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A CASE STUDY (MYOCARDIAL INFARCTION)

Submitted by: Gonzales, Ralph Renzo P. Guzman, Jamie Rose Gumapac, Hazel Lazaro, BSN 2Y0-5

OVERVIEW Myocardial infarction (MI) or acute myocardial infarction (AMI), commonly known as a heart attack, is the interruption of blood supply to a part of the heart, causing heart cells to die. This is most commonly due to occlusion (blockage) of a coronary artery following the rupture of a vulnerable atherosclerotic plaque, which is an unstable collection of lipids (fatty acids) and white blood cells (especially macrophages) in the wall of an artery. The resulting ischemia (restriction in blood supply) and oxygen shortage, if left untreated for a sufficient period of time, can cause damage or death (infarction) of heart muscle tissue (myocardium).

SYMPTOMS Chest pain is a major symptom of heart attack. You may feel the pain in only one part of your body, or it may move from your chest to your arms, shoulder, neck, teeth, jaw, belly area, or back. The pain can be severe or mild. It can feel like: A tight band around the chest Bad indigestion Something heavy sitting on your chest Squeezing or heavy pressure

The pain usually lasts longer than 20 minutes. Rest and a medicine called nitroglycerin may not completely relieve the pain of a heart attack. Symptoms may also go away and come back. Other symptoms of a heart attack include: Anxiety Cough Fainting Light-headedness, dizziness Nausea or vomiting Palpitations (feeling like your heart is beating too fast or irregularly) Shortness of breath Sweating, which may be extreme

Some people (the elderly, people with diabetes, and women) may have little or no chest pain. Or, they may experience unusual symptoms (shortness of breath, fatigue, weakness). A "silent heart attack" is a heart attack with no symptoms.

CAUSES, INCIDENCE, and RISK FACTORS Most heart attacks are caused by a blood clot that blocks one of the coronary arteries. The coronary arteries bring blood and oxygen to the heart. If the blood flow is blocked, the heart starves for oxygen and heart cells die. In atherosclerosis, plaque builds up in the walls of your coronary arteries. This plaque is made up of cholesterol and other cells. A heart attack can occur as a result of the following: The slow buildup of plaque may almost block one of your coronary arteries. A heart attack may occur if not enough oxygen-containing blood can flow through this blockage. This is more likely to happen when you are exercising. The plaque itself develops cracks (fissures) or tears. Blood platelets stick to these tears and form a blood clot (thrombus). A heart attack can occur if this blood clot completely blocks the passage of oxygen-rich blood to the heart. This is the most common cause. Occasionally, sudden, significant emotional or physical stress, including an illness, can trigger a heart attack.

Risk factors for heart attack and coronary artery disease include: Increasing age (over age 65) Male gender Diabetes Family history of coronary artery disease (genetic or hereditary factors) High blood pressure Smoking Too much fat in your diet Unhealthy cholesterol levels, especially high LDL ("bad") cholesterol and low HDL ("good") cholesterol Chronic kidney disease

TREATMENT

If you had a heart attack, you will need to stay in the hospital, possibly in the intensive care unit (ICU). You will be hooked up to an ECG machine, so the health care team can look at how your heart is beating. Life-threatening irregular heartbeats (arrhythmias) are the leading cause of death in the first few hours of a heart attack. These arrythmias may be treated with medications or electrical cardioverson/defibrillation. The health care team will give you oxygen, even if your blood oxygen levels are normal. This is done so that your body tissues have easy access to oxygen and your heart doesn't have to work as hard. An intravenous line (IV) will be placed into one of your veins. Medicines and fluids pass through this IV. You may need a tube inserted into your bladder (urinary catheter) so that doctors can see how much fluid your body removes.

ANGIOPLASTY AND STENT PLACEMENT Angioplasty, also called percutaneous coronary intervention (PCI), is the preferred emergency procedure for opening the arteries for some types of heart attacks. It should preferably be performed within 90 minutes of arriving at the hospital and no later than 12 hours after a heart attack. Angioplasty is a procedure to open narrowed or blocked blood vessels that supply blood to the heart. A coronary artery stent is a small, metal mesh tube that opens up (expands) inside a coronary artery. A stent is often placed after angioplasty. It helps prevent the artery from closing up again. A drug eluting stent has medicine in it that helps prevent the artery from closing.

THROMBOLYTIC THERAPY (CLOT-BUSTING DRUGS) Depending on the results of the ECG, certain patients may be given drugs to break up the clot. It is best if these drugs are given within 3 hours of when the patient first felt the chest pain. This is called thrombolytic therapy. The medicine is first given through an IV. Blood thinners taken by mouth may be prescribed later to prevent clots from forming. Thrombolytic therapy is not appropriate for people who have: Bleeding inside their head (intracranial hemorrhage) Brain abnormalities such as tumors or blood vessel malformations Stroke within the past 3 months (or possibly longer)

Head injury within the past 3 months

Thrombolytic therapy is extremely dangerous in women who are pregnant or in people who have: A history of using blood thinners such as coumadin Had major surgery or a major injury within the past 3 weeks Had internal bleeding within the past 2-4 weeks Peptic ulcer disease Severe high blood pressure

OTHER MEDICINES FOR HEART ATTACKS

Many different medicines are used to treat and prevent heart attacks. Nitroglycerin helps reduce chest pain. You may also receive strong medicines to relieve pain. Antiplatelet medicines help prevent clots from forming. Aspirin is an antiplatelet drug. Another one is clopidogrel (Plavix). Ask your doctor which of these drugs you should be taking. Always talk to your health care provider before stopping either of these drugs. For the first year after a heart attack, you will likely take both aspirin and clopidogrel every day. After that, your health care provider may only prescribe aspirin. If you had angioplasty and a coronary stent placed after your heart attack, you may need to take clopidogrel with your aspirin for longer than one year.

Other medications you may receive during or after a heart attack include: Beta-blockers (such as metoprolol, atenolol, and propranolol) help reduce the strain on the heart and lower blood pressure. ACE inhibitors (such as ramipril, lisinopril, enalapril, or captopril) are used to prevent heart failure and lower blood pressure. Lipid-lowering medications, especially statins (such as lovastatin, pravastatin, simvastatin, atorvastatin, and rosuvastatin) reduce blood cholesterol levels to prevent plaque from increasing. They may reduce the risk of another heart attack or death.

CORONARY ARTERY BYPASS SURGERY Coronary angiography may reveal severe coronary artery disease in many vessels, or a narrowing of the left main coronary artery (the vessel supplying most of the blood to the heart). In these circumstances, the cardiologist may recommend emergency coronary artery bypass surgery (CABG). This procedure is also called "open heart surgery." The surgeon takes either a vein or artery from another location in your body and uses it to bypass the blocked coronary artery.

DIET Changes in diet can make a big difference. Studies suggest that people who eat a healthy diet may halve their chance of a further MI compared to those who do not eat healthily. See separate leaflet called 'Healthy Eating' for more details.

Briefly: Eat at least five portions of a variety of fruit and vegetables each day. They are rich in vitamins and minerals. These can be fresh, frozen or dried. Do not eat much saturated fat. It is not just about the total fat content of the diet, but also the type of fat in the diet. Try to avoid eating foods that are high in saturated fat. Foods that are high in saturated fat include meat pies, sausages, butter, cream, hard cheese, cakes, biscuits and foods that contain coconut or palm oil. Eating foods that are high in unsaturated fat can help to reduce your cholesterol level. Foods high in unsaturated fat include oily fish (such as herring, mackerel, sardine, salmon), avocados, nuts and seeds, sunflower, rapeseed and olive oil. Eat a low-fat diet rich in fruits and vegetables and low in animal fat. Eat fish twice a week. Baked or grilled fish is better than fried fish. Frying can destroy some of the health benefits. Reduce you salt intake. Many foods contain hidden salt. Lowering your salt intake can reduce your risk of another MI and also other cardiovascular diseases. Alcohol A little alcohol may be beneficial. People who drink one glass of wine per day, or about half a pint of beer per day, may have less risk of heart disease compared to those who do not drink at all. It is probably the alcohol rather than anything else in the drink that is the active ingredient. The exact way this works is not clear. Alcohol may affect the way atheroma is formed.

However, drinking too much alcohol can be harmful. Men should drink no more than 21 units per week (and no more than four units in any one day). Women should drink no more than 14 units per week (and no more than three units in any one day). One unit is about half a pint of normal strength beer, or two thirds of a small glass of wine, or one small pub measure of spirits. A MEDITERRANEAN DIET Eating a Mediterranean style diet is thought to be one of the best ways to reduce the risk of having an MI. This type of diet is, in effect, a summary of the advice above. That is - meals with poultry rather than red meat, lots of wholegrain pasta and breads and plenty of fruit, vegetables, olive oil, oil-rich fish, accompanied by a small glass of wine or beer. CHOLESTEROL Cholesterol is involved in the formation of atheroma. Eating a healthy diet (described above) will help to lower cholesterol. In addition, most people who have an MI are advised to take a statin drug to lower the cholesterol level. Statins work by reducing the amount of cholesterol that is made in your liver.