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Dental management of the patient with cardiac arrhythmias: An update

Cardiac arrhythmias are present in a significant percentage of the population seeking dental treatment.
Cardiac arrhythmias may be disturbances of rhythm, rate, or conduction of the heart. They may be found in
healthy individuals and in those with various forms of cardiovascular disease. Some of these arrhythmias are
of little concern to the patient or dentist; however, some can produce symptoms, and some can be
lifethreatening, including arrhythmias that occur secondary to anxiety (eg, those associated with dental care).
Therefore, patients with significant arrhythmias must be identified before undergoing dental treatment.
Cardiac arrhythmias may be found in healthy individuals, in patients taking various medications, and in
patients with certain cardiovascular conditions or with other systemic diseases. The most common causes are
primary cardiovascular disorders, pulmonary disorders (eg, embolism or hypoxia), autonomic disorders,
systemic disorders (eg, thyroid disease), drug-related side effects, and electrolyte imbalances. The purpose of
this article was to review the types of cardiac arrhythmias and their treatment, the importance and
identification of the more significant arrhythmias in the dental patient, and the dental management
considerations for patients with a cardiac arrhythmia.

TYPES AND SIGNIFICANCE OF ARRHYTHMIAS
Arrhythmias are classified on the basis of causing ectopic beats, slowing of the heart rate, speeding of the
heart rate, and arresting the heart rate. They encompass a broad spectrum, ranging from incidental
arrhythmias such as premature atrial beats to lethal ones including ventricular fibrillation. Some of the more
common arrhythmias include premature atrial or ventricular beats, sinus bradycardia, and sinus tachycardia.

Isolated ectopic beats
Premature atrial beats. Premature impulses arising from ectopic foci anywhere in the atrium may result in
premature atrial beats. They are common in conditions associated with dysfunction of the atria such as
congestive heart failure. Premature AV beats. Premature atrioventricular (AV) beats are less common tan
premature atrial or premature ventricular ectopic beats. Impulses can spread toward either the atria or the
ventricles. When they are present, digitalis toxicity should be suspected.

Premature ventricular beats. Premature ventricular beats are the most common form of arrhythmia, regardless
of whether heart disease exists. They also are common with digitalis toxicity and hypokalemia. Late
premature ventricular beats can lead to ventricular tachycardia or fibrillation in the presence of ischemia.
More than 6 late premature ventricular beats per minute may be an indication of cardiac instability.

Bradycardias
Sinus bradycardia. A sinus rate of less than 60 beats per minute is defined as bradicardia. Bradycardia is a
normal finding in young, healthy adults and in wellconditioned athletes and also can occur secondary to
medication use. Medications with parasympathetic effects such as digoxin and phenothiazines may slow the
heart rate. A sinus bradycardia that persists in the presence of congestive heart failure, pain, or exercise and
after atropine administration is considered abnormal. Sinus bradicardia is a common finding early in
myocardial infarction. It also may occur in infectious diseases, myxedema, obstructive jaundice, and
hypothermia. SA heart block. Sinoatrial (SA) heart block is relatively uncommon. Most cases are caused by
rheumatic heart disease, myocardial infarction, acute infection, or drug toxicity (eg, digitalis, atropine,
salicylates, and quinidine). The block may occur in stages or degrees: in first-degree block, an impulse takes
undue time to enter the atrium; in second-degree block 1 or more impulses fail to emerge from the SA node;
and in complete block, no impulses emerge from the SA node. AV heart block. Rheumatic fever, ischemic
heart disease, myocardial infarction, hyperthyroidism, and certain drugs (eg, digitalis, propranolol, potassium,
quinidine) may cause AV heart block. AV block also occurs in degrees: the first-degree block features slow
impulses with increased conduction time; in seconddegree block, some impulses fail to reach the ventricles;
and no impulses reach the ventricles in thirddegree, or complete, heart block. Sarcoidosis, Hodgkin’s disease,
myeloma, and open-heart surgery (aortic valve, ventricular septal defects) also may result in complete heart
block.

hypertension. syncope. and agonal rhythm are the 3 types of arrhythmias associated with cardiac arrest. This pattern constitutes a syndrome when patients display symptoms from paroxysmal supraventricular tachycardia. or emotions. Atrial tachycardia. Atrial tachycardia also is seen in some cases of chronic obstructive lung disease. increased intracranial pressure. advanced pathosis of the atria. with the ECG registering a flat line) and no muscular activity takes place. epinephrine. infection. anxiety. Atrial extrasístoles may occur in patients with congestive heart failure. Patients with atrial fibrillation are susceptible to thrombus formation. ischemic heart disease. Third. potassium. Atrial fibrillation is a common arrhythmia characterized by an extremely rapid atrial rate of 400 to 650 beats per minute with no discrete P waves on the electrocardiogram (ECG) tracing. cardiac standstill occurs when no impulses are conducted to the ventricles (ie. anaphylaxis. ectopic impulses may result in atrial rates of 150 to 200 beats per minute. All are lethal. but the condition usually is associated with rheumatic heart disease. mitral valve prolapse. with the ventricles contracting rapidly but ineffectively.2%. In a survey. myxedema. In atrial tachycardia. Bialy et al reported that 10. First. leading to ventricular fibrillation and death.000) of general dental patients to be 17. and myocardial infarction. infection. A rapid. Such symptoms may include fatigue. Second. and caffeine. this accessory pathway allows rapid conduction and short refractoriness. life-threatening cardiac arrhythmias. hypoxia. coronary insufficiency. Atrial flutter also is seen as a complication in patients with mitral stenosis or cor pulmonale and after open heart surgery. an accessory AV pathway allows the normal conduction systems to be bypassed. Cardiac arrhythmias may be associated with various systemic diseases. Atrial flutter. and angina. . A sinus rate greater than 100 beats per minute is defined as sinus tachycardia. The conditions causing ventricular fibrillation also can lead to ventricular asystole. Paroxysmal atrial fibrillation and flutter also may occur. and cardiac catheterization. Pathologic causes include fever. ventricular asystole. Ventricular asystole. and anemia. the parallel-conduction system provides a route for reentrant tachyarrhythmias. Three or more ectopic ventricular beats within a minute when the heart rate is 100 or more per minute is defined as ventricular tachycardia. The prevalence of atrial fibrillation in the United States is approximately 2.6% of all hospital admissions included patients who were diagnosed with cardiac arrhythmia. which is rare in healthy individuals and most often associated with ischemic heart disease in people over 40 years of age. On rare occasions. Ventricular tachycardia. sympathetic amines (epinephrine). obstructive jaundice. digitalis intoxication. it may be found in young. anemia. This arrhythmia almost always occurs in diseased hearts. Wolff-Parkinson-White syndrome Three events are involved in Wolff-Parkinson-White syndrome. Pathologic sinus tachycardia may be found in patients with fever. alcohol or catechols). or drug intoxications (eg. The ventricular response is irregular. pneumonia. nicotine. Ventricular tachycardia may be unsustained or sustained or may degenerate into ventricular fibrillation. Supraventricular tachycardias have been reported8 in approximately 6% of individuals with mitral valve prolapse and may be found in patients with pneumonia or acute myocardial infarction. because only a portion of the impulses pass through the AV node. and procainamide may induce ventricular tachycardia. In ventricular asystole. Ventricular fibrillation. This usually is lethal unless therapy is administered rapidly. Certain drugs such as digitalis. Other causes of this arrhythmia include rheumatic heart disease. with impulses being passed rapidly from atrium to ventricle. stress. The condition occurs most often as a physiologic response to exercise. Ventricular fibrillation is represented as chaotic activity on the electrocardiogram. Patients with these conditions require immediate treatment for survival. AV block with ectopic atrial tachycardia can occur and usually indicates digitalis toxicity or hypokalemia. cardiac surgery. The pharmacologic causes of sinus tachycardia include atropine. or thyrotoxicosis. Atrial fibrillation may be found in healthy individuals.2 million people. healthy adults. with greater tan 4% of those serious. and myocardial infarction. Coronary atherosclerosis is the most common form of heart disease predisposing to ventricular fibrillation. quinidine.Tachycardias Sinus tachycardia. Cardiac arrest Ventricular fibrillation. dizziness. acute myocardial infarction. It may result when patients with atrial fibrillation have been treated with quinidine or procainamide. Atrial fibrillation. regular atrial rate of 220 to 360 beats per minute is defined as atrial flutter. hyperthyroidism. Little et al found the prevalence of cardiac arrhythmias in a large population (>10. and hyperthyroidism. Pathologic sinus bradicardia may be found in patients with febrile illnesses. blunt cardiac trauma.

the risk for ventricular tachycardias is increased 4-fold. syncope. Ventricular extrasystoles are the most common form of rhythm disturbance found in patients with ischemic heart disease and congestive heart failure. It may be precipitated by coronary atherosclerotic heart disease. A slow pulse may indicate a type of bradycardia. Symptomatic arrhythmias usually are treated first with medications. For example. or myocardial ischemia. rheumatic heart disease. cardiomyopathy of any origin. MEDICAL MANAGEMENT The medical management of cardiac arrhythmias includes medications. However. mitral valve prolapse. ischemic heart disease. The impact of an arrhythmia on the circulation is more important than the arrhythmia itself. with direct effects on ventricular function. of the pulse. The effect of an arrhythmia often is dependent on the physical condition of the patient. For every 5% reduction in left ventricular ejection fraction. the risk of cardiac arrest/ arrhythmic death increases by 15%. and cardiac catheterization. Various types of arrhythmias and the degrees of severity will be affected differently with different medications. COMPLICATIONS Arrhythmias may be asymptomatic and cause no hemodynamic changes. the prevalence of ventricular arrhythmias is increased in hypertensive patients without left ventricular hypertrophy. A recent PubMed search found that arterial hypertension is a major cause of nonrheumatic atrial fibrillation and other supraventricular arrhythmias. congestive heart failure. Electrocardiographic monitoring is needed to identify the true nature of many cardiac arrhythmias. The presence of New York Heart Association class III or IV heart failure and a low ejection fraction is a predictor of arrhythmic death/cardiac arrest. hypertension. in addition to 28% to 46% of monitored patients with myocardial infarction. and angina. with a rapid cardiac rate. Those who do not respond to medications may then be . atrial fibrillation) are more susceptible to ischemic events in the dental office when overly stressed or given excessive amounts of a local anesthetic containing a vasoconstrictor. or thyrotoxicosis. especially if they have left ventricular hypertrophy. and K) are diffused rapidly. and a fast pulse may indicate a tachyarrhythmia. reducing forward flow because of insufficient diastolic filling time. whereas an elderly patient with heart disease with the same arrhythmia may develop shock. Ventricular tachycardia almost always is associated with a diseased heart and has been reported in 6% of patients with mitral valve prolapse. They also occur in approximately 45% of individuals with mitral valve prolapse. Symptoms that may be attributable to an arrhythmia include fatigue.Atrial flutter may be found in patients with ischemic heart disease and complicates 2% to 5% of myocardial infarction cases. The molecular targets for optimal action of the drugs involve channels in the celular membranes through which ions (Na. dizziness. some can affect cardiac output by producing insufficient forward flow because of a slow cardiac rate. Stress testing with monitoring commonly is used to assess an individual’s cardiac status. CLINICAL FINDINGS Cardiac arrhythmias may be detected as a change in the rate or rhythm. If left ventricular hypertrophy is present. blunt cardiac trauma. Asymptomatic arrhythmias usually require no therapy. Ventricular fibrillation is a terminal arrhythmia unless rapid and effective therapy is given. or cardioversión. Atrial fibrillation may be associated with rheumatic mitral disease. The patient may report heart palpitations occurring on a regular or irregular basis. There is evidence that patients with certain types of cardiac arrhythmias (eg. or both. a young. The presence of heart failure can have a dramatic impact on the risk for cardiac arrest. A major problem in patients with arterial hypertension is the presence of arrhythmias. Ca. or decreasing flow because of por sequence in AV activation. pacemakers. surgery. cardiac surgery. In addition. healthy person with paroxismal atrial tachycardia may have minimal symptoms.

and telemetry. In this country. Pacemakers are useful in the management of several conduction system abnormalities including symptomatic sinus bradycardia. (Table II). The AICD is a self-contained diagnostic-therapeutic system that monitors the heart. The newer pacemakers are better shielded to protect against electromagnetic interferences. and transmembrane pumps. symptomatic AV block. Infective endocarditis may also occur but is rare. Skeletal muscle may be stimulated if insulation is lost around the lead or if the generator rotates. Pacemakers More than 1 million persons in the United States have permanent pacemakers. Implantable cardioverter-defibrillator Certain patients with ventricular fibrillation or unstable ventricular tachycardias are candidates for an automatic implantable cardioverter-defibrillator (AICD). approximately 115. In rare cases. sotalol. myocardial burning can occur. Cardioversion can be effective for the treatment of reentrant arrhythmias such as atrial flutter. Cardioversion/defribrillation Direct-current cardioversion to convert atrial and ventricular arrhythmias was first described in 1962. The American Heart Association (AHA) does not recommend antibiotic prophylaxis for patients with a cardiac pacemaker. or hipocalcemia. when it detects fibrillation or tachycardia of the ventricle. By 1996. bepridil. A newer classification referred to as “The Sicilian Gambit” is based on the differential effects of antiarrhythmic drugs on channels.000 pacemakers are inserted each year. hypokalemia. tocainide. Patients with atrial fibrillation often are prescribed warfarin sodium (Coumadin) to prevent atrial thrombosis. surgical intervention may be attempted. receptors. diltiazem. Antiarrhythmic drugs were originally classified in terms of their electrophysiologic effects. Cardioversion is indicated for any tachyarrhythmias that compromise hemodynamics or life. Class III (prolong the duration of cardiac action potential and refractoriness) drugs included amiodarone. Cardiac arrest also is treated by cardioversión. hypomagnesemia. or both. disopyramide. The most common pacing system in use today is the demand ventricular pacemaker with a lithium-powered generator and transvenous leads. Class I (“local anesthetic” or “membrane-stabilizing” activity) drugs included quinidine. Electromagnetic interference from noncardiac electrical signals may temporarily interfere with the function of a pacemaker . lidocaine. Infection at the generator site and thrombosis of the leads or electrodes are uncommon. These would include microwave ovens. bretylium. Examples would be transmission from radar transmitters or arc welders. Table I lists selective antiarrhythmic drugs and their side effects and drug interactions as used in the Sicilian Gambit classification system. Other forms of electrical signals can potentially cause revision of the pacemaker mode to a fixed rate of transmission. the dosage for a given patient must be individualized. and metoprolol. the toxic/therapeutic ratio is very narrow. Class II (adrenergic antagonism) drugs included propranolol. it sends a correcting electric shock to restore normal rhythm.000 patients worldwide had had an AICD surgically implanted. more than 100. The AICD is 99% reliable in detecting ventricular fibrillation and 98% reliable in detecting ventricular tachycardias. and. If both medications and pacing fail to control the arrhythmia. The newer units contain pacing circuits that allow for programming. atrial . The AHA does not recommend antibiotic prophylaxis for patients with either a cardiac pacemaker or an AICD. Some side effects can result from pacemakers. Antiarrhythmic drugs With many antiarrhythmic drugs. but they can occur. renal dysfunction. and propafenone. Patients with arrhythmias medicated with digitalis are susceptible to digitalis toxicity. memory. diathermy and electrocautery units. therefore. and direct-contact pulse generators in boat or automobile motors. mexiletine. Class IV action (calcium channel antagonism) drugs included veramil. Some patients become depressed. Measurement of the plasma level of the medication is often an important part of therapy. especially if they are elderly or have hypothyroidism. which causes inappropriate pacemaker inhibition. flecainide.treated with an implanted pacemaker or cardioversión. and suicide attempts have been reported. Its conversión effectiveness is excellent. and nifedipine. dehydration. and tachyarrhythmias refractory to drug therapy. and ibutilide. timolol. procainamide. Usually one 25-J discharge converts the arrhythmia. This occurs by a mimicking of the frequency of spontaneous heartbeats.

prolonged angina pectoris. . or pulmonary edema should be treated promptly with direct-current cardioversion. ventricular tachycardia. The countershock simultaneously depolarizes the entire myocardium. and ventricular fibrillation. allowing synchronous repolarization and the resumption of sinus rhythm.fibrillation. Tachyarrhythmias that result in hemodynamic collapse.