INFARK MIOKARD ACUTE (IMA)

Acute myocardial infarction or ima from World Health Organization (WHO)

WHO data of 2004 reported that acute myocardial infarction (IMA)) is the leading
cause of death in the world. As many as 7.2 million (12.2%) of deaths occurred due
to IMA (IMA) acute myocardial infarction worldwide. According to data from the
American Heart Association (AHA) in 2015, the mortality rate of cardiovascular
disease in the United States is 31.3%.

DEFINITION OF INFARK MIOKARD AKUT

Myocardial infarction is the death / myocardial tissue necrosis due to a sudden

drop in coronary artery blood flow to the heart or sudden increase in oxygen demand
without adequate perfusion of the coronary artery.

The cause of acute myocardial infarction (IMA) / ETIOLOGI acute

myocardial infarction (IMA) Myocardial infarction can be caused by:

 critical narrowing of the coronary arteries from atherosclerosis or complete

arterial occlusion due to embolus or thrombus.
 Decreased coronary blood flow may also be caused by shock and hemorrhage.
 Imbalances between the supply and myocardial oxygen demand.

SIGNS AND SYMPTOMS

Signs and symptoms of myocardial infarction (TRIAGE) are:

1. Clinical

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a. Chest pain that occurs suddenly and continuously does not subside, usually above
the lower sternal region and upper abdomen, this is the main symptom.

b. The severity of the pain may increase steadily until the pain is unbearable.

c. The pain is very painful, like a puncture that can radiate to the shoulder and
continue down towards the arm (usually the left arm).

d. Pain starts spontaneously (does not occur after activity or emotional disturbance),
persists for several hours or days, and does not disappear with the help of rest or
nitroglycerin (NTG).

e. Pain may spread to the jaw and neck.

f. Pain is often accompanied by shortness of breath, pale, cold, severe diaphoresis,

dizziness or head feels floating and nausea vomiting.

g. Patients with diabetes mellitus will not experience severe pain because the
neuropathy that accompanies diabetes can disrupt the neuroreseptor (collect pain
experience).

2. Laboratotium

Cardiac enzyme examination

CPK-MB / CPK

The issoenzymes found in the heart muscle increase between 4-6 hours, peaking
within 12-24 hours, returning to normal within 36-48 hours.

LDH / HBDH

Rising within 12-24 hours and it takes a long time to get back to normal

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AST / SGOT

Rising (less real / special) occurs within 6-12 hours, peaking in 24 hours, returning to
normal within 3 or 4 days

3. EKG

ECG changes occurring in the early phase of high and symmetrical T waves.
After this there is a segment elevation ST. Changes that occur later is the wave Q /
QS which indicates the existence of necrosis.

COMPLICATIONS

Complications of acute myocardial infarction (IMA) are: cardiogenic shock,

septal rupture or ventricular wall, pericarditis, myocardial stunning and
thromboembolism.

DIAGNOSTIC

Diagnosis of AMI can be established by:

Anamnesis

The chest pain caused by IMA is as follows:

- Pain substernal, precordial, epigastrium. Pain radiates to the left arm, neck
and jaw.

- Chest pain more than 30 minutes

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 - The quality of chest pain as it is pressed, squeezed, feels heavy

- Chest pain is not lost by rest or sublingual nitrate administration

- Can be accompanied by palpitasi, shortness of breath, sweat and pale

(Schneider & Seckler, 1981)

Pain score according to White

0: No pain

1: Pain on one side, without disturbing the activity

2: More pain in one place & result in disruption of activity, for example
difficulty getting out of bed, difficult to bend head etc.

- Examination of ECG

ECG changes occurring in the early phase of high and symmetrical T waves. After
this there is a ST segment elevation. The subsequent changes are the presence of Q /
QS waves indicating the presence of necrosis.

- Cardiac enzyme examination

CPK-MB / CPK

The issoenzymes found in the heart muscle increase between 4-6 hours, peaking
within 12-24 hours, returning to normal within 36-48 hours.

LDH / HBDH

Rising within 12-24 hours and it takes a long time to get back to normal

AST / SGOT

Rising (less real / special) occurs within 6-12 hours peaking in 24 hours back to
normal in 3 or 4 days

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TREATMENT / MANAGEMENT

The goal of medical management is to minimize myocardial damage by:

relieving pain, providing rest and preventing complications such as lethal
dysrhythmias and cardiogenic shock.

1. Giving oxygen is done during onset of chest pain.

2. Analgesic (morphine sulfate). Pharmacotherapy:

 Vasodilator to increase oxygen sulpai (NTG).

 Anticoagulant (Heparin).
 Thrombolytics (streptokinase, tissue plasminogen activator <t-pA>,
anistreplase) are only effective when administered within 6 hours of onset of
chest pain, during transmural tissue neurosis.

Myocardial infarction is a damage to the heart muscle in certain parts of the

settled due to lack of supply of oxygen-rich blood flow. The dead heart muscle can
not function as before.

In everyday terms, Myocard Infarction (myocardial infarction) is often called a

heart attack. Myocardial infarction itself in medical terms means there is damage to
the heart muscle tissue settling due to lack of oxygen supply. When the heart muscle
is damaged it can not return to its original function, and the heart's ability to pump
blood becomes lessened.

What Causes Myocardial Infarction?

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 The main cause of myocardial infarction is the imbalance between supply and
oxygen demand in cardiac muscle tissue. Oxygen needs in the heart muscle tissue is
high, but the supply (supply) of oxygen to the area is less.

The heart muscles need a supply of oxygen in order to continue pumping

blood throughout the body. When cardiac muscle activity increases, then the need for
oxygen also increases. If you do not get enough oxygen for a long time, over time the
heart muscle tissue can be damaged and persistent.

Heart blood vessels that supply blood to the heart muscles are called coronary
arteries. The reduced supply of oxygen to the heart muscle tissue can be caused by a
blockage in the coronary artery called atherosclerosis, ie the presence of plaque in the
heart's blood vessel. So the blood that carries oxygen can not reach the heart muscle.
Myocardial infarction is more common due to blockage of the heart's blood vessels or
ischemia.

Who is more at risk of heart disease?

There are irreversible risk factors that can increase the occurrence of
myocardial infarction such as old age, male sex is more at risk, and also heredity.

However, there are many other risk factors that can still be controlled to avoid
myocardial infarction, such as:

 Smoke
 Hyperkolessterolemia (blood cholesterol levels above normal)
 Diabetes mellitus
 Hypertension
 Obesity
 Stress

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  Less exercise
 Consume less fruits and vegetables
 Alcohol addiction
 Etc

What are the characteristics and symptoms of myocardial infarction that can be
observed?

Patients who experience a heart attack are usually abrupt without any previous
signs. However, in some cases, patients may experience preliminary symptoms before
an attack, such as:

 Limp
 Uncomfortable in the chest
 Restless
 Shortness of breath
 Nausea
 Dizzy

In the event of a heart attack, the pain in the chest is very characteristic with the
following characteristics:

 Severe chest pain and not decreased for 30-60 minutes

 The location of the pain is felt behind the breastbone and often spreads to the
neck, shoulders, jaw and also the left arm.
 Chest sensations such as depression, pain, heat or burning, and punctured
 In some patients there can be complaints on the solar plexus, such as bloating
and a lot of gas in the stomach.

The general condition of the patient at the time of the attack, can be found
examination of vital signs as follows:

 The pulse increases with irregular rhythms

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  Blood pressure increases
 Breathing frequency increases
 Coughing, wheezing, there is sputum production

Enforcement Diagnosis

At the time of the patient suffered a heart attack, the patient will feel very
painful so it is not possible to do anamnesa to know the history of the disease. The
doctor can take a brief history to the patient's family, then perform first aid to
stabilize the patient's condition.

Some checks that can be done to help establish a diagnosis include:

 Blood laboratory examination. Components examined include levels of

troponin, creatinine kinase (CK), myoglobin, blood lipid levels, inflammatory
markers, as well as full blood tests.
 Electrocardiography (EKG). The EKG serves to record electrical activity in
the heart. It is an important primary check to establish a heart attack diagnosis.
 Cardiac imaging. X-ray examination or cardiac CT scan may be performed
after the patient's condition is stable.

Treatment of Myocardial Infarction

Any patient with myocardial infarction should be assisted immediately by a

trained health worker and have an ACLS training certificate (Advanced Cardiac Life
Support) or taken to the ER for emergency medical assistance. The first aid that can
be given aims to stabilize the patient's condition. Some actions that can be done
include:

 Provide additional oxygen support and monitor oxygen saturation with the
help of pulse oximetry tool. Low oxygen levels when oxygen saturation is less
than 90%.
 Administration of aspirin drugs by chewing.

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Patients with a history of aspirin allergy should be given aspirin as a first aid.
Because aspirin is useful to thin the blood.

 Provision of nitroglycerin drugs placed under the tongue (sublingual) to

overcome the pain. Nitroglycerin serves to dilate blood vessel diameter
(vasodilatation), so the need for oxygen in muscle tissue is reduced.
Nitroglycerin should not be administered to patients who have low blood
pressure or a weak pulse.
 Giving morphine-class painkillers. Common painkillers are sold freely,
unable to cope with chest pain due to heart attack.
 Examination of ECG heart record. To know the types of myocardial
infarction.

Once the patient's condition is stable, reperfusion of blood flow can be performed.
The main principle of the help given is to return blood vessel blood flow to the heart
as soon as possible, so as not to happen necrosis or damage to the heart muscle that
settled. Interventional action that can be done is Percutaneous Coronary Intervention
(PCI) or with Coronary Artery Bypass Graft (CABG) operation.

Prognosis

The prognosis of myocardial infarction in each person varies, depending on the

extent of damaged heart muscle tissue and also how quickly the treatment is given. In
a great heart attack, the patient can die instantaneously. However, in other cases,
rapid treatment before 6 hours of first-time symptoms can provide a good prognosis.