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Ischaemic Heart Disease Clinical Aspects For DENTIST A

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Title: Ischaemic Heart Disease Clinical Aspects For DENTIST A


1
Ischaemic Heart DiseaseClinical Aspects For
DENTIST
2
Coronary Heart Disease
  • A leading cause of SICKNESS and DEATH

3
Risk Factors for Cardiovascular Disease
  • Hypertension
  • High cholesterol
  • Obesity
  • Cigarette smoking
  • Physical inactivity
  • Diabetes mellitus
  • Kidney disease
  • Older age (gt55 ? gt 65 ?)
  • Family history of premature cardiovascular
    disease
  • Obstructive sleep apnea
  • Periodontal disease ?

4
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)

5
Ischaemic heart diseaseDefinition
  • An imbalance between the supply of oxygen and the
    myocardial demand resulting in myocardial
    ischaemia.
  • Angina pectoris
  • symptom not a disease
  • chest discomfort associated with abnormal
    myocardial function in the absence of myocardial
    necrosis
  • Supply
  • Atheroma, thrombosis, spasm, embolus
  • Demand
  • Anaemia, hypertension, high cardiac output
    (thyrotoxicosis, myocardial hypertrophy)

6
Ischaemic heart diseaseManifestations
  • Sudden death
  • Acute coronary syndrome ( Myocardial Infarction
    Unstable Angina )
  • Stable angina pectoris
  • Heart failure
  • Arrhythmia
  • Asymptomatic

7
Ischaemic heart diseaseEpidemiology
  • 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

8
Ischaemic heart diseaseAetiology
  • 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, OCP, soft water

Atherosclerosis
9
Risk Factors for Ischemic Heart Disease
  • Family History
  • Smoking
  • Hypertension
  • Diabetes Mellitus
  • Hypercholesterolaemia
  • Lack of exercise Obesity
  • Age Sex
  • PRIMARY PREVENTION

10
Non-Modifiable Risk Factor SEX
11
Non-Modifiable Risk Factor AGE
12
Non-Modifiable Risk Factor FAMILY HISTORY
13
Modifiable Risk Factor DIABETES
14
Modifiable Risk Factor SMOKING
15
Modifiable Risk Factor OBESITY
16
Modifiable Risk Factor DYSLIPIDEMIA
17
Spectrum of the Atherosclerotic Process
  • Coronary Arteries (angina, MI, sudden death)
  • Cerebral Arteries (stroke)
  • Peripheral Arteries (claudication)

18
Ischaemic heart diseaseAcute coronary syndromes
Atherosclerosis
Coronary Artery spasm
Fatal / Non-Fatal AMI
Unstable Angina
19
Warning Signs and Symptoms of Heart attack
  • Pressure, fullness or a squeezing pain in the
    center of your chest that lasts for more than a
    few minutes.
  • Pain extending beyond your chest to your
    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

20
Angina Pectoris
  • At least 70 occlusion of coronary artery
    resulting in pain. What kind of pain?
  • Chest pain
  • Radiating pain to
  • Left shoulder
  • Jaw
  • Left or Right arm
  • Usually brought on by physical exertion as the
    heart is trying to pump blood to the muscles, 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

21
Clinical Patterns of Angina Pectoris
  • Stable - pain pattern and characteristics
    relatively unchanged over past several months
    (better prognosis)
  • Unstable - pain pattern changing in occurrence,
    frequency, intensity, or duration (poorer
    prognosis) MI pending

22
TREATMENT
  • MEDICATIONS
  • Nitrates- vasodilator eg ISDN. ISMN
  • Pain reliever- eg Morphine
  • Beta-blockers
  • Statins- cholesterol lowering drugs. Eg
    Atorvastatin, Simvastatin

23
Ischaemic heart diseaseRelevance 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!

24
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

25
Chest PainMyocardial ischaemia
  • Site
  • Jaw to navel, retrosternal, left submammary
  • Radiation
  • Left chest, left arm, jaw.mandible, teeth,
    palate
  • Quality/severity
  • tightness, heaviness, compressionclenched fists
  • Precipitating/relieving factors
  • physical exertion, cold windy weather, emotion
  • rest, sublingual nitrates
  • Autonomic symptoms
  • sweating, pallor, peripheral vasoconstriction,
    nausea and vomiting

26
Chest PainDifferential diagnosis
  • Cardiac pathology
  • Pericarditis, aortic dissection
  • Pulmonary pathology
  • Pulmonary embolus, pneumothorax, pneumonia
  • Gastrointestinal pathology
  • Peptic ulcer disease, reflux, pancreatitis, café
    coronary
  • Musculoskeletal pathology
  • Trauma, Tietzes Syndrome

27
Acute Myocardial InfarctionAssessment
  • 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

28
Acute Myocardial InfarctionConfirming the
diagnosis
  • Typical chest pain
  • Electrocardiographic changes
  • ST elevation
  • new LBBB
  • Myocardial enzyme elevation
  • Creatine kinase (CK-MB)
  • Troponin

29
Acute Myocardial InfarctionTreatment
  • 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

30
Surgical Treatment
  • Percutaneous Transluminal Coronary Angioplasty
    (PTCA)
  • balloon expansion that can provide 90 dilitation
    of vessel lumen

31
Stent Placement
  • With use of just the balloon, re-occlusion of the
    artery can occur within months
  • Placement of a stent delays or prevents
    re-occlussion

32
Surgical Treatment
  • Coronary Artery By-Pass Graft (CABG)
  • The graft bypasses the obstruction in the
    coronary artery
  • Graft sources
  • saphenous vein
  • internal mammary artery
  • radial artery

33
Acute Myocardial InfarctionComplications
  • Sudden Death (18 within 1 hour, 36 within 24
    hours)
  • 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

34
Sudden Death
  • 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, 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

35
Dental Considerations
  • 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

36
RISK
  • 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

37
Management for Low-Intermediate Risk
  • Short appointments
  • AM appointments
  • Comfort
  • Vital Signs Taken
  • Avoidance of Epinephrine within Local Anesthetic
    or Retraction Cord
  • O2 Availability

38
Dentistry Cardiovascular Medicine
  • AMI
  • GA within 3/12 of AMI 30 re-infarction rate _at_
    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)

39
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 patients 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

40
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.
  • If there is any doubt or question, consult with
    the cardiologist.

41

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

42
Dental Considerations for IHD
  • 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 ABCs
  • Angina
  • In situations of angina pectoris, all operatories
    should have nitroglycerin to be placed
    sublingually

43
Dental Considerations for IHD
  • Emergent Situations
  • Chest Pain-MI
  • STOP PROCEDURE
  • Remove everything from patients mouth
  • Give sublingual nitroglycerin
  • Wait 5 minutes ? if pain persists, give more
    nitroglycerin, assume MI
  • 101
  • Give chewable aspirin ? ABCs

44
Dental Management Stable Angina/Post-MI gt4-6
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

45
Dental ManagementUnstable Angina or MI lt 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

46
Intraoperative Chest Pain
  • 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
  • Give aspirin tablet to chew and swallow
  • Monitor vital signs, administer oxygen, and
  • be prepared to provide life support

47
Conclusion
  • When treating patients with Ischemic Heart
    Disease or recent MI
  • Use caution and common sense
  • When in doubt
  • CONSULT THE CARDIOLOGIST
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