Chapter 5

Cardiac Arrhythmias
Cardiac Arrhythmias

• Little (p. 67)

• Cardiac arrhythmia, which refers to any variation in the normal
heartbeat, includes disturbances in rhythm, rate, or the conduction
pattern of the heart
• Most arrhythmias are of little clinical concern; however, some can produce
symptoms, and a few may be life threatening
• Potentially fatal arrhythmias can be precipitated by strong emotion, such as
anxiety or anger, and by various drugs, both of which are factors likely to be
encountered in the dental setting
General Description

• Little (pp. 67-71)

• Incidence and prevalence
• Etiology
• Pathophysiology and complications
• Supraventricular arrhythmias
• Ventricular arrhythmias
• Disorders of repolarization
Incidence and Prevalence

• Little (p. 67)

• Cardiac arrhythmias are relatively common in the general
population, and their prevalence increases with age
• They occur more frequently in elderly persons, people with a long history of
smoking, patients with underlying ischemic heart disease, and patients
taking certain drugs or having various systemic diseases
• The most common type of persistent arrhythmia is atrial fibrillation (AF),
which affects approximately 2.6 million people
Incidence and Prevalence (cont’d)

• Little and associates found the prevalence of cardiac arrhythmias in a

large population of more than 10,000 general dentistry patients to
be 17.5%, and more than 4% of those were serious, potentially life-
threatening cardiac arrhythmias
• To manage their arrhythmias, more than 500,000 people in North America
have implanted pacemakers
Etiology

• Little (pp. 67-68; Fig. 5-1)

• Cardiac contractions are controlled by a complex system of
specialized excitatory and conductive neuronal circuitry
• The normal pattern of sequential depolarization involves structures
of the heart in the following order
• Sinoatrial (SA) node
• Atrioventricular node (AV) node
• Bundle of His
• Right and left bundle branches
• Subendocardial Purkinje network
Etiology (cont’d)

• Little (pp. 67-68; Fig. 5-2)

• The primary anatomic pacemaker for the heart is the SA
node
• The SA node regulates the functions of the atria and is responsible
for production of the P wave (atrial depolarization) of the ECG
• Simultaneous depolarization of the ventricles produces the QRS
complex on ECG
• The T wave is formed by repolarization of the ventricles
• Repolarization of the atria occurs at about the same time as
depolarization of the ventricles, and this usually is obscured by the
QRS wave
Etiology (cont’d)

• Normal cardiac function depends on cellular automaticity (impulse

formation), conductivity, excitability, and contractility
• Under normal conditions, the SA node is responsible for impulse formation
• However, other cells or groups of cells also are capable of generating
impulses
Etiology (cont’d)

• Disorders of conductivity (block or delay) paradoxically may lead to

rapid cardiac rhythm through the mechanisms of reentry
• Reentry arrhythmias occur when accessory or ectopic pacemakers re-excite
previously depolarized fibers before they would become depolarized in the
normal sequential impulse pathway, typically producing tachyarrhythmias
Etiology (cont’d)

• Little (p. 68; Table 5-1, 5-2)

• The most common causes of arrhythmias include
• Primary cardiovascular disorders
• Pulmonary disorders (e.g., embolism, hypoxia)
• Autonomic disorders
• Systemic disorders (e.g., thyroid disease)
• Drug-related adverse effects
• Electrolyte imbalances
• Cardiac arrhythmias also are associated with many systemic diseases
and various drugs or other substances
Pathophysiology and Complications

• Little (p. 68)

• The outcome with an arrhythmia often depends on the nature of the
arrhythmia and the physical condition of the patient
• Arrhythmias are classified by site of origin
• Any arrhythmia that arises above the bifurcation of the His bundle into right
and left bundle branches is classified as supraventricular
• Supraventricular cardiac arrhythmias may be broadly categorized into
tachyarrhythmias and bradyarrhythmias
Supraventricular Arrhythmias

• Sinus node disturbances

• Disturbances of atrial rhythm
• Tachycardias involving the AV junction
• Heart block
• Ventricular arrhythmias
• Disorders of repolarization
Sinus Node Disturbances

Sinus arrhythmia—characterized by phasic variation in

sinus cycle length
• Respiratory—heart rate increases with inhalation and
decreases with exhalation
• Nonrespiratory—unrelated to respiratory effort; seen with
digitalis intoxication
Sinus tachycardia
• Tachycardia—in an adult, is defined as a heart rate greater
than 100 beats per minute, with otherwise normal ECG
Sinus bradycardia
• Bradycardia—defined as a heart rate less than 60 beats per
minute, with an otherwise normal ECG
Disturbances of Atrial Rhythm

• Premature atrial complexes

• Impulses arising from ectopic foci anywhere in the atrium may result
in premature atrial beats
• Atrial flutter
• Characterized by a rapid, regular atrial rate of 250 to 350 beats per
minute
• Atrial fibrillation
• Characterized by rapid, disorganized, and ineffective atrial
contractions that occur at a rate of 350 to 600 beats per minute
• Atrial tachycardia
• Any tachycardia arising above the AV junction for which the ECG
shows a P wave configuration different from that for sinus rhythm
Tachycardias Involving the AV Junction

• Preexcitation syndrome (e.g., Wolff-Parkinson-White syndrome)

• In some persons, additional electrical bridges connect the atria and
ventricles, bypassing the normal pathways and forming the basis for
preexcitation syndromes such as Wolff-Parkinson-White syndrome
Heart Block

• AV Block—a disturbance of impulse conduction that may be

permanent or transient, depending on the underlying
anatomic or functional impairment
• Classified by severity, with various forms divided into three
categories
• First-degree—conduction time is prolonged, but all impulses are
conducted
• Second-degree—two forms
• Type I—characterized by progressive lengthening of conduction time
until an impulse is not conducted
• Type II—occasional or repetitive sudden block of conduction of an
impulse without previous lengthening of conduction time
• Third-degree—no impulses are conducted
Ventricular Arrhythmias

• Premature ventricular complexes

• Characterized by the premature occurrence of an abnormally shaped
QRS complex (ventricular contraction), followed by a pause
• Ventricular tachycardia
• The occurrence of three or more ectopic ventricular beats (PVCs) at a
rate of 100 or more per minute is defined as ventricular tachycardia
(VT)
• Ventricular flutter and fibrillation
• Lethal arrhythmias characterized by chaotic, disorganized electrical
activity that results in failure of sequential cardiac contraction and
inability to maintain cardiac output
Disorders of Repolarization

• Long QT syndrome
• A disorder of the conduction system in which the recharging of the heart
during repolarization (i.e., the QT interval) is delayed
• Caused by a genetic mutation in myocardial ion channels and by certain
drugs, or may be the result of a stroke
• Can lead to fast, chaotic heartbeats, which can trigger unexplained syncope,
a seizure, or sudden death
Clinical Presentation

• Little (pp. 71-72)

• Signs and symptoms
• Laboratory findings
Signs and Symptoms

• Little (p. 71; Box 5-2)

• Arrhythmias may be symptomatic or asymptomatic; however,
symptoms alone cannot be relied on to determine the seriousness of
an arrhythmia
• The symptoms most commonly associated with cardiac arrhythmias include
palpitations, lightheadedness, feeling faint, syncope, and those related to
congestive heart failure
Laboratory Findings

• Little (pp. 71-72)

• The ECG is the primary tool used in the identification and diagnosis of
cardiac arrhythmias
• Additional tests
• Exercise or stress testing
• Long-term or ambulatory ECG (Holter) recording
• Baroreceptor reflex sensitivity testing
• Body surface mapping
• Upright tilt-table testing
• Electrode catheter techniques
Medical Management

• Little (pp. 72-75)

• Antiarrhythmic drugs
• Implanted permanent pacemakers
• Implantable cardioverter-defibrillators
• Electromagnetic interference
• Radiofrequency catheter ablation
• Surgery
• Cardioversion and defibrillation
Antiarrhythmic Drugs

• Little (p. 72; Table 5-3)

• Antiarrhythmic drugs are classified on the basis of their effect on
sodium, potassium, or calcium channels and whether they block beta
receptors
• Class I—work primarily by blocking the fast sodium channels
• Class II—β-adrenergic-blocking agents
• Class III—prolong duration of the cardiac action potential and enhance
refractoriness through their effects on potassium channels
• Class IV—calcium channel blockers
Antiarrhythmic Drugs (cont’d)

• Many of the antiarrhythmic drugs have very narrow therapeutic

ranges
• Blood levels that are not too high or too low may be difficult to
achieve, with resultant over- or undermedicating
• Undermedicated patients may be at increased risk for an adverse event
during dental treatment
• In those who are overmedicated, drug toxicity also is a possibility
Implanted Permanent Pacemakers

• Little (pp. 72-74; Fig. 5-3)

• A permanent, implanted pacemaker consists of a lithium battery–
powered generator implanted subcutaneously in the left
infraclavicular area that produces an electrical impulse
• The impulse is transmitted by a lead inserted into the heart through the
subclavian vein to an electrode in contact with endocardial or myocardial
tissue
Implanted Permanent Pacemakers (cont’d)

• Pacemakers are capable of very specific individualized pacing

programs or modes
• Most pacemakers are of the demand variety, which can detect the patient’s
natural heartbeat and prevent competitive pacemaker firing
• Newer units contain pacing circuits that allow for programming, memory,
and telemetry
Implanted Permanent Pacemakers (cont’d)

• Complications are infrequent but have been reported as a result of

pacemaker placement
• Infective endocarditis rarely may occur; however, antibiotic prophylaxis for
dental treatment is not recommended
Implantable Cardioverter-Defibrillators

• Little (p. 74)

• ICDs are capable not only of delivering a shock but of providing
antitachycardia pacing (ATP) and ventricular bradycardia pacing
• ATP has the advantage of terminating a rhythm disturbance without
delivering a shock
Electromagnetic Interference

• Little (p. 74; Box 5-3)

• Electromagnetic interference (EMI) from nonintrinsic
electrical activity can temporarily interfere with the function
of a pacemaker or ICD
• Numerous sources of EMI are present in daily life, industry, and
medical and dental settings
• Several studies suggest that dental devices may cause EMI
with pacemakers and ICDs
• Electrosurgery units, ultrasonic bath cleaners, ultrasonic scaling
devices, and battery-operated curing lights have produced EMI with
pacemakers and ICDs
Radiofrequency Catheter Ablation

• Little (p. 74)

• A technique whereby a catheter (electrode) is introduced
percutaneously into a vein and is threaded into the heart
• The catheter is positioned in contact with the area determined to be the
anatomic source of an arrhythmia
• Radiofrequency energy is then delivered, which results in irreversible tissue
destruction, destroying the ectopic pacemaker
Surgery

• Little (pp. 74-75)

• Direct surgical approaches designed to interrupt accessory pathways
consist of resection of tissue and ablation
• Indirect approaches, such a aneurysmectomy, coronary artery bypass
grafting, or relief of valvular regurgitation or stenosis, may be useful in
selected patients
Cardioversion and Defibrillation

• Little (p. 75; Fig. 5-4)

• Transthoracic delivery of an electric shock can be performed
electively (cardioversion)
• To terminate persistent or refractory arrhythmias
• On an emergency basis (defibrillation), to terminate a lethal arrhythmia
• The shock terminates arrhythmias caused by reentry by
simultaneously depolarizing large portions of the atria and ventricles,
thereby causing reentry circuits to disappear momentarily
Cardioversion and Defibrillation (cont’d)

• The most common arrhythmias treated by

cardioversion/defibrillation are VF, VT, AF, and atrial flutter
• Treatment of VF—always emergent
• Treatment of VT—may be elective or emergent
• Treatment of atrial flutter and AF—usually elective
Cardioversion and Defibrillation (cont’d)

• Several types of automated external defibrillators (AEDs) are

available for inclusion in the dental office
• An AED should be considered for inclusion in the dentist’s emergency
medical kit
• Use of AEDs is now taught as part of basic and advanced
cardiopulmonary resuscitation courses
• Familiarity with these devices and their applications among laypersons is
encouraged by public health agencies
Dental Management

• Little (pp. 75-79)

• Medical considerations
• Stress and anxiety reduction
• Use of vasoconstrictors
• Warfarin (Coumadin)
• Dabigatran (Pradaxa)
• Pacemakers/ICDs and antibiotic prophylaxis
• Pacemakers/ICDs and electromagnetic interference
• Digoxin toxicity
• Treatment planning considerations
• Oral manifestations
Medical Considerations

• Little (p. 75)

• Stress associated with dental treatment or use of excessive
amounts of injected epinephrine may lead to life-
threatening cardiac arrhythmias in susceptible dental
patients
• Patients with an existing arrhythmia, diagnosed or undiagnosed, are
at increased risk for adverse events in the dental environment
• Patients at risk for developing an arrhythmia may be in danger in the
dental office if they are not identified and measures are not taken to
minimize situations that can precipitate an arrhythmia
Medical Considerations (cont’d)

• Little (p. 76; Box 5-4)

• The process of identification is accomplished by obtaining a thorough
medical history, including a pertinent review of systems, and taking
and evaluating vital signs
• Patients with a known history of arrhythmia should be interviewed carefully
to ascertain the type of arrhythmia, how it is being treated, medications
being taken, presence of a pacemaker or defibrillator, effects on their
activity, and stability of their disease
Medical Considerations (cont’d)

• The dentist must make a determination of the risk involved in

providing dental treatment to a patient with a history of arrhythmia
and must decide whether the benefits of treatment outweigh any
risk
• This often requires consultation with the physician
• The American College of Cardiology (ACC) and the American Heart
Association (AHA) have published guidelines that can help make this
determination
Medical Considerations (cont’d)

• Little (p. 76; Box 5-5)

• ACC/AHA guidelines provide an estimate of risk that a
serious event may occur during noncardiac surgery in
patients with various arrhythmias
• Patients with a significant arrhythmia are at major risk for
complications and are not candidates for elective dental care
• The presence of other types of arrhythmias carries
significantly less risk
• Patients with these types of arrhythmias can undergo elective dental
treatment with only minimally increased risk for an adverse event
Medical Considerations (cont’d)

• Little (pp. 76-77; Box 5-6)

• The type and magnitude of the planned dental procedure
also must be considered in determination of perioperative
risk
• Dental procedures would certainly be included in the low- risk
category
• Nonsurgical dental procedures are likely to carry even less risk than
that for surgical procedures
• More extensive oral and maxillofacial surgical procedures, and
perhaps some of the more extensive periodontal surgical procedures,
probably would be included in the intermediate cardiac risk category
under “head and neck procedures”
Stress and Anxiety Reduction
• Stress reduction strategies for patients with arrhythmias of low to
intermediate risk may include
• Establishing good rapport
• Scheduling short appointments in the morning
• Ensuring comfortable chair position
• Pretreatment assessment of vital signs
• Preoperative oral sedation
• Intraoperative use of nitrous oxide–oxygen sedation
• Ensuring excellent local anesthesia
• Providing effective postoperative pain control
Use of Vasoconstrictors

• Use of vasoconstrictors in local anesthetics poses potential

problems for patients with arrhythmias because of the
possibility of precipitating cardiac tachycardia or another
arrhythmia
• A local anesthetic without vasoconstrictor may be used as needed
• If a vasoconstrictor is necessary, patients in the low to intermediate
risk category and those taking nonselective beta blockers can safely
be given up to 0.036 mg epinephrine (two cartridges containing
1:100,000 epinephrine); intravascular injections are to be avoided
Warfarin (Coumadin)

• Patients with atrial fibrillation often are given anticoagulation

therapy (warfarin) to prevent thrombus formation, embolism, and
stroke; thus, they are at risk for increased bleeding
• The target range for anticoagulation in patients with atrial fibrillation usually
is an INR between 2 and 3 times the normal value
• Minor oral surgery, such as simple extractions, can be performed without
altering or stopping the warfarin regimen, provided the INR is within the
therapeutic range
Dabigatran (Pradaxa)

• Patients who have atrial fibrillation may be taking the newer

anticoagulant dabigatran to prevent thrombus formation, embolism,
and stroke
• Dabigatran is an oral antithrombin medication that is reported to cause no
increase in major bleeding
• Thus, it is not predicted to cause major concern for bleeding during and after
invasive dental procedures
Pacemakers/ICDs and Antibiotic Prophylaxis

• Patients with pacemakers or ICDs are not at risk for bacterial

endocarditis related to dental procedures
• Antibiotic prophylaxis is not indicated
Pacemakers/ICDs and Electromagnetic
Interference
• Little (p. 79; Box 5-3, 5-7)
• The risk of encountering significant EMI with a pacemaker in the
dental office is low
• In the dental setting, only electrosurgery, ultrasonic bath cleaners, curing
lights, and ultrasonic scalers have been shown to produce potential
interference
• These devices should not be used on or around a patient with a pacemaker
Digoxin Toxicity

• Little (p. 79)

• Because the therapeutic range for digoxin is very narrow, toxicity can
easily occur
• Signs of toxicity include hypersalivation, nausea and vomiting, headache,
drowsiness, and visual distortions, with objects appearing yellow or green
• The dentist should be alert to these changes and should refer the patient
reporting such changes to the physician
Treatment Planning Considerations

• Little (p. 79; Box 5-7)

• A patient susceptible to cardiac arrhythmias can receive virtually any
indicated dental procedure once the arrhythmia has been identified
and the aforementioned steps are taken
• Complex dental procedures should be scheduled over several appointments
to avoid overstressing the patient
Oral Manifestations

• Little (p. 79; Table 5-3)

• The only significant oral complications found in patients with
arrhythmias are those that occur as adverse effects of the
medications used to control arrhythmia