the most severe and lethal form of coronary heart disease.
This implies death of the heart muscle.
Secondary to coronary artery disease, there is infarction of the heart muscle. Coronary (Ischaemic) heart disease (IHD) is the result of progressive myocardial ischaemia due to persistently reduced coronary blood flow, usually because of atherosclerosis (atheroma). Hypertension is a major contributory factor. Other contributory factors are : - Smoking - High fat diets (hyperlipidaemia) - Lack of exercise - Genetic component (in some cases) Higher incidence of IHD in : - Hyperlipoproteinaemias - Diabetes mellitus - Hypothyroidism IHD itself causes no symptoms but impaired coronary blood flow causes progressive damage to the heart, can go on to cardiac failure and can cause dysrhythmias. Usually the first signs of IHD are its dramatic complications, namely angina pectoris or myocardial infarction without warning or history of heart disease. Angina pectoris and myocardial infarction are the main acute manifestations of IHD. Aspirin, beta – blocker and cholesterol – lowering appear to be the most effective way to treat patients with IHD. Between 30 and 50 percent of patients die within the first hour after the attack of MI and a further 10 – 20 percent within the next few days. CAUSES
Most commonly occlusion of coronary
vessels occurs. Anoxia, ischemia and infarct are present. SIGNS AND SYMPTOMS 1. Crushing chest pain or crushing retrosternal pain (a) More severe than angina, possibly radiating to left arm, shoulder, neck, jaw (on rare occasions pain is felt in the left mandible alone). (b) Longer than 15 minutes. (c) Not relieved by nitroglycerin tablets. (d) Squeezing or heavy feeling. (The patient usually clutches his chest with the fist which is known as Levine’s Sign). 2. Cyanosis, pale or ashen appearance. 3. Weakness 4. Cold sweat 5. Nausea, vomiting 6. Air hunger and fear of impending death 7. Increased, irregular pulse beat of poor quality and containing palpitations. 8. Feeling of impending doom. A significant number of patients (diabetics and elderly) have silent (painless) infarctions. This may be due to hyposensitivity to pain, including dental pain.
In about 10 percent of cases pain is slight or even
absent and the first sign of a myocardial infarct may then be the sudden onset of left ventricular failure, shock, loss of consciousness or death. Characteristic electrocardiographic (ECG) changes and the release of heart muscle enzymes into the blood confirm the diagnosis. 9. The signs of left ventricular failure are : (a) Cold extremities, hypotension (b) Oliguria (c) Low volume pulse, low pulse pressure. (d) Quite first heart sound (e) 3rd heart sound (f) Fine crepts at bases of lungs. 9. Signs of tissue damage are (a) Fever (b) Leucocytosis (c) Raised ESR POTENTIAL PROBLEMS RELATED TO DENTAL CARE 1. Stress and anxiety related to dental visit could precipitate an anginal attack, myocardial infarction or sudden death in the office. 2. Patient may have some degree of congestive heart failure. 3. Electrical interference could occur with the use of certain dental equipment if pacemaker in place. 4. Use of excessive amount of epinephrine could precipitate a dangerous elevation of blood pressure if patient taking a non-selective beta – blocker. 5. Patient taking aspirin, other platelet aggregation inhibitor or coumadin could experience excessive bleeding with invasive dental procedures. 6. Potential exists for endarteritis of coronary artery stent in the immediate post-placement period as a result of dentally induced bacteremia ORAL MANIFESTATIONS Usually none as a direct result of MI; however, may see drug-related changes such as dry mouth, taste changes or stomatitis; also may have excessive post surgical bleeding due to platelet aggregation inhibition or anticoagulation DIAGNOSIS Diagnosis is based on history, characteristic symptoms, signs and investigations. Characteristic sign and symptoms : Changes in heart rate Dysrhythmias Hypotension Shock Fever and leucocytosis ECG changes Rise in serum enzymes. INVESTIGATIONS 1. Electrocardiography (ECG) : the most sensitive and specific method to diagnose MI. Occasionally, ECG may be normal initially, but changes appear later on, hence, ECG should be repeated after at least 12 hours of pain chest to detect the changes. The changes are seen in ST segment and T wave. The earliest change is ‘ST’ segment elevation followed by appearance of ‘Q’ wave and ‘T’ wave inversion. 2. Blood Test : Leucocytosis Raised ESR Plasma enzymes : The cardiac muscle is rich in enzymes which are released within few hours of MI and their peak levels appear. The enzymes most widely studied are : i. CK (Creatinine Kinase) ii. AST (Aspartate aminotransferase) iii. LDH (Lactic acid dehydrogenase) 3. Chest X–ray: to detect acute pulmonary oedema or congestion, pericardial effusion, cardiomegaly etc. 4. Echocardiography: for assessing ventricular function and detecting complications such as ventricular septal or chordae tendinae rupture etc. 5. Radionuclide scanning : to assess left ventricular function. Infarct ‘avid’ scanning is possible because some isotopes i.e. pyrophosphate are taken up by freshly infracted myocardium, hence is useful in diagnosis of those patients who have non-specific ECG changes and normal cardiac enzyme levels. MANAGEMENT The patient should be kept at rest, reassured as well as possible and given oxygen by a face mask. Morphine, 10 mg., preferably by slow i.v. injection (2 mg/min) or upto 15 mg i.m. according to the size of the patients, plus cyclizine 50 mg, or alternatively, nitrous oxide with at least 28 percent oxygen, should be given to relieve pain. Ventricular fibrillation is an important cause of death, but controllable by defibrillation. If there is cardiac arrest the patient must be given external cardiac massage and oxygen or mouth – to – mouth ventilation. Thrombolytic agent and aspirin may be indicated. Aspirin 75 mg. daily or 300 mg. on alternate days Stop smoking, low fat intake, more exercise. Beta – blockers, particularly atenolol or metoprolol given i.v. in the acute phase, can lessen mortality and oral propranolol or timolol, in the convalescent stage, can reduce the risk of recurrence after a myocardial infarct, but such drugs are contraindicated for patients with asthma or in heart failure. Various steps in treatment of MI patients are : 1. Place patient in most comfortable position. 2. Administer oxygen at 10 L/min. flow 3. Activate EMS (911 call) 4. Monitor and record vital signs 5. Reassure patient 6. CPR DENTAL MANAGEMENT Prevention of Problems : Recent myocardial infarction (<1 month) (major risk) : Elective dental care should be postponed if possible, if necessary, should be provided in consultation with physician. Management may include establishment of IV line, sedation, electrocardiogram, pulse oximeter, cautious use of vasocons-trictors, and prophylactic nitroglycerine. Past myocardial infarction (more than 1 month) (minor intermediate risk): Elective dental care may be provided with these considerations: (a) Short, morning appointments, comfortable chair position, pretreatment of vital signs, nitroglycerine available, stress reduction measures, limit quantity of vasoconstrictor, avoid epinephrine in retraction cords, avoid anticholinergics, ensure pain control. (b) If patient taking aspirin, excess bleeding usually controllable by local measures only. (c) If patient taking coumadin, international normalized ratio should be 3.5 or less for invasive procedures. (d) If coronary artery stent in place, prophylactic antibiotics should be provided for dental procedures likely to result in significant bleeding for first 2 –4 weeks only. TREATMENT PLANNING MODIFICATIONS
Recent myocardial infarction : Dental Rx should be limited
to that which is absolutely necessary such as for infection or pain. Past myocardial infarction : Any desired dental Rx may be provided, taking into consideration appropriate management considerations.
General anesthesia is contraindicated after a recent MI,
though the risk declines with time. The prognosis of recurrent infarction is also influenced by the time after the first attack; elective surgery under GA should therefore be postponed for at least 3 months and preferably a year. COMPLICATIONS 1. Immediate : (a) Arrhythmias and conduction disturbances (b) Post – myocardial angina (c) Acute circulatory failure (d) Pericarditis (e) Mechanical complications like papillary muscle dysfunction, rupture of ventricle. (f) Mural thrombosis and embolism (g) Sudden death 2. Late Complications : (a) Post–myocardial infarction syndrome (Dressler’s syndrome). (b) Ventricular aneurysm.