Download Atherosclerotic coronary vascular disease

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
Platelet clumping
Fibrin
PLAQUE
RUPTURE AND
BLOOD
CLOTTING IN
AN ATHEROSCLEROTIC
BLOOD
VESSEL
Red blood
cells
Red blood cells
and fibrin
Platelet plug
HMG COA REDUCTASE
INHIBITORS
Drug
Strengths Equipotent Daily Monthly
Dosage
Dose Cost $
Fluvastatin
(Lescol)
Lovastatin*
(Mevacor)
Pravastatin*
(Pravachol)
Simvastatin
(Zocor)
20, 40
20
20-80
34 -77
10, 20, 40
10
10-80
37-234
10, 20, 40
10
10-40
53-96
5, 10, 20,
40
5
5-40
53-106
Use of HMg COAs can reduce cholesterol by 35%. * Should not be used
cyclosporine, niacin, gemfibrozil - myositis; however no reports with fluv
Atherosclerotic coronary
vascular disease
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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
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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 PECTORIS
status
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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
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LABORATORY TESTS
chest radiograph, fluoroscopy
EKG
echocardiography
technicium Tc 99 scan
enzymes ( LDH, ALT, AST)
angiography
DENTAL MANAGEMENT for
ANGINA PECTORIS
• mild
diagnosed, monitored
infrequent symptoms
use NGN <2 x week; exertion only
easily controlled
• moderate
diagnosed, ± monitored
occasional symptoms
use 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
• moderate simple tx
vitals, sedation
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
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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
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NO EPINEPHRINE
anticoagulants( Coumadin)
PT or INR, BT
arrhythmias
CHF
Rxs: side-effects, interactions,
adjustment