Ischaemic Heart Disease Clinical Aspects For DENTIST
Coronary Heart Disease
A leading cause of SICKNESS and DEATH
Risk Factors for Cardiovascular Disease
Hypertension High cholesterol Obesity Cigarette smoking Physical inactivity Diabetes mellitus Kidney disease Older age (>55 ♂; > 65 ♀) Family history of premature cardiovascular disease Obstructive sleep apnea Periodontal disease ?
Coronary Heart Disease: Myocardial Ischemia
Decreased blood supply (and thus oxygen) to the myocardium that can result in acute coronary syndromes:
Angina pectoris ( Stable ) Unstable Angina Myocardial infarction Sudden death (due to fatal arrhythmias)
embolus Anaemia. spasm. thrombosis. high cardiac output (thyrotoxicosis. Angina pectoris symptom not a disease chest discomfort associated with abnormal myocardial function in the absence of myocardial necrosis Supply
Atheroma.Ischaemic heart disease Definition
An imbalance between the supply of oxygen and the myocardial demand resulting in myocardial ischaemia. myocardial hypertrophy)
Ischaemic heart disease Manifestations
Sudden death Acute coronary syndrome ( Myocardial Infarction & Unstable
Stable angina pectoris Heart failure Arrhythmia Asymptomatic
Ischaemic heart disease Epidemiology
Commonest cause of death in the Western world. (up to 35% of total mortality) Over 20% males under 60 years have IHD Health Survey : 3% of adults suffer from angina 1% have had a myocardial infarction in the past 12 months
Ischaemic heart disease Aetiology
Age. diabetes mellitus. Male. high alcohol consumption. smoking. OCP. +ve family history Modifiable – strong association Dyslipidaemia.weak association Lack of exercise. type A personality. hypertension Modifiable . soft water
Risk Factors for Ischemic Heart Disease Family History
Smoking Hypertension Diabetes Mellitus Hypercholesterolaemia Lack of exercise Obesity Age & Sex
Non-Modifiable Risk Factor:
Non-Modifiable Risk Factor:
Non-Modifiable Risk Factor:
Modifiable Risk Factor:
Modifiable Risk Factor: SMOKING
Modifiable Risk Factor: OBESITY
Modifiable Risk Factor:
sudden death) Cerebral Arteries (stroke) Peripheral Arteries (claudication)
. MI.Spectrum of the Atherosclerotic Process
Coronary Arteries (angina.
Ischaemic heart disease Acute coronary syndromes
Fatal / Non-Fatal AMI
Coronary Artery spasm
fullness or a squeezing pain in the center of your chest that lasts for more than a few minutes.may occur with or without chest discomfort Sweating Impending sense of doom Lightheadedness Fainting Nausea and vomiting
. back or even your teeth and jaw.Warning Signs and Symptoms of Heart attack
1) 2) 3) 4) 5) 6) 7)
Pressure. Pain extending beyond your chest to your shoulder. Increasing episodes of chest pain Prolonged pain in the upper abdomen Shortness of breath. arm.
At least 70% occlusion of coronary artery resulting in pain. it requires more blood that is not available due to the blockage of the coronary artery(ies) Is self limiting usually stops when exertion is ceased
. What kind of pain? Chest pain Radiating pain to: Left shoulder
Left or Right arm Usually brought on by physical exertion as the heart is trying to pump blood to the muscles.
. intensity.pain pattern and characteristics
relatively unchanged over past several months (better prognosis)
Unstable . frequency. or duration (poorer prognosis).Clinical Patterns of Angina Pectoris
Stable .pain pattern changing in
cholesterol lowering drugs. Eg: Atorvastatin.vasodilator eg: ISDN. ISMN 2) Pain reliever. Simvastatin
MEDICATIONS 1) Nitrates.eg: Morphine 3) Beta-blockers 4) Statins.
Ischaemic heart disease Relevance to Dentistry
IHD is common Subjects with IHD have more severe dental caries and periodontal disease – association or causation? Angina is a cause of pain in the mandible. teeth or other oral tissues Stress provokes ACS!
Partial or total occlusion of one or more of the coronary arteries due to an atheroma. there is usually involvement of 3 or 4 occluded coronary vessels
. thrombus or emboli resulting in cell death (infarction) of the heart muscle When an MI occurs.
left submammary Radiation Left chest. heaviness. pallor. cold windy weather. left arm. palate Quality/severity tightness.Chest Pain Myocardial ischaemia
Site Jaw to navel. retrosternal.mandible. peripheral vasoconstriction. teeth. emotion rest. nausea and vomiting
. sublingual nitrates Autonomic symptoms sweating. jaw…. compression…clenched fists Precipitating/relieving factors physical exertion.
pneumothorax.Chest Pain Differential diagnosis
Pericarditis. reflux. pneumonia Peptic ulcer disease. „café coronary‟ Trauma. pancreatitis. Tietze‟s Syndrome
. aortic dissection
Acute Myocardial Infarction Assessment
30% of deaths occur in the first 2 hours.
(Cardiac muscle death occurs after 45 mins of ischaemia)
Symptoms and signs of myocardial ischaemia Also
Changes in heart rate /rhythm Changes in blood pressure
Acute Myocardial Infarction Confirming the diagnosis
Typical chest pain Electrocardiographic changes
ST elevation new LBBB
Myocardial enzyme elevation
Creatine kinase (CK-MB) Troponin
sublingual nitrate) Aspirin Thrombolysis Primary angioplasty Beta-Blockers ACE inhibitors Prepare for basic life support
.Acute Myocardial Infarction Treatment
Stop dental treatment Call for help Rest. sit up and reassure patient Oxygen Analgesia (opiate.
Percutaneous Transluminal Coronary Angioplasty (PTCA)
balloon expansion that can provide 90% dilitation of vessel lumen
With use of just the balloon. reocclusion of the artery can occur within months Placement of a stent delays or prevents reocclussion
Coronary Artery ByPass Graft (CABG) The graft bypasses the obstruction in the coronary artery Graft sources:
saphenous vein internal mammary artery radial artery
Acute Myocardial Infarction Complications
Sudden Death (18% within 1 hour. 36% within 24
Non-fatal arrhythmia Acute left ventricular failure Cardiogenic shock Papillary muscle rupture and mitral regurgitation Myocardial rupture and tamponade Ventricular aneurysm and thrombus Distal Embolisation
the heart is unable to contract fully resulting in lack of blood being pumped to the vital organs V-Fib requires shock from defibrillator “SHOCKABLE RHYTHM”
Sudden Cardiac Death is also known as a “Massive Heart Attack” in which the heart converts from sinus rhythm to ventricular fibrillation In V-Fib.
Assessment and Overall Management Pharmaceuticals Emergency Situations Oral Effects of Pharmaceuticals Antibiotic Prophylaxis Post MI: when to treat Consider three areas:
How severe or stable the ischemic heart disease is The emotional state of the patient The type of dental procedure
Major Risk for Perioperative Procedures:
Unstable Angina (getting worse) Recent MI Stable Angina History of MI
Intermediate Risk for Perioperative Procedures:
Most dental procedures. even surgical procedures fall within the risk of less than 1% Some procedures fall within an intermediate risk of less than 5% Highest risk procedures those done under general anesthesia
Management for Low-Intermediate Risk
Short appointments AM appointments Comfort Vital Signs Taken Avoidance of Epinephrine within Local Anesthetic or Retraction Cord O2 Availability
Dentistry & Cardiovascular Medicine
GA within 3/12 of AMI: 30% re-infarction rate @ 1/52 post op Avoid routine LA dental treatment for 3/12 (emergency treatment only) Avoid excess dosage. reduce anxiety Avoid elective surgery under GA for1 year (specialist) Be aware of medications (bleeding. hypotension)
be it severe or minimal that may effect the patient‟s daily life MI within 1 month Major Cardiac Risk MI within longer then 1 month: Stable routine dental care ok Unstable treat as Major Cardiac Risk Older studies suggest high re-infarction rates when surgery performed within 3 months.Post MI: When to Treat
Why delay treatment? Remember that with an MI there is damage to the heart. this was abdominal and thoracic surgery under general anesthesia New research suggests delaying elective tx for 1 month is advisable. Emergent care should be done with local anesthetic without epinephrine and monitoring of vital signs When in doubt:
. 3-6 months… however.
.Dental Management Correlate
Elective dental care is ok if it has been longer than 4-6 weeks since the MI and the patient does not report any ischemic symptoms. consult with the cardiologist. If there is any doubt or question.
Raise chair slowly Allow patient to take his/her time Assist patient in standing When patients on Plavix or Aspirin. expect increased bleeding because of decreased platelet aggregation
.Dental Considerations for IHD
Orthostatic Hypotension due to use of anti-hypertensives (beta blockers.
all operatories should have nitroglycerin to be placed sublingually
. follow ABC‟s In situations of angina pectoris. have good patient history.Dental Considerations for IHD
Remember that pain in the jaw may be referred pain from the myocardium assess the situation.
Dental Considerations for IHD
STOP PROCEDURE Remove everything from patient‟s mouth Give sublingual nitroglycerin Wait 5 minutes if pain persists. give more nitroglycerin. assume MI 101 Give chewable aspirin ABC‟s
0. night before and 1 hour before Have nitroglycerin available – may consider using prophylacticaly
Use pulse oximeter to assure good breathing and oxygenation Oxygen intraoperatively (if needed) Excellent local anesthesia . in limited amount (max 0. and post-op vital signs Pre-medication as needed
anxiolytic (triazolam. intra-op. morning appointments Preop.use epinephrine. if needed.Dental Management: Stable Angina/Post-MI >4-6 weeks
Minimize time in waiting room Short.20mg) Avoid epinephrine in retraction cord
.04mg) or levonordefrin (max. oxazepam).
infection control. IV line Use vasoconstrictors cautiously if needed
. pain management) Consultation with physician to help manage Consider treating in outpatient hospital facility or refer to hospital dentistry ECG. do only what must be done (e. pulse oximetry.g.Dental Management: Unstable Angina or MI < 3 months
Avoid elective care For urgent care: be as conservative as possible.
assume MI in progress and activate the EMS
Give aspirin tablet to chew and swallow Monitor vital signs. administer oxygen.Intraoperative Chest Pain
Stop procedure Give nitroglycerin If after 5 minutes pain still present. give another nitroglycerin If pain persists. give another nitroglycerin If after 5 more minutes pain still present. and be prepared to provide life support
When treating patients with Ischemic Heart Disease or recent MI…
Use caution and common sense When in doubt: