med emergency- cardiovascular emergencies

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Chapter 11
Angina Pectoris and Myocardial
Infarction

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Objectives
• Upon completion of this chapter, you will
be able to:
– Name the major parts of the heart
– Explain how atherosclerosis affects the
coronary arteries
– Describe the progression of coronary artery
disease
– Define angina pectoris
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Objectives (cont’d.)
– Explain the difference between stable and
unstable angina
– List three precipitating factors of angina
– Describe the signs and symptoms of angina
– Explain how the dentist may diagnose angina
– Describe the treatment for angina
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Objectives (cont’d.)
– List two side effects of nitroglycerin
– Define myocardial infarction
– Describe the signs and symptoms of
myocardial infarction
– Describe the treatment for myocardial
infarction
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Objectives (cont’d.)
– Describe the two differences between angina
and myocardial infarction
– Explain how stress is a precipitating factor of
angina
– Explain what the dental team can do to
prevent angina or myocardial infarction from
occurring in the dental office
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Anatomy of the Heart
• Four chambered, hollow muscular organ
• Pericardium: wall that encloses the heart
– Three layers:
• Epicardium (external layer)
• Myocardium (middle layer)
• Endocardium (inner layer)
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Anatomy of the Heart (cont’d.)
Figure 11-2: Anatomy of the human heart
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Anatomy of the Heart (cont’d.)
• Four chambers:
– Atria: upper chambers
• Separated into right and left sides by the interatrial
septum
– Ventricles: lower chambers
• Separated into right and left sides by the
interventricular septum
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Anatomy of the Heart (cont’d.)
• Right atrium receives blood from all
tissues except for the lungs
– Blood then pumped to the right ventricle,
where pulmonary artery exits and carries
blood to the lungs
• Left atrium receives oxygenated blood
from the lungs via pulmonary veins
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Anatomy of the Heart (cont’d.)
– Left ventricle connected to the aorta and
pumps blood to all the body except the lungs
• Two types of valves in the heart chambers:
– Atrioventricular valves
• Consist of the tricuspid and mitral valves
– Semilunar valves
• Consist of the pulmonary and aortic valves
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Anatomy of the Heart (cont’d.)
• Heart muscle must receive an adequate
supply of oxygenated blood
– Myocardium is supplied with blood by the first
branches of the aorta
– Left coronary artery supplies blood to the left
and right ventricles and left atrium
– Right coronary artery supplies blood to the left
and right ventricles and the right atrium
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Coronary Artery Disease
• Arteriosclerosis (hardening of the arteries)
– Artery walls become thickened and inelastic
• Atherosclerosis (form of arteriosclerosis)
– Affects the coronary arteries and causes
coronary artery disease
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Coronary Artery Disease
(cont’d.)
– Degree of narrowing determines the adverse
effects a patient experiences
• Angina pectoris
• Myocardial infarction
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Angina Pectoris
• Latin phrase: “strangling of the chest”
• Episodes of pain when the heart
experiences oxygen deficiency
• May be the first sign of atherosclerotic
disease
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Signs and Symptoms
• Pain:
– Usually in the substernal area of the chest
– Can be located anywhere in the chest from
the epigastrium to the base of the neck
– May spread to the jaw and teeth
– Patient may describe as pressure/tightness
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Signs and Symptoms (cont’d.)
• Duration of the pain important:
– Usually lasts three to five minutes if
precipitating factors are removed
– Up to forty minutes if precipitating factors are
not removed
– If episode continues longer, myocardial
infarction should be considered
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Signs and Symptoms (cont’d.)
• Physical signs are not very reliable
• Patient may:
– Appear pale or grey, with cold/clammy skin
– Experience a feeling of impending doom
• Pulse rate and blood pressure may
increase slightly
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Classifications of Angina
• Stable:
– Pain occurs from physical exertion or
emotional upset
– Does not alter in frequency, duration, or
intensity within a sixty-day period
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Classifications of Angina
(cont’d.)
• Unstable:
– Unpredictable; can occur even at rest
– Often increases in frequency, duration, and
severity
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Precipitating Factors of Angina
Episodes
• Physical exertion
• Emotional stress
• Eating or drinking something cold
• Bathing
• Dressing
• Sexual activity
• Disturbing dreams
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Diagnosis
• If patient experiences chest pain, dentist
must try to diagnosis it
– Check medical history for cardiac problems
– Can ask the following questions:
• What type of discomfort are you experiencing?
• Where is the location of your discomfort?
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Diagnosis (cont’d.)
• How long did your discomfort last?
• What preceded the discomfort?
• What provided relief?
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Treatment
• Remain calm
• Stop all dental treatment
• Position the patient
• Administer nitroglycerin
• Administer oxygen
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Treatment (cont’d.)
• Administer second dose of nitroglycerin, if
needed
• Summon EMS if needed
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Nitroglycerin
• Coronary vasodilator prescribed for the
prevention or relief of angina
– Helps dilate the coronary arteries to allow
more oxygenated blood to reach the heart
– Rapid action: within 90 seconds
• Side effects
– Orthostatic hypotension
– Severe headaches
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Myocardial Infarction
• Occurs when a portion of the myocardium
dies as a result of oxygen starvation
caused by the narrowing or complete
blockage of the artery
• Can occur in patients who have not
experienced angina pectoris
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Signs and Symptoms
• Compressing, squeezing pain usually
begins in the substernal area and then
spreads
– Pain may vary from severe to almost none
– Pain not relieved by nitroglycerin
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Signs and Symptoms (cont’d.)
• Patient may have:
– Cold and clammy skin
– Vomiting, nausea, dizziness
– Hypotension
– Shortness of breath
– Sweating
– Weakness, extreme fatigue, anxiety
– Feeling of impending doom
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Treatment
• Stop dental treatment
• Administer nitroglycerin
• Summon medical assistance if
nitroglycerin does not relieve pain
• Keep patient quiet and calm
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Treatment (cont’d.)
• Place the patient in whatever position is
most comfortable
• Provide oxygen
• Be prepared to perform CPR
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Differences between Angina and
Myocardial Infarction
• The pain associated with myocardial
infarction is:
– Greater in severity and duration
– Occurs in the absence of physical exertion or
emotional stress
• Angina patient remains motionless
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Differences between Angina and
Myocardial Infarction (cont’d.)
• The myocardial infarction patient moves
about trying to find a comfortable position
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Stress
• Stress plays a major role as a precipitating
factor of angina
• Chest discomfort from a stressful situation
tends to last longer than that caused by
physical exertion
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Prevention
• Better to try to prevent an angina attack
from occurring in the dental office than to
have to treat an episode
– Angina can lead to myocardial infarction
• Be aware of the patient’s medical history
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Prevention (cont’d.)
• Make visit as pain free as possible
• May be necessary to shorten the length of
appointments
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Summary
• Heart disease is the leading cause of
death in the United States
• Dental team should do everything possible
to alleviate undue stress
• Be aware of the signs, symptoms, and
treatment for a cardiac emergency
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