Ischaemic Heart DiseaseClinical Aspects For DENTIST

A leading cause of SICKNESS and DEATH

Coronary Heart Disease

Risk Factors for Cardiovascular DiseaseHypertensionHigh cholesterolObesity Cigarette smoking Physical inactivityDiabetes mellitusKidney diseaseOlder age (>55 ; > 65 )Family history of premature cardiovascular diseaseObstructive sleep apnea Periodontal disease ?

Coronary Heart Disease: Myocardial IschemiaDecreased blood supply (and thus oxygen) to the myocardium that can result in acute coronary syndromes:Angina pectoris ( Stable )Unstable AnginaMyocardial infarctionSudden death (due to fatal arrhythmias)

Ischaemic heart diseaseDefinitionAn imbalance between the supply of oxygen and the myocardial demand resulting in myocardial ischaemia.Angina pectorissymptom not a diseasechest discomfort associated with abnormal myocardial function in the absence of myocardial necrosisSupplyAtheroma, thrombosis, spasm, embolusDemandAnaemia, hypertension, high cardiac output (thyrotoxicosis, myocardial hypertrophy)

Ischaemic heart diseaseManifestationsSudden deathAcute coronary syndrome ( Myocardial Infarction & Unstable Angina )Stable angina pectorisHeart failureArrhythmiaAsymptomatic

Ischaemic heart diseaseEpidemiologyCommonest cause of death in the Western world. (up to 35% of total mortality)Over 20% males under 60 years have IHDHealth Survey :3% of adults suffer from angina1% have had a myocardial infarction in the past 12 months

Ischaemic heart diseaseAetiologyFixedAge, Male, +ve family historyModifiable strong associationDyslipidaemia, smoking, diabetes mellitus, obesity, hypertensionModifiable - weak associationLack of exercise, high alcohol consumption, type A personality, OCP, soft waterAtherosclerosis

Risk Factors for Ischemic Heart DiseaseFamily HistorySmokingHypertensionDiabetes MellitusHypercholesterolaemiaLack of exercise ObesityAge & SexPRIMARY 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 ProcessCoronary Arteries (angina, MI, sudden death)Cerebral Arteries (stroke)Peripheral Arteries (claudication)

Ischaemic heart diseaseAcute coronary syndromesAtherosclerosisFatal / Non-Fatal AMIUnstableAnginaCoronaryArtery spasm

Warning Signs and Symptoms of Heart attackPressure, 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 painProlonged pain in the upper abdomenShortness of breath- may occur with or without chest discomfort SweatingImpending sense of doomLightheadednessFaintingNausea and vomiting

Angina PectorisAt least 70% occlusion of coronary artery resulting in pain. What kind of pain?Chest painRadiating pain to:Left shoulderJawLeft or Right armUsually 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 PectorisStable - 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

TREATMENTMEDICATIONSNitrates- vasodilator eg: ISDN. ISMNPain reliever- eg: MorphineBeta-blockersStatins- cholesterol lowering drugs. Eg: Atorvastatin, Simvastatin

Ischaemic heart diseaseRelevance to DentistryIHD is commonSubjects 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 tissuesStress provokes ACS!

Myocardial InfarctionPartial 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 muscleWhen an MI occurs, there is usually involvement of 3 or 4 occluded coronary vessels

Chest PainMyocardial ischaemiaSiteJaw to navel, retrosternal, left submammaryRadiationLeft chest, left arm, jaw.mandible, teeth, palateQuality/severitytightness, heaviness, compressionclenched fistsPrecipitating/relieving factorsphysical exertion, cold windy weather, emotionrest, sublingual nitratesAutonomic symptomssweating, pallor, peripheral vasoconstriction, nausea and vomiting

Chest PainDifferential diagnosisCardiac pathologyPericarditis, aortic dissectionPulmonary pathologyPulmonary embolus, pneumothorax, pneumoniaGastrointestinal pathologyPeptic ulcer disease, reflux, pancreatitis, caf coronaryMusculoskeletal pathologyTrauma, Tietzes Syndrome

Acute Myocardial InfarctionAssessment30% of deaths occur in the first 2 hours.(Cardiac muscle death occurs after 45 mins of ischaemia)Symptoms and signs of myocardial ischaemia

AlsoChanges in heart rate /rhythmChanges in blood pressure

Acute Myocardial InfarctionConfirming the diagnosisTypical chest pain

Electrocardiographic changesST elevationnew LBBBMyocardial enzyme elevationCreatine kinase (CK-MB)Troponin

Acute Myocardial InfarctionTreatmentStop dental treatmentCall for helpRest, sit up and reassure patientOxygenAnalgesia (opiate, sublingual nitrate)AspirinThrombolysisPrimary angioplastyBeta-BlockersACE inhibitorsPrepare for basic life support

Surgical TreatmentPercutaneous Transluminal Coronary Angioplasty (PTCA)balloon expansion that can provide 90% dilitation of vessel lumen

Stent PlacementWith use of just the balloon, re-occlusion of the artery can occur within monthsPlacement of a stent delays or prevents re-occlussion

Surgical TreatmentCoronary Artery By-Pass Graft (CABG)The graft bypasses the obstruction in the coronary arteryGraft sources:saphenous veininternal mammary arteryradial artery

Acute Myocardial InfarctionComplicationsSudden Death (18% within 1 hour, 36% within 24 hours)Non-fatal arrhythmiaAcute left ventricular failureCardiogenic shockPapillary muscle rupture and mitral regurgitationMyocardial rupture and tamponadeVentricular aneurysm and thrombusDistal Embolisation

Sudden DeathSudden Cardiac Death is also known as a Massive Heart Attack in which the heart converts from sinus rhythm to ventricular fibrillationIn V-Fib, the heart is unable to contract fully resulting in lack of blood being pumped to the vital organsV-Fib requires shock from defibrillator SHOCKABLE RHYTHM

Dental ConsiderationsAssessment and Overall ManagementPharmaceuticalsEmergency SituationsOral Effects of PharmaceuticalsAntibiotic ProphylaxisPost MI: when to treatConsider three areas:How severe or stable the ischemic heart disease isThe emotional state of the patientThe type of dental procedure

RISKMajor Risk for Perioperative Procedures:Unstable Angina (getting worse)Recent MIIntermediate Risk for Perioperative Procedures:Stable AnginaHistory of MIMost 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 RiskShort appointmentsAM appointmentsComfortVital Signs TakenAvoidance of Epinephrine within Local Anesthetic or Retraction CordO2 Availability

Dentistry & Cardiovascular MedicineAMIGA within 3/12 of AMI: 30% re-infarction rate @ 1/52 post opAvoid routine LA dental treatment for 3/12 (emergency treatment only)Avoid excess dosage, reduce anxietyAvoid elective surgery under GA for1 year (specialist)Be aware of medications (bleeding, hypotension)

Post MI: When to TreatWhy delay treatment?Remember that with an MI there is damage to the heart, be it severe or minimal that may effect the patients daily lifeMI within 1 month Major Cardiac Risk MI within longer then 1 month:Stable routine dental care okUnstable treat as Major Cardiac RiskOlder studies suggest high re-infarction rates when surgery performed within 3 months, 3-6 months however, this was abdominal and thoracic surgery under general anesthesiaNew research suggests delaying elective tx for 1 month is advisable. Emergent care should be done with local anesthetic without epinephrine and monitoring of vital signsWhen in doubt:CONSULT THE CARDIOLOGIST

Dental Management CorrelateElective 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.

Common Situations:Orthostatic Hypotension due to use of anti-hypertensives (beta blockers, nitroglycerin)Raise chair slowlyAllow patient to take his/her timeAssist patient in standingPost-Op Bleeding:When patients on Plavix or Aspirin, expect increased bleeding because of decreased platelet aggregation

Dental Considerations for IHD

Dental Considerations for IHDEmergent Situations:Possible MI:Remember that pain in the jaw may be referred pain from the myocardium assess the situation, have good patient history, follow ABCsAngina:In situations of angina pectoris, all operatories should have nitroglycerin to be placed sublingually

Dental Considerations for IHDEmergent Situations:Chest Pain-MI:STOP PROCEDURERemove everything from patients mouthGive sublingual nitroglycerinWait 5 minutes if pain persists, give more nitroglycerin, assume MI101 Give chewable aspirin ABCs

Dental Management: Stable Angina/Post-MI >4-6 weeksMinimize time in waiting roomShort, morning appointmentsPreop, intra-op, and post-op vital signsPre-medication as neededanxiolytic (triazolam; oxazepam); night before and 1 hour beforeHave nitroglycerin available may consider using prophylacticalyUse pulse oximeter to assure good breathing and oxygenationOxygen 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 monthsAvoid elective careFor urgent care: be as conservative as possible; do only what must be done (e.g. infection control, pain management)Consultation with physician to help manageConsider treating in outpatient hospital facility or refer to hospital dentistry ECG, pulse oximetry, IV lineUse vasoconstrictors cautiously if needed

Intraoperative Chest PainStop procedureGive nitroglycerinIf after 5 minutes pain still present, give another nitroglycerinIf after 5 more minutes pain still present, give another nitroglycerinIf pain persists, assume MI in progress and activate the EMSGive aspirin tablet to chew and swallowMonitor vital signs, administer oxygen, and be prepared to provide life support

Conclusion:When treating patients with Ischemic Heart Disease or recent MIUse caution and common senseWhen in doubt:CONSULT THE CARDIOLOGIST