Atherosclerotic coronary vascular disease
description
Transcript of Atherosclerotic coronary vascular disease
Atherosclerotic coronary vascular disease
• ASYMPTOMATIC ~ 50 %• SYMPTOMATIC ~ 50 %
• ISCHEMIC HEART DISEASE = ANGINA
Increased CV risk( MI)for dentistry
• EXTREME• Recent MI• Unstable angina• Uncompensated CHF• Significant arrhythmias ( ventricular)• Severe valvular disease
– AHA. 2002. Circulation. 105:10.
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
Atherosclerotic coronary vascular disease
• RISK FACTORS• age and sex• genetics; family history• serum lipid levels• HTN• tobacco ( smoking)• elevated blood glucose
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
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.
HMG COA REDUCTASE INHIBITORS
Drug Strengths EquipotentDosage
DailyDose
MonthlyCost $
Fluvastatin(Lescol)
20, 40 20 20-80 34 -77
Lovastatin*(Mevacor)
10, 20, 40 10 10-80 37-234
Pravastatin*(Pravachol)
10, 20, 40 10 10-40 53-96
Simvastatin(Zocor)
5, 10, 20,40
5 5-40 53-106
Use of HMg COAs can reduce cholesterol by 35%. * Should not be used with certain drugs
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
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
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%
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
ISCHEMIC HEART DISEASE• PERCUTANEOUS TRANSLUMINAL
CORONARY ANGIOPLASTY ( PTCA)• balloon angioplasy• balloon angioplasy + STENT
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
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.
DENTAL MANAGEMENT for ANGINA PECTORIS
• mild diagnosed, monitored infrequent symptomsuse 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 symptomsuse NGN <8 x week;
exertion not necessarily well controlled
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
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
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
• 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
• NO EPINEPHRINE• anticoagulants( Coumadin)• PT or INR, BT• arrhythmias• CHF• Rxs: side-effects, interactions, adjustment
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!