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 %• ISCHEMIC HEART DISEASE = ANGINA

PLAQUE RUPTURE AND

BLOOD CLOTTING IN AN ATHERO-SCLEROTIC

BLOOD VESSEL

Fibrin

Platelet clumping

Red bloodcells

Platelet plugRed blood cellsand fibrin

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

Atherosclerotic coronary vascular disease

• RISK FACTORS

• age and sex

• genetics; family history

• serum lipid levels

• HTN

• tobacco ( smoking)

• elevated blood glucose

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 DISEASE

• ANGINA : most common cause= ASCVD

• also HTN

• anemia

• RHD

• CHF

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 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

• 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 PECTORIS

• MEDICAL MANAGEMENT

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

• DRUGS: vasodilators ( NGN), etc.

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 DISEASE

• LABORATORY TESTS

• chest radiograph, fluoroscopy

• EKG

• echocardiography

• technicium Tc 99 scan

• enzymes ( LDH, ALT, AST)

• angiography

DENTAL MANAGEMENT for ANGINA PECTORIS

• mild diagnosed, monitoredinfrequent symptomsuse NGN <2 x week;

exertion only easily controlled• moderate diagnosed, ± monitored

occasional symptomsuse NGN <5 x week;

exertion easily controlled

DENTAL MANAGEMENT for ANGINA PECTORIS

• severe diagnosed, ± monitored± frequent

symptoms use 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 oxygen

complex tx HOSPITALIZATION

DENTAL MANAGEMENT for ANGINA PECTORIS

• severe simple tx vitals, sedation + prophylactic NGN

• routine-complex tx HOSPITALIZATION

Surgical Treatment

• Coronary Artery By-Pass Graft (CABG)– Saphenous vein– Internal mammary artery– Radial artey

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

“MI”, “Coronary”, “Heart Attack”

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

blood flow

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

• CAUSES of DEATH from MI

• ventricular fibrillation

• cardiac arrest

• congestive heart failure

• cardiac tamponade

• thromboembolic complications

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