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Transcript of - "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
Ischaemic heart diseaseIschaemic heart diseaseDefinitionDefinition
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
Ischaemic heart diseaseIschaemic heart diseaseDefinitionDefinition
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
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
Ischaemic heart diseaseIschaemic heart diseasePathophysiologyPathophysiology
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)
Dentistry & Cardiovascular Dentistry & Cardiovascular MedicineMedicine
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
Dentistry & Cardiovascular Dentistry & Cardiovascular MedicineMedicine
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
Cardiopulmonary Cardiopulmonary resuscitationresuscitation
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
www.resus.org.ukwww.resus.org.uk
Cardiopulmonary Cardiopulmonary resuscitationresuscitation
Adult basic life supportAdult basic life support
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
www.resus.org.ukwww.resus.org.uk
Cardiopulmonary Cardiopulmonary resuscitationresuscitation
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
www.resus.org.ukwww.resus.org.uk
Cardiopulmonary Cardiopulmonary resuscitationresuscitation
Adult basic life supportAdult basic life support
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
www.resus.org.ukwww.resus.org.uk