‡ Angina pectoris is the name given to paroxysms of severe ischaemic chest pain which are typically precipitated by effort

and relieved by rest. or ‡ It is a clinical syndrome of episodic chest discomfort resulting from transient myocardial ischaemia, produced by exertion, emotion or stress and which is relieved by rest or nitrates. ‡ The usual cause of angina is coronary atherosclerosis.

PATHOPHYSIOLOGY
‡ Angina occurs when the oxygen demands of the myocardium exceed that which is provided to it by the coronary arteries. ‡ The pain is due to ischemia and usually persists till the oxygen supply is restored or the demand for oxygen reduces. ‡ There is no permanent damage to the myocardium

Precipitating Factors
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Physical exertion Stress Heavy meals Lying flat (angina decubitus) Cold exposure Smoking Emotional disturbances Vivid dreams (nocturnal angina)

‡

Some patients feel pain during initial period of walking but later on, it does not come up despite greater effort called µstart ± up angina¶. Angina occuring on lying flat or in recumbent position is called µangina decubitus¶, seen in patients with heart failure. Angina at night is called µnocturnal angina¶. It is usually precipitated by vivid dreams.

‡

‡

Stable Angina Angina is termed stable if it occurs only on exertion and is relieved by rest, within 10 minutes and there have been no changes in the frequency or duration of symptoms or precipitating factors within the previous 60 days. Unstable Angina Is that in which there are changes in pattern, frequency or duration of precipitating factors, sudden onset angina is considered to be unstable. Prinzmetal¶s Angina Is angina at rest, commonly at night and is caused by coronary artery spasm.

CLINICAL FEATURES
‡ More common in males ‡ Age 40 to 60 years ‡ Tightness, heaviness, compression or constriction of the chest may be complaints but the pain is rarely of the unbearable, crushing and persistent nature of myocardial infarction. ‡ The typical site is behind the sternum radiating to the left particularly, sometimes to the left upper arm and occasionally to left mandible, teeth, tongue or palate. ‡ Patients who develop angina often have no history of heart disease ‡ The mortality rate in angina is about 4 percent per year.

SIGNS AND SYMPTOMS
1. Substernal pain or pain referred to arms, neck or abdomen. 2. Pain lasting less than 15 minutes and possibly radiating to the left shoulder. 3. Positive response to nitroglycerine. 4. Vital signs are normal 5. No hypotension, sweating or nausea occurs

POTENTIAL PROBLEMS RELATED TO DENTAL CARE
1. Stress and anxiety related to dental visit could precipitate an anginal attack, MI, or sudden death in the office. 2. For patient taking a non-selective beta blocker, the use of excessive amount of epinephrine could precipitate a dangerous elevation of blood pressure. 3. Patient taking aspirin or other platelet aggregation inhibitor could experience excessive bleeding. 4. Potential to cause endarteritis of coronary artery stent in the immediate post-placement period exists as a result of dentally induced bacteremia.

ORAL MANIFESTATIONS
Usually none as a direct result of angina, however, may see drug related changes such as dry mouth, taste changes, or stomatitis; also may have excessive post surgical bleeding due to platelet aggregation inhibition

INVESTIGATIONS
1. Resting ECG : may be absolutely normal or may show changes of previous myocardial ischaemia (changes in ST ± T waves). Exercise ECG (Stress test) : the most widely used test in the diagnosis of ischaemic heart dz. involves 12 ± lead ECG recording before, during and after exercise on a tread mill or using a bicycle ergometer. The flat ST segment depression more than 1 mm. below the baseline and lasting longer than 0.08 second is taken as positive stress test. Isotope scanning : done by intravenous administration of a radioisotope (Thallium ± 201) to assess regional myocardial perfusion by gamma camera. The images are recorded at rest, immediately after exercise and 2-4 hours later.
Coronary angiography

2.

3.

4.

MANAGEMENT
AIMS AND OBJECTIVES : 1. To identify and control risk factors. 2. To assess the severity, extent of the disease and any contributory factor. 3. To control symptoms. 4. To improve the life expectancy.

TREATMENT:
Although the pain of angina can be relieved by rest it is more quickly relieved by giving nitrates, such as glyceryl trinitrate (nitroglycerin), which lowers peripheral vascular resistance and reduces the oxygen demands of the heart. y Amyl nitrate, isosorbide dinitrite and erythrityl tetranitrate are also used. y Calcium channel blockers (like Nefidipine, Verapamil) and occassionaly potassium channel activators (like Nicorandil) may be used. y Aspirin often prescribed for anti ± platelet activity. ‡ Artery or vein coronary by pass grafts, or angioplasty, may be used to improve the coronary flow when angina fails to respond to drugs using saphenous vein, or percutaneous transluminal coronary angioplasty (PTCA) are commonly used both resulting in a 5 year survival of over 85 percent.
y

Steps in Rx1. Place patient in semi-reclining or sitting ± up position with head elevated. 2. Administer nitroglycerin 0.3mg. tablet sublingual or spray amyl nitrate bud (3 tablet, 1 tablet every 5 minutes upto a total of 3 tablets). 3. Administer oxygen at 10 L/min. flow. 4. Put patient at rest and give reassurance. 5. Monitor and record vital signs.

DENTAL MANAGEMENT
‡ Dental care should be carried out with effective local analgesia, minimal anxiety, oxygen saturation and BP and pulse monitoring and at short appointments. ‡ Adrenaline ± containing LA solutions are satisfactory but a maximum of 4 ml. solution containing 1 in 80,000 adrenaline should be used. ‡ Gingival retraction cords containing adrenaline should be avoided. ‡ Mepivacaine 3 percent is preferable for use in patients taking beta ± blockers. ‡ Preoperative glyceryl trinitrate and oral sedation, with intra ± operative nasally delivered oxygen and ECG / BP monitoring are adviced.

PREVENTION OF PROBLEMS
Unstable Angina (Major risk) : Elective dental care should be postponed if possible; if care is necessary, it should be provided in consultation with physician. Management may include establishment of IV line, sedation, electrocardiogram, pulse oximeter, cautious use of vasoconstrictor and prophylactic nitroglycerin.

Stable Angina (low ± intermediate risk) : Elective dental care may be provided with the following management considerations : (a) Short, morning appointments, comfortable chair position, pretreatment vital signs, nitroglycerin available, stress reduction measures, limit quantity of vasoconstrictor, avoid epinephrine in retraction cords, avoid anticholinergics, ensure excellent intraoperative and postoperative pain control. (b) If patient taking aspirin, excess bleeding is usually controllable by local measures only. (c) If coronary artery stent in place, prophylactic antibiotics may be provided for dental procedures likely to result in significant bleeding for first 2-4 weeks only.

TREATMENT PLANNING MODIFICATIONS Unstable Angina Dental RX should be limited to that which is absolutely necessary, such as for infection or pain. Stable Angina Any desired dental treatment may be provided taking into consideration appropriate management considerations.

ANGINA IN DENTAL OFFICE
‡ If a patient experiences chest pain, dental RX must be stopped. ‡ If there is history of angina, the patient should be given glyceryl trinitrate 0.5 mg. sublingually and oxygen, and be kept sitting upright. ‡ Vital signs should be monitored. ‡ The pain should be relieved in 2-3 minutes, the patient should then rest and be accompanied home. ‡ If chest pain is not relieved within about 5 minutes, myocardial infarction is the probable cause and medical help should be summoned

ADVICE TO PATIENTS WITH ANGINA
To be Done
y Maintain ideal body weight y Regular restricted physical exercise y Sublingual nitrate before undertaking exertion y Change in life style

Not to be Done
y Smoking y Undue over excitement y Overindulgence in alcohol, sexual activity y Sternuous or unaccustomed exercise y Sudden exposure to cold weather y Heavy meals

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