Management of patients with coronary artery disease
MANAGEMENT OF PATIENTS WITH CORONARY ARTERY DISEASE
Department of Periodontics and Oral Medicine
University of Michigan - School of Dentistry
Telephone: (734) 763-3375 FAX: (734) 764-2469
CAD Common in General Population• > 60 million with cardiovascular disease• Heart disease leading cause of death
- More than 30% of deaths- Most are acute myocardial infarction- > 5l4,000 die each year, 350,000 before reaching the hospital
• Atherosclerotic blockage of coronary arteries, resulting in coronary blood flow• Real effect - decreased blood flow decreases oxygen delivery to myocardium
- No problem under resting or moderate activity - sufficient oxygen supply- Acute oxygen demand shortage if heart works harder, ischemia- Ischemic heart, resultant angina pectoris, may result in MI
• Majority can be safely treated in dental office, WITH APPROPRIATE PREPARATION• 90% of life-threatening situations can be avoided
- Pretreatment evaluation- Modifying dental therapy
• 10% must be prepared for recognition, management and treatment of possible medical
• Can the patient tolerate and survive dental therapy
• Recognition of CAD• Manifestations of CAD
Recognition of CAD from Medical HistoryA. Known CAD - Establishing Severity of Disease
• Establish severity of disease• Patient symptoms; chest pain, dyspnea, etc. • Frequency of symptoms
- Increasing or lack of control indicates more severe disease process
- Exercise, physical exertion, agitation or stress
• How patient treats symptoms• How CAD is being medically managed• More severe and/or harder to control
- Greater number of cardiac medications and/or dosages
• Use and response to nitroglycerin• Other medications used
- Oral nitrates; isosorbide dinitrate- Transcutaneous nitrates - patches- Calcium channel blockers- Beta-blockers – specific or nonspecific- Others or combinations
- Patient's tolerance before symptoms; stress needed to produce symptoms- Patient's lifestyle, active or sedentary- Climb stairs, walk on level ground before forced to stop
• Symptoms or diagnosis of congestive heart failure
• Results of exercise tolerance test• Cardiac surgery and dates
- Angioplasty and/or bypass grafting- Number of cardiac procedures
- Hypertension- Hypercholesterolemia - especially low-density lipoproteins- Smoking- Diabetes mellitus- Family history
ASA I-IV categorization is a judgement based on:• Medical history• Drug history• Physical and clinical examination
• Emotional evaluation• Medical consultation• Personal experiences
A patient without systemic disease, a normal, healthy patient
• ASA II: A patient with mild systemic disease• ASA III: A patient with severe systemic disease that limits activity, but is not
• ASA IV: A patient with incapacitating systemic disease that is a constant threat to life
Systolic Disastolic Classification ________________________________________________________ Normal ________________________________________________________ Prehypertension ________________________________________________________ Stage 1 hypertension ________________________________________________________ Stage 2 hypertension ________________________________________________________ Major Concern BASIC CAVEAT of treating medically compromised patients. Never jeopardize the patient's medical control or stability. The first consideration of treatment planning is the systemic phase!
• Prevent patient's heart from becoming overexerted to develop symptoms• Maximize amount of oxygen to heart• Minimize cardiac workload
- Stressed, agitated patients, increases HR and BP
• Modifications based on severity of patient's CADA. Minimize stress during dental treatment
• Relaxed office atmosphere• Explain procedures, decreases fear of unknown and surprises
- Mild expected unpleasant experience is less stressful, i.e. injections, probing, etc., if
- Allow sufficient time for maximum effort
B. Adjunctive methods of relaxation to decrease stress and anxiety
• Headphones• Hypnosis• Videotapes• Distraction techniques
• Nitrous Oxide/Oxygen or Oxygen alone at 4-6 L/minute• Diazepam - Valium• Others - Xanax, etc. by patient's previous experience and usage• Prophylactic dose of sublingual Nitroglycerin or patch, especially if used on prn basis
D. At each appointment have a pre and post treatment BP, pulse and evaluation
• Ask and record if any changes in their health• Make certain they have taken their regular medications• Compare information to baseline
• Six months after MI - N.B. new information can treat sooner with permission from M.D.
Immediate post infarction:- Site of infarction weaker, may rupture- Cardiac arrhythmias- Time for collateral circulation revascularization
• Some suggest more extensive, invasive procedures should be delayed for one year• Consultation with cardiologist
- Specific questions for safe dental management
• Worsening symptoms defer elective dental therapy until medical control or therapy• 20% of unstable angina progress to acute MI within three months• Angina pectoris• Wait 30 days after initial or infrequent attack of angina pectoris• Early AM appointments best• Correlate to medication schedule• Time of year important for some CAD patients
Appointment Timing and Duration• Patient - One long premedicated appointment best• Logistics - patient transportation• Office demands; vacation schedules• Coordinate with other medical care
VI. Local Anesthetics and Cardiac Patients
A. Advantages of administering minute physiologic amounts of epinephrine for dental
treatment outweighs dangers- Nonstressed adult 70 kg - .007-.014 mg epi per minute- Stressed is .280 mg- Epi 1:100,000 is .018-.054 mg or 1-3 cartridges- Therefore, many agree 1-2 or .04 mg is within safety limits.
VIII. Prepare for Cardiac Emergency Situation
• Office emergency plan• Community emergency services• Office staff preparation - BLS, CPR, etc. • Adequate emergency kit• Know specific cardiac emergency signs, symptoms, management and treatment
A. Little JW and Falace DA. Dental Management of the Medically Compromised Patient,
6th Ed. St. Louis: CV Mosby Co., 2002.
B. Malamed SF. Handbook of Medical Emergencies in the Dental Office, 6th Ed. St.
C. Berkow R, Editor-in-Chief. The Merck Manual of diagnosis and Therapy, 17th Ed.
Rahway NJ: Merck Research laboratories, Division of Merck & Co., Inc.
D. Tyler MT, Editor. Medically Complex Patients. American Academy of Oral Medicine,
E. Jeske, A.H., and Suchko, G.D., Lack of a Scientific Basis for Routine Discontinuation
of Oral Anticoagulation Therapy Before Dental Treatment. JADA, Vol. 134: 1492-1497, Nov. 2003.
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