Cardiac arrhythmias

Dental management of the medically compromised patient

Dr. Sharon Ayalon

The Department of Oral Medicine Hadassah University Hospital Medical Center

Significance
Lethal arrhythmias may be induced by dental treatment. Patient with arrhythmia must be identified.

Incidence and prevalence

17.2% of general dental patient. Of those 4% life threatening.
Little et al. 1990.

10% of general population

Furberg et al. 1993

Most common causes

CAD Pulmonary disorders (PE, hypoxia) Autonomic disorders Systemic disorders Drug related side effects. Electrolyte imbalance.

Drug induced arrhythmias

Digitalis Morphine Beta blockers Calcium channel blockers Atropine Epinephrine Nicotine Caffeine Alcohol Tobacco Tricyclic antidepressants Amphetamines Quinidine Procainamide

Systemic Diseases causing arrhythmias

Infectious diseases: febrile illness hypothermia Cardiovascular: cardiomyopathy, MI, open heart surgery, CHF, CAD, RHD, MVP, Mitral stenosis, HTN, Thyroid: myxedema, hyperthyroidism, thyrotoxicosis, Malignancy: Hodgkins disease, myeloma, anaphylaxis. Pulmonary: obstructive lung disease, pneumonia Misc: anemia obstructive jaundice, increased cranial pressure.
See table p. 96 Little

The conduction system

SA node regulates function of the atria (P wave). AV node - Gate prevents too many atrial impulses from entering the ventricle. Bundle of his Bundle branches Purkinje network (subendothelial)

Etiology of arrhythmias
Disorders in automaticity
Ectopic pacemakers

Disorders in conductivity
Refractoriness complete=block,
incomplete = delay of conductivity

Complications
Asymptomatic Decreased CO
Cardiogenic shock CHF MI (especially in the dental office)

Heart beat determination by ECG

1 inch=1 second Big cube=1/5 second=0.2 second. Each thin line=0.04 seconds. 60/0.8= 75 beats per minute (60/0.8)

Classification
Isolated ectopic beats Bradycardias tachycardia Pre-excitation syndrome Cardiac arrest

Atrial Ventricular supraventricular

Isolated ectopic beats

Premature atrial beats ectopic foci at the atrium. (CHF). Premature AV beats the least common (digitalis toxicity). Premature ventricular beats most common form of arrhythmias.

Premature ventricular beats

85% of people between ages 60-85. 80% pts. With MI Digitalis, hypokalemia May lead to VT or VF when ischemia is present. >6/min instability.

Bradycardias

Sinus bradycardia sinus rate less the 60 beats per minute. Common in young healthy adults and athletes. Beta blockers induced (also digoxin, phenothiazines. Abnormal if: CHF, pain, exercise, after atropine administration. MI, infectious disease, myxedema, obstructive jaundice, hypothermia.

SA heart block
Uncommon. RHD, MI, infection, drug toxicity (digitalis, atropine, salicylates quinidine) 1st degree impulse takes longer to enter the atria. 2nd degree one or more impulses fail to emerge from the SA node Complete SA block no impulses enter the atria.

AV block
RF, IHD, MI, hyperthyroidism, Drugs (digitalis, propranolol, potassium, quinidine. 50% CHD

First degree AV block

Prolonged PQ interval (more then 0.2 sec).

second degree AV block

Complete AV block

Sinus tachycardia

Heart rate greater then 100b/min Exercise, anxiety, stress, atropine, epinephrine, nicotine, caffeine Fever, hypoxia, infections, anemia, hyperthyroidism.

Atrial tachycardia
Ectopic impulses 150-200bpm Digitalis toxicity, hypokalemia. COPD advanced pathology of the atria, MI, pneumonia, drug intoxication.

Atrial flutter

Rapid regular rat of 220-360 bpm. Ischemic heart disease in adults>40 Digitalis intoxication (rare) Mitral stenosis, cor pulmonale. Open heart surgery

Atrial fibrillation
Extremely rapid atrail rate400-650bpm. No discrete P waves on ECG. May be found in healthy individuals, RHD, HTN, ischemic heart disease, thyrotoxicosis, Mitral stenosis

Atrial fibrillation
Poor atrial transport of blood Generation of impulses that excite rapid and irregular ventricular response. Peripheral emboli or PE May precipitate CHF in pts. With cardiac disease. Warfarin treatment

Ventricular tachycardia monomorphic

Three or more ectopic ventricular beats at a rate of 100 or more/min. Digitalis, epinephrine, potassium, quinidine procainamide may induce VT. May progress to VF If pulseless considered and treated as VF

Ventricular tachycardia Polymorphic Torsade de point

Wolfe-Parkinson White preexcitation syndrome

Accessory AV pathway allows normal conduction systems to be bypassed. Rapid conduction and short refractoriness Reentry tachyarhythmias (PAF, SVT, atrial flutter, VF, death.

Ventricular fibrillation
Lethal unless therapy is administered. Causes - CAD, RHD, anaphylaxis, blunt cardiac trauma, MVP, cardiac surgery, Digitalis intoxication, cardiac catheterization.

Asystole

No impulses are conducted No musculature activity takes place. Causes - CAD, RHD, anaphylaxis, blunt cardiac trauma, MVP, cardiac surgery, Digitalis intoxication, cardiac catheterization

Signs and symptoms

Signs Slow heart (<60bpm) Symptoms Palpitations Fatigue, Dizziness Syncope Syncope, CHF, Angina

Fast heart rate (>100bpm)

Medical treatment
Medications Pacemakers Surgery Cardioversion

Antiarrhytmics drugs
Digoxin Quinidine Procaineamid Disopyramide Lidocaine Propranolol Verapamil Sotalolol Amiodarone

See tables p. 106 and p. 112 little

Pacemakers
Modern most common VVIs
Paces the ventricles Senses the ventricle Inhibited by patients own ventricular activity.

For refractory arrhythmias (blocks Bradycardia and tachyarrithmias. AICD automatic cardioverterdefibrilator.

Pacemakers keep in mind

Electromagnetic interference
Microwave oven Ultrasonic scalers (cavitron) Electric pulp testers Diathermy/electrcauter units

No Antibiotic prophylaxis needed.

Patient identification
Undetected arrhythmias
Rapid/slow pulse rate. Irregular pulse rhythm Palpitations, dizziness, syncope, Angina, Dyspnea.

Pacemaker Drugs for arrhythmias

Susceptibility to development of arrhythmia during dental treatment

IHD Valvular heart disease Thyroid disease COPD

Risk stratification
Low risk
no medical treatment Atrial arrhythmias PVCs Young active individuals with sinus bradycardia.

Risk stratification
Moderate risk
Chronic medication use Asymptomatic Atrial arrhythmias Ventricular arrhythmias Medications known to affect sinus node. Pacemakers.

Risk stratification
High risk
Symptomatic Pulse >100 or <60 with another type of arrhythmia. Irregular pulse rhythm Irregular pulse and bradycardia Bradycardia with pacemaker.

Dental treatment
If suspected arrhythmia refer for diagnosis and management. Establish current status type and severity. If pacemaker type of pacemaker, type of arrhythmia, need for prophylaxis. If AF, PAF Coumadin? INR? Underlying conditions causing arrhythmias. Reduce anxiety (stress reduction protocol)

Dental treatment - precautions

Reduce anxiety Epi 1:100,000 but not if severe arrhythmia. No more then 2 cartridges of anesthetic. No intraligamentary or intraosseous injections. No epi in gingival packing/to control local bleeding. Avoid general anesthesia. Avoid use of electrical equipment that may interfere with pacemaker. Manage underlying disease as indicated. Monitor for digitalis intoxication GI, neurological, cardiovascular)

Emergency
Stop procedure Vital signs Call 101 Administer Oxygen Trendelenburg (reduce hypotension) Nitroglycerin if indicated Vagal maneuver (hypotension with tachycardia) CPR