Angina Pectoris (Dental Practitioner)

The term angina is derived from the ancient Greek word for a chocking sensation.

Obstruction of the arterial supply to the myocardium is one of the most common health problems dentists encounter.

Angina is a symptom of ischemic heart disease produced when myocardial blood supply cannot be sufficiently increased to meet the increased oxygen requirement that result from coronary artery disease

This condition occurs primarily in men over 40 and is also prevalent in postmenopausal women.

Aetiology:

  • The basic disease process is a progressive narrowing or spasm (or both) of one or more of the coronary arteries.
  • The most frequent cause of  angina is
    • Atheromatous obstruction of the large coronary vessels, coronary atheroma,  which is termed atherosclerotic, classical or stable angina. In this form of angina, pain occurs when myocardial oxygen demand increases such as during exercise- it is therefore ‘angina of effort
    • Angina can also result from the transient spasm of localized sections of coronary vessels. This form of angina is classified as Prinzmetal’s  or variant angina and can occur at rest.
    • Unstable angina is angina that occurs suddenly at rest or with minimal physical activity and increases in severity and frequency. This form of angina heralds the occurance of myocardial infarction (death of an area of myocardium due to blockage or prolonged occlusion of a coronary artery) and results from platelet aggregation at a site of a ruptured atheromatous plaque. Treatment with aspirin, which inhibit platelet aggregation, has been found to reduce the risk of myocardial infarction by approximately 50% in patients with unstable angina.
  • This leads to a discrepancy between the myocardial oxygen demand and the ability of the coronary arteries to supply oxygen-carrying blood.
  • Myocardial oxygen demand can be increased, for example, by exertion, emotion (such as anxiety), or during digestion of a large meal.
  • There are a large number of risk factors, some of which are fixed and others modifiable:
    • Fixed:
      • Age
      • Male gender
      • Family History
    • Modifiable (Hard):
      • Hyperlipidemia
      • Smoking
      • Hypertension
      • Diabetes
    • Modifiable (Soft):
      • Obesity
      • Lack of exercise
      • High intake of alcohol
      • Personality
      • Oral contraceptive

Clinical Features:

  • Clinical Features depend on the rate and severity of narrowing of the vessels and the degree of oxygen demand of the cardiac muscle.
  • The myocardium becomes Ischemic, Producing a heavy pressure or squeezing sensation (sudden very severe pain) in the patient’s substernal region that can radiate into the left shoulder and arm. Very occasionally the pain may radiate to the left mandibular region.
  • The pain is caused by the accumulation of metabolites, such as adenosine, released from myocardium that has become ischematic due to an imbalance in oxygen supply relative to oxygen demand.
  • The patient may complain of an intense sense of being unable to breath adequately (shortness of breath).
  • Stimulation of vagal activity commonly occurs with nausea, sweating, and bradycardia.

If the symptoms persist for longer than 15 minutes and don’t respond to rest or anti-anginal medication then you must consider the possibility of an MI (Myocardial Infarction).

The discomfort typically disappears once the myocardial work requirements are lowered or the oxygen supply to the heart muscle is increased.

Sources:

  • Contemporary Oral and Maxillofacial Surgery, 5th Edition
    Hupp. Ellis III. Tucker
  • Handbook of Local Anesthesia 5th Edition Stanley F. Malamed
  • Essential Human Disease for Dentists
    Sproat. Burke.  McGurk
  • Pharmacology and Dental Therapeutics, 3rd Edition
    Seymour. Meechan. Yates
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