Bypass Graft (CABG) (Osborne, Wraa, Watson, & Hollerand, 2013)

Prognosis Pathophysiology • One-third of patients die from STEMI with 24 hours of ischemic attack. • Mortality rate for MI is about 30% • Half of this percentage accounts for deaths prior to admission to hospital. • 5-10% of survivors die within the first year following an acute MI. • About 50% of patients that have MI are admitted to the hospital within the following year. (Zafari, 2014)

Case Study • HPI: 61 year-old male presented to the emergency room on 02/03/2014 complaining of chest pain. Patient reports that about one week prior (01/26/2014), he experienced six episodes of this feeling within an hour, and that the pain lessened with each episode. When it began occurring again 8 days later, he decided to come to the ER. Patient states the pain in his chest pain would come and go and he described it as an “intense heaviness that was squeezing my heart” -- a 10/10. He said that activities such as walking or eating would aggravated it, and that until it dissipated, nothing would ease it.

PMH: history of smoking (50-pack-year) • Diagnostic: A 12-lead EKG was performed revealing spontaneous ST changes in the inferior leads. Also labs that were drawn revealed a slightly elevated troponin level. • Labs: • Triponin I: 0.24 upon admission and 0.75 the following morning. • CPK: 60 upon admission and 68 the following day. • Diagnosis/Intervention: Patient was diagnosed with acute coronary syndrome, and was sent to undergo a percutaneous coronary intervention (angioplasty). Procedure revealed a 95% occlusion of the right coronary artery, and a bare metal stent was successfully placed in the artery.

CORE MEASURES • Aspirin within 24 hours of arrival • Aspirin prescribed at discharge • ACE inhibitors or angiotensin-receptor blockers for left ventricular systolic dysfunction at discharge • Beta-blocker prescribed at discharge • Statin prescribed at discharge if LDL is greater than or equal to 100 • Thrombolytic agent received within 30 minutes of hospital arrival or documented reason for delay • Percutaneous coronary intervention received within 90 minutes of hospital arrival or documented reason for delay • Documentation of adult smoking cessation advice or counseling • Reduce mortality

Medical Interventions: Aspirin • Joint Commission Core Measure: • Aspirin is to be administered at arrival to the emergency department, and is to be prescribed to the patient at discharge. • Rationale: • According to the Joint Commission, Aspirin is estimated to prevent recurring myocardial infarction (MI) in up to 4% of patients previously treated for an acute MI. Current guidelines recommend that any person arriving to the emergency department with a suspected MI immediately receive aspirin and continue on therapy after discharge (Joint Commission, 2014). • Our Patient Medication Orders: • While in the hospital, our patient was taking aspirin (Aspir 81) by mouth daily in the chewable form. The therapeutic effect of aspirin in this patient case is decreased incidence of MI due to the decreased platelet aggregation action. • Upon discharge of the facility, the patient was prescribed the same dose of aspirin to be continued at home.

Medical Interventions: ACE Inhibitors • Joint Commission Core Measure: • Angiotensin Converting Enzyme Inhibitor (ACEI) for patients with Left Ventricular Systolic Dysfunction (LVSD) • Rationale: • Clinical trials have determined that beginning angiotensin converting enzyme inhibitor (ACEI) therapy after a patient has recovered from an Acute MI improves long-term survival (Joint Commission, 2014). • Our Patient Medication Orders: • While in the hospital, our patient was taking ACE Inhibitor Lisinopril 5mg by mouth daily. The therapeutic effect of Lisinopril in this patient case incudes the reduction of risk of death or development of heart failure after a MI. • Upon discharge, our patient prescribed the ACE Inhibitor Lisinopril 5mg oral tablet daily to be continued at home.

Medical Interventions: Adult Smoking Cessation • Joint Commission Core Measure: • Adult smoking cessation and advice/counseling • Rationale: • Smoking is known to trigger coronary spasms, reduce the anti-ischemic effects of beta blockers, and increases mortality after an Acute MI. Evidence indicates that within one year of quitting smoking, a patient's risk of acute myocardial reinfarction and AMI mortality is reduced(Joint Commission, 2014). • Our Patient Education on Smoking Cessation: • The nurse spoke to the patient about the importance of smoking cessation but the patient declinedby stating he isn’t going to quit. • The nurse provided pamphlets on smoking cessation and encouraged the patient to consider quitting due to his current health conditions

Medical Interventions: Beta Blockers • Joint Commission Core Measure: • A Beta Blocker is to be administered upon arrival to the emergency department and is to be prescribed for continued use at discharge. • Rationale: • Evidence indicates that beta blocker therapy reduces both the degree of infarction and incidence of complications in patients not receiving concomitant thrombolytic therapy, and the incidence of reinfarction in patients who receive thrombolytic therapy. In addition, several placebo-controlled trials have shown that long-term beta blocker therapy decreases mortality by reducing the incidence of sudden and nonsudden cardiac death (Joint Commission, 2014). • Our Patient Medication Orders: • As the Joint Commission suggests, our patient was started on the Beta Blocker Metoprolol 50 mg, by mouth, two times daily. Metoprolol is indicated for the prevention of MI and decreased mortality in patients with recent MI. • The patient’s discharge medications included metoprolol 50mg to be continued at home.

Medical Interventions: Thrombolytic Therapy • Joint Commission Core Measure: • Time to thrombolysis • Rationale: • Evidence indicates that the timing of reperfusion is critical to the effective management of AMI patients and the earlier therapy is initiated, the better the outcome. The greatest benefits of thrombolytic therapy are evident in the first 3 hours after the onset of symptoms, but there is proven benefit for up to 12 hours after the onset of symptoms (Joint Commission, 2014). • Our Patient Medication Orders • Our patient was initiated on prasugrel (Effient) 10 mg by mouth daily. The therapeutic effects of this drug is to decrease thrombotic events including cardiovascular death, nonfatal MI and nonfatal stroke. • He was prescribed this medication to be continued upon discharge home

Medical Interventions: Statin • Taking a Statin Medication is not currently a part of the Joint Commission Core Measures, but it is just as important as taking any and all of the other medications discussed previously. • Statin drugs are used to help lower cholesterol, which in turn slows the build up of atherosclerosis in the arteries which can potentially lead to a MI if the artery becomes partially or completely occluded. • Our Patient Medication Orders: • Our patient was taking atorvastatin 80mg by mouth at bedtime while in the hospital. The therapeutic effects of atorvastatin include reduction of the lipids/cholesterol which reduces the risk of MI and stroke sequelae. • He was prescribed this medication to be continued upon discharge home

Medical Interventions: Inpatient Mortality • Joint Commission Core Measure • Inpatient Mortality • Rationale: • Mortality of patients with AMI represents a significantly deleterious outcome that is potentially related to the quality of care. This rate-based indicator identifies an undesirable outcome of care, and measures only intrahospital inpatient mortality (Joint Commission, 2014). • Our Patient: • Our patient did not pass while in the hospital, so this standard is not applicable to our case.

Supporting Evidence of JCAHO Core Measures • A 12 year study was performed with a total of with a total of 61,238 participants with a first time diagnosis of ST-elevation MI between the years of 1996 and 2007 by The Register of Information and Knowledge about Swedish Heart Intensive Care Admission (RIKS-HIA) (Held et al., 2011). • The purpose of their study was to describe the adoption of new treatments consisting of the use of aspirin, clopidogrel, β-blockers, statins, and angiotensin-converting enzyme (ACE) inhibitors in reducing the mortality rate of patients with ST-elevation myocardial infarction (STEMI) (Held et al., 2011). • Findings over the 12 year study: • The Estimated In Hospital Mortality decreased from 12.5% to 7.2% • The estimated 30-day mortality rate decreased from 15.0% to 8.6% • The estimated 1 year mortality rate decreased from 21.0% to 13.3% • In the end, between 1996 and 2007, there was an increase in the prevalence of evidence-based treatments throughout Swedish Hospitals for Acute MI. With the implementation of evidenced based practice throughout their countries hospitals, there was a decrease in 30-day and 1-year mortality that was sustained during long-term follow-up. This evidence shows us that by hospitals following specific treatment guidelines such as the Core Measures outlined by the Joint Commission, more practical and effective care can be initiated and better patient outcomes will be the end result.

Nursing Diagnosis Altered tissue perfusion (myocardial) related to narrowing of the right coronary artery associated with atherosclerosis.

NCLEX What is the primary reason for administering morphine to a client with MI? • To sedate the client • To decrease the client’s pain • To decrease the client’s anxiety • To decrease oxygen demand on the client’s heart

NCLEX Which diagnostic tool is used to determine the location of myocardial damage for a patient with a myocardial infarction (MI)? • Cardiac catheterization • Cardiac enzymes • Echocardiogram • Electrocardiogram

References American Heart Association. (2013, January 23). About heart attacks. Retrieved from http://www.heart.org/HEARTORG/Conditions/HeartAttack/AboutHeartAttacks/About-Heart- Attacks_UCM_002038_Article.jsp Held, C., Jernberg, T., Johanson, P., Lindback, J., Svennblad, & Wallentin, L. (2011, April 27). Association between adoption of evidence-based treatment and survival for patients with ST-elevation myocardial infarction. The Journal of the American Medical Association, 305(16). doi:10.1001/jama.2011.522 Joint Commission. (2014). A comprehensive review of development and testing for national implementation of hospital core measures. Retrieved from http://www.jointcommission.org/assets/1/18/A_Comprehensive_Review_of_Development_for_Core_ Measures.pdf Osborn, K. S., Wraa, C. E., Watson, A., & Hollerand, R. (2013). Medical-surgical nursing: Preparation for practice (2nd ed.). Upper Saddle River, NJ: Pearson-Prentice Hall. Sommors, M. S. (2013). Diseases and disorders (4th ed.). Retrieved from http://nursing.unboundmedicine.com/nursingcentral/ub/index/Diseases-and-Disorders/All_Entries/A World Health Organization (WHO). (2013, July). The top 10 causes of death.Retrieved from http://who.int/mediacentre/factsheets/fs310/en/ Zafari, A. M.(2014). Myocardial Infarction. Medscape. Retrieved from http://emedicine.medscape.com/article/155919-overview#aw2aab6b2b8aa

Myocardial Infarction