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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

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Ischaemic heart disease clinical aspects for dentist

Ischaemic Heart DiseaseClinical Aspects For DENTIST

Ischaemic heart disease clinical aspects for dentist

Coronary Heart Disease

A leading cause of SICKNESS and DEATH

Risk factors for cardiovascular disease
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
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
Ischaemic heart diseaseDefinition

  • An imbalance between the supplyofoxygen and the myocardialdemand resulting in myocardial ischaemia.

  • Anginapectoris

    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)

Ischaemic heart disease manifestations
Ischaemic heart diseaseManifestations

  • Sudden death

  • Acute coronary syndrome ( Myocardial Infarction & Unstable Angina )

  • Stable angina pectoris

  • Heart failure

  • Arrhythmia

  • Asymptomatic

Ischaemic heart disease epidemiology
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

Ischaemic heart disease aetiology
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


Risk factors for ischemic heart disease
Risk Factors for Ischemic Heart Disease

  • Family History

  • Smoking

  • Hypertension

  • Diabetes Mellitus

  • Hypercholesterolaemia

  • Lack of exercise Obesity

  • Age & Sex


Spectrum of the atherosclerotic process
Spectrum of the Atherosclerotic Process

  • Coronary Arteries (angina, MI, sudden death)

  • Cerebral Arteries (stroke)

  • Peripheral Arteries (claudication)

Ischaemic heart disease acute coronary syndromes
Ischaemic heart diseaseAcute coronary syndromes



Artery spasm

Fatal /

Non-Fatal AMI



Warning signs and symptoms of heart attack
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

Angina pectoris
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
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



  • Nitrates- vasodilator eg: ISDN. ISMN

  • Pain reliever- eg: Morphine

  • Beta-blockers

  • Statins- cholesterol lowering drugs. Eg: Atorvastatin, Simvastatin

Ischaemic heart disease relevance to dentistry
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!

Myocardial infarction
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
Chest PainMyocardial ischaemia

  • Site

    Jaw to navel, retrosternal, left submammary

  • Radiation

    Left chest, left arm, jaw….mandible, teeth, palate

  • Quality/severity

    tightness, heaviness, compression…clenched 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
Chest PainDifferential diagnosis

  • Cardiacpathology

    • Pericarditis, aortic dissection

  • Pulmonarypathology

    • Pulmonary embolus, pneumothorax, pneumonia

  • Gastrointestinalpathology

    • Peptic ulcer disease, reflux, pancreatitis, ‘café coronary’

  • Musculoskeletalpathology

    • Trauma, Tietze’s Syndrome

Acute myocardial infarction assessment
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

Acute myocardial infarction confirming the diagnosis
Acute Myocardial InfarctionConfirming the diagnosis

  • Typical chest pain

  • Electrocardiographic changes

    • ST elevation

    • new LBBB

  • Myocardial enzyme elevation

    • Creatine kinase (CK-MB)

    • Troponin

Acute myocardial infarction treatment
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

Surgical treatment
Surgical Treatment

  • Percutaneous Transluminal Coronary Angioplasty (PTCA)

    • balloon expansion that can provide 90% dilitation of vessel lumen

Stent placement
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

Surgical treatment1
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

Acute myocardial infarction complications
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

Sudden death
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
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

Ischaemic heart disease clinical aspects for dentist

  • 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

Management for low intermediate risk
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
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
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 patient’s 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:


Dental management correlate
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.

Ischaemic heart disease clinical aspects for dentist

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

Dental considerations for ihd
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 ABC’s

    • Angina:

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

Dental considerations for ihd1
Dental Considerations for IHD

  • Emergent Situations:

    • Chest Pain-MI:


      • Remove everything from patient’s mouth

      • Give sublingual nitroglycerin

      • Wait 5 minutes  if pain persists, give more nitroglycerin, assume MI

      • 101

      • Give chewable aspirin  ABC’s

Dental management stable angina post mi 4 6 weeks
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
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
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 toprovide life support


  • When treating patients with Ischemic Heart Disease or recent MI…

    • Use caution and common sense

    • When in doubt: