2. Atherosclerotic coronary vascular disease ASYMPTOMATIC ~ 50 % SYMPTOMATIC ~ 50 % ISCHEMIC HEART DISEASE = ANGINA

3. Increased CV risk( MI)for dentistry EXTREME Recent MI Unstable angina Uncompensated CHF Significant arrhythmias ( ventricular) Severe valvular disease –AHA. 2002. Circulation. 105:10.

4. Increased CV risk( MI) for dentistry MODERATE previous MI ANY angina ANY CHF ( walking flight of stairs) ANY arrhythmias IDDM CVA Renal disease HTN- AHA. 2002. Circulation. 105:10. Advanced age

5. Atherosclerotic coronary vascular disease RISK FACTORS age and sex genetics; family history serum lipid levels HTN tobacco ( smoking) elevated blood glucose

6. Atherosclerotic coronary vascular disease RISK FACTORS : cigarette smoking : 2- 6 X CVD than non- smokers ( degree and duration dependent) increased risk of complications: angina, MI, cardiac arrest Framingham study: >5000 smokers; 5 -year death rate = 22 % smokers; 15% if discontinued

7. Modifying risk factors 400,000 patients without smoking, cholesterol or HTN risk 75-88% decrease in risk of adverse CVD 48-58 % decreased mortality risk Additional 5.8 - 9.2 years of life Stamler J, et al. JAMA. 1999; 282:2012-2018.

8. HMG COA REDUCTASE INHIBITORS Use of HMg COAs can reduce cholesterol by 35%. * Should not be used with certain drugs

10. ANGINA PECTORIS 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

11. 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

13. ISCHEMIC HEART DISEASE PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY ( PTCA) insertion of catheter to “clean out” and widen occluded vessels invasive!! complications = thrombosis, emboli, arrhythmias induces MI = 1%; CVA= 1%; death= 1% minor complications = 5-10%

15. ISCHEMIC HEART DISEASE PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY ( PTCA) RESULTS: 85-90 % relief of angina in 25 % of cases angina returns to previous level within 6-12 months if no recurrence of angina/stenosis > 1 yr.= EXCELLENT PROGNOSIS

16. ISCHEMIC HEART DISEASE PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY ( PTCA) balloon angioplasy balloon angioplasy + STENT

18. ISCHEMIC HEART DISEASE Coronary artery bypass graft ( CABG) indicated with 2 > occluded coronary arteries (proximal obstruction) most common left anterior desending c.a. complications ; death = 1% vein grafts occlude to previous level 10% within 1st year; 2 % per year afterwards, depending on lifestyle

19. ISCHEMIC HEART DISEASE post-CABG 5-yr. mortality = 50 % RESULTS : complete relief = 60 % partial relief = 20-30 % no relief = 10 % use sapphenous vein; currently no synthetic material re-op: limited ; maybe int. mammary a.

20. DENTAL MANAGEMENT for ANGINA PECTORIS milddiagnosed, monitored infrequent symptoms use NGN <2 x week; exertion only easily controlled moderatediagnosed, ± monitored occasional symptoms use NGN <5 x week; exertion easily controlled

21. DENTAL MANAGEMENT for ANGINA PECTORIS severediagnosed, ± monitored ± frequent symptoms use NGN <8 x week; exertion not necessarily well controlled

22. DENTAL MANAGEMENT for ANGINA PECTORIS mild most dental tx vitals, sedation moderate simple tx vitals, sedation ± prophylactic NGN vitals, sedation + routine tx prophylactic NGN complex tx HOSPITALIZATION severe simple tx vitals, sedation + prophylactic NGN routine-complex tx HOSPITALIZATION

25. ISCHEMIC HEART DISEASE MYOCARDIAL INFARCTION Approx. 550,000 deaths per year in U.S. 20 % sudden death( <2 hrs.) from MI ASCVD>>>occlusion>>>anoxia>>> ischemia>>>infarct>>>necrosis PAIN : longer and more severe than angina same location, character, pattern, radiates not relieved by nitrates or rest

26. 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)

27. 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

28. MYOCARDIAL INFARCTION short, non-stressful appointments schedule at BEST time for patient changes>>>> STOP- POSTPONE dental tx sedation : N 2 O 2 good anesthesia, pain control, anxiety reduction, etc. prophylactic oxygen ( nasal cannula) ± NGN; ALWAYS have NGN available!

29. MYOCARDIAL INFARCTION NO EPINEPHRINE anticoagulants( Coumadin) PT or INR, BT arrhythmias CHF Rxs: side-effects, interactions, adjustment

30. MYOCARDIAL INFARCTION short, non-stressful appointments schedule at BEST time for patient changes>>>> STOP- POSTPONE dental tx sedation : N 2 O 2 good anesthesia, pain control, anxiety reduction, etc. prophylactic oxygen ( nasal cannula) ± NGN; ALWAYS have NGN available!