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  • Most myocardial infarctions occur when the lumen of one of the cardiac vessels becomes so narrow or blocked that blood cannot pass through, or if an atheromatous plaque ruptures and blocks the lumen.  

    • Either event can result in ischemia, and when the oxygen deficit is prolonged, the area of myocardium supplied by that particular vessel may undergo necrosis.  

  • Ischemic myocardial pain results from an imbalance between the oxygen supply and the oxygen demand of the the muscle.  

  • Complications of myocardial infarction include weakend heart muscle, which results in acute congestive heart failure, postinfarction angina, infarct extension, cardiogenic shock, pericarditis and arrhythmias.  

  • Causes of death in a patient who has had an acute MI include ventricular fibrillation, cardiac standstill, congestive heart failure, embolism, and rupture of the heart wall or septum.

Myocardial Infarction

Introduction

Risks to the dental patient

Management During Treatment

  • During the first few weeks after an MI increased risk for reinfarction and life-threatening arrhythmias

  • Patient may be on antiplatelet agents or on coumadin and subject to increased bleeding

Questions to Ask 

  • Patients with unstable angina or very recent MI who require immediate treatment

Clinical Findings 

  • Patients, particularly women may have atypical pain referred to the neck, lower jaw or teeth.  The pattern of pain with activity and disappearance of pain at rest indicates pain of cardiac origin.

Prevention 

  • Stress reduction protocol

  • Determine INR before invasive procedures if on blood thinners

  • Elective treatment should be postponed for patients within 6 months of an MI or for a patient with unstable angina.

  • If treatment becomes necessary, perform as conservatively as possible, directed toward pain relief, infection control or control of bleeding. Assess the risk of treatment compared to the benefits of treatment.  

  • Use of NSAIDs should be avoided in patients with cardiovascular disease, particularly with a history of MI - NSAIDS for only 7 days increases the risk of subsequent MI.

  • Local anesthetic with vasoconstrictor should be avoided if possible.  If indicated, cardiac dose of vasoconstrictor can be used with caution.

  • Avoid all epinephrine impregnated gingival retraction cord.

  • Local hemostatic measures should be used rather than decreasing the dosage of any anticoagulant or antiplatelet.  If INR is greater than 3.5, treatment should be postponed until INR is less than 3.5

Post-Operative Care

  • Adequate pain relief

References

Dental Management of the Medically Compromised Patient.  Little, Falace, Miller and Rhodus. 8th Edition

Medical Consultation Recommended 

  • When was your last heart attack?

  • How many heart attacks have you had?

  • Do you have congestive heart failure or arrhythmias?

  • Do you continue to have chest pain (see Ischemic Heart Disease)?

  • What do you do for exercise?

  • What medications are you taking?  Are you taking these medications as directed?

  • How often do you see your physician?

  • Are you anxious or fearful about dental treatment?

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