Atypical Ischemic Attack during Dental Treatment of The Elderly Dental Outpatient with Three-vessel Coronary Artery Disease

Atypical Ischemic Attack during Dental Treatment of The Elderly Dental Outpatientwith Three-vessel Coronary Artery Disease
Tsuneto Ohwatari1 and Hiroshi Uematsu2

A case report

Dentists are confronted with geriatric patients in adaily clinical practice with increase of elderly population

A 74-yr-old man visited the gerodontic clinic within Japan. Although medical emergency in dental carethe chief complaint of denture treatment. Oral examina-

have been mentioned to occur in relatively low frequen-tion revealed the need to extract six teeth. At 35 yr of age,

cy1, the growing elderly population may provide an

he was diagnosed with hypertension. At the age of 47, heincreasing risk for dental care due to various systemic

was admitted to the hospital with a diagnosis of unstablediseases, especially cardiovascular diseases. Ischemic

angina pectoris, hyperlipidemia and glucose intolerance.

heart disease is one of the most popular cardiovascular

At 63 yr of age, he was admitted to the hospital urgently

diseases in the elderly dental outpatients2. The elderlywith loss of consciousness, and was diagnosed with acutewith ischemic heart disease is at high risk for ischemic

myocardial infarction with frequent ventricular prematureattack, which necessitate emergency medical treatment.

beats. Coronary angiography and an intracoronary

We report the elderly dental outpatient with three-ergonovine test were performed. The former examination

vessel coronary artery disease who developed atypicaldemonstrated triple vessel disease with a severe stenosis

ischemic heart attack, which was required emergencyof the right coronary artery (#1: 90%, #2: 100%), left

medical admission, during dental treatment.

main coronary artery (50%), left descending coronary
artery (#9: 90%), and circumflex (#11: 74%, #13: 75%)
(Figure 1). His aortic pressure, left ventricular pressure
andstrokevolumeindex

were174/74mmHg,172/10mmHg and 86, respectively. Significant defects
Lecturer, Gerodontology, Department of Gerodontology, Division of Gerontology and Gerodontology, Graduate School,
Tokyo Medical and Dental University
2Professor Chairman, Gerodontology, Department of Gerodontology, Division of Gerontology and Gerodontology, Graduate
School, Tokyo Medical and Dental University
Address for correspondence : Tsuneto Ohwatari, DDS, PhD.
Tokyo Medical and Dental University, 5-45, Yushima, 1Chome, Bunkyo-Ku, Tokyo, Japan.
Business telephone: (81) 3-5803-5560
Home telephone: (81) 3-5607-2936
Fax: (81) 3-5803-0208
E-mail: t.owatari.gerd@tmd.ac.jp
1were seen in territory of the right coronary artery. Electrocardiogram showed ST depression in V4-6. From
above results, he was diagnosed with myocardial infarction and unstable angina pectoris from triple vessel disease with moderately impaired left ventricular function.
However, coronary artery bypass grafting or percutaneous transluminal coronary angioplasty was not performed because of the difficulty in the identification for
main cause of angina pectoris due to diffuse ischemic
region in myocardium. He admitted 13 times for thetreatment or examination of ischemic heart attack there― 30 ―

ヘルスサイエンス・ヘルスケア

Volume 3，No.1（2003）

was no medical complication such as anginal attack

after.
He has been taking nine drugs: one anti-platelet

except for occasional ventricular premature beats necessi-agent, two calcium channel blockers, one nitroglycerin,

tating no medical treatment during dental procedures. He

one diuretic, one coronary vasodilator, one antiarrhyth-also did not complaint significant pain during the treat-

mic drug, one gout suppressant, and one benzodiazepine.

ments.

Preoperative electrocardiography showed left ventricular

However, on the following dental treatment after a

hypertrophy and old inferior myocardial infarction. Chest

series of tooth extractions, he complained of weakness,

radiographs revealed a widened cardiac shadow (CTR:dizziness, palpitation, and sweating with slight decrease56%) and advanced aortic sclerosis.

of blood pressure just after complaint of slight pain dur-

Arterial blood pressure and heart rate at first med-ing root canal treatment without local anesthesia andical examination were 158/74 mm Hg and 56 beats/min

sedation. The monitor ECG, however, did not show sig-

respectively. The patient frequently subjected shortnessnificant change. The procedure was interrupted immedi-of breath, palpitation, and chest discomfort at slight work

ately and oxygen and sublingual nitroglycerin wasin his daily life.

administered. We carried him to the cardiology clinic on

Tooth extractions were carried out three times. Eacha charge of atypical ischemic attack. He was diagnosed

procedure was scheduled during the period when hisof anginal attack and was admitted urgently for the fur-anginal attack was absent at least one week. We proposed

ther work-up and treatment.

him tooth extraction under intravenous sedation withDiscussion

midazoram for the purpose of effective stress reduction.
In spite of fear to dental care, he rejected intravenous

The prevalence of ischemic heart diseases increases

sedation and made a choice of inhalation sedation

substantially with age3. Americans with diagnosis ofinstead. Therefore, we performed these dental proceduresischemic heart disease in 1996, 57 percent were 65 years

under 30% nitrous oxide inhalation sedation withor older4, and almost 85 percent of death from ischemic

3.6˜5.4ml 3% prilocaine with 0.03 U/ml felypressin.

heart disease are elderly. The severity and diffuse distrib-Monitoring devices such as automated blood pressure

ution of the coronary obstruction also increases with age,recording device, monitor EGG, and pulse oximeter werepresumably as a result of prolonged exposure to athero-applied, and intravenous line for the emergency drugsclerotic risk factors. The impact of risk factors foradministration was provided. As a consequence, there

ischemic heart disease, such as hypertension, diabetes,hyperlipidemia and left ventricular hypertrophy, increases with age. Elderly patients have more multivessel disease and lower cardiac function than do younger
patients5. Our patient was diagnosed as triple vessel disease with decreased cardiac function and frequently complained of chest discomfort.
Little et al. recommended the following protocols
for the pre or intraoperative dental management of thepatients with unstable angina pectoris or recent myocardial infarction: continuous monitoring of vital signs

Coronary angiography showed severe stenosis in multi vessels.

including pulse oximeter, intravenous line, prophylactic

Figure 1. Coronary arteriogramand supplemental nitroglycerin, inhalation or intravenous― 31 ―Atypical Ischemic Attack during Dental Treatment of The Elderly Dental Outpatient with Three-vessel Coronary Artery Disease

sedation, and pain control with local anesthesia; probably

did not show these changes. Because almost all his

best to avoid vasoconstrictors6. In the dental manage-

myocardium was ischemic state due to three vessel dis-ment for tooth extractions of our patient, we followed

ease, potential might be counteracted and typical ECG

above protocols and there was no medical emergency

changes might not be appeared.

perioperatively. However, we did not expect strong pain

We conclude that the relief of anxiety and fear forand psychiatric stress for dental care of root canal, there-

dental treatment and the effective control of pain must before we did not use local anesthesia and sedation. Pain,essential in order to prevent ischemic attacks in elderly

anxiety, and fear reported to activate the sympathoadren-dental outpatients with severe ischemic heart disease,al system and lead to the release of catecholamines ineven if the treatment is suspected to be accompanied byamounts that reduced oxygen delivery become insuffi-

relatively low physical and/or psychiatric stress.

cient in relation to myocardial oxygen demand in thepatient with advanced coronary atherosclerotic disease 7,References

8. Our patient complained relatively strong pain by dental01） Shampaine GS： Patient assessment and preventive measures for medical emergencies in the dental office， Dental
Clinics of North America，1999，43（3），383-400.
02） Tsuneto Ohwatari, Hiroshi Uematsu, Masahiro Umino：
The relationship between the history and high blood pressure
at first medical examination in the elderly dental outpatients，
J Jpn Dent Soc Anesthesiol, 2000, 28, 195-203.
03）Cheitlin MD, Zipes DP (Braunwald E, Zipes DP, Libby P,Ed.) : Chapter 57 Cardiovascular Disease in the Elderly(Braunwald's Heart Disease), 5th, W.B. Saunders Company，Philadelphia, 2001,.
04） American Heart Association : Coronary heart disease
and angina pectoris, Web site : www.amhrt.org/statistics/04corny.html, 1999.
05）Reynen K, Bachmann K : Coronary arteriography in elderly patients : Risk, therapeutic consequences and long-term follow-up, Coron Artery Dis, 1997, 8, 657-666.
06） Little JW, Falace DA, Miller CS, Rhodus NL (Little JW,Falace DA, Miller CS, Rhodus NL, editors) : Ischemic heartdisease (Dental management of the medically compromisedpatient), 6th edition, Mosby, St,Louis, 2002, 79-93.
07） Umino M, Ohwatari T, Simoyama K, Nagao M : Unexpected atrial fibrillation during tooth extraction in a sedated
elderly patient, Anesth Prog, 1994, 41, 77-80.
08） Findler M, Galib D, Meidan Z, Yakirevitch V, Garfunkel
AA : Dental treatment in very high risk patients with active
ischemic heart disease, Oral Medicine, Oral Pathology, OralRadiology, & Endodontics, 1993, 76, 298-300.
09） Wenger NK : Cardiovascular disease in the elderly, Curr
Probl Cardiol, 1992, 17, 609-690.
10）Elveback L, Lie JT : Continued high incidence of coronary
artery disease at autopsy in Olmsted County, Minnesota, 1950
to 1979, Circulation, 1984, 70, 345-349.
11） Coodley EL : Coronary artery disease in the elderly, Post-procedure and might felt anxiety and/or fear. These physical and/or psychiatric stresses might induce ischemic
attack.
Ischemic attack of our patient did not accompany
typical symptom of ischemic attack such as chest discomfort. We wondered if his symptoms were due toanginal attack or not at first. Although angina is a common first presentation of ischemic heart disease, that frequently do not occur in the elderly. The presence of significant ischemic heart disease without typical symptoms
increases with age. Because only about 20 percent ofpeople older than 80 have clinically evident ischemic
heart disease9 and over 50 percent have significant
ischemic heart disease at autopsy10, a large number of
elderly people must have significant ischemic heart disease without symptoms. For this reason, almost 30 percent of ischemic heart diseases in the elderly are silent
ischemia11. The reason for increased silent ischemia inthe elderly patient is not known, but it may be related tomental status changes impairing perception or recall ofischemic pain, to the development of collaterals that
reduce the severity of the myocardial ischemia, to autonomic dysfunction, or to increased sensitivity to endogenous endomorphins12.
An electrocardiogram taken during chest discomfort
usually shows definite ST segment elevation or depression, or marked T wave inversion. However, our patient― 32 ―

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grad Med, 1990, 87, 223-228.
12） Ambepitiya G, Roberts M, Ranjadayalan K, Tallis R :Silent exertional myocardial ischemia in the elderly : A quan-Volume 3，No.1（2003）

titative analysis of anginal perceptual threshold and the influence of autonomic function, J Am Geriatr Soc, 1994, 42, 732737.

歯科治療中に非定型的な心筋虚血発作を起こした
冠状動脈 3枝の高度狭窄を伴う高齢歯科患者の一例
大 渡 凡 人，植 松宏（東京医科歯科大学大学院医歯学総合研究科 老化制御学系 口腔老化制御学講座 口腔老化制御学分野）

高齢者人口の増加により、重篤な循環器疾患を有する高齢者の歯科受診が増えている。我々は重篤な虚血性心疾患である 3 枝病変を合併する高齢者の歯科治療において典型的症状を伴わない心筋虚血発作を経験した。
患者は 74 歳の男性で義歯作成を前提に、多数歯抜歯および根管治療を含む修復処置を予定した。病歴は#1．3 枝病変による不安定狭心症および心筋梗塞、#2．高血圧症、#3．高脂血症、#4．耐糖能異常であり、特に #1 では13 回入退院を繰り返している。
歯科治療は 1 週間以上発作の無い時期を選んで行った。抜歯では循環系モニターおよび笑気吸入鎮静法下に、循環系作動薬投与のための静脈路を確保した上で 0.03IU/ml felypressin含有 3% propitocaine を用いて行った。一連の抜歯は何らの異常なく終了した。しかし、引き続いて行った根管内処置では、強い疼痛を予測しなかったため、モニター以外の対策を行わなかった。患者は治療による疼痛を自覚後に、めまい、動悸および冷汗を訴えた。胸部痛は伴わなかったが、典型的症状を伴わない心筋虚血発作を疑い循環器内科に搬送したところ、心筋虚血発作として即日入院となった｡
高齢者では典型的症状を伴わない心筋虚血発作が多く、十分な注意が必要である｡また、重篤な虚血性心疾患では特に厳重な疼痛対策や精神的ストレスの緩和が必要である｡― 33 ―