Atherosclerotic coronary vascular disease
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Atherosclerotic coronary vascular disease. leading cause of death in the U.S. !! men > 40 y.o. women > 50 y.o. declining rates since 1980 : 42 % !! lifestyle alterations 7-9 million Americans. Atherosclerotic coronary vascular disease. ASYMPTOMATIC ~ 50 % SYMPTOMATIC ~ 50 %

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Atherosclerotic coronary vascular disease

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Atherosclerotic coronary vascular disease

Atherosclerotic coronary vascular disease

  • leading cause of death in the U.S. !!

    • men > 40 y.o.

    • women > 50 y.o.

  • declining rates since 1980 : 42 % !!

  • lifestyle alterations

  • 7-9 million Americans


  • Atherosclerotic coronary vascular disease1

    Atherosclerotic coronary vascular disease

    • ASYMPTOMATIC ~ 50 %

    • SYMPTOMATIC ~ 50 %

      • ISCHEMIC HEART DISEASE = ANGINA


    Atherosclerotic coronary vascular disease

    Platelet clumping

    Fibrin

    PLAQUE RUPTURE AND BLOOD CLOTTING IN AN ATHERO-SCLEROTIC BLOOD VESSEL

    Red blood

    cells

    Red blood cells

    and fibrin

    Platelet plug


    Hmg coa reductase inhibitors

    HMG COA REDUCTASE INHIBITORS

    Use of HMg COAs can reduce cholesterol by 35%. * Should not be used with

    cyclosporine, niacin, gemfibrozil - myositis; however no reports with fluvastatin


    Atherosclerotic coronary vascular disease2

    Atherosclerotic coronary vascular disease

    • RISK FACTORS

    • age and sex

    • genetics; family history

    • serum lipid levels

    • HTN

    • tobacco ( smoking)

    • elevated blood glucose


    Ischemic heart disease

    ISCHEMIC HEART DISEASE

    • ASCVD: coronary arteries>>> decreased blood supply to myocardium= ischemia >>>pain= ANGINA

    • May be slowly OR rapidly progressive; with or without symptoms


    Ischemic heart disease1

    ISCHEMIC HEART DISEASE

    • ANGINA : most common cause= ASCVD

    • also HTN

    • anemia

    • RHD

    • CHF


    Cardiac arrest

    CARDIAC ARREST

    • sudden cardiac death

    • >90% associated with underlying CVD

    • 30 % of all natural deaths in U.S.

    • cardiac arrhythmias: ventricular fibrillation

    • most common in early am


    Angina pectoris status

    ANGINA PECTORISstatus

    • initial; exertional or at rest; LEVEL

    • STABLE vs. PROGRESSIVE

    • FREQUENCY- SEVERITY- CONTROL

    • brief chest pain ( 1-3 minutes)

    • ususally size of fist in mid-chest

    • aching, squeezing, tightness

    • may radiate, left shoulder, arm, mandible, palate, tongue


    Angina pectoris

    ANGINA PECTORIS

    • DENTAL OFFICE

    • STRESS, ANXIETY, FEAR>>>> release of endogenous epinephrine>>> increased HR, BP ( HR x MAP > 12,000 !!) >>> increased cardiac load, O2 demand>>> additional epinephrine ( LA) >>> exacerbated angina


    Angina pectoris1

    ANGINA PECTORIS

    • MEDICAL MANAGEMENT

    • exercise, weight loss, diet, smoking cessation, other medical conditions control: diabetes, HTN, thyroid, anemia, arrhythmias

    • DRUGS: vasodilators ( NGN), etc.


    Angina pectoris2

    ANGINA PECTORIS

    • DRUGS

    • vascular dilators: alleviate coronary artery spasms; open up occluded vessels, increase blood flow

    • NGN, under tongue, transdermal patches

    • longer acting NITRATES


    Ischemic heart disease2

    ISCHEMIC HEART DISEASE

    • LABORATORY TESTS

    • chest radiograph, fluoroscopy

    • EKG

    • echocardiography

    • technicium Tc 99 scan

    • enzymes ( LDH, ALT, AST)

    • angiography


    Dental management for angina pectoris

    DENTAL MANAGEMENT for ANGINA PECTORIS

    • milddiagnosed, monitoredinfrequent symptomsuse NGN <2 x week; exertion onlyeasily controlled

    • moderatediagnosed, ± monitoredoccasional symptomsuse NGN <5 x week; exertion easily controlled


    Dental management for angina pectoris1

    DENTAL MANAGEMENT for ANGINA PECTORIS

    • severediagnosed, ± monitored± frequent symptomsuse NGN <8 x week; exertion not necessarily well controlled


    Dental management for angina pectoris2

    DENTAL MANAGEMENT for ANGINA PECTORIS

    • mild most dental tx vitals, sedation

    • moderate simple tx vitals, sedation ± prophylactic NGN vitals, sedation + routine tx prophylactic NGNoxygen complex tx HOSPITALIZATION


    Dental management for angina pectoris3

    DENTAL MANAGEMENT for ANGINA PECTORIS

    • severe simple tx vitals, sedation + prophylactic NGN

    • routine-complex tx HOSPITALIZATION


    Surgical treatment

    Surgical Treatment

    • Coronary Artery By-Pass Graft (CABG)

      • Saphenous vein

      • Internal mammary artery

      • Radial artey


    Dental considerations cabg

    Dental Considerations - CABG

    • The CABG is not considered a risk condition for BE, therefore antibiotic prophylaxis is not necessary

    • Avoid use of vasoconstrictor for the first 3 months due to electrical instability of the heart during this period


    Post myocardial infarction

    Post-Myocardial Infarction

    “MI”, “Coronary”, “Heart Attack”

    Infarction - an area of necrosis in tissue due to ischemia resulting from obstruction of blood flow


    Prognosis after infarction

    Prognosis After Infarction

    • Hospital discharge after 7 days

    • 50% of survivors are at increased risk of further cardiac events

    • Without further treatment, 5-15% will die in first year; similar number will have reinfarction

    • With treatment, morbidity and mortality markedly reduced (<3% in GUSTO trial)


    Myocardial infarction

    MYOCARDIAL INFARCTION

    • CAUSES of DEATH from MI

    • ventricular fibrillation

    • cardiac arrest

    • congestive heart failure

    • cardiac tamponade

    • thromboembolic complications


    Myocardial infarction1

    MYOCARDIAL INFARCTION

    • history of past -MI

    • best to wait >6 months= NO ROUTINE CARE! If so, AHA prophylaxis

    • physical status, Rxs, vital signs, fatigue, CHF, cardiac reserve

    • CLOSE MONITORING !!

    • MEDICAL CONSULTATION


    Myocardial infarction2

    MYOCARDIAL INFARCTION

    • short, non-stressful appointments schedule at BEST time for patient

    • changes>>>> STOP- POSTPONE dental tx sedation : N2O2

    • good anesthesia, pain control, anxiety reduction, etc.

    • prophylactic oxygen ( nasal cannula) ± NGN; ALWAYS have NGN available!


    Myocardial infarction3

    MYOCARDIAL INFARCTION

    • NO EPINEPHRINE

    • anticoagulants( Coumadin)

    • PT or INR, BT

    • arrhythmias

    • CHF

    • Rxs: side-effects, interactions, adjustment


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