atherosclerotic coronary vascular disease leading cause of death in the u.s. !! men > 40 y.o....
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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
Atherosclerotic coronary vascular disease
• ASYMPTOMATIC ~ 50 %
• SYMPTOMATIC ~ 50 %• ISCHEMIC HEART DISEASE = ANGINA
PLAQUE RUPTURE AND
BLOOD CLOTTING IN AN ATHERO-SCLEROTIC
BLOOD VESSEL
Fibrin
Platelet clumping
Red bloodcells
Platelet plugRed blood cellsand fibrin
HMG COA REDUCTASE INHIBITORS
Drug Strengths EquipotentDosage
DailyDose
MonthlyCost $
Fluvastatin(Lescol)
20, 40 20 20-80 34 -77
Lovastatin*(Mevacor)
10, 20, 40 10 10-80 37-234
Pravastatin*(Pravachol)
10, 20, 40 10 10-40 53-96
Simvastatin(Zocor)
5, 10, 20,40
5 5-40 53-106
Use of HMg COAs can reduce cholesterol by 35%. * Should not be used with cyclosporine, niacin, gemfibrozil - myositis; however no reports with fluvastatin
Atherosclerotic coronary vascular disease
• RISK FACTORS
• age and sex
• genetics; family history
• serum lipid levels
• HTN
• tobacco ( smoking)
• elevated blood glucose
ISCHEMIC HEART DISEASE
• ASCVD: coronary arteries>>> decreased blood supply to myocardium= ischemia >>>pain= ANGINA
• May be slowly OR rapidly progressive; with or without symptoms
ISCHEMIC HEART DISEASE
• ANGINA : most common cause= ASCVD
• also HTN
• anemia
• RHD
• CHF
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
ANGINA PECTORISstatus
• 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
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
ANGINA PECTORIS
• MEDICAL MANAGEMENT
• exercise, weight loss, diet, smoking cessation, other medical conditions control: diabetes, HTN, thyroid, anemia, arrhythmias
• DRUGS: vasodilators ( NGN), etc.
ANGINA PECTORIS
• DRUGS
• vascular dilators: alleviate coronary artery spasms; open up occluded vessels, increase blood flow
• NGN, under tongue, transdermal patches
• longer acting NITRATES
ISCHEMIC HEART DISEASE
• LABORATORY TESTS
• chest radiograph, fluoroscopy
• EKG
• echocardiography
• technicium Tc 99 scan
• enzymes ( LDH, ALT, AST)
• angiography
DENTAL MANAGEMENT for ANGINA PECTORIS
• mild diagnosed, monitoredinfrequent symptomsuse NGN <2 x week;
exertion only easily controlled• moderate diagnosed, ± monitored
occasional symptomsuse NGN <5 x week;
exertion easily controlled
DENTAL MANAGEMENT for ANGINA PECTORIS
• severe diagnosed, ± monitored± frequent
symptoms use NGN <8 x week; exertion not necessarily well controlled
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
DENTAL MANAGEMENT for ANGINA PECTORIS
• severe simple tx vitals, sedation + prophylactic NGN
• routine-complex tx HOSPITALIZATION
Surgical Treatment
• Coronary Artery By-Pass Graft (CABG)– Saphenous vein– Internal mammary artery– Radial artey
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
Post-Myocardial Infarction
“MI”, “Coronary”, “Heart Attack”
Infarction - an area of necrosis in tissue due to ischemia resulting from obstruction of
blood flow
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)
MYOCARDIAL INFARCTION
• CAUSES of DEATH from MI
• ventricular fibrillation
• cardiac arrest
• congestive heart failure
• cardiac tamponade
• thromboembolic complications
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
MYOCARDIAL INFARCTION• short, non-stressful appointments
schedule at BEST time for patient• changes>>>> STOP- POSTPONE
dental tx sedation : N2O2
• good anesthesia, pain control, anxiety reduction, etc.
• prophylactic oxygen ( nasal cannula) ± NGN; ALWAYS have NGN available!
MYOCARDIAL INFARCTION
• NO EPINEPHRINE
• anticoagulants( Coumadin)
• PT or INR, BT
• arrhythmias
• CHF
• Rxs: side-effects, interactions, adjustment
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