Chest Discomfort

Chest Discomfort

The appearance of chest discomfort in the perioperative period in a patient who may haveischemic heart disease calls for rapid identification of the cause so that approve.

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BOX 2-4

Clinical Characteristics of Chest Pain Caused by Myocardial Ischemia or Infarction

Discomfort (Pain) Described by Patients as Being:
1. Squeezing, bursting, pressing, burning, choking, or
crushing in character (not typically sharp or stabbing
in quality)
2. Substernally located, with variable radiation to left
shoulder, arm, or left side (or a combination of these
areas) of neck and mandible
3. Frequently associated at the onset with exertion,
heavy meal, anxiety, or upon assuming horizortal
posture .
4. Relieved by vasodilators, such as nitroglycerin, or
rest (in the case of angina)
5. Accompanied by dyspnea, nausea, weakness, palpitations,
perspiration, or a feeling of impending
doom (or a combination of these symptoms)

priate measures can be taken (Box 2-4). Discomfort from cardiac ischemia is frequently described as a squeezing· sensation, with a feeling of heaviness on the chest (Box 2-5). It usually begins in a retrosternallocation, radiating
to the left shoulder and arm. Patients with documented heart disease who have had such discomfort in the past will usually be able to confirm that the discomfort is cardiac in origin. For patients who are unable to remember
such a sensation in the past or who have been assured by their physician that such discomfort does not represent heart disease, further ipformation is useful before assuming a cardiac origin of the symptom. The patient should be asked to describe the exact location of the discomfort and any radiation, how the discomfort is changing with time, and if postural position affects the discomfort. Pain resulting from gastric reflux into the esophagus because of chair position should improve when the patient sits up and is .given an antacid. Discomfort caused by costechondritis
or pulmonary conditions should vary with res” pirations or be stimulated by pressure on the thorax. The only other common condition that can occur with chest discomfort is anxiety. which may be difficult to. differentiate from cardiagenic problems without the use of menitaring
devices not commonly present in the dental office.

If chest discomfort is suspected to be caused by myocardial ischemia or if that possibility cannot be ruled out, measures should be instituted that decrease myocardial work and increase myocardial ox}’gen supply. All dental care must be stopped, even if the surgery is only partially
finished. The patient should be reassured that everything is under control while vital signs are being obtained, oxygen administration is stinted, and nitroglycerin is administered sublingually or by oral spray. The nitroglycerin dose should be 0.4 mg dissolved sublingually and repeated
(if necessary) every 5 minutes as long as systolic blood pressure is at least 90 mm Hg, up to a maximum of 3 .doses, If vital signs remain normal, the chest discomfort is relieved, and the Jl11011nt of nitroglycerin that was

Box 2-5

Differential Diagnosis of Acute-Onset Chest Pain

Common Causes
Cardiovascular system; Angina pectoris, M}
Gastrointestinal tract: Dyspepsia (i.e., heartburn), hiatal
hernia, reflux esophagitis, gastric ulcers
Musculoskeletal system: lntercostal muscle spasm, rib or
chest muscle contusions
~sychologic: Hyperventilation
Uncommon Causes
Cardiovascular system: Pericarditis, dissecting aortic
Respiratory system: Pulmonary embolism, pleuritis, tracheobronchitis,
mediastinitis, pneumothorax –
Gastrointestinal tract: Esophageal rupture, achalasia
Musculoskeletal system: Osteochondritis, chondrosternitis
.Psychologic: Psychogenic chest pain (i.e., imagined. chest pain).

required to relieve the discomfort was not more than normally necessary for that patient, they should be discharged with plans for future surgery to be done in an oral and maxillofacial surgery office or in a hospital after
conferring with their physician (Fig. 2-3). Some circumstances do require transport to an emergency facility. If the pulse is irregular, rapid, or weak, or the blood pressure is found to be below baseline, outside emergency help’ should be summoned while the patient is placed in an almost supine position and oxygen and nitroglycerin therapy.are started. Venous access should be initiated and a slow DsW drip begun, if possible, for use
by emergency personnel. Another serious situation requiring transfer to a hospital is a case in. which the patient’s discomfort is not relieved after 20 minutes of appropriate therapy. In this case it should be presumed
that a myocardial infarction (Ml) is in progress. Such a patient is especially prone to the appearance of serious cardiac dysrhythmias. or cardiac arrest; therefore vital _signs should be monitored frequently, and BLSshould be
instituted if indicated. Morphine sulfate (4 to 6 mg) may be administered 1M or SC to help relieve the discomfort and reduce anxiety. Morphine also provides a beneficial

FIG. 2·3 Management of patient having chest discomfort while undergoing dent!!.,surg!!L. __
FIG. 2·3 Management of patient having chest discomfort while undergoing dental surgery

effect for patients who are developing pulmonary edema (see Fig. 2-3). Transfer to a hospital should be expedited .• because thrombolytic agents and/or an angioplasty procedure may be able to preserve some or all of the ischemic myocardium.


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