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Ischaemic Heart Disease Clinical Aspects Dr Chris Gale Clinical Research Fellow Medical Research Council University of Leeds
Aims and Objectives <ul><li>Ischaemic   heart   disease </li></ul><ul><ul><li>Definition, manifestations, epidemiology, ae...
Ischaemic heart disease Definition
Ischaemic heart disease Definition
Ischaemic heart disease Definition <ul><li>An imbalance between the  supply   of   oxygen  and the  myocardial   demand  r...
Ischaemic heart disease Definition <ul><li>Supply </li></ul><ul><ul><li>Atheroma, thrombosis, spasm, embolus </li></ul></u...
Ischaemic heart disease Manifestations <ul><li>Sudden death </li></ul><ul><li>Myocardial infarction </li></ul><ul><li>Acut...
Ischaemic heart disease Epidemiology <ul><li>Commonest cause of death in the Western world. (up to 35% of total mortality)...
Ischaemic heart disease Aetiology
Ischaemic heart disease Aetiology <ul><li>Fixed </li></ul><ul><ul><li>Age, Male, +ve family history </li></ul></ul><ul><li...
Ischaemic heart disease Pathophysiology
Ischaemic heart disease Pathophysiology <ul><li>Response to injury hypothesis </li></ul><ul><li>ATHEROSIS </li></ul><ul><l...
Ischaemic heart disease Pathophysiology
Ischaemic heart disease Acute coronary syndromes Atherosclerosis Fatal /  non-fatal AMI Unstable angina Coronary Artery sp...
Ischaemic heart disease Acute coronary syndromes <ul><li>Fatal   AMI </li></ul><ul><li>Small, fat rich plaques.  Plaque RU...
Ischaemic heart disease Risk factors and prevention
Ischaemic heart disease Risk factors and prevention <ul><li>Family History </li></ul><ul><li>Smoking </li></ul><ul><li>Hyp...
Ischaemic heart disease Relevance to dentistry <ul><li>IHD is common </li></ul><ul><li>Subjects with IHD have more severe ...
Chest Pain Myocardial ischaemia <ul><li>Site </li></ul><ul><li>Jaw to navel, retrosternal, left submammary </li></ul><ul><...
Chest Pain Myocardial ischaemia <ul><li>Precipitating/relieving factors </li></ul><ul><li>physical exertion, cold windy we...
Chest Pain Differential diagnosis <ul><li>Cardiac   pathology </li></ul><ul><ul><li>Pericarditis, aortic dissection </li><...
Acute Myocardial Infarction <ul><li>250,000 deaths per year. </li></ul><ul><li>150,000 presentations to hospital. </li></u...
Acute Myocardial Infarction Assessment <ul><li>Symptoms and signs of myocardial ischaemia </li></ul><ul><li>Also </li></ul...
Acute Myocardial Infarction Confirming the diagnosis <ul><li>Typical chest pain </li></ul><ul><li>Electrocardiographic cha...
Acute Myocardial Infarction Treatment <ul><li>Stop dental treatment </li></ul><ul><li>Call for help </li></ul><ul><li>Rest...
Acute Myocardial Infarction Medical treatment <ul><li>Rest, oxygen, analgesia, aspirin </li></ul><ul><li>Thrombolysis </li...
Acute Myocardial Infarction Complications <ul><li>Death ( 18% within 1 hour,   36% within 24 hours) </li></ul><ul><li>Non-...
Dentistry & Cardiovascular Medicine <ul><li>AMI </li></ul><ul><ul><li>GA within 3/12 of AMI: 30% re-infarction rate @ 1/52...
Dentistry & Cardiovascular Medicine <ul><li>ANGINA </li></ul><ul><ul><li>Take a history…is the condition stable? </li></ul...
Dentistry & Cardiovascular Medicine <ul><li>DIABETES </li></ul><ul><ul><li>Hypoglycaemia (esp.in Type I) </li></ul></ul><u...
Cardiopulmonary resuscitation Adult basic life support Check responsiveness Open airway Check breathing Breathe Assess 10 ...
Cardiopulmonary resuscitation Adult basic life support <ul><li>Ensure safety of rescuer and victim </li></ul><ul><li>Check...
Cardiopulmonary resuscitation Adult basic life support <ul><li>Check breathing </li></ul><ul><ul><li>look for chest moveme...
Cardiopulmonary resuscitation Adult basic life support <ul><li>Assess circulation </li></ul><ul><ul><li>carotid pulse only...
Cardiopulmonary resuscitation Adult basic life support <ul><li>Choking  (‘café coronary’) </li></ul><ul><ul><li>allow coug...
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- "Ischemic Heart Disease - Clinical Patterns" (Leeds Dental ...

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

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

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