How Can I Treat A Patient With Previous Myocardial Infarction (MI)?
This medical Condition Consult is presented by the JCDA Oasis Team. The consult is also available through the JCDA Oasis Mobile
| Myocardial infarction (MI) is a consequence of obstruction in the coronary artery blood supply to the heart, resulting in death of the myocardium. Predisposing risk factors include atherosclerosis (thickening of arterial wall caused by the accumulation of lipid plaques), obesity, smoking, hyperlipidemia, family history of MI, and undue stress. |  |
| LA/Vasoconstrictors | Drug Interactions | |
| Use vasoconstrictors with caution, due to increased risk for adverse outcomes1. Increased risk of cardiac arrhythmias in patients taking digitalis (e.g., digoxin).2. Increased risk of a hypertensive episode followed by bradycardia in patients taking nonselective beta-blockers (e.g., propranolol).3. Risk of complications increases with high doses of vasoconstrictors | Prescribe with caution
1. NSAIDs and ASA with Digoxin, Captopril, Propranolol: limit prescribing to 4 days or less. 2. Antibiotics (e.g., erythromycin, tetracycline) with Digoxin, Propranolol. 3. Barbiturates, benzodiazepines with Digoxin, Verapamil, Lovastatin. |
| Recommended | Effects on Bleeding | |
| 1. Epinephrine-containing local anesthetic can be used with minimal risk if the dose is limited to 0.036 mg epinephrine (2 cartridges containing 1:100,000 epi) or 0.20 mg levonordefrin (2 cartridges containing 1:20,000 levo)2. AVOID the use of epinephrine-impregnated retraction cord and epinephrine 1:50,000 concentrations. | Increased risk, monitor patient
Low-dose ASA (75–325 mg/day), antiplatelet agents (e.g. clopidogrel), and oral anticoagulants (e.g., warfarin) can increase the risk of surgical and postoperative bleeding. |
| Defer Elective Care | Scheduling of Visits | |
| Delay routine dental treatment for 6 weeks if patient has had a revascularization procedure (i.e. coronary artery bypass graft or stent placement). | Short, morning appointments for stress and anxiety reduction. |
| General Treatment | Orthostatic Hypotension | |
| 1. Prior to dental treatment, ask the patient about unstable angina and exercise tolerance.2. Prescribe adequate analgesia during the appointments to minimize pain, discomfort, and anxiety. | 1. Consider semisupine chair position for patients with cardiovascular disease.2. Discharge patient slowly to avoid orthostatic hypotension. |
| Oral Manifestations | ||
| Xerostomia
Taste changes Stomatitis Gingival hyperplasia |
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Could you please confirm the maximum recommended cartridges for Lidocaine 2% with epinephrine 1:100 000?
As per an Update on Local Anesthetics in Dentistry by Dr.Haas,it is supposed to be 13 but Malamed says it should be 11.
As per the calculation max epinephrine dose for a healthy individual is 0.2mg, which is contained in 11 cartridge of Lidocaine 2% with epinephrine 1:100 000.
Kindly advise
For a healthy patient, 13 cartridges of Lidocaine 2% with epinephrine 1:100,000 can be given (calculation is based on the maximum recommended dose of 500 mg of Lidocaine) [Dr. Haas]
For a patient with a significant cardiovascular disease, maximum 2 cartridges of Lidocaine 2% with 1:100,000 epinephrine can be given per appointment (calculation is based on the maximum of 0.04 mg of epinephrine per appointment to ASA 3, 4 patients). [Dr. Malamed]