Ischemic Heart Disease

Question 1

Ischemic Heart Disease

• Definition: lack of oxygen to heart muscles
• Atherosclerosis: #1 cause of coronary heart disease
• 1/3 of all deaths in America

Answer 1

Atherosclerosis:

• thickening of inner layer of arterial wall due to accumulation of lipid plaques, resulting in diminished blood flow and O2 supply.
• most common cause of

1. coronary heart disease (angina, MI)
2. cerebrovascular disease (stroke)
3. peripheral artery disease (intermittent claudication)

Risk factors: #1 HTN, male, older age, family history, hyperlipidemia, smoking, phy inactivity, obesity, insulin resistance, DM, stress, depression.

Smoking is the #1 modifiable risk factor (lower risk within 2 years of quitting)

Question 2

Acute coronal syndrome

Spectrum of ischemia from unstable angina to MI

Acute coronary events (MI) can occur when vessels are less than 50% occluded by plaque.

Sudden cardiac death #1 cause V-fib

Answer 2

Angina pectoris: may radiate to L/R arm, neck, lower jaw

Women: less chest pain, more fatigue and SOB

Stable

• Reproducible, consistent, precipitated by phy efforts
• Relief: rest, nitroglycerin

Unstable (poorer prognosis)

• New-onset pain, increase in frequency/intensity, precipitated by less effort than before, pain at rest.
• Not relieved by nitroglycerin
• Often experience acute MI within a short time
• Not candidates for elective dental tx

Question 3

Medical Management

Pharmacological

• Nitrates (nitroglycerin) – relieve symptoms only
• Beta blockers
• Calcium channel blockers
• Statins
• ACE inhibitors
• Antiplatelet: aspirin, Clopidogrel (Plavix)

Answer 3

Surgical

CABG, Stents

• No Abx prophy
• Avoid EPI for 3 months

CABG coronary artery bypass graft

Question 4

Dental Management

Carotid calcification on PAN: atherosclerotic plaque in carotid arteries

Answer 4

BP: monitor, pulse Ox

Dental tx: Defer if UNSTABLE anginaor MI in last month. Emergency tx: consider prophylactic Nitroglycerin, supplemental O2. Monitor vitals (pulse Ox)

Bleeding: anticipate if on aspirin/plavix

INR: 3.5 or below OK to treat surgically (warfarin)

Chair: orthostatic hypotension

Anxiety: consider preop BNZ or N2O

Emergencies: have nitroglycern ready

EPI: 2 carp 1:100K ok if stable. No EPI if high risk or CABG/stent for 3 months.

Abx prophy: No needed for CABG/stent

NSAIDs: limit to less than 1 week in pts with history of MI. Naproxen ok. NSAIDs can increase risk of new MI.