• Angina pectoris is the name given to

paroxysms of severe ischaemic chest pain

which are typically precipitated by effort and
relieved by rest.
or
• It is a clinical syndrome of episodic chest
discomfort resulting from transient
myocardial ischaemia, produced by exertion,
emotion or stress and which is relieved by
rest or nitrates.

• The usual cause of angina is coronary

atherosclerosis.
 PATHOPHYSIOLOGY
• Angina occurs when the oxygen demands of
the myocardium exceed that which is provided
to it by the coronary arteries.
• The pain is due to ischemia and usually
persists till the oxygen supply is restored or the
demand for oxygen reduces.
• There is no permanent damage to the
myocardium
 Precipitating Factors
• Physical exertion
• Stress
• Heavy meals
• Lying flat (angina decubitus)
• Cold exposure
• Smoking
• Emotional disturbances
• Vivid dreams (nocturnal angina)
• Some patients feel pain during initial
period of walking but later on, it does not
come up despite greater effort called ‘start –
up angina’.
• Angina occuring on lying flat or in
recumbent position is called ‘angina
decubitus’, seen in patients with heart failure.
• Angina at night is called ‘nocturnal angina’.
It is usually precipitated by vivid dreams.
Stable Angina
Angina is termed stable if it occurs only on exertion and is
relieved by rest, within 10 minutes and there have been no
changes in the frequency or duration of symptoms or
precipitating factors within the previous 60 days.
 
Unstable Angina
Is that in which there are changes in pattern, frequency or
duration of precipitating factors, sudden onset angina is
considered to be unstable.
 
Prinzmetal’s Angina
Is angina at rest, commonly at night and is caused by
coronary artery spasm.
 CLINICAL FEATURES
• More common in males
• Age 40 to 60 years
• Tightness, heaviness, compression or constriction of the chest
may be complaints but the pain is rarely of the unbearable,
crushing and persistent nature of myocardial infarction.
• The typical site is behind the sternum radiating to the left
particularly, sometimes to the left upper arm and occasionally
to left mandible, teeth, tongue or palate.
• Patients who develop angina often have no history of heart
disease
• The mortality rate in angina is about 4 percent per year.
 SIGNS AND SYMPTOMS
1. Substernal pain or pain referred to arms, neck or
abdomen.
2. Pain lasting less than 15 minutes and possibly
radiating to the left shoulder.
3. Positive response to nitroglycerine.
4. Vital signs are normal
5. No hypotension, sweating or nausea occurs
 POTENTIAL PROBLEMS RELATED TO
DENTAL CARE
1. Stress and anxiety related to dental visit could precipitate
an anginal attack, MI, or sudden death in the office.
2. For patient taking a non-selective beta blocker, the use of
excessive amount of epinephrine could precipitate a
dangerous elevation of blood pressure.
3. Patient taking aspirin or other platelet aggregation inhibitor
could experience excessive bleeding.
4. Potential to cause endarteritis of coronary artery stent in the
immediate post-placement period exists as a result of
dentally induced bacteremia.
 ORAL MANIFESTATIONS

  Usually none as a direct result of

angina, 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
 INVESTIGATIONS
1. Resting ECG : may be absolutely normal or may show
changes of previous myocardial ischaemia (changes in ST – T
waves).
2. Exercise ECG (Stress test) : the most widely used test in the
diagnosis of ischaemic heart dz. involves 12 – lead ECG
recording before, during and after exercise on a tread mill or
using a bicycle ergometer.
The flat ST segment depression more than 1 mm. below the
baseline and lasting longer than 0.08 second is taken as
positive stress test.
3. Isotope scanning : done by intravenous administration of a
radioisotope (Thallium – 201) to assess regional myocardial
perfusion by gamma camera. The images are recorded at rest,
immediately after exercise and 2-4 hours later.
4. Coronary angiography
 MANAGEMENT
AIMS AND OBJECTIVES :

1. To identify and control risk factors.

2. To assess the severity, extent of the
disease and any contributory factor.
3. To control symptoms.
4. To improve the life expectancy.
TREATMENT:
  Although the pain of angina can be relieved by rest it is
more quickly relieved by giving nitrates, such as glyceryl
trinitrate (nitroglycerin), which lowers peripheral vascular
resistance and reduces the oxygen demands of the heart.
   Amyl nitrate, isosorbide dinitrite and erythrityl tetranitrate
are also used.
   Calcium channel blockers (like Nefidipine, Verapamil) and
occassionaly potassium channel activators (like Nicorandil) may
be used.
   Aspirin often prescribed for anti – platelet activity.
• Artery or vein coronary by pass grafts, or angioplasty, may be
used to improve the coronary flow when angina fails to respond
to drugs using saphenous vein, or percutaneous transluminal
coronary angioplasty (PTCA) are commonly used both resulting
in a 5 year survival of over 85 percent.
Steps in Rx-
1. Place patient in semi-reclining or sitting
– up position with head elevated.
2. Administer nitroglycerin 0.3mg. tablet
sublingual or spray amyl nitrate bud (3
tablet, 1 tablet every 5 minutes upto a total
of 3 tablets).
3. Administer oxygen at 10 L/min. flow.
4. Put patient at rest and give reassurance.
5. Monitor and record vital signs.
 DENTAL MANAGEMENT
• Dental care should be carried out with effective local analgesia,
minimal anxiety, oxygen saturation and BP and pulse monitoring
and at short appointments.
• Adrenaline – containing LA solutions are satisfactory but a
maximum of 4 ml. solution containing 1 in 80,000 adrenaline
should be used.
• Gingival retraction cords containing adrenaline should be
avoided.
• Mepivacaine 3 percent is preferable for use in patients taking
beta – blockers.
• Preoperative glyceryl trinitrate and oral sedation, with intra –
operative nasally delivered oxygen and ECG / BP monitoring are
adviced.
PREVENTION OF PROBLEMS
Unstable Angina (Major risk) :
Elective dental care should be postponed if
possible; if care is necessary, it should be provided
in consultation with physician. Management may
include establishment of IV line, sedation,
electrocardiogram, pulse oximeter, cautious use of
vasoconstrictor and prophylactic nitroglycerin.
Stable Angina (low – intermediate risk) :
Elective dental care may be provided with the following
management considerations :
(a)   Short, morning appointments, comfortable chair position,
pretreatment vital signs, nitroglycerin available, stress
reduction measures, limit quantity of vasoconstrictor,
avoid epinephrine in retraction cords, avoid
anticholinergics, ensure excellent intraoperative and
postoperative pain control.
(b)  If patient taking aspirin, excess bleeding is usually
controllable by local measures only.
(c)  If coronary artery stent in place, prophylactic antibiotics
may be provided for dental procedures likely to result in
significant bleeding for first 2-4 weeks only.
TREATMENT PLANNING MODIFICATIONS

Unstable Angina
Dental RX should be limited to that which is
absolutely necessary, such as for infection or pain.
 
Stable Angina
Any desired dental treatment may be provided
taking into consideration appropriate management
considerations.
ANGINA IN DENTAL OFFICE
• If a patient experiences chest pain, dental RX must be
stopped.
• If there is history of angina, the patient should be
given glyceryl trinitrate 0.5 mg. sublingually and
oxygen, and be kept sitting upright.
• Vital signs should be monitored.
• The pain should be relieved in 2-3 minutes, the
patient should then rest and be accompanied home.
• If chest pain is not relieved within about 5 minutes,
myocardial infarction is the probable cause and
medical help should be summoned
 ADVICE TO PATIENTS WITH ANGINA
To be Done Not to be Done

  Maintain ideal body weight   Smoking

  Regular restricted physical   Undue over excitement

exercise
 Sublingual nitrate before   Overindulgence in alcohol,
undertaking exertion sexual activity

  Change in life style  Sternuous or unaccustomed

exercise
    Sudden exposure to cold
weather
    Heavy meals