Managing coronary ischaemic syndromes in dental practice
Coronary ischaemic syndromes include stable angina and acute coronary syndromes (eg ST elevation myocardial infarction, non–ST elevation acute coronary syndrome).
Typical symptoms of an acute coronary syndrome include crushing or heavy central chest pain that may radiate to the arms, neck, back and jaw, shortness of breath, nausea and sweating. However, atypical presentations are also common. Some patients, particularly elderly patients or patients with diabetes, have no pain.
Patients with stable angina experience episodic retrosternal chest discomfort (pain or tightness) that lasts 10 minutes or less and subsides promptly with rest. It is commonly triggered by physical activity or emotional stress. However, new or increasing symptoms indicate an acute coronary syndrome, which is a medical emergency.
In dental practice, follow the advice in Management of angina or an acute coronary syndrome in dental practice for first-aid management of patients with angina or an acute coronary syndrome.
Ensure that patients with a history of angina bring their medication (eg glyceryl trinitrate spray or tablets) when presenting for dental treatment, and have it in a readily accessible place.
If chest pain occurs in a patient with a history of angina:
- Stop dental treatment.
- Measure blood pressure, heart rate and pulse oximetry.
- Assess consciousness by talking to the patient.
- To relieve symptoms, use glyceryl trinitrate. Ask the patient to sit down (because of the possibility of hypotension), then give:
1 glyceryl trinitrate spray 400 micrograms sublingually, repeat every 5 minutes if pain persists, up to a total of 3 doses if tolerated
OR
1 glyceryl trinitrate tablet 300 to 600 micrograms sublingually, repeat every 5 minutes if pain persists, up to a total of 3 doses if tolerated.
If pain persists for more than 10 minutes despite taking 2 doses of glyceryl trinitrate, give a third dose and manage as for severe or new chest pain (see below).
If the patient recovers, do not proceed with dental treatment; refer for medical evaluation even if the patient appears well.
If chest pain is severe or new:
- Call 000.
- For patients with a history of angina, give glyceryl trinitrate as above.
- For all patients, give:
aspirin 300 mg orally, chewed or dissolved before swallowing.
- Measure blood pressure, heart rate and pulse oximetry.
- Start supplemental oxygen if SaO2 is less than 90%, and titrate to SaO2 90 to 96% if possible.
- Provide reassurance until assistance arrives.
- If the patient loses consciousness, start basic life support (for ‘Basic life support flow chart’, see Basic life support flow chart). Use an automated external defibrillator if available.