Hypertension & Ischemic Heart Disease

Dr.Ziad H. Delemi B.D.S, F.I.B.M.S (M.F.)

Mosul university- College of dentistry-oral & maxillofacial surgery department
DENTALMANAGEMENTOF THE MEDICALLYCOMPROMISED PATIENT
Hypertension & Ischemic Heart Disease

Mosul university- College of dentistry-oral & maxillofacial surgery department

Blood pressure resulting from cardiac out put multiplied by peripheral arteriolar resistance, cardiac out put resulted from heart rate multiplied by stroke volume. As in the following equation : B.P.= C.O. * P.R. C.O.= H.R. * S.V.
Normal physiology

Mosul university- College of dentistry-oral & maxillofacial surgery department

Hypertension: is a persistently raised blood pressure resulting from increased peripheral arteriolar resistance, & it is used to describe patient with blood pressure more than 140/90 mmHg.
Age (>55 ♂; > 65 ♀)Diabetes mellitus Family historyObesityPhysical inactivityTobacco usage, particularly cigarettesAlcoholism Major Risk Factors:

Mosul university- College of dentistry-oral & maxillofacial surgery department

CLASSIFICATION OF BLOOD PRESSURE IN ADULTS 18 OR OLDER
DIASTOLIC
SYSTOLIC
Pressure (mm Hg)
Pressure (mm Hg)
Category
< 85
< 130
Normal BP
85-89
130-139
High Normal BP
Hypertension
90-99
140-159
Stage I
100-109
160-179
Stage II
110-119
180-209
Stage III
> 120
> 210
Stage IV
From the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure.


Mosul university- College of dentistry-oral & maxillofacial surgery department
Signs and symptoms
Signs: Early : Increase blood pressure reading Narrowing of retinal arterioles Retinal hemorrhage Advanced Protein urea papilledema Angina pectoris Hematuria

Mosul university- College of dentistry-oral & maxillofacial surgery department

Symptoms: Occipital headache Failing vision Ringing ears dizziness Weakness Tingling of hand and feet
Signs and symptoms

Mosul university- College of dentistry-oral & maxillofacial surgery department

Oral Manifestations of Antihypertensives drugs
Lichenoid drug reactions------- (thiazides, beta blockers). Gingival hyperplasia----------------- (Ca channel blockers). Altered taste ---------------(beta blockers, ACE inhibitors). Lupus-like lesions -------------(direct vasodilators mouth). Angioedema / cough -----------------------(ACE inhibitors). Burning mouth -----------------------------(ACE inhibitors). Xerostomia. salivary gland swelling or pain. Erythema multiforme. Facial palsy (malignant hypertension). Nausea and vomiting. Excessive bleeding post operatively and trauma

Mosul university- College of dentistry-oral & maxillofacial surgery department

Medical treatment of hypertension
Treat the secondary causes Weight reduction in obese patients Stop smoking, avoid salty food, avoid stress Drugs :Diuretics (Frusemide, Thaizide) Beta-blocker (Tenormin, Inderal) Captopril (ACEI , Capotin) Calcium antagonist (Nephidipin, Verapamil) Vasodilator (Prazocine) Na-nitroprusside

Mosul university- College of dentistry-oral & maxillofacial surgery department

Dental management of patient with hypertension
Detection & referral if blood pressure >180/110 mm.Hg Reduce stress & anxiety Terminate procedure if the patient over stressed Avoid orthostatic hypotension Avoid stimulation of gag reflex Drug consideration: use minimal LA with adrenaline <0.036mg aspirate before injection &inject slowly avoid adrenalin socked gingival cord avoid GA


Mosul university- College of dentistry-oral & maxillofacial surgery department
Relative contraindications of using LA with adrenalin:
Sever & very sever uncontrolled hypertension. Refractory cardiac arrhythmia. Recent myocardial infarction (less than 6months). Recent stroke (less than 6months). Unstable angina. Recent coronary artery bypass graft (less than 3months). Uncontrolled congestive heart failure. Uncontrolled hyperthyroidism.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Ischemic Heart Disease
Coronary atherosclerosis involves atherosclerotic process affect the intima of the artery then thickening & thus narrowing of the lumen & diminished blood flow & oxygen supply.Major Risk Factors :Tobacco use.Physical inactivity.ObesityHigh blood pressure.Diabetes (Doubles the risk of CVD)High levels of cholesterol(LDL’s & HDL’s)

Mosul university- College of dentistry-oral & maxillofacial surgery department

Angina Pectoris
It is a transient myocardial ischemia resulting from imbalance between coronary blood flow & oxygen demand

Mosul university- College of dentistry-oral & maxillofacial surgery department

Signs & symptoms of angina pectoris
Chest discomfort or central chest pain as compression or tightness or heaviness or squeezing or constriction. Referred pain to tip of left shoulder or along medial side of forearm Choking sensation or pain of teeth in the left side mandible Breathlessness some times is the only presentation

Medical Management of Angina

Medications Nitrates (Angised, Isordil))Beta blockers (Tenormin) Calcium channel blockers (Adalat) Anti-platelet agents (aspirin)Antihyperlipidemics (Simvastatin)Surgery 1- mechanical revascularization 2-Percutaneous transluminal coronary angioplasty/ “balloon” angioplasty / stent3-Coronary artery bypass graft (CABG)


Mosul university- College of dentistry-oral & maxillofacial surgery department
Stent Placement
mechanical revascularization

Mosul university- College of dentistry-oral & maxillofacial surgery department

Coronary Artery By-Pass Graft (CABG)

Mosul university- College of dentistry-oral & maxillofacial surgery department

Dental Management of Stable Angina &Post-MI more than 6 months
Minimize time in waiting room.Short, morning appointments.Preop, intra-op, and post-op vital signs.Pre-medication as needed:anxiolytic (diazepam, medazolam); night before and 1 hour beforeHave nitroglycerin available – may consider using prophylacticalyUse pulse oximeter to assure good breathing and oxygenation.Nitrous oxide/oxygen intraoperatively (if needed.)Excellent local anesthesia - use epinephrine, if needed, in limited amount (max 0.04mg) or levonordefrin (max. 0.20mg).Avoid epinephrine in retraction cord.If patient taking warfarin PT less than 2times INR.If patient taking aspirin daily 100mg no effect clinically.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Myocardial infarction
is a complete obstruction of blood flow of one or more coronary arteries by a thrombus & there is rupture of athermanous plaque which lead to necrosis & cardiac damage & may lead to sudden death due to arrhythmia (ventricular fibrillation or asystole)

Mosul university- College of dentistry-oral & maxillofacial surgery department

Signs & symptoms of Acute MI
1-Sever retroseternal chest pain lasting from 1\2 – 1 hour. 2-Ant. MI sympathetic stimulation (pallor, sweating, tachycardia).3-Inf. MI parasympathetic stimulation (vomiting, Bradycardia).4-Breathlessness. 5-Syncope or collapse. 6-Extreme tiredness & weakness. Investigation
History ECG after 6h. (ST elevation ) then permanent Q wave Cardiac enzymes (Troponins, creatinine phosphokinase CPK, lactate dehydrogenase LDH, Echo. CXR


Mosul university- College of dentistry-oral & maxillofacial surgery department
Medical Management of Acute MI
Early prehospital supportive care. Coronary care unit monitoring(DC shock to treat VF) Early use of thrombolytics (streptokinase, Alteplase) Indicated only for use in patients with ST-segment elevation MI Coronary angioplasty . Coronary artery by-pass graft (CABG). Adjunctive pharmacologic therapy (O2, narcotics morphine, plasil , anxiolytics, beta-blockers, aspirin, heparin, warfarin, nitrates, calcium-channel blockers, digitalis, ACE inhibitors).

Mosul university- College of dentistry-oral & maxillofacial surgery department

Dental Management ofUnstable Angina or MI less than 6 months
Avoid elective care Consultation with physician . For urgent care: be as conservative as possible; do only what must be done (e.g. infection control, pain management) Prophylactic nitroglycerin. Consider treating in outpatient hospital facility or refer to hospital dentistry. ECG, pulse oximetry, IV line.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Intraoperative Chest Pain
Stop procedure Give nitroglycerin If after 5 minutes pain still present, give another nitroglycerin If after 5 more minutes pain still present, give another nitroglycerin If pain persists, assume MI in progress and call an ambulance Give aspirin tablet to chew and swallow Monitor vital signs, administer oxygen, and be prepared to provide life support