Ischaemic Heart Disease Clinical Aspects For DENTIST

Coronary Heart Disease

A leading cause of SICKNESS and DEATH

Risk Factors for Cardiovascular Disease

Hypertension High cholesterol Obesity Cigarette smoking Physical inactivity Diabetes mellitus Kidney disease Older age (>55 ; > 65 ) Family history of premature cardiovascular disease Obstructive sleep apnea Periodontal disease ?

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)

Ischaemic heart disease Definition

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 Anaemia, hypertension, high cardiac output (thyrotoxicosis, myocardial hypertrophy)

Demand

Ischaemic heart disease Manifestations

Sudden death Acute coronary syndrome ( Myocardial Infarction & Unstable

Angina )

Stable angina pectoris Heart failure Arrhythmia Asymptomatic

Ischaemic heart disease Epidemiology

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

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, OCP, soft water

Atherosclerosis

Risk Factors for Ischemic Heart Disease Family History

Smoking Hypertension Diabetes Mellitus Hypercholesterolaemia Lack of exercise Obesity Age & Sex

PRIMARY

PREVENTION

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

Spectrum of the Atherosclerotic Process

Coronary Arteries (angina, MI, sudden death) Cerebral Arteries (stroke) Peripheral Arteries (claudication)

Ischaemic heart disease Acute coronary syndromes

Atherosclerosis

Fatal / Non-Fatal AMI

Unstable Angina

Coronary Artery spasm

Warning Signs and Symptoms of Heart attack

1) 2) 3) 4) 5) 6) 7)

8)
9) 10)

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

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

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

TREATMENT
MEDICATIONS 1) Nitrates- vasodilator eg: ISDN. ISMN 2) Pain reliever- eg: Morphine 3) Beta-blockers 4) Statins- cholesterol lowering drugs. Eg: Atorvastatin, Simvastatin

Ischaemic heart disease Relevance 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!

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

Chest Pain Myocardial 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

Chest Pain Differential diagnosis

Cardiac pathology

Pericarditis, aortic dissection

Pulmonary embolus, pneumothorax, pneumonia Peptic ulcer disease, reflux, pancreatitis, caf coronary Trauma, Tietzes Syndrome

Pulmonary pathology

Gastrointestinal pathology

Musculoskeletal pathology

Acute Myocardial Infarction Assessment

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

Acute Myocardial Infarction Confirming the diagnosis

Typical chest pain Electrocardiographic changes

ST elevation new LBBB

Myocardial enzyme elevation

Creatine kinase (CK-MB) Troponin

Acute Myocardial Infarction 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

Surgical Treatment

Percutaneous Transluminal Coronary Angioplasty (PTCA)

balloon expansion that can provide 90% dilitation of vessel lumen

Stent Placement

With use of just the balloon, reocclusion of the artery can occur within months Placement of a stent delays or prevents reocclussion

Surgical Treatment

Coronary Artery ByPass Graft (CABG) The graft bypasses the obstruction in the coronary artery Graft sources:

saphenous vein internal mammary artery radial artery

Acute Myocardial Infarction Complications

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

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

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

RISK

Major Risk for Perioperative Procedures:

Unstable Angina (getting worse) Recent MI Stable Angina History of MI

Intermediate Risk for Perioperative Procedures:

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

Management for Low-Intermediate Risk

Short appointments AM appointments Comfort Vital Signs Taken Avoidance of Epinephrine within Local Anesthetic or Retraction Cord O2 Availability

Dentistry & Cardiovascular Medicine

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)

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

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.

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 When patients on Plavix or Aspirin, expect increased bleeding because of decreased platelet aggregation

Post-Op Bleeding:

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 In situations of angina pectoris, all operatories should have nitroglycerin to be placed sublingually

Angina:

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

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

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

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

Conclusion:

When treating patients with Ischemic Heart Disease or recent MI

Use caution and common sense When in doubt:

CONSULT

THE CARDIOLOGIST