- Chest pain can be caused by cardiac or non-cardiac issues. Cardiac causes include angina and myocardial infarction, while non-cardiac includes muscle strain, pericarditis, esophagitis, and pulmonary embolism. - Angina is chest pain or discomfort due to temporary lack of oxygen to the heart muscle, usually brought on by exertion or stress, and relieved by rest. Myocardial infarction is a more severe type of chest pain caused by cell death in the heart muscle due to an obstruction of blood flow. - For a patient presenting with chest pain, the dentist should discontinue treatment, activate emergency support, monitor vitals, and provide definitive care such as oxygen

1. Chest pain
Causes:
-
Cardiac related
-
Non cardiac related
-
Cardiac related:
- Angina pectoris
- Myocardial Infarction
Non cardiac related:
- Muscle strain (musculoskeletal)
- Pericarditis
- Eosophagitis
- Pulmonary embolism
- Acute indigestion
- Intestinal “ gas”

2. Chest pain
Non cardiac chest pain – (to be differentiated from cardiac type)
- Sharp, knife like chest pain that increases in intensity
with inspiration and diminishes with exhalation and
usually not related with cardiac syndromes.

3. Non cardiac chest pain
Musculoskeletal pain : Results from muscle strain that occurs after
exercise or physical exertion.
Pain is normally localized, does not radiate and gets aggravated by
breathing and movement.
Use of heating pad / mild analgesics may give relief.
Pericarditis: Mostly results from virus infection.
Pain similar to Angina / MI, but aggravation occurs during breathing &
swallowing.
Fever present before its onset.
Relief occurs on bending forward from the waist.
-
-

4. Non cardiac chest pain
Eosophagitis: Substernal / epigastric burning pain produced by
eating/lying down after meal. Relieved by antacids.
Pulmonary embolism: Severe chest pain associated with coughing up
of blood – tinged sputum.
Pain of indigestion & “gas”: Sharp & knife like, increasing in
intensity with breathing, which helps to differentiate from pain of ischemic
heart diseases.

5. Cardiac chest pain
Angina & MI- Most common causes of ischemic heart
disease related chest pain in the dental office.

6. Angina Pectoris
Angina (Latin word) = Spasmodic/suffocating pain.
Pectoris (Latin word) = Chest.
- Thoracic pain – Squeezing, dull aching, and heavy.
- As a result of a moderate inadequacy of the coronary
circulation (myocardial ischemia ) with out myocardial
necrosis.
Usually substernal, precipitated by exercise, emotion or a
heavy meal, radiating to the left shoulder, left arm,
hand and fingers, left side of neck, face and mandible.
Relieved by vasodilator drugs and a few minutes rest.

7. Angina Pectoris
Clinical features:
Type of pain
Dull, pressure
Duration
2-5 mnts. Always < 15-20 mnts
Onset
Gradual
Location
Substernal
Reproducible
With exertion
Associated symptoms
Present
Palpation of chest wall
Not painful

8. Angina Pectoris
Predisposing factors:
Lipo protein disorders, smoking, hypertension, Insulin
resistance & diabetes, exercise & obesity, mental
stress & cardiovascular risk, estrogen status (risk
increases with high levels)
Precipitating factors:
Exercise, hot humid environment, cold weather, large
meals, stress, smoking, high altitudes etc.

9. Angina Pectoris- Types
Stable angina: Results from Coronary artery obstruction by atheromatous
plaque.
Triggered by 4 „E s‟: exercise, emotion, cold and eating.
Pain – last for 1-15 mnts, builds gradually to max: intensity. Relieved by rest /
administration of nitroglycerin.
Variant angina (Prinzmetal‟s angina): Occur at rest. Nitroglycerin
relieves pain.
Calcium channel blockers –main form of treatment to reduce the incidence of acute
events.
Unstable angina: Result of atherosclerotic progression. High chance of
getting MI. Precipitated by the factors for angina. It occurs at rest (or with minimal
exertion) lasting for more than 20 mnts. Extremely significant to dentistry because
of the associated risk of MI.

10. Angina Pectoris
Medical management:
Main aim: Eliminate myocardial ischemia by either
decreasing myocardial oxygen requirement or increasing
oxygen delivery to the heart.
- Bed rest.
- Administration of nitrates (including IV‟s nitroglycerin).
- Beta blockers and calcium channel blockers.
- Psychological rest & reassurance.
- If no improvement, surgical intervention.
- Only emergency dental care should be considered.

11. Management of chest pain with a H/o Angina pectoris
Recognize problem
Discontinue dental treatment
Activate office emergency team
Position patient comfortably
Assess ABC
Provide definitive management

12. Management of chest pain with a H/o Angina pectoris
With H/o Angina:
-Administer vasodilator & Oxygen
- If pain resolves, consider future dental treatment modifications, vital signs.
- If pain doesn‟t resolve – activate EMS, administer aspirin, monitor & record vital signs
.
With no H/o Angina:
- Activate EMS immediately, administer oxygen & consider nitroglycerin, monitor & record.

13. Drugs for prevention/treatment of angina
NITRATES
GENERIC NAME
ROUTE OF ADMINISTRATION
DOSAGE
Nitroglycerin
Sublingual tablet
0.15 – 0.9 mg
Sublingual spray
0.4 mg
Transdermal patch
0.2 – 0.8 mg every 12
hrs
IV‟s
5 – 200 µg / min
Isosorbid dinitrate
Oral
5 – 80 mg twice/thrice
daily
Isosorbid mononitrate
Oral
20 – 40 mg twice daily

14. Drugs for prevention/treatment of angina
Other drugs:
Selective beta blockers – Atenolol
Non selective beta blockers – Propranalol
Calcium channel blockers - Nifedipine

15. Acute Myocardial Infarction
Due to deficient coronary arterial blood supply to a
region of myocardium that results in cellular death
& necrosis.
Severe & prolonged substernal pain similar to, but
more intense & of longer duration than Angina
pectoris.

16. Acute Myocardial Infarction
Predisposing factors:
- Coronary artery disease
-
- Obesity - Stress - Family history of CVS diseases
- Abnormal ECG - High BP - Enlarged heart size - High blood cholesterol -
-

17. Acute Myocardial Infarction
Signs & symptoms:
Pain – Severe to intolerable.
Prolonged, ≥30 mnts.
Crushing, choking
Retrosternal
Radiates to left arm, hand, shoulders, neck and jaw.
Nausea & vomiting, weakness, dizziness, palpitations,
restlessness, skin – cool, pale and moist.

18. Management of chest pain with a H/o MI
Recognize problem
Discontinue dental treatment
Activate office emergency team
Position patient comfortably
Assess ABC
Provide definitive management

19. Management of chest pain with a H/o MI
With H/o Angina:
- Follow protocol for patients with angina
With no H/o Angina:
- Activate EMS immediately.
- Administer Oxygen & consider Nitroglycerin.
- Administer aspirin, manage pain, monitor & record vital
signs.
- Prepare to manage complications (eg: sudden cardiac
arrest).
- Stabilize & transfer to hospital emergency department.