- "Ischemic Heart Disease - Clinical Patterns" (Leeds Dental

Ischaemic Heart DiseaseIschaemic Heart DiseaseClinical AspectsClinical Aspects

Dr Chris Gale Clinical Research Fellow Dr Chris Gale Clinical Research Fellow Medical Research CouncilMedical Research Council

University of LeedsUniversity of Leeds

Aims and ObjectivesAims and Objectives

IschaemicIschaemic heartheart diseasedisease– Definition, manifestations, epidemiology, Definition, manifestations, epidemiology,

aetiology, pathophysiology, risk factors and aetiology, pathophysiology, risk factors and prevention, relevance to dentistryprevention, relevance to dentistry

ChestChest painpain– Differential diagnosisDifferential diagnosis

AcuteAcute myocardialmyocardial infarctioninfarction– Assessment, treatment, complicationsAssessment, treatment, complications

CardiopulmonaryCardiopulmonary resuscitationresuscitation

Ischaemic heart diseaseIschaemic heart diseaseDefinitionDefinition



An imbalance between the An imbalance between the supplysupply ofof oxygenoxygen and the and the myocardialmyocardial demanddemand resulting in myocardial ischaemia.resulting in myocardial ischaemia.

AnginaAngina pectorispectorissymptom not a diseasesymptom not a diseasechest discomfort associated with abnormal chest discomfort associated with abnormal myocardial function in the absence of myocardial function in the absence of myocardial necrosismyocardial necrosis


SupplySupply– Atheroma, thrombosis, spasm, embolusAtheroma, thrombosis, spasm, embolus

DemandDemand– Anaemia, hypertension, high cardiac Anaemia, hypertension, high cardiac

output (thyrotoxicosis, myocardial output (thyrotoxicosis, myocardial hypertrophy)hypertrophy)

Ischaemic heart diseaseIschaemic heart diseaseManifestationsManifestations

Sudden deathSudden death Myocardial infarctionMyocardial infarction Acute coronary syndromeAcute coronary syndrome Stable angina pectorisStable angina pectoris Heart failureHeart failure ArrhythmiaArrhythmia AsymptomaticAsymptomatic

Ischaemic heart diseaseIschaemic heart diseaseEpidemiologyEpidemiology

Commonest cause of death in the Western Commonest cause of death in the Western world. (up to 35% of total mortality)world. (up to 35% of total mortality)

Over 20% males under 60 years have IHDOver 20% males under 60 years have IHD Health Survey For England (1993):Health Survey For England (1993):

3% of adults suffer from angina3% of adults suffer from angina

1% have had a myocardial infarction in the 1% have had a myocardial infarction in the

past 12 monthspast 12 months

Ischaemic heart diseaseIschaemic heart diseaseAetiologyAetiology

Ischaemic heart diseaseIschaemic heart diseaseAetiologyAetiology

FixedFixed– Age, Male, +ve family historyAge, Male, +ve family history

ModifiableModifiable – – strong associationstrong association– Dyslipidaemia, smoking, diabetes mellitus, Dyslipidaemia, smoking, diabetes mellitus,

obesity, hypertensionobesity, hypertension ModifiableModifiable - - weak associationweak association

– Lack of exercise, high alcohol consumption, Lack of exercise, high alcohol consumption, type A personality, OCP, soft watertype A personality, OCP, soft water

Atherosclerosis

Ischaemic heart diseaseIschaemic heart diseasePathophysiologyPathophysiology


Response to injury hypothesisResponse to injury hypothesis ATHEROSISATHEROSIS

Accumulation of cholesterol within the vessel wall intima. Accumulation of cholesterol within the vessel wall intima. Smooth muscle cell proliferationSmooth muscle cell proliferation

SCLEROSISSCLEROSISExpansion of fibrous tissueExpansion of fibrous tissue

INFLAMMATIONINFLAMMATIONChronic inflammatory cells migrate into wall, release Chronic inflammatory cells migrate into wall, release cytokinescytokines

GROWTH FACTORS/INFLAMMATORY MEDIATORSGROWTH FACTORS/INFLAMMATORY MEDIATORS


An atherosclerotic lesion

a

Schematic illustration

Endothelium Smooth muscle cell

Macrophage foam cellThrombus formation

Media(smooth muscle cells)

Lymphocytes

Ischaemic heart diseaseIschaemic heart diseaseAcute coronary syndromesAcute coronary syndromes

AtherosclerosisAtherosclerosis

Fatal / non-fatal AMI Unstable

angina

CoronaryArtery spasm

Ischaemic heart diseaseIschaemic heart diseaseAcute coronary syndromesAcute coronary syndromes FatalFatal AMIAMI

Small, fat rich plaques. Plaque RUPTURE. Small, fat rich plaques. Plaque RUPTURE. Thrombus in lipid core and on plaques surface. Thrombus in lipid core and on plaques surface. Vessel lumen OCCLUDED. Vessel lumen OCCLUDED.

NonNon--fatalfatal AMIAMIPlaque EROSION rather than rupture. OCCLUSIVE Plaque EROSION rather than rupture. OCCLUSIVE thrombus. thrombus.

UnstableUnstable anginaanginaUsually mod-severe stenosis. Multiple vessels. Collaterals Usually mod-severe stenosis. Multiple vessels. Collaterals often formed. Thrombus formation and vasoconstriction. often formed. Thrombus formation and vasoconstriction. Myocardial infarction may ensueMyocardial infarction may ensue..

Ischaemic heart diseaseIschaemic heart diseaseRisk factors and preventionRisk factors and prevention

Ischaemic heart diseaseIschaemic heart diseaseRisk factors and preventionRisk factors and prevention

Family HistoryFamily History SmokingSmoking HypertensionHypertension Diabetes MellitusDiabetes Mellitus HypercholesterolaemiaHypercholesterolaemia Lack of exerciseLack of exercise

PRIMARY PREVENTIONPRIMARY PREVENTION

Ischaemic heart diseaseIschaemic heart diseaseRelevance to dentistryRelevance to dentistry

IHD is commonIHD is common Subjects with IHD have more severe Subjects with IHD have more severe

dental caries and periodontal disease – dental caries and periodontal disease – association or causation?association or causation?

Angina is a cause of pain in the Angina is a cause of pain in the mandible, teeth or other oral tissuesmandible, teeth or other oral tissues

Stress provokes ACS!Stress provokes ACS!

Chest PainChest PainMyocardial ischaemiaMyocardial ischaemia

SiteSiteJaw to navel, retrosternal, left Jaw to navel, retrosternal, left submammarysubmammary

RadiationRadiationLeft chest, left arm, jaw….mandible, teeth, Left chest, left arm, jaw….mandible, teeth, palatepalate

QualityQuality//severityseveritytightness, heaviness, compression…tightness, heaviness, compression…clenched fistsclenched fists

Chest PainChest PainMyocardial ischaemiaMyocardial ischaemia

Precipitating/relieving factorsPrecipitating/relieving factors

physical exertion, cold windy weather, physical exertion, cold windy weather, emotionemotion

rest, sublingual nitratesrest, sublingual nitrates Autonomic symptomsAutonomic symptoms

sweating, pallor, peripheral sweating, pallor, peripheral vasoconstriction, nausea and vomitingvasoconstriction, nausea and vomiting

Chest PainChest PainDifferential diagnosisDifferential diagnosis

CardiacCardiac pathologypathology– Pericarditis, aortic dissectionPericarditis, aortic dissection

PulmonaryPulmonary pathologypathology– Pulmonary embolus, pneumothorax, pneumoniaPulmonary embolus, pneumothorax, pneumonia

GastrointestinalGastrointestinal pathologypathology– Peptic ulcer disease, reflux, pancreatitis, ‘café Peptic ulcer disease, reflux, pancreatitis, ‘café

coronary’coronary’

MusculoskeletalMusculoskeletal pathologypathology– Trauma, Tietze’s SyndromeTrauma, Tietze’s Syndrome

Acute Myocardial InfarctionAcute Myocardial Infarction

250,000 deaths per year.250,000 deaths per year. 150,000 presentations to hospital.150,000 presentations to hospital. 30% of deaths occur in the first 2 hours.30% of deaths occur in the first 2 hours.

(Cardiac muscle death occurs after 45 mins (Cardiac muscle death occurs after 45 mins of ischaemia)of ischaemia)

Acute Myocardial InfarctionAcute Myocardial InfarctionAssessmentAssessment

Symptoms and signs of myocardial Symptoms and signs of myocardial ischaemiaischaemia

AlsoAlso– Changes in heart rate /rhythmChanges in heart rate /rhythm– Changes in blood pressureChanges in blood pressure

Acute Myocardial InfarctionAcute Myocardial InfarctionConfirming the diagnosisConfirming the diagnosis

Typical chest painTypical chest pain

Electrocardiographic changesElectrocardiographic changes– ST elevationST elevation– new LBBBnew LBBB

Myocardial enzyme elevationMyocardial enzyme elevation– Creatine kinase (CK-MB)Creatine kinase (CK-MB)– TroponinTroponin

Acute Myocardial InfarctionAcute Myocardial InfarctionTreatmentTreatment

Stop dental treatmentStop dental treatment Call for helpCall for help Rest, sit up and reassure patientRest, sit up and reassure patient OxygenOxygen Analgesia (opiate, sublingual nitrate)Analgesia (opiate, sublingual nitrate) AspirinAspirin Prepare for basic life supportPrepare for basic life support

Acute Myocardial InfarctionAcute Myocardial InfarctionMedical treatmentMedical treatment

Rest, oxygen, analgesia, aspirinRest, oxygen, analgesia, aspirin ThrombolysisThrombolysis Primary angioplastyPrimary angioplasty Beta-BlockersBeta-Blockers ACE inhibitorsACE inhibitors

Acute Myocardial InfarctionAcute Myocardial InfarctionComplicationsComplications

Death (Death (18% within 1 hour,18% within 1 hour, 36% within 24 hours)36% within 24 hours) Non-fatal arrhythmiaNon-fatal arrhythmia Acute left ventricular failureAcute left ventricular failure Cardiogenic shockCardiogenic shock Papillary muscle rupture and mitral Papillary muscle rupture and mitral

regurgitationregurgitation Myocardial rupture and tamponadeMyocardial rupture and tamponade Ventricular aneurysm and thrombusVentricular aneurysm and thrombus

Dentistry & Cardiovascular Dentistry & Cardiovascular MedicineMedicine

AMIAMI– GA within 3/12 of AMI: 30% re-infarction rate GA within 3/12 of AMI: 30% re-infarction rate

@ 1/52 post op@ 1/52 post op– Avoid routine LA dental treatment for 3/12 Avoid routine LA dental treatment for 3/12

(emergency treatment only)(emergency treatment only)– Avoid excess dosage, reduce anxietyAvoid excess dosage, reduce anxiety– Avoid elective surgery under GA for1 year Avoid elective surgery under GA for1 year

(specialist)(specialist)– Be aware of medications (bleeding, Be aware of medications (bleeding,

hypotension)hypotension)


ANGINAANGINA– Take a history…is the condition stable?Take a history…is the condition stable?– Medication present esp. GTNMedication present esp. GTN– Minimise anxietyMinimise anxiety– Prophylactic GTNProphylactic GTN– If angina peri-dental treatment give GTNIf angina peri-dental treatment give GTN– Consult the physician for anything but minor treatment Consult the physician for anything but minor treatment

under LA under LA – Consider co-existing pathology and SE of medicationConsider co-existing pathology and SE of medication– Avoid elective surgery under GA for 3/12 in recent onset Avoid elective surgery under GA for 3/12 in recent onset

angina, bundle branch block, unstable angina (specialist)angina, bundle branch block, unstable angina (specialist)– Patients with CABG do not require A/BPatients with CABG do not require A/B


DIABETESDIABETES– Hypoglycaemia (esp.in Type I)Hypoglycaemia (esp.in Type I)– Susceptible to oral infection / poor healingSusceptible to oral infection / poor healing

HYPERTENSIONHYPERTENSION– No contraindication to routine dental No contraindication to routine dental

treatmenttreatment– Drugs may cause oral pathology e.g.NifedipineDrugs may cause oral pathology e.g.Nifedipine

Cardiopulmonary Cardiopulmonary resuscitationresuscitation

Adult basic life supportAdult basic life supportCheck responsivenessCheck responsiveness

Open airwayOpen airway

Check breathingCheck breathing

BreatheBreathe

AssessAssess10 sec only10 sec only

CirculationCirculation No circulationNo circulation

Continue rescue breathingContinue rescue breathing Compress chest 100 pm, 15:2Compress chest 100 pm, 15:2

Check circulation every minuteCheck circulation every minute

www.resus.org.ukwww.resus.org.uk


Adult basic life supportAdult basic life support

Ensure safety of rescuer and victimEnsure safety of rescuer and victim Check responsivenessCheck responsiveness Shout for help if not responsiveShout for help if not responsive Open airwayOpen airway

– head tilthead tilt– chin liftchin lift




Check breathingCheck breathing– look for chest movementlook for chest movement– listen over mouthlisten over mouth– feel air on cheekfeel air on cheek

BreatheBreathe– 2 slow (2 second) breaths2 slow (2 second) breaths– pinch nose closed and open mouth using pinch nose closed and open mouth using

chin liftchin lift



Adult basic life supportAdult basic life support Assess circulationAssess circulation

– carotid pulse only if confident…don’t waste timecarotid pulse only if confident…don’t waste time Circulation presentCirculation present

– continue breathing, check each minutecontinue breathing, check each minute No circulationNo circulation

– start chest compressions @ 15:2start chest compressions @ 15:2– heal of hand over sternum, straight armsheal of hand over sternum, straight arms– depress 4-5cm, 100 bpmdepress 4-5cm, 100 bpm– continue until responsive/help/exhaustedcontinue until responsive/help/exhausted




Choking Choking (‘café coronary’)(‘café coronary’)– allow coughingallow coughing– 5 blows to the upper back5 blows to the upper back– 5 abdominal thrusts5 abdominal thrusts


Documents

- "Ischemic Heart Disease - Clinical Patterns" (Leeds Dental