- Preoperative Risk Assessment and Optimization
- Thorough preoperative evaluation is critical. Guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) emphasize assessing cardiac risk using tools like the Revised Cardiac Risk Index (RCRI) or NYHA functional classification. Recent myocardial infarction (<6 weeks), unstable angina, or decompensated heart failure warrants postponing elective procedures. Continuing beta-blockers is standard, while holding ACE inhibitors 12-24 hours prior may reduce intraoperative hypotension risk.
- Include stress testing or functional capacity assessment (e.g., METs <4 indicates higher risk) if not recently done. Ensure clear communication with the patient’s cardiologist for tailored optimization, especially for antiplatelet or anticoagulant management (e.g., bridging heparin in high-risk patients).
- Choice and Limitation of Local Anesthetics with Vasoconstrictors
- Limiting epinephrine to ≤0.036 mg (approximately 4 cartridges of 1:100,000 lidocaine) is consistent with American Dental Association (ADA) recommendations for patients with cardiovascular disease to minimize risks of tachycardia, hypertension, or arrhythmias. Plain anesthetics (e.g., mepivacaine 3% without epinephrine) are safer in severe cases.
- Aspirate carefully during injection to avoid intravascular administration, which could exacerbate cardiovascular effects. Consider articaine (4% with 1:200,000 epinephrine) for lower epinephrine doses if vasoconstriction is needed. Monitor for signs of epinephrine-related effects (e.g., palpitations) during administration.
- Intraoperative Monitoring and Hemodynamic Management
- Continuous monitoring (ECG, BP, SpO2) is essential in outpatient settings, as dental procedures can induce stress responses that trigger ischemia or arrhythmias. Supplemental oxygen and emergency preparedness (e.g., nitroglycerin, defibrillator) align with ACLS guidelines. Avoiding QT-prolonging drugs is prudent in patients with heart disease, particularly those with long QT syndrome or on antiarrhythmic medications.
- Use pulse oximetry and capnography if sedation is employed to detect hypoventilation early. Phenylephrine is a good choice for hypotension, but ensure availability of short-acting beta-blockers (e.g., esmolol) for reflex tachycardia. Sedation, if needed, should favor low-dose midazolam over agents with stronger cardiovascular effects.
- Antibiotic Prophylaxis and Infection Control
- The American Heart Association (AHA) 2021 guidelines recommend prophylaxis for high-risk patients (e.g., prosthetic heart valves, previous endocarditis, certain congenital heart defects) undergoing invasive dental procedures likely to cause bacteremia (e.g., extractions, periodontal surgery). Amoxicillin (2g orally 30-60 minutes prior) is standard unless allergic.
- Clarify that prophylaxis is not needed for low-risk patients (e.g., mitral valve prolapse without regurgitation) to avoid unnecessary antibiotic use. Ensure strict aseptic technique to minimize infection risk, as bacteremia can be catastrophic in these patients.
- Postoperative Care and Emergency Preparedness
- Postoperative monitoring for cardiovascular complications (e.g., angina, heart failure exacerbation) is crucial, especially in the first 24-48 hours. Multimodal pain management avoiding NSAIDs in patients with renal dysfunction or on anticoagulants is appropriate. ACLS readiness is essential in outpatient settings.
- Provide clear patient instructions for recognizing symptoms like chest pain or shortness of breath and seeking immediate care. Schedule follow-up within 24-48 hours for high-risk patients. Consider acetaminophen or low-dose opioids for pain if NSAIDs are contraindicated, and ensure discharge with a responsible adult for monitoring.
