Causes, Risk Factors And Management Of Myocardial Infarction

Smoking and Alcohol consumption increase the risk of myocardial infarction

Question:

Discuss about the Myocardial Infarction : Symptoms and Treatments.

Smoking and alcohol consumption are the most causes of myocardial infarction. Mr. Savea was associated with smoking and alcohol consumption. Older age, family history, genetic factors, hypertension, obesity, diabetes mellitus, high cholesterol and low density lipoprotein levels are the risk factors associated with myocardial infarction. Myocardial infarction can also be developed due lack of physical activity, lack of exercise and mental stress. Smoking, obesity, lack of exercise and stress are responsible for occurrence of myocardial infarction in 36 %, 20 %, 12 % and 3 % people respectively. Mr. Savea is older person and associated with obesity, hypertension and high level of cholesterol. Hence, these factors are responsible for occurrence of myocardial infarction in Mr. Savea. Chest pain can occur in people with angina. Reduced supply of blood to heart muscles is responsible for the occurrence of chest pain in angina. This angina can be developed due to myocardial infraction. Systemic embolism can be developed due to Mitral valve stenosis and systemic embolism can leads to myocardial infraction. Mr. Savea is associated with both angina and Mitral valve stenosis (Mehta et al., 2014; Cardoz et al. 2015).

Worldwide 15.9 million populations are suffering through myocardial infraction and approximately 1 million people in US are suffering through myocardial infraction. Myocardial infraction treatment is expensive and it ranked fifth position in expensive treatment and approximately 10 % patients end into the death due to myocardial infraction. These risk factors for myocardial infraction are same in all parts of the world. Upto 5 cigarettes consumption per day can lead to myocardial infraction in 40 % people. Mr. Savea was affected adversely due to myocardial infraction because it was difficult for him to attend his job due to myocardial infraction. Myocardial infraction adversely affected Mr. Savea both socially and psychologically.

Being a myocardial infraction patient, Mr. Savea could’t participate in social activities and could’t meet friends. Hence, he might feel socially isolated due to myocardial infraction. Psychological effects like depression and low moral can exist in Mr. Savea. More amount of money need to be spend on the treatment of myocardial infraction and he could not attend his job. Hence, there would be considerable financial impact on Mr Savea’s family. Mr. Savea’s family might be under stressful condition due to diseased condition (Valensi et al., 2011).

Myocardial infraction is predominantly associated with chest pain. Insufficient blood supply to myocardial cells is mainly responsible for the occurrence of chest pain. Imbalanced blood supply and demand to the myocardiaum are also responsible for chest pain. Chest pain in myocardial infarction can lasts upto 20 minutes. Chest pain in myocardial infarction radiate to shoulder and right arm (Malik et al., 2013).

Patients with myocardial infraction are also associated with shortness of breath. Shortness of breath impairment in myocardial infration reflects effect of cardiovascular impairment on functioning of respiratory system. As a result of heart damage, cardiac output from the left ventricle can be reduced. This leads to the left ventricular failure and as a result pulmonary edema. Pulmonary edema adversely affects breathing pattern by affecting amount of exhaled and inhaled air. Reduced inhalation of air can lead to reduced oxygen saturation. Reduced oxygen saturation leads to compensatory mechanism of increased breathing rate to supply more amount of oxygen. Increased breathing rate leads to shortened breath in patients with myocardial infraction (Botker et al., 2016).

Age, family history and genetic factors are also associated with myocardial infarction

Insufficient supply of blood to the brain tissues can lead to the occurrence of loss of consciousness. Reduced supply of blood supply results in less amount of oxygen to the brain tissues which leads to the death of brain tissues, consequently brain dysfunction and loss of consciousness (Lu et al., 2015; Sandler et al., 2011).

Increased firing of the sympathetic nervous system occurs in the patients with myocardial infraction. ‘Fight or fligt response’ occurs mainly due to the activation of the sympathetic nervous system. Sweat glands get stimulated and consequently sweating occurs due to activation of sympathetic nervous system. Chest pain is responsible for the increased hormone secretion. These hormonal changes can produce bradycardia and hypertension in patients with myocardial infraction. Bradycardia and hypertension are responsible for increased sweating (Gokhroo et al., 2016). 

Less supply of oxygen to tissues results in the metabolic activity in the cells and reduced ATP generation. This reduced ATP levels can lead to fatigue development in patients with myocardial infraction.

Mainly two types of drugs can be used in the management of myocardial infraction like angiotensin converting enzyme inhibitors (ACE inhibitors) and beta-blocker. Conversion of angiotensin I (AI) to angiotensin II (AII) can be blocked by ACE inhibitors. ACE is the significant component of the renin–angiotensin system. Within 24 hours of evidence of myocardial infraction, ACE inhibitors should be administered. ST elevation MI (STEMI) patients are more beneficial with ACE inhibitors as compared to the non-ST elevation MI (NSTEMI). ACE inhibitors are helpful in reducing arteriolar resistance, increasing venous capacity, reducing cardiac volume and capacity and reducing resistance in blood vessels. Blood vessels dilatation, decreased blood pressure and reduced demand of blood by the heart can occur due to inhibition of ACE enzyme. ACE inhibitors also produce its action through activation of parasympathetic nervous system. ACE inhibitors reduce vasoconstriction effects of noreoinephrine by reducing plasma levels of norepinephrine. Zofenopril, perindopril, trandolapril, captopril, enalapril, lisinopril, and ramipril are the commonly used ACE inhibitors. Cough, hyperkalemia, headache, reduced blood pressure, dizziness, fatigue, nausea, and renal impairment are the common side effects of ACE inhibitors. Duration of survival of myocardial infarction patients can be improved by administering ACE inhibitors (Bangalore et al., 2017; Lubarsky and Coplan, 2007)

Beta blockers produce its effects by acting as competitive antagonist of endogenous catecholamines epinephrine and norepinephrine receptors on adrenergic beta receptors. These drugs are specifically administered in case of second attack of myocardial infraction. Existing beta blocker drugs are acting on all the beta adrenergic receptors and also acting on individual beta adrenergic receptors like β1, β2 and β3 receptors. These beta blockers can be administered as adjuvant therapies for ACE inhibitors and diuretics in patients with myocardial infraction. Most commonly used beta blockers are bisoprolol, carvedilol and sustained-release metoprolol (Bangalore et al., 2014). Beta blockers also produce its effects by decreasing secretion of rennin by acting on rennin-angiotensin system. Beta blockers gives relief from ischemic chest pain by reducing oxygen demand by heart, reducing heart rate, reducing blood pressure and reducing contractibility of blood vessels. Beta blockers increases ventricular fibrillation threshold and reduces ventricular fibrillation. Beta blockers also reduce infract size and prevent development of infraction (Kezerashvili et al., 2012).

Symptoms of myocardial infarction include chest pain and shortness of breath

Nurse should assess characteristics of pain in Mr. Savea by verbalizing him and collecting non-verbal cues for him. Nurse should evaluate intensity of pain in him on scale of 0 – 10 and compare it with the previous episodes of pain in him. Nurse should instruct Mr. Savea to report pain in timely manner and he should report pain in terms of duration and intensity. Pain can be relieved in Mr. Savea by providing calm and relaxed environment. For this purpose he should be taught with deep breathing which is a relaxation technique. His attention also should be distracted form pain. Antianginals like nitroglycerin, beta blockers like propranolol and analgesis like morphine should be administered in him to relieve him from pain (Ignatavicius and Workman, 2015).

For the assessment of cardiac output, nurse should record blood pressure in Mr. Savea. This blood pressure should be assessed by asking him to sit and stand. Along with blood pressure heart rate and respiratory rate also should be assessed. Mr. Savea should perform different activities while recording heart rate and blood pressure. In between these activities, suitable rest should be provided to him. Caffeinated and carbonated drinks should be avoided in him. Cardiac output, ECG, chest X-ray and laboratory tests like cardiac enzymes, ABG (arterial blood gas) and electrolytes should be assessed in Mr. Savea. Antidysrhythmic medications should be administered in Mr. Savea and pacemaker should be used (deWit and Kumagai, 2014). Impairment in tissue perfusion is associated with conditions like anxiety, lethargy and confusion in Mr. Savea. Nurse should monitor for these conditions in Mr. Savea. Tissue perfusion also can be monitored by monitoring food consumption and urine output. Assessment of erythema and edema should be performed in Mr. Savea. Tests for ABGs, BUN, prothrombin time, creatinine, and electrolytes should be performed in Mr. Savea. Anticoagulant and antacid drugs should be administered in Mr. Savea. Reperfusion therapy also should be performed in Mr. Savea (Anderson and Taylor, 2014).

2000 mL/24 hr fluid balance should be maintained in Mr. Savea. This fluid balance should be in the range of cardiovascular tolerance. Reduced cardiac output should be recorded and fluid balance should be balanced. Antidiuretic drugs should be administered in Mr. Savea along with the administration of low sodium and liquid administration (Ignatavicius and Workman, 2015).

Nurse should advise him to increase activity level in stepwise manner. These activities include getting up form bed and ambulation in sitting position. Nurse should monitor all the activities of Mr. Savea and assess intolerance in his activities to provide required nursing intervention (deWit and Kumagai, 2014).

Nurse should monitor Mr. Savea’s behavior for abandonment and rejection from tests and medication consumption. Anxiety behavior should be noted in the form of verbal and non-verbal from. For the management of anxiety, nurse should inform him about detailed procedure to be carried out and information about the medications. Nurse should give him confidence for improvement in his condition. Nurse should take him in confidence and provide comfortable environment for his anxiety management (Ignatavicius and Workman, 2015).

References:

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Bangalore, S., Makani, H., Radford, M., Thakur, K., et al., (2014). Clinical outcomes with β-blockers for myocardial infarction: a meta-analysis of randomized trials. The American Journal of Medicine. 127(10), 939–53.

Bangalore, S., Fakheri, R., Wandel, S., Toklu, B., Wandel, J., and Messerli, F.H. (2017). Renin angiotensin system inhibitors for patients with stable coronary artery disease without heart failure: systematic review and meta-analysis of randomized trials. British Medical Journal, doi: 10.1136/bmj.j4.

Botker, M. T., Stengaard, C., Andersen, M. S., Sondergaard, H. M., et al., (2016). Dyspnea, a high-risk symptom in patients suspected of myocardial infarction in the ambulance? A population-based follow-up study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 24, 15. doi:  10.1186/s13049-016-0204-9.

Cardoz, J., Jayaprakash, K., and George, R. (2015). Mitral stenosis and acute ST elevation myocardial infarction. Proceedings (Baylor University Medical Center), 28(2), 207–209.

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Gokhroo, R. K., Ranwa, B. L., Kishor, K., Priti, K., et al., (2016). Sweating: A Specific Predictor of ST-Segment Elevation Myocardial Infarction Among the Symptoms of Acute Coronary Syndrome: Sweating In Myocardial Infarction (SWIMI) Study Group. Clinical Cardiology, 39(2), 90–95 (2016)

Ignatavicius, D. D., and Workman, M. L. (2015). Medical-surgical Nursing: Patient-centered Collaborative Care. Elsevier Health Sciences.

Kezerashvili, A., Marzo, K., and De Leon, J. (2012). Beta Blocker Use After Acute Myocardial Infarction in the Patient with Normal Systolic Function: When is it “Ok” to Discontinue? Current Cardiology Reviews, 8(1), 77–84.

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Lubarsky, L., and Coplan, N. L. (2007).  Angiotensin-Converting Enzyme Inhibitors in Acute Myocardial Infarction: A Clinical Approach. Preventive Cardiology, 10(3), 156–159.

Malik, M. A., Khan, S. A., Safdar, S., and Taseer, I. (2013). Chest Pain as a presenting complaint in patients with acute myocardial infarction (AMI). Pakistan Journal of Medical Sciences, 29(2), 565–568.

Mehta, P.K., Wei, J., and Wenger, N.K. (2014). Ischemic heart disease in women: A focus on risk factors. Trends in Cardiovascular Medicine, 25(2), 140–151.

Sandler, B., Furniss, S., and McWilliams, E. (2011). Transient loss of consciousness in a patient with a Brugada like ECG. Clinical Practice, 1(4), e123.

Valensi, P., Lorgis, L., Cottin, Y., Cottin, L. (2011). Prevalence, incidence, predictive factors and prognosis of silent myocardial infarction: a review of the literature. Archives of Cardiovascular Diseases, 104(3), 178–88.