Angina & MI

Management of Dental Patients Experiencing Cardiac Emergencies

Overview

  • The sudden onset of chest pain during dental care may be cardiac or noncardiac in origin.

  • Chest pain from cardiac origin typically results from Coronary Artery Disease (CAD), which leads to angina pectoris or acute myocardial infarction (AMI).

  • Proper evaluation of each patient's medical history is critical before dental treatment to identify individuals at risk of CAD.

  • Vital emergency procedures can substantially increase chances of survival.

Learning Objectives

  • Upon reading the material, students will learn:

    • The management of patients experiencing anginal attacks, AMI, and cardiac arrest.

    • The differentiation between symptoms of angina pectoris and AMI.

    • Identification of risk factors for CAD and understanding the associated pathophysiology.

    • Factors that may precipitate anginal attacks or AMI.

    • Differentiation between cardiac-related and non-cardiac-related chest pain.

Chest Pain: Cardiac vs. Noncardiac

  • Cardiac Chest Pain:

    • Often due to CAD.

    • May escalate to life-threatening conditions such as AMI.

  • Noncardiac Chest Pain:

    • More localized and sharper.

    • Aggravated by movement or breathing and usually not lasting long.

Risk Factors for Coronary Artery Disease (CAD)

  1. Unmodifiable Risk Factors:

    • Gender: Traditionally more common in males; however, CAD affects women significantly post-menopause.

    • Increasing Age: Most new-onset CAD occurs after age 65.

    • Heredity / Family History: A family history of premature CAD increases risk (younger than 65 for females, younger than 55 for males).

  2. Modifiable Risk Factors:

    • Tobacco Use: Increases CAD risk significantly.

    • Hypertension: Especially systolic pressure > 140 mmHg in individuals over 50.

    • Hypercholesterolemia: High levels of LDL cholesterol promote atherosclerosis.

    • Diabetes: Accelerates the progression of atherosclerosis and increases cardiovascular risk.

    • Obesity and Physical Inactivity: Correlate with hypertension and hypercholesterolemia, thus impacting CAD risk.

Pathophysiology of CAD

  • Atherosclerosis:

    • A slow, inflammatory arterial disease characterized by plaque build-up in arteries, leading to reduced blood flow to the myocardium.

    • The buildup of cholesterol, triglycerides, and cellular debris forms plaques, causing myocardial ischemia if untreated.

  • Can lead to angina or AMI severe enough for potentially fatal consequences.

Forms of Angina Pectoris

  1. Stable Angina:

    • Predictable with exertion; lasts 1-15 minutes; responds to rest or nitroglycerin.

    • Symptoms: Dull, constant pressure in the left area of the chest.

  2. Unstable Angina (UA):

    • Occurs at rest or with minimal exertion; may last longer, indicate worsening cardiac condition.

    • Risk of transitioning to AMI; symptoms include persistent chest pain.

  3. Variant Angina (Prinzmetal’s Angina):

    • Occurs spontaneously, often at rest; can happen during sleep; typically due to vessel spasm.

    • Symptoms can mimick other forms of angina but may be less predictable.

    • Nitroglycerin administration provides relief.

Management of Anginal Attack

  • Recognition:

    • Symptoms include generalized chest discomfort, heaviness, pressure, and possible radiation to the shoulders, arms, neck, or jaw; may accompany sweating, nausea, and apprehension.

  • Evaluate Symptoms:

    • Assess the patient’s medical history for existing angina or risk factors; differentiate between anginal and non-cardiac pain.

  • Position the Patient:

    • Place the patient in a semi-upright or upright position to facilitate breathing.

  • Implement Emergency Protocol:

    • Administer oxygen (4-6 L/min via nasal cannula).

    • Administer nitroglycerin (sublingual or spray): 1 tablet or 1-2 sprays every 5 minutes; do not exceed 3 doses in 15 minutes. Monitor vital signs continuously.

  • Refer:

    • Activate emergency medical services (EMS) if pain persists despite treatment, especially if pain lasts longer than a prescribed duration.

Signs and Symptoms of Acute Myocardial Infarction (AMI)

  • Typical Symptoms:

    • Prolonged chest pain (>20 minutes): sensations as heaviness, pressure, or burning; may radiate to arms, shoulders, neck, and back; accompanied by nausea, weakness, and dyspnea.

    • Notably, victims may show signs of diohoresis and apprehension (Levine sign).

Management of an Acute Myocardial Infarction

  • Recognize Symptoms: Same as angina but must be handled with more urgency, given the risk of fatal complications.

  • Activate Emergency Protocol: Immediate activation of EMS is critical here as AMIs present significant immediate risks.

  • Administer Oxygen: At a flow rate of 2-6 L/min, considering patient comfort and emergency measures.

  • Medications:

    • Administer nitroglycerin if previously established; otherwise, emergency kit supply may be used.

    • Aspirin: 162 to 325 mg orally (chewed) unless contraindicated, to enhance myocardial oxygenation and mitigate damage.

  • Continuous Monitoring: Maintain vigilant observation of vital signs throughout the emergency treatment.

  • Pain Management: Administer nitrous oxide if available to counter pain effectively during management until EMS arrives.

  • Cardiac Arrest Response: Activate BLS protocol (CAB) and AED if the patient’s condition declines. CPR initiation during AMI or collapse significantly improves survival chances.

Case Study: Manny Rodriquez

  • Patient Profile: 55-year-old male with a history of cardiac illness; presents with distinct symptoms indicating an AMI, such as crushing chest pain and associated classic signs.

  • Management: Immediate assessment and management, including activation of emergency services, monitoring vital signs, and administration of appropriate medications had a positive outcome.

  • Follow-Up: An analysis of needed follow-ups with the patient's physician post-AMI emphasizes the importance of interdisciplinary communication regarding care.

Summary of Emergency Protocol**: R.E.P.A.I.R.

  • R: Recognize Signs and symptoms

  • E: Evaluate Symptoms

  • P: Position Patient

  • I: Implement Emergency Protocol

  • R: Refer to Emergency Services

  • A: Activate CABs of CPR

Additional Notes

  • Importance of Timing: The profound impact of early identification and response during episodes of chest pain emphasizes continuous training in BLS and preparedness to act promptly in a dental setting.

  • Role of Dentists: Dentists must be equipped to deal with medical emergencies effectively and work closely with patients and healthcare systems for optimal treatment outcomes.