Acute coronary syndrome (ACS) is a
syndrome (a set of
signs and symptoms) due to decreased
blood flow in the
coronary arteries
The coronary arteries are the arterial blood vessels of coronary circulation, which transport oxygenated blood to the heart muscle. The heart requires a continuous supply of oxygen to function and survive, much like any other tissue or organ ...
such that part of the
heart muscle is unable to function properly or
dies Dies may refer to:
* Dies (deity), the Roman counterpart of the Greek goddess Hemera, the personification of day, daughter of Nox (Night) and Erebus (Darkness).
* Albert Christoph Dies (1755–1822), German painter, composer, and biographer
* Jos ...
.
The most common symptom is centrally located pressure-like
chest pain, often radiating to the left shoulder or angle of the jaw, and associated with
nausea
Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. While not painful, it can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of th ...
and
sweating
Perspiration, also known as sweating, is the production of fluids secreted by the sweat glands in the skin of mammals.
Two types of sweat glands can be found in humans: eccrine glands and apocrine glands. The eccrine sweat glands are distri ...
. Many people with acute coronary syndromes present with symptoms other than chest pain, particularly women, older people, and people with
diabetes mellitus
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...
.
Acute coronary syndrome is subdivided in three scenarios depending on the duration of symptoms, the presence of
ECG changes and blood test results:
ST elevation myocardial infarction (STEMI, 30%),
non-ST elevation myocardial infarction (NSTEMI, 25%), or
unstable angina (38%). Generally, when symptoms occur for less than 30 minutes, it is unstable angina. When symptoms are prolonged for more than 30 minutes, the diagnosis is acute
myocardial infarction
A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which ma ...
.
ACS should be distinguished from
''stable'' angina, which develops during physical activity or stress and resolves at rest. In contrast with stable angina, unstable angina occurs suddenly, often at rest or with minimal exertion, or at lesser degrees of exertion than the individual's previous angina ("crescendo angina"). New-onset angina is also considered unstable angina, since it suggests a new problem in a coronary artery.
Signs and symptoms
The cardinal symptom of critically decreased blood flow to the heart is chest pain, experienced as tightness around or over the chest and (often, but not always) radiating to the left arm and the left angle of the jaw. This may be associated with
diaphoresis (sweating),
nausea
Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. While not painful, it can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of th ...
and
vomiting
Vomiting (also known as emesis and throwing up) is the involuntary, forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose.
Vomiting can be the result of ailments like food poisoning, gastroenter ...
, as well as
shortness of breath
Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing di ...
. In many cases, the sensation is "atypical", with pain experienced in different ways or even being completely absent (which is more likely in female patients and those with
diabetes
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...
). Some may report
palpitation
Palpitations are perceived abnormalities of the heartbeat characterized by awareness of cardiac muscle contractions in the chest, which is further characterized by the hard, fast and/or irregular beatings of the heart.
Symptoms include a rap ...
s, anxiety or a
sense of impending doom (
angor animi
Angor animi (also referred to as angina animi,Gairdner's disease. Online Medical Dictionary. ''CancerWeb. Centre for Cancer Education.'' Newcastle University. http://cancerweb.ncl.ac.uk/cgi-bin/omd?query=Gairdner%27s+disease (accessed: May 04, 200 ...
) and a feeling of being acutely ill. The description of the chest discomfort as a pressure has little utility in aiding a diagnosis as it is not
specific for ACS.
Though ACS is usually associated with
coronary thrombosis, it can also be associated with
cocaine
Cocaine (from , from , ultimately from Quechua: ''kúka'') is a central nervous system (CNS) stimulant mainly used recreationally for its euphoric effects. It is primarily obtained from the leaves of two Coca species native to South Am ...
use. Chest pain with features characteristic of cardiac origin (angina) can also be precipitated by profound
anemia
Anemia or anaemia (British English) is a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of hemoglobin. When anemia comes on slowly, t ...
,
brady- or
tachycardia (excessively slow or rapid heart rate),
low or
high blood pressure, severe
aortic valve stenosis (narrowing of the valve at the beginning of the aorta),
pulmonary artery hypertension and a number of other conditions.
Pathophysiology
In those who have ACS,
atheroma rupture is most commonly found 60% when compared to atheroma erosion (30%), thus causes the formation of
thrombus which block the coronary arteries. Plaque rupture is responsible for 60% in ST elevated
myocardial infarction
A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which ma ...
(STEMI) while plaque erosion is responsible for 30% of the STEMI and vice versa for Non ST elevated myocardial infarction (NSTEMI). In plaque rupture, the content of the plaque are lipid rich, collagen poor, with abundant inflammation which is
macrophage predominant, and covered with a thin fibrous cap. Meanwhile, in plaque erosion, the plaque is rich with
extracellular matrix
In biology, the extracellular matrix (ECM), also called intercellular matrix, is a three-dimensional network consisting of extracellular macromolecules and minerals, such as collagen, enzymes, glycoproteins and hydroxyapatite that provide s ...
,
proteoglycan,
glycoaminoglycan, but without fibrous caps, no inflammatory cells, and no large lipid core. After the
coronary arteries
The coronary arteries are the arterial blood vessels of coronary circulation, which transport oxygenated blood to the heart muscle. The heart requires a continuous supply of oxygen to function and survive, much like any other tissue or organ ...
are unblocked, there is a risk of
reperfusion injury due spreading inflammatory mediators throughout the body. Investigations is still underway on the role of
Cyclophilin D
Peptidylprolyl isomerase D (cyclophilin D), also known as PPID, is an enzyme which in humans is encoded by the ''PPID'' gene on chromosome 4. As a member of the peptidyl-prolyl cis-trans isomerase (PPIase) family, this protein catalyzes the cis- ...
in reducing the reperfusion injury.
Other, less common, causes of acute coronary syndrome include spontaneous coronary artery dissection, ischemia in the absence of obstructive coronary artery disease (INOCA), and myocardial infarction in the absence of obstructive coronary artery disease (MINOCA).
Diagnosis
Electrocardiogram
In the setting of acute chest pain, the
electrocardiogram is the investigation that most reliably distinguishes between various causes. The ECG should be done as early as practicable, including in the ambulance if possible. If this indicates acute heart damage (elevation in the ''ST segment'', new
left bundle branch block), treatment for a heart attack in the form of
angioplasty or
thrombolysis is indicated immediately (see below). In the absence of such changes, it is not possible to immediately distinguish between unstable angina and NSTEMI.
Imaging and blood tests
As it is only one of the many potential causes of
chest pain, the patient usually has a number of tests in the
emergency department, such as a
chest X-ray,
blood tests (including
myocardial markers such as
troponin I or T, and
H-FABP and/or a
D-dimer
D-dimer (or D dimer) is a fibrin degradation product (or FDP), a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis. It is so named because it contains two D fragments of the fibrin protein joined by a cros ...
if a
pulmonary embolism is suspected), and telemetry (monitoring of the heart rhythm).
Combination of troponin levels (less than 5 ng/L) with low
TIMI
The Thrombolysis In Myocardial Infarction, or TIMI Study Group, is an Academic Research Organization (ARO) affiliated with Brigham and Women's Hospital and Harvard Medical School dedicated to advancing the knowledge and care of patients with ca ...
scores can help to predict those with low possibility of myocardial infarction and discharge them safely from the emergency department.
Coronary CT angiography combined with Troponin levels is also helpful to
triage those who are susceptible to ACS. F-fluoride
positron emission tomography is also helpful in identifying those with high risk, lipid-rich coronary plaques.
Prediction scores
The ACI-TIPI score can be used to aid diagnosis; using seven variables from the admission record, this score predicts crudely which patients are likely to have myocardial ischemia.
For example, according to a
randomized controlled trial
A randomized controlled trial (or randomized control trial; RCT) is a form of scientific experiment used to control factors not under direct experimental control. Examples of RCTs are clinical trials that compare the effects of drugs, surgical t ...
, males having chest pain with normal or non-diagnostic
ECG are at higher risk for having acute coronary syndrome than women.
In this study, the
sensitivity was 65.2% and
specificity was 44%. This particular study had an 8.4% prevalence of acute coronary syndrome, which means the
positive predictive value
The positive and negative predictive values (PPV and NPV respectively) are the proportions of positive and negative results in statistics and diagnostic tests that are true positive and true negative results, respectively. The PPV and NPV des ...
of being a male with chest pain and having coronary syndrome is 9.6% and
negative predictive value
The positive and negative predictive values (PPV and NPV respectively) are the proportions of positive and negative results in statistics and diagnostic tests that are true positive and true negative results, respectively. The PPV and NPV des ...
is 93.2%
click hereto adjust these results for people at higher or lower risk of acute coronary syndrome).
In a second
cohort study, exercise electrocardiography was similarly found to be a poor predictor of acute coronary syndrome at follow-up.
Of the patients who had a coronary event at 6 years of follow up, 47% had a negative ECG at the start of the study. With an average follow up of 2.21 years the
receiver operating characteristic
A receiver operating characteristic curve, or ROC curve, is a graph of a function, graphical plot that illustrates the diagnostic ability of a binary classifier system as its discrimination threshold is varied. The method was originally develope ...
curves gave resting ECG a score of 0.72 and exercise ECG a score of 0.74.
There are not only prediction scores for diagnosis of ACS, but also prognosis. Most notably, the GRACE ACS Risk and Mortality score helps diagnose, and based upon that score predicts mortality rate of a given patient. It takes into account both clinical (blood pressure, heart rate, EKG findings) and medical history in its scoring system.
Prevention
Acute coronary syndrome often reflects a degree of damage to the coronaries by
atherosclerosis. Primary prevention of atherosclerosis is controlling the risk factors: healthy eating, exercise, treatment for
hypertension and
diabetes
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...
, avoiding
smoking
Smoking is a practice in which a substance is burned and the resulting smoke is typically breathed in to be tasted and absorbed into the bloodstream. Most commonly, the substance used is the dried leaves of the tobacco plant, which have b ...
and controlling
cholesterol
Cholesterol is any of a class of certain organic molecules called lipids. It is a sterol (or modified steroid), a type of lipid. Cholesterol is biosynthesized by all animal cells and is an essential structural component of animal cell memb ...
levels; in patients with significant risk factors,
aspirin
Aspirin, also known as acetylsalicylic acid (ASA), is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain, fever, and/or inflammation, and as an antithrombotic. Specific inflammatory conditions which aspirin is used to treat inc ...
has been shown to reduce the risk of cardiovascular events. Secondary prevention is discussed in
myocardial infarction
A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which ma ...
.
After a ban on smoking in all enclosed public places was introduced in Scotland in March 2006, there was a 17% reduction in hospital admissions for acute coronary syndrome. 67% of the decrease occurred in non-smokers.
Treatment
People with presumed ACS are typically treated with aspirin,
clopidogrel
Clopidogrel — sold under the brand name Plavix, among others — is an antiplatelet medication used to reduce the risk of heart disease and stroke in those at high risk. It is also used together with aspirin in heart attacks and following ...
or
ticagrelor,
nitroglycerin, and if the chest discomfort persists
morphine
Morphine is a strong opiate that is found naturally in opium, a dark brown resin in poppies ('' Papaver somniferum''). It is mainly used as a pain medication, and is also commonly used recreationally, or to make other illicit opioids. T ...
.
Other
analgesics such as
nitrous oxide
Nitrous oxide (dinitrogen oxide or dinitrogen monoxide), commonly known as laughing gas, nitrous, or nos, is a chemical compound, an oxide of nitrogen with the formula . At room temperature, it is a colourless non-flammable gas, and ha ...
are of unknown benefit.
[ Angiography is recommended in those who have either new ST elevation or a new left or right bundle branch block on their ECG.][ Unless the person has low oxygen levels additional oxygen does not appear to be useful.
]
STEMI
If the ECG confirms changes suggestive of myocardial infarction
A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which ma ...
(ST elevations in specific leads, a new left bundle branch block or a true posterior MI pattern), thrombolytics
Thrombolysis, also called fibrinolytic therapy, is the breakdown (lysis) of blood clots formed in blood vessels, using medication. It is used in ST elevation myocardial infarction, stroke, and in cases of severe venous thromboembolism (massive p ...
may be administered or primary coronary angioplasty may be performed. In the former, medication is injected that stimulates fibrinolysis, destroying blood clots obstructing the coronary arteries
The coronary arteries are the arterial blood vessels of coronary circulation, which transport oxygenated blood to the heart muscle. The heart requires a continuous supply of oxygen to function and survive, much like any other tissue or organ ...
. In the latter, a flexible catheter is passed via the femoral or radial arteries and advanced to the heart to identify blockages in the coronaries. When occlusions are found, they can be intervened upon mechanically with angioplasty and usually stent deployment if a lesion, termed the ''culprit'' lesion, is thought to be causing myocardial damage. Data suggest that rapid triage, transfer and treatment is essential. The time frame for door-to-needle thrombolytic administration according to American College of Cardiology (ACC) guidelines should be within 30 minutes, whereas the door-to-balloon Percutaneous Coronary Intervention (PCI) time should be less than 90 minutes. It was found that thrombolysis is more likely to be delivered within the established ACC guidelines among patients with STEMI as compared to PCI according to a case control
Case or CASE may refer to:
Containers
* Case (goods), a package of related merchandise
* Cartridge case or casing, a firearm cartridge component
* Bookcase, a piece of furniture used to store books
* Briefcase or attaché case, a narrow box to ca ...
study.
NSTEMI and NSTE-ACS
If the ECG does not show typical changes, the term "non-ST segment elevation ACS" is applied. The patient may still have had a "non-ST elevation MI" (NSTEMI). The accepted management of unstable angina and acute coronary syndrome is therefore empirical treatment with aspirin, a second platelet inhibitor
An antiplatelet drug (antiaggregant), also known as a platelet agglutination inhibitor or platelet aggregation inhibitor, is a member of a class of pharmaceuticals that decrease platelet aggregation and inhibit thrombus formation. They are effectiv ...
such as clopidogrel, prasugrel or ticagrelor, and heparin (usually a low-molecular weight heparin
Low-molecular-weight heparin (LMWH) is a class of anticoagulant medications. They are used in the prevention of blood clots and treatment of venous thromboembolism (deep vein thrombosis and pulmonary embolism) and in the treatment of myocardial i ...
), with intravenous nitroglycerin and opioid
Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioid use ...
s if the pain persists. The heparin-like drug known as fondaparinux
Fondaparinux (trade name Arixtra) is an anticoagulant medication chemically related to low molecular weight heparins. It is marketed by GlaxoSmithKline. A generic version developed by Alchemia is marketed within the US by Dr. Reddy's Laboratories.
...
appears to be better than enoxaparin.
A blood test is generally performed for cardiac troponins twelve hours after onset of the pain. If this is positive, coronary angiography is typically performed on an urgent basis, as this is highly predictive of a heart attack in the near-future. If the troponin is negative, a treadmill exercise test or a thallium scintigram may be requested.
If there is no evidence of ST segment elevation on the electrocardiogram, delaying urgent angioplasty until the next morning is not inferior to doing so immediately. Using statins in the first 14 days after ACS reduces the risk of further ACS.
In a cohort study comparing NSTEMI and STEMI, people with NSTEMI had a similar risk of death at one year after PCI as compared to people with STEMI (3.4% vs 4.4%). However, NSTEMI had significantly more "major cardiac events" (death, myocardial infarction
A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which ma ...
, disabling stroke
A stroke is a disease, medical condition in which poor cerebral circulation, blood flow to the brain causes cell death. There are two main types of stroke: brain ischemia, ischemic, due to lack of blood flow, and intracranial hemorrhage, hemorr ...
, or requiring revascularization) at one year (24.0% vs 16.6%).
Cocaine
Cocaine (from , from , ultimately from Quechua: ''kúka'') is a central nervous system (CNS) stimulant mainly used recreationally for its euphoric effects. It is primarily obtained from the leaves of two Coca species native to South Am ...
-associated ACS should be managed in a manner similar to other patients with acute coronary syndrome except beta blockers should not be used and benzodiazepines should be administered early.
Prognosis
TIMI score
The TIMI
The Thrombolysis In Myocardial Infarction, or TIMI Study Group, is an Academic Research Organization (ARO) affiliated with Brigham and Women's Hospital and Harvard Medical School dedicated to advancing the knowledge and care of patients with ca ...
risk score can identify high risk patients in non-ST segment elevation MI ACS and has been independently validated.
Global Registry of Acute Coronary Events (GRACE) score
Based on a global registry of 102,341 patients, the GRACE Risk Score
Grace may refer to:
Places United States
* Grace, Idaho, a city
* Grace (CTA station), Chicago Transit Authority's Howard Line, Illinois
* Little Goose Creek (Kentucky), location of Grace post office
* Grace, Carroll County, Missouri, an uninc ...
estimates in-hospital, 6 months, 1 year, and 3-year mortality risk after a heart attack
GRACE Score 2.0 Calculator
Killip class
The Killip class The Killip classification is a system used in individuals with an acute myocardial infarction (heart attack), taking into account physical examination and the development of heart failure in order to predict and stratify their risk of mortality. Ind ...
ification consists of 4 classes based on clinical symptoms. It predicts 30-day mortality after myocardial infarction.
Biomarkers for diagnosis
The aim of diagnostic markers is to identify patients with ACS even when there is no evidence of heart muscle damage.
* Ischemia-Modified Albumin (IMA) – In cases of Ischemia – Albumin undergoes a conformational change and loses its ability to bind transitional metals (copper or cobalt). IMA can be used to assess the proportion of modified albumin in ischemia. Its use is limited to ruling out ischemia rather than a diagnostic test for the occurrence of ischemia.
* Myeloperoxidase (MPO) – The levels of circulating MPO, a leukocyte enzyme, elevate early after ACS and can be used as an early marker for the condition.
* Glycogen Phosphorylase Isoenzyme BB-( GPBB) is an early marker of cardiac ischemia and is one of three isoenzyme of Glycogen Phosphorylase.
* Troponin is a late cardiac marker of ACS
Biomarkers for risk determination
The aim of prognostic markers is to reflect different components of pathophysiology of ACS. For example:
* Natriuretic peptide – Both B-type natriuretic peptide (BNP) and N-terminal Pro BNP can be applied to predict the risk of death and heart failure following ACS.
* Monocyte chemo attractive protein (MCP)-1 – has been shown in a number of studies to identify patients with a higher risk of adverse outcomes after ACS.
Day of admission
Studies have shown that for ACS patients, weekend admission is associated with higher mortality and lower utilization of invasive cardiac procedures, and those who did undergo these interventions had higher rates of mortality and complications than their weekday counterparts. This data leads to the possible conclusion that access to diagnostic/interventional procedures may be contingent upon the day of admission, which may impact mortality. This phenomenon is described as weekend effect
In healthcare, the weekend effect is the finding of a difference in mortality rate for patients admitted to hospital for treatment at the weekend compared to those admitted on a weekday. The effects of the weekend on patient outcomes has been a c ...
.
Valvular heart disease
Valvular heart disease is characterized by damage to or defective in one of the four heart valves: the mitral, aortic, tricuspid or pulmonary. Some types of valvular heart disease include valvular stenosis, valvular prolapse and regurgitation.
Oral manifestations
Oral infections may pose risk during postoperative period of heart valve surgery. Oral health in patients scheduled for heart valve surgery is poorer than in individuals without valve disease. Most of them experience periodontitis due to high dental plaque
Dental plaque is a biofilm of microorganisms (mostly bacteria, but also fungi) that grows on surfaces within the mouth. It is a sticky colorless deposit at first, but when it forms tartar, it is often brown or pale yellow. It is commonly found be ...
scores, reflecting poorer dental hygiene. This situation could favour the appearance of bacteremia following tooth brushing in these individuals. Bacteremia secondary to periodontal infection is known to be one of the primary causes of infectious endocarditis
Infective endocarditis is an infection of the inner surface of the heart, usually the valves. Signs and symptoms may include fever, small areas of bleeding into the skin, heart murmur, feeling tired, and low red blood cell count. Complicatio ...
, particularly in patient with heart valve disorders. Therefore, treatment of dental disease should be done prior to performing heart surgery. Periodontal treatment is advised in patients with advanced periodontitis
Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. In its early stage, called gingivitis, the gums become swollen and red and may bleed. It is considered the main cau ...
, followed by root planing
Scaling and root planing, also known as conventional periodontal therapy, non-surgical periodontal therapy or deep cleaning, is a procedure involving removal of dental plaque and calculus (scaling or debridement) and then smoothing, or planing, ...
and ultrasound
Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies ...
treatment. Those teeth not amenable to treatment and with poor prognosis should be removed as pre-surgical preventive measures.
Dental management
The two main concerns during dental treatment for people of patient with valvular heart disease are the risk of infective endocarditis and bleeding in anti coagulated patients. Endocarditis
Endocarditis is an inflammation of the inner layer of the heart, the endocardium. It usually involves the heart valves. Other structures that may be involved include the interventricular septum, the chordae tendineae, the mural endocardium, or the ...
is more likely to occur in patients who have previously had endocarditis and those with certain cardiac lesions. Risk of a normally functioning prosthesis being infected after a dental procedure is probably no higher than risk in patient with damaged native valves. However, mortality and morbidity is much higher should prosthesis become infected. Patient with native valve disease can often stop or reduce their anticoagulants, but those with prosthetic valves should not discontinue anticoagulants without cardiological advice. Mechanical mitral valves are prone to thrombosis
Thrombosis (from Ancient Greek "clotting") is the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system. When a blood vessel (a vein or an artery) is injured, the body uses platelets (th ...
, which cause emboli
An embolism is the lodging of an embolus, a blockage-causing piece of material, inside a blood vessel. The embolus may be a blood clot (thrombus), a fat globule ( fat embolism), a bubble of air or other gas ( gas embolism), amniotic fluid ( amn ...
if adequate anti-coagulation is not maintained, although short term modification may be possible.
Heart failure
Heart failure
Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome, a group of signs and symptoms caused by an impairment of the heart's blood pumping function. Symptoms typically include shortness of breath, excessive fatigue, ...
(HF) is defined as the incapacity of the heart to function properly, pumping insufficient blood towards the tissues and leading to fluid accumulation within the lungs, liver and peripheral tissues.
Oral manifestations
Most if not all patients with heart failure will be undergoing drug treatments for their condition and these drugs can produce a series of oral manifestation. In this context, angiotensin-converting enzyme (ACE) inhibitors such as captopril and enalapril can produce burning mouth sensation lichenoid reactions and a loss of taste sensation, while diuretic
A diuretic () is any substance that promotes diuresis, the increased production of urine. This includes forced diuresis. A diuretic tablet is sometimes colloquially called a water tablet. There are several categories of diuretics. All diuretics i ...
s like furosemide can produce xerostomia.
Dental management
Consultation with the supervising physician is highly advised in order to understand the patient's current condition and the medication prescribed. The patient should be receiving medical care, and heart failure should be compensated. Dental treatment is to be limited to patients who are in stable condition, since these people are at a high risk of developing questionable arrhythmias and even sudden death secondary to cardiopulmonary arrest. Stress and anxiety
Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
are to be avoided during the visits, which in turn should be brief (< 30 minutes) and are to be scheduled for the morning sessions. The patient should be seated on the chair in a semi-supine position, with control of body movements (which should be slow), to avoid orthostatic hypotension
Orthostatic hypotension, also known as postural hypotension, is a medical condition wherein a person's blood pressure drops when standing up or sitting down. Primary orthostatic hypertension is also often referred to as neurogenic orthostatic hyp ...
. In patients who has been administered with digitalis agents (digoxin, methyl-digoxin), the vasoconstrictor
Vasoconstriction is the narrowing of the blood vessels resulting from contraction of the muscular wall of the vessels, in particular the large arteries and small arterioles. The process is the opposite of vasodilation, the widening of blood vess ...
dose should be limited to two anaesthetic carpules, since this drug combination can cause arrhythmias. Aspirin
Aspirin, also known as acetylsalicylic acid (ASA), is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain, fever, and/or inflammation, and as an antithrombotic. Specific inflammatory conditions which aspirin is used to treat inc ...
(acetylsalicylic acid) can lead to fluid and sodium retention, and therefore should not be prescribed in patients with heart failure.
In emergency (i.e., lung edema
Pulmonary edema, also known as pulmonary congestion, is excessive liquid accumulation in the tissue and air spaces (usually alveoli) of the lungs. It leads to impaired gas exchange and may cause hypoxemia and respiratory failure. It is due to ...
), after contacting the emergency service, the patient should be seated with the legs lowered, and receiving nasal oxygen at a rate of 4–6 liters/minute. Sublingual nitroglycerin tablets are indicated (0.4-0.8 mg), and the dose may be repeated every 5 or 10 minutes if blood pressure is maintained.
Arrhythmia
Arrhythmias are variations in normal heart rate due to cardiac rhythm, frequency or contraction disorders. The most common type of cardiac arrhythmia is atrial fibrillation.
Oral manifestations
Many anti-arrhythmic drugs have side effects such as gingival hyperplasia or xerostomia.
Dental management
Consultation with the supervising physician is also advised in order to understand the patient's current condition and the type of arrhythmia involved, as well as the medication prescribed. It must be checked that the patient uses the medication correctly. Stress and anxiety can be reduced with anxiolytics. Short visits in the morning are to be preferred. Patient monitoring, with recording of the pulse, is indicated before treatment. It is very important to limit the use of vasoconstrictor in local anesthesia
Local anesthesia is any technique to induce the absence of sensation in a specific part of the body, generally for the aim of inducing local analgesia, that is, local insensitivity to pain, although other local senses may be affected as well. It ...
, with no more than two carpules. The treatment planned should not be too long or complicated. Although modern pacemakers are more resistant to electromagnetic interferences, caution is required when using electrical devices like ultrasound and electric scalpels that might interfere with pacemakers – especially the older models, since such devices developed in the last 30 years are bipolar and are generally not affected by the small electromagnetic fields generated by dental equipment. It is therefore important to know the type of pacemaker, the degree of electromagnetic protection of the generator, and the nature of the arrhythmia. If arrhythmia develops during dental treatment, the procedure should be suspended, oxygen is to be given, and the patient vital signs are to be assessed: body temperature (normal values: 35.5-37oC), pulse (normal values: 60-100 bpm), respiratory frequency (normal values in adults: 14-20 cycles or respirations per minute), blood pressure (normal values: systolic blood pressure under 140 mmHg and diastolic blood pressure under 90 mmHg). Sublingual nitrites are to be administered if there is chest pain. The patient should be placed in the Trendelenburg position, with vagal maneuvering where necessary (valsalva maneuver
The Valsalva maneuver is performed by a forceful attempt of exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut while expelling air out as if blowing up a balloon. Variations of the maneuver can ...
, massage in the carotid pulse region). The dental team should be prepared for basic cardiopulmonary resuscitation
Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spont ...
and initiation of the emergency procedure for evacuation to a hospital centre, if necessary.
See also
* Allergic acute coronary syndrome (Kounis syndrome)
References
External links
{{DEFAULTSORT:Acute Coronary Syndrome
Medical emergencies
Ischemic heart diseases
Syndromes affecting the heart