Cardio E  (2nd) Injury: injuriST: ST segment elevation (at

least 1mm above isoelectric line) (secondary

Myocardial Infarction (Heart Attack) to rapid repolarization)
 (3rd) Ischemia: Tischemia: T wave inversion
Myo – Muscle - Cause of T wave inversion (ischemia) is
delayed repolarization
Cardial – Heart
- As the area of injury becomes ischemic,
Infarction – Death myocardial repolarization is altered and
delayed, causing the T wave to invert
= Death of the heart muscle 3. Echocardiography
- To evaluate ventricular function
Pathophysiology 4. Cardiac Enzymes
- Myoglobin usually arises 1 hour after
- Complete obstruction of coronary arteries
myocardial infarctijn
leading to myocardial necrosis > arrhythmia
- Troponin arises 3 hours after MI (#1 most
(abnormal heart rhythm) > cardiogenic shock
specific, accurate indicator of MI)
Signs and Symptoms - Creatinine Kinase MB arises 4-6 hours after MI
- AST Alanine Serum Transferase: 8hrs
1. Chest pain - LDH Lactate dehydrogenase: 24hrs
- Unrelieved by rest or nitroglycerin 5. Blood chemistry
- #1 presenting symptom of myocardial Normal
infarction - Cholesterol : <200mg/dl
- Lasts for >20mins - Triclycerides: <150mg/dl
2. SNS (sympathetic nervous system) Stimulation - LDL (low density lipoprotein, bad chrolesterol
- Cool skin that carries fats and deposits it to the lining of
- Pallor blood vessels): <100mg/dl
- Diaphoresis (sweating) - HDL (high density lipoprotein , good
- Tachycardia cholesterol that carries fats from the blood
- Tachypnea vessels and deposits it to the liver): >60mg/dl
3. If with Diabetes Mellitus - vLDL (very low density lipoprotein): <40mg/dl
- No severe pain secondary to neuropathy (DM
is a condition characterized by hyper viscosity
of the blood secondary to higher than normal
blood sugar level, may cause micro occlusion
including small blood vessels which may
damage the nerve, thus DM pt may not feel
chest pain)

Diagnostic Tests

1. Patient history
- ssx
2. ECG
- performed within 10mins of pain onset or
upon arrival at emergency room
- ECG typically manifests the pathologic Q
wave, the elevated ST segment and inverted T
wave

When there’s infarction, the area of infarction will

be the one to register in pathologic Q wave

 (1st) Infarction: InfarQtion: pathologic Q wave

The secondary injury will cause ST segment

elevation
 Management - to reroute blood to bypass the occlusion

1. Oxygenation Uses:
2. Medication
(a) Greater saphenous vein – has least number of
>For pain relief tributaries
(b) Lesser saphenous vein – found in lower
Morphine Sulfate (drug of choice) extremity
Side effect > carotid endarderectomy
- Respiratory depression (most dangerous)
- Constipation (most common)
- Pruritus (idiosyncratic – uncommon)
(image) percutaneous transluminal coronary angioplasty

>For reperfusion (restore blood flow to affected area)

Thrombolytic meds (tissue-plasminogen activator)

(urokinase, streptokinase, alteplase)

- Must be given within 3hours before there is

hardening or irreversible myocardial necrosis
- In case of bleeding: antidote – aminocaproic
acid – plasminogen inhibitor
- Watch out for cardiac arrhythmias (side effect
of antidote), it’s associated with reperfusion
of cardiac tissues

3. Hemodynamic Stability
- First 48 hours (very critical)
- Monitor VS (BP and HR)
- Look for possibility of
 Arrhythmia (BP decreases)

Chemical
PTCA – tube with a balloon and a stent that is used to flatten /remove
Anti-arrhythmic drugs (Na channel blockers) atheroma, or restore the patency of occluded blood vessel.

- Lidocaine
- Procainamide
- Quinidine (image) coronary artery bypass graft

Electrical

- Defibrillation

*Cardiogenic Shock management

- drug of choice: Lidocaine (anti-arrhythmic effect)

- Dopamine (A1, B2)

- dobutamine (inotropic) (A1, B1, B2)

4. Surgery

> percutaneous transluminal coronary angioplasty: for

1-2 affected vessels

- balloon tipped catheter with stent

> coronary artery bypass graft: for >3 affected vessels

CABG – saphenous vein is used to connect blood vessels that are
obstructed by blockage and internal mammary artery graft that is
used to connect subclavian vein and another artery that has been
blocked

5.Maintenance medications

>Anticoagulants: to reduce circulation fibrinogen

- heparin
- warfarin
>angiotensin-converting enzyme inhibitors: blocks the
conversion of angiotensin 1 (mild vasoconstrictor) to
angiotensin 2 (potent vasoconstrictor) in the
pulmonary circilation
- captopril
- enalapril

Side effect
- Cough (nonproductive): blocks the breakdown
of bradykinin (inflammatory mediator)

>Beta1 Blockers: decreases the heart rate (#1

determinant of cardiac metabolic demand)

> CCBS (calcium channel blockers)

- amlodipine
- nicardipine

>Antilipemics (statins): blocks enzyme HMG CoaA

(hydroxymetheylglutaryl coenzyme A), thus
decreasing cholesterol formation

Side Effect
- Muscle pain (myalgia – secondary to decrease
protein in muscles)

6.Nutritional support
- NPO first 24 hrs (for surgery)
- General liquid diet
- Soft diet (decreased fat, Na, calories)
- Prevent constipation: increase fluids, fibers
- Laxative: dulcolax

7.Sexual needs
resume if
- (a) the pt can climb stairs without shortness of
breathe (or 6weeks after surgery)
- Best time: early in the morning naol
- Do it in a familiar place with a familiar partner
(reduce anxiety)
- Prolong foreplays (for slow acceleration of
cardiac function)