Ischaemic Heart Ischaemic Heart DiseaseDisease

Clinical Aspects ForClinical Aspects For DENTIST DENTIST

A leading cause of SICKNESS and A leading cause of SICKNESS and DEATHDEATH

Coronary Heart Disease

Risk Factors for Risk Factors for Cardiovascular DiseaseCardiovascular Disease

HypertensionHypertension High cholesterolHigh cholesterol Obesity Obesity Cigarette smoking Cigarette smoking Physical inactivityPhysical inactivity Diabetes mellitusDiabetes mellitus Kidney diseaseKidney disease Older age (>55 Older age (>55 ♂; > 65 ♀)♂; > 65 ♀) Family history of premature Family history of premature

cardiovascular diseasecardiovascular disease Obstructive sleep apnea Obstructive sleep apnea Periodontal disease ?Periodontal disease ?

Coronary Heart Disease:Coronary Heart Disease: Myocardial Ischemia Myocardial Ischemia

Decreased blood Decreased blood supply (and thus supply (and thus oxygen) to the oxygen) to the myocardium that myocardium that can result in acute can result in acute coronary syndromes:coronary syndromes: Angina pectoris Angina pectoris

( Stable )( Stable ) Unstable AnginaUnstable Angina Myocardial infarctionMyocardial infarction Sudden death (due to Sudden death (due to

fatal arrhythmias)fatal arrhythmias)

Ischaemic heart diseaseIschaemic heart diseaseDefinitionDefinition

An imbalance between the An imbalance between the supplysupply ofof oxygenoxygen and the and the myocardialmyocardial demanddemand resulting in resulting in myocardial ischaemia.myocardial ischaemia.

AnginaAngina pectorispectorissymptom not a diseasesymptom not a diseasechest discomfort associated with abnormal chest discomfort associated with abnormal myocardial function in the absence of myocardial myocardial function in the absence of myocardial necrosisnecrosis

SupplySupply Atheroma, thrombosis, spasm, embolusAtheroma, thrombosis, spasm, embolus

DemandDemand Anaemia, hypertension, high cardiac output Anaemia, hypertension, high cardiac output

(thyrotoxicosis, myocardial hypertrophy)(thyrotoxicosis, myocardial hypertrophy)

Ischaemic heart diseaseIschaemic heart diseaseManifestationsManifestations

Sudden deathSudden death Acute coronary syndrome Acute coronary syndrome ( Myocardial ( Myocardial

Infarction & Unstable Angina )Infarction & Unstable Angina )

Stable angina pectorisStable angina pectoris Heart failureHeart failure ArrhythmiaArrhythmia AsymptomaticAsymptomatic

Ischaemic heart diseaseIschaemic heart diseaseEpidemiologyEpidemiology

Commonest cause of death in the Western Commonest cause of death in the Western world. (up to 35% of total mortality)world. (up to 35% of total mortality)

Over 20% males under 60 years have IHDOver 20% males under 60 years have IHD Health Survey :Health Survey :

3% of adults suffer from angina3% of adults suffer from angina

1% have had a myocardial infarction in the 1% have had a myocardial infarction in the past 12 monthspast 12 months

Ischaemic heart diseaseIschaemic heart diseaseAetiologyAetiology

FixedFixed Age, Male, +ve family historyAge, Male, +ve family history

ModifiableModifiable – – strong associationstrong association Dyslipidaemia, smoking, diabetes mellitus, Dyslipidaemia, smoking, diabetes mellitus,

obesity, hypertensionobesity, hypertension ModifiableModifiable - - weak associationweak association

Lack of exercise, high alcohol consumption, type Lack of exercise, high alcohol consumption, type A personality, OCP, soft waterA personality, OCP, soft water

Atherosclerosis

Risk Factors for Ischemic Risk Factors for Ischemic Heart DiseaseHeart Disease Family HistoryFamily History

SmokingSmoking HypertensionHypertension Diabetes MellitusDiabetes Mellitus HypercholesterolaemiaHypercholesterolaemia Lack of exerciseLack of exercise Obesity Obesity Age & SexAge & Sex

PRIMARY PREVENTIONPRIMARY 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 Spectrum of the Atherosclerotic ProcessAtherosclerotic Process

Coronary Arteries (angina, MI, Coronary Arteries (angina, MI, sudden death)sudden death)

Cerebral Arteries (stroke)Cerebral Arteries (stroke) Peripheral Arteries (claudication)Peripheral Arteries (claudication)

Ischaemic heart diseaseIschaemic heart diseaseAcute coronary Acute coronary

syndromessyndromes

AtherosclerosisAtherosclerosis

Fatal / Non-Fatal AMI Unstable

Angina

CoronaryArtery spasm

Warning Signs and Warning Signs and Symptoms of Heart attackSymptoms of Heart attack

1)1) Pressure, fullness or a squeezing pain in the Pressure, fullness or a squeezing pain in the center of your chest that lasts for more than a center of your chest that lasts for more than a few minutes.few minutes.

2)2) Pain extending beyond your chest to your Pain extending beyond your chest to your shoulder, arm, back or even your teeth and jaw.shoulder, arm, back or even your teeth and jaw.

3)3) Increasing episodes of chest painIncreasing episodes of chest pain4)4) Prolonged pain in the upper abdomenProlonged pain in the upper abdomen5)5) Shortness of breath- may occur with or without Shortness of breath- may occur with or without

chest discomfort chest discomfort 6)6) SweatingSweating7)7) Impending sense of doomImpending sense of doom8)8) LightheadednessLightheadedness9)9) FaintingFainting10)10) Nausea and vomiting Nausea and vomiting

Angina PectorisAngina Pectoris At least 70% occlusion of coronary At least 70% occlusion of coronary

artery resulting in pain. What kind artery resulting in pain. What kind of pain?of pain? Chest painChest pain Radiating pain to:Radiating pain to:

Left shoulderLeft shoulder JawJaw Left or Right armLeft or Right arm

Usually brought on by physical Usually brought on by physical exertion as the heart is trying to exertion as the heart is trying to pump blood to the muscles, it pump blood to the muscles, it requires more blood that is not requires more blood that is not available due to the blockage of the available due to the blockage of the coronary artery(ies)coronary artery(ies)

Is self limitingIs self limiting usually stops when usually stops when exertion is ceasedexertion is ceased

Clinical Patterns of Clinical Patterns of Angina PectorisAngina Pectoris

StableStable - pain pattern and - pain pattern and characteristics relatively unchanged characteristics relatively unchanged

over past several months (better over past several months (better prognosis) prognosis)

UnstableUnstable - pain pattern changing - pain pattern changing in occurrence, frequency, intensity, in occurrence, frequency, intensity, or duration (poorer prognosis); MI or duration (poorer prognosis); MI pendingpending

TREATMENTTREATMENT

MEDICATIONSMEDICATIONS1)1) Nitrates- vasodilator eg: ISDN. ISMNNitrates- vasodilator eg: ISDN. ISMN2)2) Pain reliever- eg: MorphinePain reliever- eg: Morphine3)3) Beta-blockersBeta-blockers4)4) Statins- cholesterol lowering drugs. Eg: Statins- cholesterol lowering drugs. Eg:

Atorvastatin, SimvastatinAtorvastatin, Simvastatin

Ischaemic heart diseaseIschaemic heart diseaseRelevance to DentistryRelevance to Dentistry

IHD is commonIHD is common Subjects with IHD have more severe Subjects with IHD have more severe

dental caries and periodontal dental caries and periodontal disease – association or causation?disease – association or causation?

Angina is a cause of pain in the Angina is a cause of pain in the mandible, teeth or other oral tissuesmandible, teeth or other oral tissues

Stress provokes ACS!Stress provokes ACS!

Myocardial InfarctionMyocardial Infarction

Partial or total occlusion of one or more Partial or total occlusion of one or more of the coronary arteries due to an of the coronary arteries due to an atheroma, thrombus or emboli resulting atheroma, thrombus or emboli resulting in cell death (infarction) of the heart in cell death (infarction) of the heart musclemuscle

When an MI occurs, there is usually When an MI occurs, there is usually involvement of 3 or 4 occluded involvement of 3 or 4 occluded coronary vesselscoronary vessels

Chest PainChest PainMyocardial ischaemiaMyocardial ischaemia

SiteSiteJaw to navel, retrosternal, left submammaryJaw to navel, retrosternal, left submammary

RadiationRadiationLeft chest, left arm, jaw….mandible, teeth, palateLeft chest, left arm, jaw….mandible, teeth, palate

QualityQuality//severityseveritytightness, heaviness, compression…clenched fiststightness, heaviness, compression…clenched fists

Precipitating/relieving factorsPrecipitating/relieving factorsphysical exertion, cold windy weather, emotionphysical exertion, cold windy weather, emotionrest, sublingual nitratesrest, sublingual nitrates

Autonomic symptomsAutonomic symptomssweating, pallor, peripheral vasoconstriction, sweating, pallor, peripheral vasoconstriction, nausea and vomitingnausea and vomiting

Chest PainChest PainDifferential diagnosisDifferential diagnosis

CardiacCardiac pathologypathology Pericarditis, aortic dissectionPericarditis, aortic dissection

PulmonaryPulmonary pathologypathology Pulmonary embolus, pneumothorax, pneumoniaPulmonary embolus, pneumothorax, pneumonia

GastrointestinalGastrointestinal pathologypathology Peptic ulcer disease, reflux, pancreatitis, ‘café Peptic ulcer disease, reflux, pancreatitis, ‘café

coronary’coronary’

MusculoskeletalMusculoskeletal pathologypathology Trauma, Tietze’s SyndromeTrauma, Tietze’s Syndrome

Acute Myocardial Acute Myocardial InfarctionInfarction

AssessmentAssessment 30% of deaths occur in the first 2 hours.30% of deaths occur in the first 2 hours.

(Cardiac muscle death occurs after 45 mins (Cardiac muscle death occurs after 45 mins of ischaemia)of ischaemia)

Symptoms and signs of myocardial Symptoms and signs of myocardial ischaemiaischaemia

AlsoAlso Changes in heart rate /rhythmChanges in heart rate /rhythm Changes in blood pressureChanges in blood pressure

Acute Myocardial Acute Myocardial InfarctionInfarction

Confirming the diagnosisConfirming the diagnosis Typical chest painTypical chest pain

Electrocardiographic changesElectrocardiographic changes ST elevationST elevation new LBBBnew LBBB

Myocardial enzyme elevationMyocardial enzyme elevation Creatine kinase (CK-MB)Creatine kinase (CK-MB) TroponinTroponin

Acute Myocardial Acute Myocardial InfarctionInfarctionTreatmentTreatment Stop dental treatmentStop dental treatment

Call for helpCall for help Rest, sit up and reassure patientRest, sit up and reassure patient OxygenOxygen Analgesia (opiate, sublingual nitrate)Analgesia (opiate, sublingual nitrate) AspirinAspirin ThrombolysisThrombolysis Primary angioplastyPrimary angioplasty Beta-BlockersBeta-Blockers ACE inhibitorsACE inhibitors Prepare for basic life supportPrepare for basic life support

Surgical TreatmentSurgical Treatment

Percutaneous Percutaneous Transluminal Transluminal Coronary Coronary Angioplasty Angioplasty (PTCA)(PTCA) balloon expansion balloon expansion

that can provide that can provide 90% dilitation of 90% dilitation of vessel lumenvessel lumen

Stent PlacementStent Placement

With use of just With use of just the balloon, re-the balloon, re-occlusion of the occlusion of the artery can artery can occur within occur within monthsmonths

Placement of a Placement of a stent delays or stent delays or prevents re-prevents re-occlussionocclussion

Surgical TreatmentSurgical Treatment Coronary Artery Coronary Artery

By-Pass Graft By-Pass Graft (CABG)(CABG)

The graft bypasses The graft bypasses the obstruction in the obstruction in the coronary the coronary arteryartery

Graft sources:Graft sources: saphenous veinsaphenous vein internal mammary internal mammary

arteryartery radial arteryradial artery

Acute Myocardial InfarctionAcute Myocardial InfarctionComplicationsComplications

Sudden Death (Sudden Death (18% within 1 hour,18% within 1 hour, 36% 36% within 24 hours)within 24 hours)

Non-fatal arrhythmiaNon-fatal arrhythmia Acute left ventricular failureAcute left ventricular failure Cardiogenic shockCardiogenic shock Papillary muscle rupture and mitral Papillary muscle rupture and mitral

regurgitationregurgitation Myocardial rupture and tamponadeMyocardial rupture and tamponade Ventricular aneurysm and thrombusVentricular aneurysm and thrombus Distal EmbolisationDistal Embolisation

Sudden DeathSudden Death

Sudden Cardiac Death is also known as a Sudden Cardiac Death is also known as a “Massive Heart Attack” in which the heart “Massive Heart Attack” in which the heart converts from sinus rhythm to ventricular converts from sinus rhythm to ventricular fibrillationfibrillation

In V-Fib, the heart is unable to contract In V-Fib, the heart is unable to contract fully resulting in lack of blood being fully resulting in lack of blood being pumped to the vital organspumped to the vital organs

V-Fib requires shock from defibrillator V-Fib requires shock from defibrillator “SHOCKABLE RHYTHM”“SHOCKABLE RHYTHM”

Dental ConsiderationsDental Considerations Assessment and Overall ManagementAssessment and Overall Management PharmaceuticalsPharmaceuticals Emergency SituationsEmergency Situations Oral Effects of PharmaceuticalsOral Effects of Pharmaceuticals Antibiotic ProphylaxisAntibiotic Prophylaxis Post MI: when to treatPost MI: when to treat Consider three areas:Consider three areas:

How severe or stable the ischemic heart How severe or stable the ischemic heart disease isdisease is

The emotional state of the patientThe emotional state of the patient The type of dental procedureThe type of dental procedure

RISKRISK Major Risk for Perioperative Procedures:Major Risk for Perioperative Procedures:

Unstable Angina (getting worse)Unstable Angina (getting worse) Recent MIRecent MI

Intermediate Risk for Perioperative Intermediate Risk for Perioperative Procedures:Procedures: Stable AnginaStable Angina History of MIHistory of MI

Most dental procedures, even surgical Most dental procedures, even surgical procedures fall within the risk of less than 1%procedures fall within the risk of less than 1%

Some procedures fall within an intermediate Some procedures fall within an intermediate risk of less than 5%risk of less than 5%

Highest risk procedures Highest risk procedures those done under those done under general anesthesiageneral anesthesia

Management for Low-Management for Low-Intermediate RiskIntermediate Risk

Short appointmentsShort appointments AM appointmentsAM appointments ComfortComfort Vital Signs TakenVital Signs Taken Avoidance of Epinephrine within Avoidance of Epinephrine within

Local Anesthetic or Retraction CordLocal Anesthetic or Retraction Cord O2 AvailabilityO2 Availability

Dentistry & Dentistry & Cardiovascular MedicineCardiovascular Medicine

AMIAMI GA within 3/12 of AMI: 30% re-GA within 3/12 of AMI: 30% re-

infarction rate @ 1/52 post opinfarction rate @ 1/52 post op Avoid routine LA dental treatment for Avoid routine LA dental treatment for

3/12 (emergency treatment only)3/12 (emergency treatment only) Avoid excess dosage, reduce anxietyAvoid excess dosage, reduce anxiety Avoid elective surgery under GA for1 Avoid elective surgery under GA for1

year (specialist)year (specialist) Be aware of medications (bleeding, Be aware of medications (bleeding,

hypotension)hypotension)

Post MI: When to TreatPost MI: When to Treat Why delay treatment?Why delay treatment?

Remember that with an MI there is damage to the heart, Remember that with an MI there is damage to the heart, be it severe or minimal that may effect the patient’s daily be it severe or minimal that may effect the patient’s daily lifelife

MI within 1 month MI within 1 month Major Cardiac Risk Major Cardiac Risk MI within longer then 1 month:MI within longer then 1 month:

Stable Stable routine dental care ok routine dental care ok Unstable Unstable treat as Major Cardiac Risk treat as Major Cardiac Risk

Older studies suggest high re-infarction rates when surgery Older studies suggest high re-infarction rates when surgery performed within 3 months, 3-6 months… however, this was performed within 3 months, 3-6 months… however, this was abdominal and thoracic surgery under general anesthesiaabdominal and thoracic surgery under general anesthesia

New research suggests delaying elective tx for 1 month is New research suggests delaying elective tx for 1 month is advisable. Emergent care should be done with local advisable. Emergent care should be done with local anesthetic without epinephrine and monitoring of vital signsanesthetic without epinephrine and monitoring of vital signs

When in doubt:When in doubt:

CONSULT THE CARDIOLOGISTCONSULT THE CARDIOLOGIST

Dental Management Dental Management CorrelateCorrelate

Elective dental care is ok if it has been Elective dental care is ok if it has been longer than 4-6 weeks since the MI longer than 4-6 weeks since the MI andand the patient does not report any the patient does not report any ischemic symptoms. ischemic symptoms.

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

Common Situations:Common Situations:

Orthostatic Hypotension due to use of anti-Orthostatic Hypotension due to use of anti-hypertensives (beta blockers, nitroglycerin…)hypertensives (beta blockers, nitroglycerin…)

Raise chair slowlyRaise chair slowly Allow patient to take his/her timeAllow patient to take his/her time Assist patient in standingAssist patient in standing

Post-Op Bleeding:Post-Op Bleeding: When patients on Plavix or Aspirin, expect increased When patients on Plavix or Aspirin, expect increased

bleeding because of decreased platelet aggregation bleeding because of decreased platelet aggregation

Dental Considerations for IHD

Dental Considerations for Dental Considerations for IHDIHD

Emergent Situations:Emergent Situations: Possible MI:Possible MI:

Remember that pain in the jaw may be Remember that pain in the jaw may be referred pain from the myocardium referred pain from the myocardium assess assess the situation, have good patient history, the situation, have good patient history, follow ABC’sfollow ABC’s

Angina:Angina: In situations of angina pectoris, all In situations of angina pectoris, all

operatories should have nitroglycerin to be operatories should have nitroglycerin to be placed sublinguallyplaced sublingually

Dental Considerations Dental Considerations for IHDfor IHD

Emergent Situations:Emergent Situations: Chest Pain-MI:Chest Pain-MI:

STOP PROCEDURESTOP PROCEDURE Remove everything from patient’s mouthRemove everything from patient’s mouth Give sublingual nitroglycerinGive sublingual nitroglycerin Wait 5 minutes Wait 5 minutes if pain persists, give more if pain persists, give more

nitroglycerin, assume MInitroglycerin, assume MI 101 101 Give chewable aspirin Give chewable aspirin ABC’s ABC’s

Dental Management: Dental Management: Stable Angina/Post-MI >4-6 Stable Angina/Post-MI >4-6

weeksweeks Minimize time in waiting roomMinimize time in waiting room Short, morning appointmentsShort, morning appointments Preop, intra-op, and post-op vital signsPreop, intra-op, and post-op vital signs Pre-medication as neededPre-medication as needed

anxiolytic (triazolam; oxazepam); night before and 1 hour anxiolytic (triazolam; oxazepam); night before and 1 hour beforebefore

Have nitroglycerin available – may consider using Have nitroglycerin available – may consider using prophylacticalyprophylacticaly

Use pulse oximeter to assure good breathing and Use pulse oximeter to assure good breathing and oxygenationoxygenation

Oxygen intraoperatively (if needed)Oxygen intraoperatively (if needed) Excellent local anesthesia - use epinephrine, if needed, Excellent local anesthesia - use epinephrine, if needed,

in limited amount (max 0.04mg) or levonordefrin (max. in limited amount (max 0.04mg) or levonordefrin (max. 0.20mg)0.20mg)

Avoid epinephrine in retraction cordAvoid epinephrine in retraction cord

Dental Management:Dental Management:Unstable Angina or MI < 3 monthsUnstable Angina or MI < 3 months

Avoid elective careAvoid elective care For urgent care: be as conservative as For urgent care: be as conservative as

possible; do only what must be done (e.g. possible; do only what must be done (e.g. infection control, pain management)infection control, pain management)

Consultation with physician to help Consultation with physician to help managemanage

Consider treating in outpatient hospital Consider treating in outpatient hospital facility or refer to hospital dentistry facility or refer to hospital dentistry

ECG, pulse oximetry, IV lineECG, pulse oximetry, IV line Use vasoconstrictors cautiously if neededUse vasoconstrictors cautiously if needed

Intraoperative Chest Intraoperative Chest PainPain

Stop procedureStop procedure Give nitroglycerinGive nitroglycerin If after 5 minutes pain still present, give If after 5 minutes pain still present, give

another nitroglycerinanother nitroglycerin If after 5 more minutes pain still present, If after 5 more minutes pain still present,

give another nitroglyceringive another nitroglycerin If pain persists, assume MI in progress and If pain persists, assume MI in progress and

activate the EMSactivate the EMS Give aspirin tablet to chew and swallowGive aspirin tablet to chew and swallow Monitor vital signs, administer oxygen, and Monitor vital signs, administer oxygen, and

be prepared tobe prepared to provide life supportprovide life support

Conclusion:Conclusion: When treating patients with Ischemic When treating patients with Ischemic

Heart Disease or recent MI…Heart Disease or recent MI… Use caution and common senseUse caution and common sense When in doubt:When in doubt:

CONSULT THE CONSULT THE CARDIOLOGISTCARDIOLOGIST