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 blood cells Platelet plug Red blood cells and fibrin

HMG COA REDUCTASE INHIBITORS 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 PECTORIS status 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 milddiagnosed, monitored infrequent symptoms use NGN <2 x week; exertion only easily controlled moderatediagnosed, ± monitored occasional symptoms use NGN <5 x week; exertion easily controlled

DENTAL MANAGEMENT for ANGINA PECTORIS severediagnosed, ± 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 : N 2 O 2 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