Chest pain


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Chest pain

  1. 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. 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. 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. 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. 5. Cardiac chest pain Angina & MI- Most common causes of ischemic heart disease related chest pain in the dental office.
  6. 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. 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. 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. 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. 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. 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. 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. 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. 14. Drugs for prevention/treatment of angina Other drugs: Selective beta blockers – Atenolol Non selective beta blockers – Propranalol Calcium channel blockers - Nifedipine
  15. 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. 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. 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. 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. 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.