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Note: This is a quick reference review for the management of coronary artery disease (CAD) which causes stable angina, unstable angina, and myocardial infarction. The article also assumes that the reader has a background knowledge in medicine. This article was written by a dental student using notes and textbooks as references. Please feel free to comment with any suggestions or changes. This article is intended to be used as a reference. If you are experiencing any of these symptoms please consult a physician.

Coronary artery disease is usually characterized by substernal chest pressure.

Risk factors include smoking, high BP, diabetes, hypercholesterolemia, stress, anxiety.

Symptoms include chest pain in the form of ache, pressure, squeeze, a heavy feeling, palpitations, and syncope. There are few signs to look for unless CAD is accompanied by cardiac heart failure.

Underlying diseases include HTN, hyperlipidemia (xanthoma), and diabetes (retinal changes).

Lab findings of the following can contribute to or worsen CAD: anemia, hyperthyroidism, diabetes, lipids, homocysteine, and C-reactive protein (CRP).

There are various cell markers that can indicate CAD. Myocardial specific cell markers include troponin I, troponin T and these show up about 3 hours post injury. A trauma specific cell marker includes creatine kinase (CK-MB).

Diagnosis is done by EKG, chest xray, echocardiography, cardiac catheterization and angiogram. A stress test can be performed: nuclear injection -> perfusion -> exercise -> Bruce-Protocol and EKG.

Stable Angina is predictable and for the most part constant. Think of it as a ‘99% blockage’. Treatment includes treating associated diseases, decreasing risk factorsand lifestyle modifications. Likely medications include NG, long lasting nitrates, antiplatelets, beta blockers, CCB’s, and ACE inhibitors. Patients may also have undergone revascularization surgery such as angioplasty - stents, coronary artery bypass graft using mammary arteries or saphenous vein.

Dental treatment of MI >1mo: AM appointments, comfortable chair position, vital signs, NG on hand. Stress reduction in the form of communication, oral sedation, nitrous, and good local anesthesia for pain control.

• limit epinephrine to 2 carpules of 1:100,000 epinephrine
• avoid retraction cord w/ epinephrine
• excellent pain control
• avoid anticholinergics (scopolamine/atropine)
• patients may be on an aspirin regimen - keep them on aspirin but be prepared to control the bleeding.

Unstable Angina is a new changing pain at rest. Results from a small plaque that ruptures (not a 99% blockage) and blocks or occludes an artery suddenly. Avoid elective care and get a consult from a physician. There are no oral manifestations but there may be pain in the lower jaw and lower teeth which can be a symptom of abnormal angina. Drug related signs may be xerostomia, taste change, stomatitis, and bleeding (anticoagulants). Patients may be on nitrates, BB’s, CCB’s, Ace Inhibitors, statins, and aspirin.

Dental treatment of MI <1mo: Defer treatment until patient is stable. In an emergency such as pain, infection or bleeding prophylactic NG can be given. Consider an IV line, sedation, oxygen, EKG and pulse ox. Caution should be used with epinephrine. Carbocaine (mepivicaine) is a better alternative because it has no epinephrine.

Acute coronary syndrome is a term used to encompass clinical symptoms associated with a MI. Patients should be taken to the hospital immediately. Early treatment includes chewing aspirin and an anticoagulant (heparin/LMWH).

Other facts:

• Ischemia can be seen on an EKG as a T wave inversion
• Acute MI can be seen as an ST elevation (greater than 4mm) and should be treated immediately.