Atherosclerotic coronary vascular disease

2. Atherosclerotic coronary vascular disease • ASYMPTOMATIC ~ 50 % • SYMPTOMATIC ~ 50 % • ISCHEMIC HEART DISEASE = ANGINA

3. Increased CV risk( MI)for dentistry • EXTREME • Recent MI • Unstable angina • Uncompensated CHF • Significant arrhythmias ( ventricular) • Severe valvular disease • AHA. 2002. Circulation. 105:10.

4. 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

5. Atherosclerotic coronary vascular disease • RISK FACTORS • age and sex • genetics; family history • serum lipid levels • HTN • tobacco ( smoking) • elevated blood glucose

6. 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

7. 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.

8. HMG COA REDUCTASE INHIBITORS Use of HMg COAs can reduce cholesterol by 35%. * Should not be used with certain drugs

10. 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

11. 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

13. 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%

15. 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

16. ISCHEMIC HEART DISEASE • PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY ( PTCA) • balloon angioplasy • balloon angioplasy + STENT

18. 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

19. 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.

20. DENTAL MANAGEMENT for ANGINA PECTORIS • mild diagnosed, monitored infrequent symptoms use NGN <2 x week; exertion only easily controlled • moderate diagnosed, ± monitored occasional symptoms use NGN <5 x week; exertion easily controlled

21. DENTAL MANAGEMENT for ANGINA PECTORIS • severe diagnosed, ± monitored ± frequent symptoms use NGN <8 x week; exertion not necessarily well controlled

22. 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

25. 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

26. 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)

27. 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

28. 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!

29. MYOCARDIAL INFARCTION • NO EPINEPHRINE • anticoagulants( Coumadin) • PT or INR, BT • arrhythmias • CHF • Rxs: side-effects, interactions, adjustment

30. 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!