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Managing Adult Medical Emergencies in the Dental Office

Course Number: 516

Angina Pectoris

Angina pectoris (Table 4) is an acute coronary syndrome associated with transient ischemia to the myocardium. Hypoxia (and at times anoxia) results from diseases and conditions which lead to atherosclerosis and obstruction of coronary arteries by fatty deposits that limits and/or impairs coronary blood flow. Precipitating factors that increase cardiac oxygen demand in the presence of decreased perfusion of the myocardium include physical exertion, emotional stress, cold, recent meal. Unstable angina pectoris may occur spontaneously at rest.

Table 4. Angina Pectoris.

  • Identify at-risk patient
    • Reduce anxiety
    • Ensure profound local anesthesia
      • Use local anesthetic agents containing a vasoconstrictor congruent with the patient’s functional capacity
Signs and symptoms:
  • Mild to moderate substernal pain of sudden onset
    • Squeezing
    • Tight
    • Heavy
    • Radiates to the left shoulder, arm, and jaw
  • BP ↑ from baseline
Emergency response:
  • Place patient in an upright or semi-reclining position
    • Note the time and administer nitroglycerin
      • 0.4 mg, tablet/spray, SL
      • Administer oxygen
        • 2 to 4 L/min by nasal cannula
      • Reevaluate vital signs
    • If pain is not relieved 5 minutes after the initial dose, repeat nitroglycerin
      • 0.4 mg, tablet/spray, SL
      • Reevaluate vital signs
    • If pain is not relieved 10 minutes after the initial dose, repeat nitroglycerin
      • 0.4 mg, tablet/spray, SL
      • Reevaluate and record vital signs
  • In a conscious patient, chest pain lasting more than 10 minutes must be assumed to be due to unstable angina or myocardial infarction
    • Notify EMS
      • Monitor vital signs
        • If at any time the patient becomes unresponsive, no normal breathing, and no palpable pulse consider the diagnosis of cardiac arrest
          • Immediate CPR and defibrillation congruent with current recommendations
Nota bene:
  • Signs of recovery: pain subsides, vital signs return to baseline values
  • Signs of deterioration: persistent pain, unstable vital signs, altered mentation
  • Adverse reaction to nitroglycerin includes flushing, headaches, dizziness, nausea, and vomiting; syncope and paradoxical angina pectoris due to nitrate-induced vasodilation has been reported