Info

Drug Class

Dosage

Description

Rationale

Antiplatelet therapy Varies with drug

Antiplatelet therapy Varies with drug

Recombinant tissue-plasminogen activator (alteplase, rt-PA)

IV bolus of 15 mg followed by IV Infusion 0.75 mg/kg over 30 min; then 0.50 mg/kg over 60 min

Aspirin, clopidogrel, glycoprotein Ilb/IIIa antagonist such as eptifibatide, tirofiban

Thrombolytic agent; tenecteplase (TNK-tPA) is a genetically engineered variant of rt-PA with lower incidence of mild/moderate bleeding

Prevents formation of thrombus; Inhibits platelet function by blocking cyclooxygenase

Less likely to cause hypotension and allergic reaction than other drugs; more expensive than other agents and associated with a higher risk of intracranial hemorrhage but more efficacious

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654 Myocardial Infarction

Pharmacologic Highlights (continued)

Medication or Drug Class

Dosage

Description

Rationale

Reteplase (r-PA)

Streptokinase

Heparin

10 units IV bolus, repeated 30 min later

1.5 million units over 60 min IV

1000 units per IV started 4 hr after thrombolytic agents and continued for 48 hr

Thrombolytic agent

Thrombolytic agent

Anticoagulant; low-molecular-weight heparin (enoxaparin) may also be used

Reduced fibrin specificity but longer half life than rt-PA

1%-2% have allergic reactions; 10% have hypotension

Prevents additional thrombus formation in the coronary arteries

Other Drugs: Vasodilators such as nitrates, beta-adrenergic blockers, calcium antagonists, or angiotensin-converting enzyme inhibitors are given to increase coronary perfusion and decrease afterload if the patients blood pressure is adequate. Usually the patient requires pain medication, with parenteral morphine the drug of choice. Anti-dysrhythmics, sedatives, and stool softeners may be given.

Independent

The focus is to control pain and related symptoms, to reduce myocardial oxygen consumption during myocardial healing, and to provide patient/family education. Remember that chest pain may indicate continued tissue damage; therefore, manage chest pain immediately. In addition to the pharmacologic methods mentioned here, a variety of measures can be used to reduce the cardiac workload during periods of chest pain. To decrease oxygen demand, encourage the patient to maintain bedrest for the first 24 hours; encourage rest throughout the entire hospitalization. Create a quiet, restful environment and encourage family involvement in the patient's care. Discourage any straining such as Valsalva's maneuver.

Because anxiety and fear are common among both patient and families, encourage everyone to discuss their concerns and express their feelings. Use a calm, reassuring voice; give simple explanations about care and procedures; and stay with the patient during periods of high anxiety if possible. Discuss with the patient and family the diagnosis, the activity and diet restrictions, and medical treatment. Numerous lifestyle changes may be needed. A cardiac rehabilitation program is helpful in limiting risk factors and in providing additional guidance, social support, and encouragement. The goals of a cardiac rehabilitation program are to reduce the risk of another MI through re-education and implementation of a secondary prevention program and to improve the quality of life for the MI victim. The program provides progressive monitored exercise, additional teaching, and psychosocial support. An exercise stress test is used before beginning exercise to evaluate the patient's response to physical activity and to determine an appropriate program. There are usually three phases to cardiac rehabilitation: in hospital, outpatient, and follow-up.

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