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Coronary heart disease

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Definition

Coronary atherosclerosis manifests itself in coronary heart disease.
Due to narrowing of the coronary arteries perfusion and oxygen supply of the cardiac muscles are reduced (myocardial ischemia).
The progression of coronary sclerosis is asymptomatic for rather a long period of time.
Angina pectoris (breast pang) only occurs with a higher degree of stenosis and under physical and psychic strain. Increasing stenosis results in unstable angina pectoris with a smooth transition to myocardial infarction.

Acute coronary syndrome is a collective term for angina pectoris symptoms in connection with ECG changes indicative of myocardial ischemia.
These symptoms range from unstable angina to an acute infarction. However, this differentiation is not necessary for the initial treatment of a patient whose medical history and complaints are indicative of acute coronary syndrome.
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Causes

Risk factors of atherosclerosis include:
  • Lipid metabolism disorders
  • Hypertension
  • Diabetes mellitus
  • Smoking

Symptoms of angina pectoris

  • Chest pain, narrowing sensation in the chest, retrosternal pressure (stenocardia)

    The imbalance between supply of and demand for myocardial oxygen lead to local myocardial ischemia resulting in chest pain once a certain extent is reached.
    In angina pectoris, myocardial ischemia is reversible without subsequent necrosis.

    The location of pain may vary:
    • Primarily behind the sternum (retrosternal)
    • Radiating to the left arm, right arm, neck, mandible, shoulder, finger tips
  • Anxiety
  • Agitation
  • Short duration, usually < 5 minutes
Angina pectoris can be stable, i.e. it may be provoked by certain exertion and is then relieved by nitroglycerin.
The following situations are referred to as unstable angina pectoris:
  • Any first manifestation of angina
  • Angina with the slightest exertion
  • Angina at rest
  • Angina of increasing duration, severity and frequency
  • Increasing amounts of anti-angina medication are required
The guiding symptom of CHD is angina pectoris

Risk in management

Physical or psychic stress, i.e. pain, can result in an increased myocardial oxygen demand.
  • Angina pectoris attack as a result of this stress
  • Risk of myocardial infarction

Risk reduction

  • Minimisation of stress
    • Only short treatment sessions in the morning
    • Painless treatment through effective local anaesthesia
    • Patient should take the nitroglycerin preparation home
  • Pre-medication (2.5-5mg valium)
  • Monitoring (a changing pulse rate and rhythm indicate excessive strain on the patient)
  • Obtain i.v. access
  • Dental treatment only in exceptional cases in case of:
    • Unstable angina pectoris
    • Myocardial infarction < 6 months

Management of angina pectoris attacks

  1. Place the patient in a sitting position, elevate the upper body
  2. Administer nitroglycerin unless the patient suffers from hypotension (systolic blood pressure <90mm/Hg)
    1-2 puffs of nitroglycerin spray
    Nitroglycerin is the drug of choice.
    Dose: 1-2 capsules sublingual (have patient bite the capsule through) or 2-4 puffs
    One capsule contains 0.8mg, one stroke 0.4mg
    Effect: arterial vasodilation with improved oxygen supply of the heart and reduction of angina pectoris disorders
  3. Administration of oxygen via a nasal tube (4-6 L/min)
  4. Establish i.v. access
  5. I.v. administration of diazepam (fractioned, 2-5-7-10 mg) or
    Slow i.v. administration of 2-5 mg morphine
  6. While performing these emergency measures, have someone call an emergency service

Signs of imminent myocardial infarction

  • Increased frequency and severity of angina pectoris attacks
  • Duration of pain > 5 minutes
  • Nausea, pale skin, sweating
    It is not possible to clinically differentiate between an angina pectoris attack and myocardial infarction.
If ischemia leads to focal necrosis of the myocardium, this is referred to as myocardial infarction.