eman angina

Angina pectoris : 

Angina pectoris Aims and objectives: 1-definition and causes 2-types 3-Who gets angina? 4-clinical features 5-dental aspects 6-oral aspects 6-when angina is an emergency 7-How can angina be prevented?

definition : 

definition -Latin for squeezing of the chest -It is not a disease itself, but rather a symptom of coronary artery disease - is chest pain, discomfort, or tightness that occurs when an area of the heart muscle is receiving decreased blood oxygen supply usually a result of narrower coronary arteries due to plaque buildup, a condition called atherosclerosis . -Atherosclerosis

Types : 

Types Stable angina Unstable angina Prinzmetal’s angina Micro vascular angina

Stable angina : 

Stable angina -Pain only on exertion or emotional stress ,heavy meal, exposure to extreme temperatures, and smoking and relieved by rest within 10 mins -Stable angina is the most common form and it appears gradually -No change in character, frequency, intensity or duration of symptoms or precipitating factor for about 60 day ( usually it is predictable) -These patients have an increased risk of a heart attack, but an episode of stable angina does not indicate that a heart attack is about to happen -Symptoms are relieved by rest or medication. -The medications most commonly used are :-nitrates (nitroglycerin), B_blockers , Ca channel blockers

Unstable angina : 

Unstable angina -is chest pain that is variable, either increasing in frequency or intensity and with irregular timing or duration -appears while the patient is at rest -does not appear gradually, it first appears as a severe episode

Prinzmetal’s angina : 

Prinzmetal’s angina caused by a vasospasm, a spasm that narrows the coronary artery and lessens the blood flow to the heart usually occurs when  a person is at rest or sleep and not after physical exertion or emotional stress.

Micro vascular angina : 

Micro vascular angina Syndrome X -occurs when the patient experiences chest pain but has no apparent coronary artery blockage -poor functioning of the tiny blood vessels that nourish the heart, arms and legs -Arteriographically normal coronary arteries

Clinical features : 

Clinical features 1-chest pain -the major symptom of angina -described as sense of strangling or choking or tightness ,heaviness,compression,constriction of the chest -sometimes radiate 2-Patients may also complain of symptoms that include indigestion, heartburn, weakness, sweating, nausea, cramping, and shortness of breath.

Dental aspects : 

Dental aspects -dental management of patients with CVD -management of stable angina -management of unstable angina -Patient with a history of angina experiences chest pain in the dental surgery -Post angioplasty -Bypass graft

Slide 11: 

-mainly consider stress reduction protocol which includes: 1-shorter appointments 2-the use of profound anesthesia 3-preoperative or intraop conscious sedation or both 4-excellent post op analgesia 5-late morning appointments -conscious sedation should be deferred for at least 3 mon for patients with MI ,recent onset angina ,unstable angina. -GA should be avoided when ever possible and deferred at least 3 mon after heart attack

Slide 12: 

-They are not candidate for elective dental therapy and consultation with the patient’s physician usually is indicated -if emergency:1-pre op anxiolytic agents are given 2-the dentist should closely monitor the patient’s haemodynamic status 3-oxygen saturation before and during treatment

Slide 13: 

-Stop all treatment and stimulation of the patient. -Position the patient comfortably; sitting upright is usually preferred. -Activate EMS (Call 911.) Administer Oxygen via mask at 10-15L/min.- Monitor and record vital signs, if monitors are available use them.- -Administer one tablet of Nitroglycerin 0.4mg sublingual or one metered dose spray. If using tablets do not touch use gloves. Nitroglycerin can be absorbed through the skin. -If no relief after two minutes repeat Nitroglycerin. Can repeat a third time if no relief. -Monitor blood pressure after each dose; do not repeat dose if systolic BP drops below 100. If no relief of angina after third dose of nitroglycerin it should be assumed the patient is suffering from a Myocardial Infarction (Heart attack.)

when angina is an emergency : 

when angina is an emergency More severe than previously experienced- -Getting worse or lasting longer than 20 minutes -Accompanied by weakness, nausea, or fainting -Unchanged after taking three nitroglycerin tablets -Happening at an unusual time (for example, during rest)

About anesthetic agents : 

About anesthetic agents -the use of LAagents with vasoconstrictor in patients with CVD remains controversial -most human studies examining haemodynamic variables after dental injections of 1.8-5.4ml of 2%lidocaine with 1:100,000 epinephrine have found no significant changes in MAP,BP,HR, in healthy patients or in those with mild to moderate CVD -generally no more than 0.04-0.54mg of epi should be administered during single visit (max of 2-3 cartridges with epi 1:100,000 ASPIRATION IS EXTREMELY IMP

Slide 16: 

-exogenous vasoconstrictors may be contraindicated in patients with sever CVD like unstable angina , recent MI , coronary artery bypass surgery , uncontrolled dysrythmias, sever HTN ,sever CHF -the use of retraction cord with vasoconstrictor should be avoided

Slide 17: 

-short appointments -smallest amount of vasoconstrictor in LA -pre or intraoperative conscious sedation -supplement oxygen delivered via nasal canula may help prevent intraoperative anginal attack -instruct the patient to bring his nitroglycerin at each appointment -include nitroglycerin in the emergency kit -in cases of acute anginal attack: give 100%oxygen and sublingual nitroglycerin

Slide 18: 

Those at an increased risk of coronary artery disease are also at an increased risk of angina. Risk factors include: -Unhealthy cholesterol levels -Hypertension (high blood pressure) -Tobacco smoking -Diabetes -Being overweight or obese -Metabolic syndrome -Sedentary lifestyle -Being over 45 for men and over 55 for women -Family history of early heart disease -race (Africans and Asians) -male gender, postmenopausal women

Slide 19: 

Angina can be prevented by changing lifestyle factors and by treating related conditions that exacerbate or contribute to angina symptoms

Slide 20: 

-Stopping smoking -Controlling weight -Regularly checking cholesterol levels -Resting and slowing down -Avoiding large meals -Learning how to handle or avoid stress -Eating fruits, vegetables, whole grains, low-fat or no-fat diary products, and lean meat and fish -Regular exercise -control HTN,DIABETES

Slide 21: 

-nitrates (like nitroglycerin) are most often prescribed for angina. Nitrates prevent or reduce the intensity of angina attacks by relaxing and widening blood vessels. Other medicines such as - beta blockers (negative chronotropic and inotropic effects, which decrease cardiac workload and oxygen demand). , - calcium channel blockers (decrease in cardiac contractility ,  Vasodilation  ), -ACE inhibitors( lower arteriolar resistance and increase venous capacity; increase cardiac output ), -oral anti-platelet medicines, anticoagulants, and -high blood pressure medications may also be prescribed to treat angina. -control diabetes -statins( lower plasma cholesterol level). These medicines are designed to lower blood pressure and cholesterol levels, slow the heart rate, relax blood vessels, reduce strain on the heart, and prevent blood clots from forming.

Slide 22: 

Elective dental care should be deferred for 6 months Emergency dental care should be in a hospital setting

Slide 23: 

These patients don’t require antibiotic cover against infective endocarditis Patients shouldn't receive epi -containing LA since it may possibly precipitate dysrhythmias

Slide 24: 

-Angina is a rare cause of pain in the mandible ,teeth or other oral tissues or pharynx. -Drugs used in the care of patients with angina may cause oral adverse effects such as 1-lichenoid lesions (ca channel blockers) 2-gingival swelling (ca channel blockers) 3- ulcers (nicorandil)

Slide 26: 

-definition -cause -symptoms -EKG -dental aspects (treatment modifications) 1-recent MI (less than 6 mon) 2- older MI (more than 6mon,less than 12 mon 3-older MI (MORE THAN 6 MON) -when to stop dental care 4-MANAGEMENT OF A SUSPECTED MYOCARDIAL INFARCTON -MI AND GENERAL ANESTHESIA

Slide 27: 

-the death of heart muscle from the sudden blockage of a coronary artery by a blood clot. - Blockage of a coronary artery deprives the heart muscle of blood and oxygen, causing injury to the heart muscle. Injury to the heart muscle causes chest pain and chest pressure sensation. If blood flow is not restored to the heart muscle within 20 to 40 minutes, irreversible death of the heart muscle will begin to occur. Muscle continues to die for six to eight hours at which time the heart attack usually is "complete." The dead heart muscle is eventually replaced by scar tissue.

Slide 28: 

Atherosclerosis is a gradual process by which plaques (collections) of cholesterol are deposited in the walls of arteries. Cholesterol plaques cause hardening of the arterial walls and narrowing of the inner channel (lumen) of the artery. Arteries that are narrowed by atherosclerosis cannot deliver enough blood to maintain normal function of the parts of the body they supply.

Slide 29: 

- Atherosclerosis -Occasionally the surface of a cholesterol plaque in a coronary artery may rupture, and a blood clot forms on the surface of the plaque. The clot blocks the flow of blood through the artery and results in a heart attack

Slide 30: 

-chest pain or pressure is the most common symptom of a heart attack -The pain is often unmistakable and described as an unbearably sense of strangling or chocking or tightness ,heaviness ,compression or constriction of the chest -Sometimes radiate -Sometimes precipitated by exercise or stress and not relieved by rest and can persists for hours -Pain may start at rest and not relieved by nitrates -Other symptoms like:-vomiting,-facial pallor ,-sweating,-restlessness,-breathlessness,-cough,-loss of consciousness -Patient may clutch chest with fist (This is called Levine’s Sign.)- -10%have silent infarction but may have nausea ,vomiting,anxiety,weakness. -heart attacks producing no symptoms or only mild symptoms can be just as serious and life-threatening as heart attacks that cause severe chest pain One cannot overemphasize the importance of seeking prompt medical attention in the presence of symptoms that suggest a heart attack. Early diagnosis and treatment saves lives, and delays in reaching medical assistance can be fatal.

Slide 31: 

-higher risk procedures such as elective surgery should be deferred -elective dental care should be deferred -simple emergency dental treatment under LA may be given during the first 6 mon after MI but the opinion of a physician should be sought first

Slide 32: 

Can normally have elective dental care carried out safely but it is wise to minimize pain and anxiety -higher risk procedures such as elective surgery may need to be deferred because of reinfarction possibility (20%for major surgeries and 5%for minor surgeries)

Slide 33: 

-Elective dental care is safe :stress reduction protocol -5%reinfarction in major surgery

Slide 35: 

-Discontinue all treatment -Clear the mouth of all foreign material. -Place patient in a comfortable position (Usually upright.) -Administer Oxygen at 10-15L/min. -Activate EMS. -Monitor and record vital signs every 5 minutes (Including blood pressure, pulse, and respiration rate.) -Give the patient an aspirin (325mg) if available and have them chew it and allow it to absorb through the oral mucosa. -If equipment available start an IV (18guage catheter with Normal Saline.) -If equipment available attach cardiac monitors. -If a provider is properly trained and equipment is available proper ACLS protocols should be initiated. -If patient looses consciousness initiate proper BLS protocols. 12. Have AED available TRANSPORT: In the case of a MI the earlier the patient is transported to a hospital and definitive treatment begun the better the chance the patient will survive with minimal cardiac damage

Slide 36: 

-The incidence of MI after GA in patients with documented preoperative reinfarcts is up to 8 times -30%of patients having GA within 3 mon of an infarct have another within the first postoperative week and at least 50%die -Elective surgery GA should be postponed for at least 3 mon ,preferably a year after the attack

Slide 37: 

-chest pain -dyspnoea -rise in HR>40 beats/min -dysrhythmias -rise in SBP>20 mmHg

Slide 38: 

MI IS documented in the EKG