Atherosclerotic coronary vascular disease

• ASYMPTOMATIC ~ 50 %

• SYMPTOMATIC ~ 50 %• ISCHEMIC HEART DISEASE = ANGINA

Increased CV risk( MI)for dentistry

• EXTREME

• Recent MI

• Unstable angina

• Uncompensated CHF

• Significant arrhythmias ( ventricular)

• Severe valvular disease– AHA. 2002. Circulation. 105:10.

Increased CV risk( MI) for dentistry

• MODERATE• previous MI• ANY angina• ANY CHF ( walking flight of stairs)• ANY arrhythmias• IDDM• CVA• Renal disease• HTN -AHA. 2002. Circulation. 105:10.

• Advanced age

Atherosclerotic coronary vascular disease

• RISK FACTORS

• age and sex

• genetics; family history

• serum lipid levels

• HTN

• tobacco ( smoking)

• elevated blood glucose

Atherosclerotic coronary vascular disease

• RISK FACTORS : • cigarette smoking : 2- 6 X CVD than non-

smokers ( degree and duration dependent) • increased risk of complications: angina, MI,

cardiac arrest• Framingham study: >5000 smokers; 5 -year

death rate = 22 % smokers; 15% if discontinued

Modifying risk factors

• 400,000 patients without smoking, cholesterol or HTN risk

• 75-88% decrease in risk of adverse CVD• 48-58 % decreased mortality risk• Additional 5.8 - 9.2 years of life

• Stamler J, et al. JAMA. 1999; 282:2012-2018.

HMG COA REDUCTASE INHIBITORS

Drug Strengths EquipotentDosage

DailyDose

MonthlyCost $

Fluvastatin(Lescol)

20, 40 20 20-80 34 -77

Lovastatin*(Mevacor)

10, 20, 40 10 10-80 37-234

Pravastatin*(Pravachol)

10, 20, 40 10 10-40 53-96

Simvastatin(Zocor)

5, 10, 20,40

5 5-40 53-106

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

ANGINA PECTORIS

• 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

• 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

ISCHEMIC HEART DISEASE

• PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY ( PTCA)

• insertion of catheter to “clean out” and widen occluded vessels

• invasive!! complications = thrombosis, emboli, arrhythmias

• induces MI = 1%; CVA= 1%; death= 1%• minor complications = 5-10%

ISCHEMIC HEART DISEASE

• PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY ( PTCA)

• RESULTS:• 85-90 % relief of angina• in 25 % of cases angina returns to previous

level within 6-12 months• if no recurrence of angina/stenosis > 1 yr.=

EXCELLENT PROGNOSIS

ISCHEMIC HEART DISEASE• PERCUTANEOUS TRANSLUMINAL

CORONARY ANGIOPLASTY ( PTCA)

• balloon angioplasy

• balloon angioplasy + STENT

ISCHEMIC HEART DISEASE

• Coronary artery bypass graft ( CABG)• indicated with 2 > occluded coronary

arteries (proximal obstruction)• most common left anterior desending c.a.• complications ; death = 1%• vein grafts occlude to previous level

10% within 1st year; 2 % per year afterwards, depending on lifestyle

ISCHEMIC HEART DISEASE

• post-CABG 5-yr. mortality = 50 %

• RESULTS : complete relief = 60 % partial relief = 20-30 %

no relief = 10 %

• use sapphenous vein;

• currently no synthetic material

• re-op: limited ; maybe int. mammary a.

DENTAL MANAGEMENT for ANGINA PECTORIS

• mild diagnosed, monitoredinfrequent symptoms

use NGN <2 x week; exertion onlyeasily controlled

• moderate diagnosed, ± monitoredoccasional symptoms

use NGN <5 x week; exertion easily controlled

DENTAL MANAGEMENT for ANGINA PECTORIS

• severe diagnosed, ± monitored± frequent symptomsuse NGN <8 x week;

exertion not necessarily well controlled

DENTAL MANAGEMENT for ANGINA PECTORIS

• mild most dental tx vitals, sedation• moderate simple tx vitals, sedation ±

prophylactic NGN vitals, sedation +

routine tx prophylactic NGN complex tx HOSPITALIZATION

• severe simple tx vitals, sedation + prophylactic NGN routine-

complex tx HOSPITALIZATION

ISCHEMIC HEART DISEASE

• MYOCARDIAL INFARCTION• Approx. 550,000 deaths per year in U.S.• 20 % sudden death( <2 hrs.) from MI• ASCVD>>>occlusion>>>anoxia>>>

ischemia>>>infarct>>>necrosis• PAIN : longer and more severe than angina• same location, character, pattern, radiates• not relieved by nitrates or rest

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

• 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 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 INFARCTION

• NO EPINEPHRINE

• anticoagulants( Coumadin)

• PT or INR, BT

• arrhythmias

• CHF

• Rxs: side-effects, interactions, adjustment

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!