Transcript 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
D rug
Strengths E quipotent D aily M onthly
D osage
D ose C ost $
Fluvastatin
(Lescol)
20, 40
20
20-80
34 -77
Lovastatin*
(M evacor)
10, 20, 40
10
10-80
37-234
P ravastatin* 10, 20, 40
(P ravachol)
10
10-40
53-96
S im vastatin 5, 10, 20,
5
5-40
53-106
(Zocor)
40
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