9. Coronary Heart Disease:
Myocardial Ischemia
• An imbalance between the supply of oxygen and the
myocardial demand resulting in myocardial ischaemia.
• 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)
10. Ischaemic heart disease
Aetiology
• Fixed
– Age, Male, +ve family history
• Modifiable – strong association
– Dyslipidaemia, smoking, diabetes mellitus, obesity,
hypertension
• Modifiable - weak association
– Lack of exercise, high alcohol consumption, type A
personality, Oral Contraceptive Pills, soft water
–PRIMARY PREVENTION
Atherosclerosis
19. Angina Pectoris
• At least 70% occlusion of coronary artery
resulting in pain.
– Chest pain
• - Characteristics: squeezing, bursting, pressing,
burning or choking
- Location: substernum
- Refer pain: L’t shoulder, arm, neck
or mandible
- Associated with exertion, anxiety
- Relieved by vasodilator (ex. NTG) or
rest
- May accompanied by dyspnea, nausea&
vomiting sensation,
palpitation
• Usually brought on by physical exertion
• Is self limiting usually stops when exertion is
ceased
20. Angina pectoris
• Potential problem related to dental care
1. Stress and anxiety related to dental visit may precipitate angina
attack
• Prevention of complication
1. Detection of patient
2. Referral of patient for medical evaluation and treatment
3. Known case with medical treatment for angina
– Stress reduction protocol
• Premedication
• Open and honest communication
• Morning appointments
• Short appointments
• Nitrous oxide - oxygen
– Avoid excessive amounts of epinephrine
21. 1. Terminate all procedures
2.
3.
Semi-reclined position
Sublingual NTG
Angina Pectoris
4. O2
5. Check vital signs
Discomfort relieved Still discomfort after 3min
6. Assume angina pectoris was present Give 2nd NTG
7. Slowly taper O2 over 5min
8. Modify dental treatment
Still discomfort after 3min
Give 3rd NTG
Still discomfort after 3min
NTG
0.6mg/tab
22. 10. Assume myocardial infarction in progress
11. On IV line
12. Prepare transport to ER
If highly suspected AMI
MONA: Morphine, Oxygen, NTG, Aspirin
23. Myocardial Infarction
• Partial or total occlusion of one or more of the coronary
arteries due to an atheroma, thrombus or emboli
resulting in cell death (infarction) of the heart muscle
• When an MI occurs, there is usually involvement of 3 or
4 occluded coronary vessels
24. Chest Pain
• Site
Jaw to navel, retrosternal, left submammary
• Radiation
Left chest, left arm, jaw….mandible, teeth, palate
• Quality/severity
tightness, heaviness, compression…clenched fists
• Precipitating/relieving factors
physical exertion, cold windy weather, emotion
rest, sublingual nitrates
• Autonomic symptoms
sweating, pallor, peripheral vasoconstriction, nausea and
vomiting
25. Treatment
• Stop dental treatment
• Call for help
• Rest, sit up and reassure patient
• Oxygen
• Analgesia (opiate, sublingual nitrate)
• Aspirin
• Thrombolysis
• Primary angioplasty
• Beta-Blockers
• ACE inhibitors
• Prepare for basic life support
• Transport patient to hospital
26. Surgical Treatment
• Percutaneous
Transluminal Coronary
Angioplasty (PTCA)
– balloon expansion that
can provide 90%
dilitation of vessel
lumen
– Stent Placement
• Coronary Artery By-
Pass Graft (CABG)
27. Dental Considerations for IHD
• Common Situations:
– Orthostatic Hypotension due to use of anti-hypertensives (beta
blockers, nitroglycerin…)
• Raise chair slowly
• Allow patient to take his/her time
• Assist patient in standing
– Post-Op Bleeding:
• When patients on Plavix or Aspirin, expect increased bleeding because of
decreased platelet aggregation
• Emergent Situations:
– Possible MI:
• Remember that pain in the jaw may be referred pain from the
myocardium assess the situation, have good patient history, follow
ABC’s
– Angina:
• In situations of angina pectoris, all operatories should have nitroglycerin
to be placed sublingually
28. RISK FOR DENTAL PROCEDURE
• Major Risk for Perioperative Procedures:
– Unstable Angina (getting worse)
– Recent MI
• Intermediate Risk for Perioperative Procedures:
– Stable Angina
– History of MI
• 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
29. Post MI: When to Treat
• Why delay treatment?
– Remember that with an MI there is damage to the heart, 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, 3-6 months… however, 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:
– CONSULT THE CARDIOLOGIST
30. Dental Management:
Stable Angina/Post-MI >4-6 weeks
• Minimize time in waiting room
• Short, morning appointments
• Preop, intra-op, and post-op vital signs
• Pre-medication as needed
– anxiolytic (triazolam; oxazepam); 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 - use epinephrine, if needed, in limited
amount (max 0.04mg) or levonordefrin (max. 0.20mg)
• Avoid epinephrine in retraction cord
31. Dental Management:
Unstable Angina or MI < 3 months
• Avoid elective care
• For urgent care: be as conservative as possible;
do only what must be done (e.g. infection
control, pain management)
• Consultation with physician to help manage
• Consider treating in outpatient hospital facility or
refer to hospital dentistry
• ECG, pulse oximetry, IV line
• Use vasoconstrictors cautiously if needed
32. Warning Signs and Symptoms of Heart
attack
1) Pressure, fullness or a squeezing pain in the center of chest
that lasts for more than a few minutes.
2) Pain extending beyond the chest to the shoulder, arm, back or
even your teeth and jaw.
3) Increasing episodes of chest pain
4) Prolonged pain in the upper abdomen
5) Shortness of breath- may occur with or without chest
discomfort
6) Sweating
7) Impending sense of doom
8) Lightheadedness
9) Fainting
10) Nausea and vomiting
33. Conclusion:
• When treating patients with Ischemic Heart Disease
or recent MI…
– Use caution and common sense
– When in doubt:
• CONSULT THE CARDIOLOGIST
35. Sequelae of Heart Failure
• Right Heart • Left Heart
Failure Failure
– Systemic – Pulmonary
venous edema
congestion (Dyspnea)
(distended
neck veins,
enlarged liver,
peripheral
edema,
ascites)
36. Symptoms of Heart Failure
Compensated (Asymptomatic)
Uncompensated (Symptomatic)
• Fatigue
• Dyspnea
• Orthopnea
• Paroxysmal Nocturnal Dyspnea
• Ankle Edema
• Weight Gain
Note: patients with a very low EF may have no symptoms
37. Functional Classification of Heart Failure
• Class I: No limitation of physical activity. No
dyspnea, fatigue, or palpitations with ordinary
physical activity
• Class II: Slight limitation of physical activity.
Fatigue, palpitations and dyspnea with ordinary
physical activity but comfortable at rest.
• Class III: Marked limitation of activity. Less than
ordinary physical activity results in symptoms but
comfortable at rest.
• Class IV: Symptoms present at rest and any physical
activity exacerbates the symptoms
38. Dental Management Considerations
(Heart Failure)
• For undiagnosed pt with symptoms of HF: avoid
elective care; refer to physician
• For patients with diagnosed HF:
– Class I (asymptomatic): routine care
– Class II (mild symptoms with exertion): elective care
OK and recommend consultation with physician
– Class III or IV (symptoms with minimal activity or at
rest): avoid elective care; if treatment necessary,
manage in consultation with physician; consider
referral to a special patient care setting; avoid use of
vasoconstrictors
45. Asthma
• Characterized by reversible airway obstruction
and associated with a reduction in expiratory
airflow
– May be precipitated by allergens, pollution,
exercise, stress, or upper respiratory tract
infection
– In status asthmaticus, patients have persistent life-
threatening bronchospasm despite drug therapy
– Signs of asthma include shortness of breath and
wheezing
46. Chronic Obstructive Pulmonary
Disease
• Irreversible airway obstruction; occurs with
either chronic bronchitis or emphysema
– Chronic bronchitis is a result of chronic
inflammation of the airways and excessive
sputum production
– Emphysema is characterized by alveolar
destruction with airspace enlargement and
airway collapse
47. Corticosteroids
• Typical side effects seen with corticosteroid
therapy do not occur with topical aerosol
administration
– Patients have a significant improvement in
pulmonary function with a decrease in wheezing,
tightness, and cough
– Reduce inflammation, secretions and swelling in
the lungs after an asthma attack
• Prolonged inhalation may cause candidiasis
48. Dental Implications of the Respiratory
Drugs
• About 10% of the population has some form
of pulmonary disease
– With severe COPD, a person can develop
pulmonary hypertension, increasing the risk for
cardiac arrhythmias
– Stress should be minimized and adrenal
supplementation instituted if the patients are
taking certain doses of steroids and the procedure
is likely to produce severe stress
59. Chronic Renal Failure Causes
• Diabetic Nephropathy
• Hypertension
• Glomerulonephritis
• HIV nephropathy
• Reflux nephropathy in children
• Polycystic kidney disease
• Kidney infections & obstructions
60. Dialysis
• ½ of patients with CRF eventually require
dialysis
• Diffuse harmful waste out of body
• Control BP
• Keep safe level of chemicals in body
• 2 types
– Hemodialysis
– Peritoneal dialysis
61. Hemodialysis
• 3-4 times a week
• Takes 2-4 hours
• Machine filters
blood and
returns it to
body
66. Hepatic Disorders
Management of Patient with Hepatic Insufficiency
1. Attempt to learn the cause of the liver problem; if the
cause is hepatitis B, take usual precautions.
2. Avoid drugs requiring hepatic metabolism or excretion; if
their use is necessary, modify the dose.
3. Screen patients w i t h severe liver disease for bleeding
disorders with platelet count, prothrombin time, partial
thromboplastin time, and Ivy's bleeding time.
4. Attempt to avoid situations in which the patient might
swallow large amounts of blood.