Transcript Management of Dental Patients with Ischemic Heart Disease

Ischaemic Heart Disease
Clinical Aspects For
DENTIST
Coronary Artery Disease
A leading cause of SICKNESS and DEATH
Coronary Heart Disease:
Myocardial Ischemia
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An imbalance between the supply of oxygen and the
myocardial demand resulting in myocardial
ischaemia.
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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)
Coronary Artery Diseases
Coronary artery disease : Is the presence of atherosclerosis
in the coronary arteries.
Angina pectoris : Is a transient discomfort (usually less than
15 minutes) due to a temporary lack of adequate blood
supply to the heart muscle. (symptom not a disease ) due to
increased demands (Anaemia, hypertension, high cardiac
output (thyrotoxicosis, myocardial hypertrophy)
Acute Coronary Syndrome : Unstable Angina &
Myocardial infarction
Due to coronary vessel obstruction
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Acute Coronary Syndromes
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Unstable Angina
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Angina that is continuing, prolonged or occurring at rest.
Represents a syndrome that lies between angina pectoris and AMI.
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Myocardial infarction (Heart Attack) is defined as death
of heart tissue due to blockage of a coronary artery
caused by atherosclerosis and thrombus formation
Ischaemic heart disease
Epidemiology
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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
Risk Factors for Cardiovascular
Disease
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Hypertension
High cholesterol
Obesity
Cigarette smoking
Physical inactivity
Diabetes mellitus
Kidney disease
Older age (>55 ♂; > 65 ♀)
Family history of premature cardiovascular disease
Periodontal disease ?
Ischaemic heart disease
Aetiology
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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
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 PRIMARY
PREVENTION
Atherosclerosis
Non-Modifiable Risk Factor:
SEX
Non-Modifiable Risk Factor:
AGE
Non-Modifiable Risk Factor:
FAMILY HISTORY
Modifiable Risk Factor:
DIABETES
Modifiable Risk Factor: SMOKING
Modifiable Risk Factor: OBESITY
Modifiable Risk Factor:
DYSLIPIDEMIA
Ischaemic heart disease
Manifestations
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Sudden death
Acute coronary syndrome ( Myocardial Infarction & Unstable
Angina )
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Stable angina pectoris
Heart failure
Arrhythmia
Asymptomatic
Angina Pectoris
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At least 70% occlusion of coronary artery
resulting in pain.
 Chest pain
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- 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
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Usually brought on by physical exertion
Is self limiting usually stops when exertion is
ceased
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Angina pectoris
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Potential problem related to dental care
1. Stress and anxiety related to dental visit may precipitate angina
attack
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Prevention of complication
1. Detection of patient
2. Referral of patient for medical evaluation and treatment
3. Known case with medical treatment for angina
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Stress reduction protocol
Premedication
 Open and honest communication
 Morning appointments
 Short appointments
 Nitrous oxide - oxygen
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Avoid excessive amounts of epinephrine
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2.
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Terminate all procedures
Semi-reclined position
Sublingual NTG
O2
Check vital signs
Discomfort relieved
6. Assume angina pectoris was present
7. Slowly taper O2 over 5min
8. Modify dental treatment
Angina Pectoris
Still discomfort after 3min
Give 2nd NTG
Still discomfort after 3min
Give 3rd NTG
Still discomfort after 3min
NTG
0.6mg/tab
10. Assume myocardial infarction in progress
11. On IV line
12. Prepare transport to ER
If highly suspected AMI
MONA: Morphine, Oxygen, NTG, Aspirin
Myocardial Infarction
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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
Chest Pain
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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
Differential diagnosis
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Cardiac pathology
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Pulmonary pathology
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Pulmonary embolus, pneumothorax, pneumonia
Gastrointestinal pathology
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Pericarditis, aortic dissection
Peptic ulcer disease, reflux, pancreatitis, ‘café coronary’
Musculoskeletal pathology
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Trauma, Tietze’s Syndrome
Assessment
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30% of deaths occur in the first 2 hours.
(Cardiac muscle death occurs after 45 minites of
ischaemia)
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Symptoms and signs of myocardial ischaemia
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Also
Changes in heart rate /rhythm
 Changes in blood pressure
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Confirming the diagnosis
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Typical chest pain
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Electrocardiographic changes ( ECG )
ST elevation
 new LBBB
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Myocardial enzyme elevation
Creatine kinase (CK-MB)
 Troponin
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Treatment
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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
Surgical Treatment
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Percutaneous
Transluminal
Coronary Angioplasty
(PTCA)
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balloon expansion that
can provide 90%
dilitation of vessel
lumen
Stent Placement
Coronary Artery ByPass Graft (CABG)
Acute Myocardial Infarction
Complications
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Sudden Death (18% within 1 hour, 36% within 24
hours)
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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
Prevention of complication
1. No routine dental care until at least 6 months after infarction
2. Medical consultation
 Current status
 Medication used
3. Stress reduction protocol
 Premedication
 Open and honest communication
 Morning appointment
 Short appointment
 Nitrous oxide - oxygen
4. Avoid excessive amounts of epinephrine
5. Check PT (Anticoagulant medication)
Dental Considerations for IHD
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Common Situations:
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Orthostatic Hypotension due to use of anti-hypertensives (beta blockers,
nitroglycerin…)
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Post-Op Bleeding:
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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
Emergent Situations:
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Possible MI:
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Remember that pain in the jaw may be referred pain from the myocardium 
assess the situation, have good patient history, follow ABC’s
Angina:
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In situations of angina pectoris, all operatories should have nitroglycerin to be
placed sublingually
RISK FOR DENTAL PROCEDURE
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Major Risk for Perioperative Procedures:
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Intermediate Risk for Perioperative Procedures:
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Unstable Angina (getting worse)
Recent MI
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
Dentistry & Cardiovascular
Medicine
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AMI
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)
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Post MI: When to Treat
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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
Dental Management:
Stable Angina/Post-MI >4-6 weeks
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Minimize time in waiting room
Short, morning appointments
Preop, intra-op, and post-op vital signs
Pre-medication as needed
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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
Dental Management:
Unstable Angina or MI < 3 months
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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
Intraoperative Chest Pain
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Stop procedure
Give nitroglycerin
If after 5 minutes pain still present, give another
nitroglycerin
If after 5 more minutes pain still present, give another
nitroglycerin
If pain persists, assume MI in progress and activate the
EMS
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Give aspirin tablet to chew and swallow
Monitor vital signs, administer oxygen, and
be prepared to provide life support
Warning Signs and Symptoms of
Heart attack
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Pressure, fullness or a squeezing pain in the center of chest that
lasts for more than a few minutes.
Pain extending beyond the chest to the shoulder, arm, back or
even your teeth and jaw.
Increasing episodes of chest pain
Prolonged pain in the upper abdomen
Shortness of breath- may occur with or without chest discomfort
Sweating
Impending sense of doom
Lightheadedness
Fainting
Nausea and vomiting
Emergency action plan for a person with signals of heart
attack
Unknown case of CAD
Known case of CAD
Recognize the signals of a heart
attack
Recognize the signals of heart attack
Stop activity and sit or lie down
Wait about 5 minutes to see if
the symptom go away. If the
pain persists :
Stop activity and sit or lie down
Take 1 nitroglycerin tablet at a time
at 3 - to 5 minutes intervals to
maximum total dose of 3 tablets. If
pain persists.
Transport patient to hospital
Conclusion:
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When treating patients with Ischemic Heart Disease or
recent MI…
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Use caution and common sense
When in doubt:
 CONSULT
THE CARDIOLOGIST
Dental Management
of
Patients with Heart Failure
What is Heart Failure?
 HF occurs when the heart is unable to pump enough
blood to meet the oxygen requirements of the body
 Nearly 10% of populations > 70 years of age will have HF
 Overall mortality close to 20%
 HF risk factors:
 CAD and its sequelae
 HTN
Cardiomyopathy
diseases
Pericardial disease
embolism
- Myocarditis,
- Valvular heart
- Pulmonary
Types and Classifications of H.F
(measured by ejection fraction [EF])
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Systolic or diastolic
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High output or low output
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Left or right sided
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Acute or chronic
Systolic HF
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Inability of heart to
contract strongly
enough to provide
adequate blood flow
to periphery
Systolic dysfunction:
- EF < 50%; results from reduced
left ventricular function
- Increased preload
- Most cases of CHF
Diastolic HF
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Abnormal relaxation
of myocardium
resulting in reduced
filling of ventricle
Common Causes of HF
Coronary Heart Disease/MI
Hypertension
Valvular Heart Disease
Arrhythmias
Myocarditis
Cardiomyopathy
Infective Endocarditis
Congenital Heart Disease
Pulmonary Hypertension
Endocrine Disorders (thyroid
disease)
MI is a leading
cause
Sequelae of Heart Failure
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Right Heart
Failure
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Systemic
venous
congestion
(distended neck
veins, enlarged
liver, peripheral
edema, ascites)
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Left Heart
Failure
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Pulmonary
edema
(Dyspnea)
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
Functional Classification of Heart
Failure (NYHA)
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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
Medical Management of Heart Failure
1. Decreased cardiac output CO
Main Problems
requiring
treatment
2. Decreased ejection fraction
- repair of diseased valves
3. Fluid overload
4. Overweight
5. HTN
Medical Management of Heart
Failure
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Treatment of underlying disease
Life-style modifications
Drug therapy
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ACE inhibitors
- Or angiotensin receptor blockers
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Beta Blockers (Coreg, Toprol-XL, or bisoprolol)
Diuretics
- Or direct-acting vasodilators
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Nitrates
Digitalis Glycosides
Heart transplant
Dental Management Considerations
(Heart Failure)
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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
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Stress management protocol
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ID underlying disease (CHD, HBP, RHD) and
manage appropriately
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Semisupine or upright chair position
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Take BP, monitor with pulse oximeter, watch for
orthostatic hypotension
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Drug Considerations
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If taking digitalis, avoid vasoconstrictors if possible
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If taking nonselective β-blocker, use vasoconstrictor
cautiously
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Watch for digitalis toxicity
To Prevent Heart Failure
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lower high blood pressure;
lose extra weight;
quit smoking, alcohol use, illegal drug use
control irregular or too-fast heart rhythms;
correct too-low or too-high thryoid function;
lower bad cholesterol and raise good cholesterol;
if diabetic, control blood sugar;
if had a heart attack, restore lost blood flow with bypass surgery or
angioplasty if possible;
if had a heart attack (even if long ago), take an ACE inhibitor or ARB, and
also take a beta-blocker to reduce risk of heart failure down the road, even if
you have no symptoms and even if your EF is normal;
if have reduced EF, take a beta-blocker and an ACE inhibitor even if you
have no symptoms;
if have significant heart valve dysfunction, get surgical repair;
perform regular echocardiograms in people who have had chemotherapy;