1. 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

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

6. PLAQUE RUPTURE AND BLOOD CLOTTING IN AN ATHERO- SCLEROTIC BLOOD VESSEL Fibrin Platelet clumping Red blood cells Platelet plug Red blood cells and fibrin

7. 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

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

9. ISCHEMIC HEART DISEASE ASCVD: coronary arteries>>> decreased blood supply to myocardium= ischemia >>>pain= ANGINA May be slowly OR rapidly progressive; with or without symptoms

10. ISCHEMIC HEART DISEASE ANGINA : most common cause= ASCVD also HTN anemia RHD CHF

11. 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

12. 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

13. 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

14. ANGINA PECTORIS MEDICAL MANAGEMENT exercise, weight loss, diet, smoking cessation, other medical conditions control: diabetes, HTN, thyroid, anemia, arrhythmias DRUGS: vasodilators ( NGN), etc.

15. ANGINA PECTORIS DRUGS vascular dilators: alleviate coronary artery spasms; open up occluded vessels, increase blood flow NGN, under tongue, transdermal patches longer acting NITRATES

16. ISCHEMIC HEART DISEASE LABORATORY TESTS chest radiograph, fluoroscopy EKG echocardiography technicium Tc 99 scan enzymes ( LDH, ALT, AST) angiography

17. 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

18. DENTAL MANAGEMENT for ANGINA PECTORIS severediagnosed, ± monitored ± frequent symptoms use NGN <8 x week; exertion not necessarily well controlled

19. 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

20. DENTAL MANAGEMENT for ANGINA PECTORIS severe simple tx vitals, sedation + prophylactic NGN routine-complex tx HOSPITALIZATION

23. Surgical Treatment Coronary Artery By-Pass Graft (CABG) –Saphenous vein –Internal mammary artery –Radial artey

25. 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

26. Post-Myocardial Infarction “MI”, “Coronary”, “Heart Attack” Infarction - an area of necrosis in tissue due to ischemia resulting from obstruction of blood flow

29. 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)

30. MYOCARDIAL INFARCTION CAUSES of DEATH from MI ventricular fibrillation cardiac arrest congestive heart failure cardiac tamponade thromboembolic complications

31. 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

32. 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!

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