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Myocardial infarction (often called a

coronary thrombosis or heart attack) is


the most severe and lethal form of
coronary heart disease.

This implies death of the heart muscle.


Secondary to coronary artery disease,
there is infarction of the heart muscle.
 Coronary (Ischaemic) heart disease (IHD) is the result of
progressive myocardial ischaemia due to persistently
reduced coronary blood flow, usually because of
atherosclerosis (atheroma).
 Hypertension is a major contributory factor. Other
contributory factors are :
- Smoking
- High fat diets (hyperlipidaemia)
- Lack of exercise
- Genetic component (in some cases)
 Higher incidence of IHD in :
- Hyperlipoproteinaemias
- Diabetes mellitus
- Hypothyroidism
 IHD itself causes no symptoms but impaired coronary blood flow
causes progressive damage to the heart, can go on to cardiac
failure and can cause dysrhythmias.
 Usually the first signs of IHD are its dramatic complications,
namely angina pectoris or myocardial infarction without warning
or history of heart disease.
 Angina pectoris and myocardial infarction are the main acute
manifestations of IHD.
 Aspirin, beta – blocker and cholesterol – lowering appear to be the
most effective way to treat patients with IHD.
 Between 30 and 50 percent of patients die within the first hour
after the attack of MI and a further 10 – 20 percent within the next
few days.
CAUSES

Most commonly occlusion of coronary


vessels occurs. Anoxia, ischemia and
infarct are present.
SIGNS AND SYMPTOMS
1. Crushing chest pain or crushing retrosternal pain
(a) More severe than angina, possibly radiating to
left arm, shoulder, neck, jaw (on rare occasions
pain is felt in the left mandible alone).
(b) Longer than 15 minutes.
(c) Not relieved by nitroglycerin tablets.
(d) Squeezing or heavy feeling.
(The patient usually clutches his chest with the
fist which is known as Levine’s Sign).
2. Cyanosis, pale or ashen appearance.
3. Weakness
4. Cold sweat
5. Nausea, vomiting
6. Air hunger and fear of impending death
7. Increased, irregular pulse beat of poor
quality and containing palpitations.
8. Feeling of impending doom.
 A significant number of patients (diabetics and
elderly) have silent (painless) infarctions. This
may be due to hyposensitivity to pain, including
dental pain.

 In about 10 percent of cases pain is slight or even


absent and the first sign of a myocardial infarct
may then be the sudden onset of left ventricular
failure, shock, loss of consciousness or death.
Characteristic electrocardiographic (ECG)
changes and the release of heart muscle enzymes
into the blood confirm the diagnosis.
9. The signs of left ventricular failure are :
(a) Cold extremities, hypotension
(b) Oliguria
(c) Low volume pulse, low pulse
pressure.
(d) Quite first heart sound
(e) 3rd heart sound
(f) Fine crepts at bases of lungs.
9. Signs of tissue damage are
(a) Fever
(b) Leucocytosis
(c) Raised ESR
POTENTIAL PROBLEMS RELATED TO DENTAL CARE
1. Stress and anxiety related to dental visit could precipitate
an anginal attack, myocardial infarction or sudden death in
the office.
2. Patient may have some degree of congestive heart failure.
3. Electrical interference could occur with the use of certain
dental equipment if pacemaker in place.
4. Use of excessive amount of epinephrine could precipitate a
dangerous elevation of blood pressure if patient taking a
non-selective beta – blocker.
5. Patient taking aspirin, other platelet aggregation inhibitor
or coumadin could experience excessive bleeding with
invasive dental procedures.
6. Potential exists for endarteritis of coronary artery stent in
the immediate post-placement period as a result of dentally
induced bacteremia
ORAL MANIFESTATIONS
Usually none as a direct result of MI;
however, may see drug-related
changes such as dry mouth, taste
changes or stomatitis; also may have
excessive post surgical bleeding due to
platelet aggregation inhibition or
anticoagulation
DIAGNOSIS
Diagnosis is based on history, characteristic symptoms,
signs and investigations.
Characteristic sign and symptoms :
 Changes in heart rate
 Dysrhythmias
 Hypotension
 Shock
 Fever and leucocytosis
 ECG changes
 Rise in serum enzymes.
INVESTIGATIONS
1. Electrocardiography (ECG) : the most sensitive and specific method to
diagnose MI. Occasionally, ECG may be normal initially, but changes
appear later on, hence, ECG should be repeated after at least 12 hours of
pain chest to detect the changes. The changes are seen in ST segment and
T wave. The earliest change is ‘ST’ segment elevation followed by
appearance of ‘Q’ wave and ‘T’ wave inversion.
2. Blood Test :
 Leucocytosis
 Raised ESR
 Plasma enzymes : The cardiac muscle is rich in enzymes which are
released within few hours of MI and their peak levels appear. The
enzymes most widely studied are :
i. CK (Creatinine Kinase)
ii. AST (Aspartate aminotransferase)
iii. LDH (Lactic acid dehydrogenase)
3. Chest X–ray: to detect acute pulmonary oedema
or congestion, pericardial effusion, cardiomegaly
etc.
4. Echocardiography: for assessing ventricular
function and detecting complications such as
ventricular septal or chordae tendinae rupture etc.
5. Radionuclide scanning : to assess left ventricular
function. Infarct ‘avid’ scanning is possible
because some isotopes i.e. pyrophosphate are
taken up by freshly infracted myocardium, hence
is useful in diagnosis of those patients who have
non-specific ECG changes and normal cardiac
enzyme levels.
MANAGEMENT
 The patient should be kept at rest, reassured as well as
possible and given oxygen by a face mask.
 Morphine, 10 mg., preferably by slow i.v. injection (2
mg/min) or upto 15 mg i.m. according to the size of the
patients, plus cyclizine 50 mg, or alternatively, nitrous
oxide with at least 28 percent oxygen, should be given to
relieve pain.
 Ventricular fibrillation is an important cause of death, but
controllable by defibrillation.
 If there is cardiac arrest the patient must be given external
cardiac massage and oxygen or mouth – to – mouth
ventilation.
 Thrombolytic agent and aspirin may be indicated.
 Aspirin 75 mg. daily or 300 mg. on alternate days
 Stop smoking, low fat intake, more exercise.
 Beta – blockers, particularly atenolol or metoprolol given i.v. in the acute
phase, can lessen mortality and oral propranolol or timolol, in the
convalescent stage, can reduce the risk of recurrence after a myocardial
infarct, but such drugs are contraindicated for patients with asthma or in
heart failure.
Various steps in treatment of MI patients are :
1. Place patient in most comfortable position.
2. Administer oxygen at 10 L/min. flow
3. Activate EMS (911 call)
4. Monitor and record vital signs
5. Reassure patient
6. CPR
DENTAL MANAGEMENT
Prevention of Problems :
 Recent myocardial infarction (<1 month)
(major risk) :
Elective dental care should be postponed if
possible, if necessary, should be provided
in consultation with physician.
Management may include establishment of
IV line, sedation, electrocardiogram, pulse
oximeter, cautious use of vasocons-trictors,
and prophylactic nitroglycerine.
 Past myocardial infarction (more than 1 month) (minor
intermediate risk):
Elective dental care may be provided with these considerations:
(a) Short, morning appointments, comfortable chair position,
pretreatment of vital signs, nitroglycerine available, stress
reduction measures, limit quantity of vasoconstrictor, avoid
epinephrine in retraction cords, avoid anticholinergics, ensure
pain control.
(b) If patient taking aspirin, excess bleeding usually
controllable by local measures only.
(c) If patient taking coumadin, international normalized ratio
should be 3.5 or less for invasive procedures.
(d) If coronary artery stent in place, prophylactic antibiotics
should be provided for dental procedures likely to result in
significant bleeding for first 2 –4 weeks only.
TREATMENT PLANNING MODIFICATIONS

 Recent myocardial infarction : Dental Rx should be limited


to that which is absolutely necessary such as for infection or
pain.
 Past myocardial infarction : Any desired dental Rx may be
provided, taking into consideration appropriate management
considerations.

General anesthesia is contraindicated after a recent MI,


though the risk declines with time. The prognosis of
recurrent infarction is also influenced by the time after the
first attack; elective surgery under GA should therefore be
postponed for at least 3 months and preferably a year.
COMPLICATIONS
1. Immediate :
(a) Arrhythmias and conduction disturbances
(b) Post – myocardial angina
(c) Acute circulatory failure
(d) Pericarditis
(e) Mechanical complications like papillary muscle
dysfunction, rupture of ventricle.
(f) Mural thrombosis and embolism
(g) Sudden death
2. Late Complications :
(a) Post–myocardial infarction syndrome (Dressler’s
syndrome).
(b) Ventricular aneurysm.