OralMedCh4

Ischemic Heart Disease Overview

• Author: Donal Scheidel, DDS

• Affiliation: Creighton University School of Dentistry

Objectives

• Describe physiology, causes, and effects of ischemic heart disease.

• Discuss appropriate management strategies for patients with ischemic heart disease.

• Interpret risk factors relating to systemic health and treatment plans.

• Discuss management approaches for patients experiencing a heart attack.

Statistics and Impact

• Ischemic heart disease is a leading health problem in the U.S.

• Atherosclerosis leads to diminished blood supply, potential heart attack, and tissue necrosis.

• Contributes to an increase in stroke and peripheral artery disease (PAD).

• Approximately 85 million Americans have some form of cardiovascular disease.

• Out of these, 18.2 million have coronary artery disease.

• 365,000 adults experience sudden heart attacks, with a 90% fatality rate.

• Mortality rates are decreasing; however, there are approximately 735,000 heart attacks annually.

Etiology: Risk Factors

• Male Gender: Higher prevalence in males.

• Older Age: Risk increases with age.

• Family History: Genetic predisposition to heart disease.

• Hyperlipidemia: Elevated levels of LDL cholesterol.

• Hypertension: High blood pressure contributes significantly.

• Cigarette Smoking: Major modifiable risk factor.

• Physical Inactivity/Obesity: Lifestyle factors that heighten risk.

• Diabetes/Insulin Resistance: Metabolic conditions exacerbate heart risks.

• Mental Stress/Depression: Psychological factors influencing heart health.

Additional Etiologic Factors

• Elevated C-Reactive Protein: Inflammation marker linked to heart disease.

• Elevated Homocysteine Levels: Associated with increased cardiovascular risk.

• Fibrinogen: A protein involved in blood clotting.

• Menopause: Hormonal changes increase risk.

• Race: Certain racial groups exhibit higher vulnerability.

• Periodontal Disease: Inflammation associated with gum disease correlates with heart disease.

Pathophysiology

• Acute Symptoms: Plaque tearing initiates a coagulation cascade leading to blood clotting and reduced blood flow downstream.

• Atherosclerotic Outcomes: Variable outcomes depend on collateral circulation and plaque characteristics.

• Patients may experience Angina Pectoris when the heart's oxygen supply is insufficient.

• Prolonged ischemia leads to cellular necrosis of heart tissue.

Symptoms

• Chest Pain: Described as aching, squeezing pressure in the mid-chest, potentially radiating to the arms or jaw.

• Duration of pain typically lasts 5-15 minutes, often relieved by nitroglycerin.

• Symptoms of Myocardial Infarction (MI) last longer than stable angina and are unresponsive to nitroglycerin.

• Other symptoms include palpitations and cardiac arrhythmias.

• Sudden Cardiac Deaths: Approximately 328,500 deaths per year in the U.S.

Medical Management

• Management of Associated Diseases: Address conditions that worsen angina.

• Lifestyle Modifications: Promote heart-healthy habits.

• Pharmacotherapy:

  • Beta Blockers: Reduce workload on the heart.

  • Calcium Channel Blockers: Help relax blood vessels.

  • ACE Inhibitors: Control blood pressure and reduce strain on the heart.

  • Anti-platelet Agents: Daily use to prevent clotting.

  • Nitrates: For acute angina episodes.

  • Statins: Lower LDL cholesterol levels.

• Invasive Procedures: Cardiac catheterization, angioplasty, and coronary artery bypass grafting.

Myocardial Infarction

• Emergency Treatment: Critical to administer aspirin and oxygen at the onset of symptoms.

• Use of Automated External Defibrillators (AED) if necessary.

• Thrombolytic medications should be given within the first three hours after symptom onset.

• Post-MI Effects: Include potential arrhythmias, congestive heart failure, or pericarditis.

Dental Management

• Consider Variables:

  • Severity of heart disease.

  • Type of dental procedures being performed.

  • Patient stability and reserve.

• Risk Assessment:

  • Recent MI, unstable angina, or significant arrhythmias present major risk.

  • History of MI or stable angina indicates moderate risk.

• Dental Procedures: Generally regarded as superficial; no premedication required for patients with stents or bypass surgeries.

Management of Moderate Risk Patients

• Schedule morning and short appointments.

• Obtain pretreatment vital signs and have nitroglycerin readily available.

• Implement stress reduction strategies such as communication, nitrous oxide, sedation, and effective anesthesia.

• Limit vasoconstrictor use to recommended amounts (2 cartridges).

• Provide appropriate post-treatment pain control.

Management of High-Risk Patients

• Avoid elective procedures until stability achieved; consult physician if needed.

• Consider administering prophylactic nitroglycerin and placing an IV line.

• Sedation and pulse oximeter monitoring are essential.

• Frequent monitoring and cautious use of epinephrine as necessary.

Post-MI Dental Treatment

• Wait 30 days post-uncomplicated MI for elective dental care; 6 months if there is heart muscle damage.

• Consult the patient’s physician regarding their condition.

• Higher risk for post-infarction disability.

• Medication Considerations:

  • Aspirin usage poses no increased risk.

  • Monitor INR levels for patients on Warfarin (must be ≤3.5 to provide care).

  • NSAIDs may increase MI risk in patients with previous incidents, although Naproxen is considered safer.