2. Symptoms that include pressure, tightness, or a heavy weight.

3. Substernal, epigastric or jaw pain

4. Mild to moderate discomfortMANAGEMENT.<br />Step 1 : TERMINATION OF THE PROCEDURE.<br />When the patient experiences chest pain, stop all dental procedures immediately.In many instances the precipitating may be a part of the dental treatment , such as the sight of a local anesthetic syringe, scalpel, or hand piece and simply by terminating the procedure the acute episode of the chest pain ends.<br />Step 2 (position): the angina patient is conscious and usually apprehensive. Position of the patient in the most comfortable manner. Commonly this will be sitting or standing upright. The supine position is rarely preferred by the angina patient and, infact, commonly makes the pain appear subjectively more intense.<br />Step 3 A-B-C (airway-breathing-circulation). Basic life support (BLS), as needed. The angina patients is conscious ,breathing spontaneously, and has a palpable pulse in the wrist, anticubital fossa and carotid artery. <br />Step 4 : (definitive care)<br />Step 4a :administration of vasodilator and oxygen .<br />A member of the emergency team should immediately get the emergency kit and oxygen. Oxygen may be administered at any time to the angina patient. A nasal cannula or nasal hood is preferred. As soon as possible, give nitroglycerin trans mucosally (nitroligual spray) or sublingually (tablet). The patient’s own nitro glycerin supply is preferred because the dosage will be correct for the patient. The no of sprays or tablet administered is determined by patient usually requirement (0.3-0.6 mg) is the usually dosage. One or two metered sprays are recommended initially, with no more than 3 metered dozes with a 15 minute period where as sublingual nitroglycerine tablets are recommended at one tablet at every 5 minutes as needed, with no more than 3 tablets every 15 minutes .in the dental office the use of nitro lingual sprays preferred to sublingual sprays because of the relative instability of the tablets.<br />EFFECTS AND SIDEEFEECTS OF NITROGLYCERINE.<br />Nitroglycerine normally reduces or eliminates angina discomfort dramatically within 2-4 minutes. Commonly observed side effects are a fullness or pounding in the head, flushing, tachycardia, and possible hypotension . The presence of hypotension represents a contraindication.<br /> ACTION OF NITROGLYCERINE.<br />Decreases coronary artery resistance and increases coronary blood flow. The probable mechanism is its ability to produce a decrease in systematic vascular resistance through arterial and venous dilation. Thus leads to a decrease in return of venous blood to heart and a decrease in cardiac output which results in a lessened cardiac work load. A decrease in cardiac work produces a lesser oxygen requirement of the myocardium and reversal of the oxygen in sufficiency that existed during the episode.<br />Step 4b : ADMINISTRATION OF ADDITIONAL VASODILATORS IF NECESSARY.<br />If the patients nitroglycerine tablets are ineffective in terminating angina pain within 5 minutes, give a second dose either from the patients drug supply or from the emergency kit , which will be fresher than the patients. Nitroglycerin tablets lose potency unless stored in tightly packed glass containers. Nitroglycerine spray is considerably more stable than sublingual tabs. A second possible explanation for the failure of nitroglycerine to provide relief is that the episode is not due to angina, but due to ACUTE MYOCARDIAL INFARCTION.<br />Step 4c : SUMMONING OF MEDICAL ASSISTANCE.<br />The American heart association recommends that in a patient with known angina pectoris, emergency medical care be sought if chest pain is not relieved by 3 nitroglycerine tablets or spray doses over a 10-minute period. In a person with previously unrecognized coronary disease, the persistence of chest pain for 2 minutes or longer is an indication for emergency medical assistance.<br />USE OF AMYL NITRATE.<br />Amyl nitrate is available in 0.3ml ampules, which are then crushed and inhaledthe patient should be in the supine position. It is used when the angina episode is severe and unrelieved by nitroglycerine and unless the patient has high BP .<br />EFFECTS AND SIDE EFFECTS OF CALCIUM SLOW CHANNEL BLOCKERS.<br />Patients known to have coronary artery spasm as a component of their angina episodes usually respond well to the administration of nifidipine (10-20mg) sublingually.<br />Nifedipine, verapamil & diltiazem are calcium channel blockers. Verapamil is the most important one.<br />By blocking calcium influx & supply to the myocardial contractile mechanism , verapamil exerts a direct depressant effect on the ionotropic state & therefore on the myocardial oxygen requirement. It also reduces contractile tone on in vascular smooth muscle , which results in coronary and peripheral vasodilation, which inturn reduces systemic vascular resistance.<br />Pain relieving opioids such as morphine & meperidine (Demerol) should not be used because they donot treat the cause of pain .<br />STEP 5 : MODIFICATION OF FURTHER DENTAL THERAPY .<br />Dental treatment may resume at any time(immediately if necessary) after cessation of the acute angina episode . permit the patient to rest until he/she is comfortable before resuming dental care or discharge.monitor and record vital signs before discharging the patient. The patient may be permitted to leave the office unescorted &operate a motor vehicle or do some activity. If the doubt persist about the recovery, seek medical assistance. <br />PATIENT WITH NO HISTORY OF CHEST PAIN<br />When no prior history of chest pain is present, but the patient experiences chest pain during dental treatment, the steps of angina management discussed earlier are appropriate, with the exception that medical assistance be sought immediately even before the administration of nitroglycerin & oxygen.<br />TERMINATE THE DENTAL PROCEDUREP-POSITION PATIENT COMFORTABLY A-B-C- ASSESS AND PERFORM BLS AS NEEDEDD- INITIATE DEFINITE CARE. H/O ANGINA NO H/O ANGINA (ADMINISTER ( SUMMON EMERGENCY NITROGLYCERINE) MEDICAL ASSISTANCE) ADMINISTER OXYGEN ADMINISTER OXYGEN PAIN RESOLVES ADMINISTER NITROGLYCERINE (MODIFY FUTURE DENTAL CARE) MONITOR VITAL SIGNS(IF NO RESPONE, OR IF PAIN RESOLVES,BUT RETURNS ). SUNMMON EMERGENCY MEDICAL ASSISTANCE.ADMINISTER FIBRINOLYSIS( ASPIRIN)MONITOR AND RECORD VITAL SIGNS <br />MANAGEMENT OF CHEST PAIN WITH HISTORY OF ANGINA PECTORIS<br />