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

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  • 1. Ischaemic Heart Disease Clinical Aspects Dr Chris Gale Clinical Research Fellow Medical Research Council University of Leeds
  • 2. Aims and Objectives
    • Ischaemic heart disease
      • Definition, manifestations, epidemiology, aetiology, pathophysiology, risk factors and prevention, relevance to dentistry
    • Chest pain
      • Differential diagnosis
    • Acute myocardial infarction
      • Assessment, treatment, complications
    • Cardiopulmonary resuscitation
  • 3. Ischaemic heart disease Definition
  • 4. Ischaemic heart disease Definition
  • 5. Ischaemic heart disease Definition
    • An imbalance between the supply of oxygen and the myocardial demand resulting in myocardial ischaemia.
    • Angina pectoris
    • symptom not a disease
    • chest discomfort associated with abnormal myocardial function in the absence of myocardial necrosis
  • 6. Ischaemic heart disease Definition
    • Supply
      • Atheroma, thrombosis, spasm, embolus
    • Demand
      • Anaemia, hypertension, high cardiac output (thyrotoxicosis, myocardial hypertrophy)
  • 7. Ischaemic heart disease Manifestations
    • Sudden death
    • Myocardial infarction
    • Acute coronary syndrome
    • Stable angina pectoris
    • Heart failure
    • Arrhythmia
    • Asymptomatic
  • 8. Ischaemic heart disease Epidemiology
    • Commonest cause of death in the Western world. (up to 35% of total mortality)
    • Over 20% males under 60 years have IHD
    • Health Survey For England (1993):
    • 3% of adults suffer from angina
    • 1% have had a myocardial infarction in the
    • past 12 months
  • 9. Ischaemic heart disease Aetiology
  • 10. Ischaemic heart disease Aetiology
    • Fixed
      • Age, Male, +ve family history
    • Modifiable – strong association
      • Dyslipidaemia, smoking, diabetes mellitus, obesity, hypertension
    • Modifiable - weak association
      • Lack of exercise, high alcohol consumption, type A personality, OCP, soft water
    Atherosclerosis
  • 11. Ischaemic heart disease Pathophysiology
  • 12. Ischaemic heart disease Pathophysiology
    • Response to injury hypothesis
    • ATHEROSIS
    • Accumulation of cholesterol within the vessel wall intima. Smooth muscle cell proliferation
    • SCLEROSIS
    • Expansion of fibrous tissue
    • INFLAMMATION
    • Chronic inflammatory cells migrate into wall, release cytokines
    • GROWTH FACTORS/INFLAMMATORY MEDIATORS
  • 13. Ischaemic heart disease Pathophysiology
  • 14. Ischaemic heart disease Acute coronary syndromes Atherosclerosis Fatal / non-fatal AMI Unstable angina Coronary Artery spasm
  • 15. Ischaemic heart disease Acute coronary syndromes
    • Fatal AMI
    • Small, fat rich plaques. Plaque RUPTURE. Thrombus in lipid core and on plaques surface. Vessel lumen OCCLUDED.
    • Non - fatal AMI
    • Plaque EROSION rather than rupture. OCCLUSIVE thrombus.
    • Unstable angina
    • Usually mod-severe stenosis. Multiple vessels. Collaterals often formed. Thrombus formation and vasoconstriction. Myocardial infarction may ensue .
  • 16. Ischaemic heart disease Risk factors and prevention
  • 17. Ischaemic heart disease Risk factors and prevention
    • Family History
    • Smoking
    • Hypertension
    • Diabetes Mellitus
    • Hypercholesterolaemia
    • Lack of exercise
    • PRIMARY PREVENTION
  • 18. Ischaemic heart disease Relevance to dentistry
    • IHD is common
    • Subjects with IHD have more severe dental caries and periodontal disease – association or causation?
    • Angina is a cause of pain in the mandible, teeth or other oral tissues
    • Stress provokes ACS!
  • 19. Chest Pain Myocardial ischaemia
    • Site
    • Jaw to navel, retrosternal, left submammary
    • Radiation
    • Left chest, left arm, jaw….mandible, teeth, palate
    • Quality / severity
    • tightness, heaviness, compression…clenched fists
  • 20. Chest Pain Myocardial ischaemia
    • Precipitating/relieving factors
    • physical exertion, cold windy weather, emotion
    • rest, sublingual nitrates
    • Autonomic symptoms
    • sweating, pallor, peripheral vasoconstriction, nausea and vomiting
  • 21. Chest Pain Differential diagnosis
    • Cardiac pathology
      • Pericarditis, aortic dissection
    • Pulmonary pathology
      • Pulmonary embolus, pneumothorax, pneumonia
    • Gastrointestinal pathology
      • Peptic ulcer disease, reflux, pancreatitis, ‘café coronary’
    • Musculoskeletal pathology
      • Trauma, Tietze’s Syndrome
  • 22. Acute Myocardial Infarction
    • 250,000 deaths per year.
    • 150,000 presentations to hospital.
    • 30% of deaths occur in the first 2 hours.
    • (Cardiac muscle death occurs after 45 mins of ischaemia)
  • 23. Acute Myocardial Infarction Assessment
    • Symptoms and signs of myocardial ischaemia
    • Also
      • Changes in heart rate /rhythm
      • Changes in blood pressure
  • 24. Acute Myocardial Infarction Confirming the diagnosis
    • Typical chest pain
    • Electrocardiographic changes
      • ST elevation
      • new LBBB
    • Myocardial enzyme elevation
      • Creatine kinase (CK-MB)
      • Troponin
  • 25. Acute Myocardial Infarction Treatment
    • Stop dental treatment
    • Call for help
    • Rest, sit up and reassure patient
    • Oxygen
    • Analgesia (opiate, sublingual nitrate)
    • Aspirin
    • Prepare for basic life support
  • 26. Acute Myocardial Infarction Medical treatment
    • Rest, oxygen, analgesia, aspirin
    • Thrombolysis
    • Primary angioplasty
    • Beta-Blockers
    • ACE inhibitors
  • 27. Acute Myocardial Infarction Complications
    • Death ( 18% within 1 hour, 36% within 24 hours)
    • Non-fatal arrhythmia
    • Acute left ventricular failure
    • Cardiogenic shock
    • Papillary muscle rupture and mitral regurgitation
    • Myocardial rupture and tamponade
    • Ventricular aneurysm and thrombus
  • 28. Dentistry & Cardiovascular Medicine
    • AMI
      • GA within 3/12 of AMI: 30% re-infarction rate @ 1/52 post op
      • Avoid routine LA dental treatment for 3/12 (emergency treatment only)
      • Avoid excess dosage, reduce anxiety
      • Avoid elective surgery under GA for1 year (specialist)
      • Be aware of medications (bleeding, hypotension)
  • 29. Dentistry & Cardiovascular Medicine
    • ANGINA
      • Take a history…is the condition stable?
      • Medication present esp. GTN
      • Minimise anxiety
      • Prophylactic GTN
      • If angina peri-dental treatment give GTN
      • Consult the physician for anything but minor treatment under LA
      • Consider co-existing pathology and SE of medication
      • Avoid elective surgery under GA for 3/12 in recent onset angina, bundle branch block, unstable angina (specialist)
      • Patients with CABG do not require A/B
  • 30. Dentistry & Cardiovascular Medicine
    • DIABETES
      • Hypoglycaemia (esp.in Type I)
      • Susceptible to oral infection / poor healing
    • HYPERTENSION
      • No contraindication to routine dental treatment
      • Drugs may cause oral pathology e.g.Nifedipine
  • 31. Cardiopulmonary resuscitation Adult basic life support Check responsiveness Open airway Check breathing Breathe Assess 10 sec only Circulation No circulation Continue rescue breathing Compress chest 100 pm, 15:2 Check circulation every minute www.resus.org.uk
  • 32. Cardiopulmonary resuscitation Adult basic life support
    • Ensure safety of rescuer and victim
    • Check responsiveness
    • Shout for help if not responsive
    • Open airway
      • head tilt
      • chin lift
    www.resus.org.uk
  • 33. Cardiopulmonary resuscitation Adult basic life support
    • Check breathing
      • look for chest movement
      • listen over mouth
      • feel air on cheek
    • Breathe
      • 2 slow (2 second) breaths
      • pinch nose closed and open mouth using chin lift
    www.resus.org.uk
  • 34. Cardiopulmonary resuscitation Adult basic life support
    • Assess circulation
      • carotid pulse only if confident…don’t waste time
    • Circulation present
      • continue breathing, check each minute
    • No circulation
      • start chest compressions @ 15:2
      • heal of hand over sternum, straight arms
      • depress 4-5cm, 100 bpm
      • continue until responsive/help/exhausted
    www.resus.org.uk
  • 35. Cardiopulmonary resuscitation Adult basic life support
    • Choking (‘café coronary’)
      • allow coughing
      • 5 blows to the upper back
      • 5 abdominal thrusts
    www.resus.org.uk

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