MANAGEMENT OF PATIENTS WITH COMPROMISING MEDICAL CONDITIONS
ISCHEMIC HEART DISEASE
Angina Pectoris. Obstruction of the arterial supply to the myocardium is one of the most common health problems dentists encounter. This condition occurs primarily men over age 40, although it is also prevalent in postmenopausal females. The basic disease process is a progressive
narrowing or spasm (or both) of one of more of the coronary arteries. This leads to a discrepancy between the myocardial oxygen demand and the ability of the coronary arteries to supply oxygen-carrying blood. Myocardial oxygen demand can be increased, for example,
by exertion, anxiety, or during digestion of a large meal. Angina is a s, mptom of ischemic heart disease produced when myocardial blood supply cannot be sufficiently sufficiently increased to meet the increased oxygen requirements that result from coronary artery disease.” The myocardium becomes ischemic, producing a heavy pressure or squeezing sensation in the patient’s sub enternal region that can radiate into the left shoulder and arm and into the mandibular region. Stimulation of activity commonly occurs with nausea, sweating. and bradycardia. The discomfort typically disappears once the myocardial work requirements are lowered or the oxygen supply to the heart muscle is increased.
The practitioner’s responsibility to a patient with a history of angina is to see all available preventive measures, thereby reducing the possibility that the surgical procedure will precipitate an angina episode. Preventive measures begin with taking a careful history of .the patient’s angina. The patient should be questioned about the events that produce angina; the frequency, duration, and severity of angina; and the response to edification or diminished activity. The patient’s physician can be consulted concerning the cardiac status.
If the patient’s angina arises only during moderately vigorous exertion and responds readily to oral nitroglycerin and if no recent increase in severity has occurred, ambulatory oral surgery procedures are usually safe when
performed with proper precautions.
However, if anginal episodes occur after only minimal exertion, if several doses of nitroglycerin are needed to relieve chest discomfort, or if the patient has unstable angina (i.e., angina present at rest or worsening in frequency,severity, ease of precipitation, duration of attack, or predictability of response to medication), elective surgery should be deferred until a medical consultation is obtained. Alternatively the patient can be referred to an oral and maxillofacial surgeon if emergency surgery is necessary.
Once the decision is made that ambulatory elective oral surgery can safely proceed, the patient should be prepared for surgery and the patient’s myocardial oxygen demand should be lowered or prevented from rising. Then creased oxygen demand during ambulatory oral surgery is the result primarily of patient anxiety, An anxiety ~ reduction protocol should therefore be used (Box 1-9). In addition, during surgery the patient can be given supplemental oxygen and prem medicated with nitroglycerin (if
the patient is extremely prone to angina). Profound local anesthesia is the best means of limiting patient anxiety. Although some controversy exists ever the use of local anesthetics containing epinephrine in angina patients,
the benefits (e.g., prolonged and accentuated anesthesia) outweigh the risks. However, care should be taken to avoid excessive epinephrine administration by using proper injection techniques. Some clinicians also advise giving no more than .f ml. of a local anesthetic solution with a 1: 100,000 concentration of epinephrine for a total adult dose of O,O~ mg in any 30-minute period. Before and during surgery, vital signs should be periodically monitored. In addition; regular verbal contact with the paticent ,to be maintain. The use of nitrous oxide or other conecious sedation methods for anxiety.
“The term angina is derived from the ancient Greek word for a checking sensation.