Electrocardiographic changes in cardiac patients having dental extractions under a local anesthetic containing a vasopressor

j Oral Maxiliofac 56: 1399-1402,

Surg 1998

Electrocardiographic Changes in Cardiac Patients Having Dental Extractions Under a Local Anesthetic Containing a Vasopressor Danielle Blinder, MD, DMD, * Yifat Manor, DMD, f Joseph Shemesh, MD,f and Shlomo Taicher, DMD,,f This study attempted to identify which group of cardiac patients is most at risk when dental extractions are performed under a local anesthetic with a vasopressor. Purpose:

and Methods: Forty cardiac patients who had dental extractions under local anesthesiawere connected to a Holter monitor for 24 hours, starting an hour before the procedure. The electrocardiogram was analyzed for the number of premature beats, ST depression, and cardiac rhythm. A mean rate was calculated for the first 2 hours after injection of the local anesthetic and for the subsequent22 hours. The preoperative electrocardiogramwas comparedwith the electrocardiogramperformed 1 week before treatment. Patients

Results: Electrocardiographic changes were observed in 15 patients (37.5%), and all occurred during the first 2 hours after injection of the local anesthetic. Of the 15 patients, eight were being treated with digoxin. Conclusions: Cardiac patients being treated with digoxin had more electrocardiographic changes after administration of a local anesthetic than other cardiac patients. When the local anesthetic contained a vasopressor, there was a greater incidence of tachycardia but lessarrhythmia or ST depression.

In a previous study, the effect of dental extraction under a local anesthetic without a vasopressor (3% mepivacaine HCl) on the cardiac function of cardiac patients was examined.’ An increase in previous or new dysrhythmias or ST segment depressions was seen in 35% of the patients during the first 2 hours after injection of the local anesthetic. Most patients *Instructor, Department of Oral and Maxillofacial Surgery, Chaim Sheba Medical Center, Tel Hashomer, and Department

The of

Oral and Maxi&facial Surgery, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Israel.

Patients

Sheba Medical Center, Tel Hashomer, Israel. §Associate Professor, Head, Department of Oral and Maxillofacial Surgery, The Chaim Sheba Medical Center, Tel Hashomer; and Head, Department of Oral and Maxillofacial Surgery, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Israel. Address correspondence and reprint requests to Dr Blinder: Department of Oral and Maxillofacial Surgery, The Chaim Sheba Medical Center, Tel Hashomer, Israel. Arnelicar~

Aswhtiorl

of Oral

and Moxillafaciul

and

Methods

Forty cardiac patients (23 men, 17 women), aged 43 to 84 years (mean, 66 years), who presented for dental extraction with local anesthesia, were selected. Eighteen of these patients had coronary artery disease, 18 had valvular disease (seven with atria1 fibrillation), two were being treated with antiarrhythmic drugs because of atria1 fibrillation, and two had malignant arterial hypertension. Fourteen of the patients were under treatment with digoxin (four becauseof congestive heart failure, two because of atria1fibrillation, and eight because of congestive heart failure and atrial fibrillation). Patients were connected to a Holter monitor (Del Mar) 1 hour before treatment, which they wore for 24

tResident, Department of Oral and Maxillofacial Surgery, The Chaim Sheba Medical Center, Tel Hashomer, Israel. *Attending Staff, The Cardiac Rehabilitation Institute, The Chalm

D 1998

who manifested these electrocardiographic changes (86%) were being treated with digoxin, suggesting an intemction between digoxin and mepivacaine.lJ The purpose of this study was to analyze the electrocardiographic changes observed postoperatively in a similar group of cardiac patients having dental extractions under a local anesthetic containing a vasopressor (2% lidocaine with l:lOO,OOO epinephrine) and to compare the results with those from the previous study.

Surgeons

0278-2391/98/5612-0007$3,00/O

1399

1400

ECG CHANGES IN CARDIAC PATIENTS

hours. They received 5 mg diazepam orally 30 minutes before injection of the local anesthetic. Patients with valvular diseasereceived prophylactic antibiotic according to the recommendations of the American Heart Association.3 All patients were treated around midmorning. The local anesthetic injected was 2% lidocaine with 1:100,000 epinephrine. Three cartridges (5.4 mL) or less were used in all patients. Injection was accomplished after preliminary negative aspiration, and clinically adequate pain control was achieved in each case. The electrocardiogram (ECG) was analyzed for the number of premature beats, ST depression (mm), and cardiac rhythm during the 2 hours after the local anesthetic was injected and during the subsequent 22-hour period. The mean rate was calculated for the two periods. A mean rate in the first two postoperative hours higher than the mean value for the 22 hours was considered pathologic. The preoperative ECG was also compared with an ECG performed 1 week before treatment.

Results The 40 patients underwent 66 dental extractions (39 teeth in the mandible and 27 in the maxilla (mean of 1.6 extractions per patient). The preoperative ECG of each patient did not show any new changes when compared with the former ECG. All new electrocardiographic changes occurred during the 2 hours after the local anesthetic had been injected and the extractions performed. No patient complained of abnormal clinical symptoms during the 2 hours, but five patients had tachycardia (>120 beats/n-&Q, three had heart rate elevation not categorized astachycardia, six exhibited

Case 1 2 i z 7 8 9 10 11 12 13 14 15

2; 76 65 62 76 76 2 81 70 77

Abbreviations: ECG, congestive heart failure;

Gender

Disease

M M M M F F F M M F M M F F F

IHD VD, AF, CHF IHD IHD AF IHD VD, CHF VD, CHF, AF AF IHD, CHF, AF VD VD, CHF, AF VD VD, CHF HTN

a new arrhythmia (three with an increased number of premature ventricular beats [PVB] , two with bigeminy and an increased number of premature ventricular beats, one with bigeminy), and one had an increased ST segment depression (Table 1). Of the 15 patients who showed postoperative electrocardiographic changes, eight were under treatment with digoxin. Table 2 summarizes finding in the patients being treated with digoxin.

Discussion In the current study, increased heart rate, tachycardia, arrhythmia, or ST segment depression occurred in 37.5% of the cardiac patients who underwent dental extraction under a local anesthetic with a vasopressor. The previous study, performed with a local anesthetic without vasopressor, showed that tachycardia, arrhythmia, or ST segment depression occurred in 35% of the patients who underwent dental extraction. In both studies, all electrocardiographic changes occurred during the 2-hour period after the local anesthetic had been injected and extractions performed, and no patient complained of abnormal clinical symptoms during that time. The electrocardiographic changes observed with and without vasopressor are shown in Table 3. When the ECGs of patients in both studies were compared, the most frequent complication after administration of a local anesthetic with a vasopressor was tachycardia or increased heart rate, 53.3% versus 7.1% in patients receiving a local anesthesic without a vasopressor. Postoperative arrhythmias were observed less frequently after injection of a local anes-

ECG Changes 2 Hours Postinjection

ECG Changes Subsequent 22 Hours

HR = lOO/min Bigeminy PVB = 32/hr HR = SO/mm HR = llO/min HR = 105/min PvB=21/hr Bigeminy PVB = 35/k PVB = 40/hr Tachycardia (lZS/min) ST depression = 3.5 mm PVB = 42/hr HR = 98/min Bigeminy Tachycardia (135/min) HR = 94/min

electrocardiographic; M, male; F, female; HTN, hypertension; HR, heart VD, valvular disease; AF, atrial fibrillation; PVB, premature ventricular beat.

rate;

HR = SO/min PVB = 9/hr HR = 65/min HR = 90/min HR = 77/min PVB = 15/hr PVB = 20/hr PVB = 20/hr HR = 88/min ST depression = 1 mm PVB = 3/hr HR = 80/min HR = 92/min HR = 72/min IHD,

ischemic

heart

disease;

CHF,

BLINDER ET AL

1401

‘” :r jl ,I Case 1” 2 3 p ;* 7 8 9

/. Age (yr)

Gender

Disease

84 68 67 51 62 66 76 76

F M F M M F M F M M

IHD, CHF, AF VD, CHF, AF AF VD, CHF, AF VD, CHF VD, CHF AF IHD, CHF, AF VD vD,AF VD, CHF, AF VD VD IHD, CHF IHD, CHF

lo* 11 12*

2: 46 49

13

81

14* 15”

M

M F M M

ECG-2

hr

PVB (b/hr); ST depression Bigeminy, PVB = 32/hr HR = 105/min

ECG-22 = 2 mm

hr

PVB = 12/hr; ST depression PVB = 9/hr HR = 77/min

PVB = 4o/hr

PVB = 2o/hr

Tachycardia (128/min) ST depression = 3.5 mm PVB = 42/hr

HR = 88/min ST depression PVB = 3/hr

HR = 98/min

HR = 8O/min

= 2 mm

= 1 mm

Bigeminy

Abbreviations: ECG, electrocardiogram; M, male; F, female; HR, heart rate; IHD, ischemic heart disease; CHF, congestive heart failure; VD, valvular disease; AF, atria1 fibrillation; PVB, premature ventricular beat *No complications.

thetic with a vasopressor, 40% versus 64.4% in patients receiving a local anesthetic without vasopressor. ECG signs of myocardial ischemia (ST depression) appeared rarely after injection of the local anesthetic with a vasopressor. The patient who had an increased ST depression also had a mild ST depression before the surgical procedure. However, four patients who had ST depression after injection of a local anesthetic without a vasopressor had no ST depression on the preoperative ECG. The types of arrhythmia that occurred differed when a vasopressor was and was not used. Six patients who had an arrhythmia after injection of a local anesthetic with a vasopressor showed PVB and bigeminy. The arrhythmias found after injection of a local anesthetic without a vasopressor were premature atria1 beats, atrial fibrillation, PVB, ventricular tachycardia, bigeminy, and trigeminy. In both studies, patients treated with digoxin showed more postoperative electrocardiographic

LocalAnesthetic Complication

Arrhythmia Arrhythmia, tachycardia, ST depression Arrhythmia, ST depression ST depression Tachycardia, increased HR Total

Without Vasopressor 9

With Vasopressor 6

1

0

2

0

1 1 14

1 8 15

changes than the other cardiac patients-53.3% after injection of a local anesthetic with a vasopressor and 88% after injection of a local anesthetic without a vasopressor. The electrocardiographic changes occurring after injection of a local anesthetic with a vasopressor were generally a tachycardia. A few ventricular arrhythmias appeared. Patients who received a local anesthetic without a vasopressor had atria1 and ventricular arrhythmias and new ST depression. No tachycardia occurred. It is noteworthy that arrhythmias have been reported in 37.5% of healthy patients who undergo multiple dental extractions under a local anesthetic with a vasopressor.* This was explained by the fact that physiologic and psychologic stress can provoke acute arrhythmias. In 1964, the American Heart Association stated that the concentrations of the vasoconstrictor normally used in dental local anesthetic solutions are not contraindicated for patients with cardiovascular disease when administered carefully with preliminary aspiration.5 However, the use of vasoconstrictors in cardiac patients is contraindicated, particularly in those with unstable angina, recent myocardial infarction, recent coronary artery bypass surgery, refractory arrhythmia, uncontrolled hypertension, and uncontrolled congestive heart failure.6 This is supported by Meechan et al7 who stated that epinephrine is a catecholamine that increases the rate and force of heart contraction and thus should be avoided in cardiac patients. In the current study, tachycardia was the main postoperative electrocardiographic change observed when a local anesthetic with a vasoconstrictor was used, and the percentage was similar to that reported

DISCUSSION

1402 in healthy patients, and was not accompanied by angina or hemodynamic deterioration. A similar percentage of postoperative electrocardiographic changes with the use of a local anesthetic without vasoconstrictor has been shown in a previous study, l but the main electrocardiographic changes were an arrhythmia or myocardial ischemia. Cardiac patients treated with digoxin have a higher rate of complications during dental extractions under local anesthesia than those not on the drug. The percentage of electrocardiographic change is decreased with the use of a vasopressor in the local anesthetic. The results of this study do not support the recommendations of those who consider the use of an anesthetic containing a vasopressor in cardiac patients as an absolute contraindication.6,7 Based on the findings in this study, a local anesthetic with a vasopressor is not contraindicated in cardiac patients. However, because this was a pilot study, this opinion should be

1 Oral Maxillofac 56:1402-1403,

confirmed with additional studies using a larger number of patients.

References 1. Blinder D, Shemesh J, Taicher S: Electrocardiographic changes in cardiac patients undergoing dental extractions under local anesthesia. J Oral Maxillofac Surg 54:162, 1996 2. Malamed SF: Discussion: Electrocardiographic changes in cardiac patients undergoing dental extractions under local anesthesia. J Oral Maxillofac Surg 54:165, 1996 3. Dajani AS, Bisno AL, Chung KJ, et al: Prevention of bacterial endocarditis: Recommendations by the American Heart Association J Am Med Assoc 264:2919, 1990 4. Driscoll EJ, Smilack ZH, Lightbody PM, et al: Sedation with intravenous diazepam. J Oral Surg 30:332, 1972 5. Report of a working conference jointly sponsored by the American Dental Association and American Heart Association: Management of dental problems in patients with cardiovascular disease. JAm Dent Assoc 68:333, 1964 6. Perusse R, Goulet JP, Turcottep: Contraindications to vasoconstrictors in dentistry: Part I. Oral Surg Oral Med Oral Path01 74:679, 1992 7. Meechan JG, Jastak JT, Donaldson D: The use of epinephrlne in dentistry. J Can Dent Assoc 60:825,1994

Surg 1998

Discussion Electrocardiographic Changes in Cardiac Patients Having Dental Extractions Under a local Anesthetic Containing a Vasopressor Stanley F. Malamed, DDS Professor University

of Anesthesia of Southern

and Medicine, School California, Los Angeles,

of Dentistry, California

This study by Blinder et al,’ as well as their original article,2 has shown that cardiovascularly compromised dental patients can indeed have peritreatment and posttreatment changesin their status.In their originalstudy, in which patients received a “plain” local anesthetic, mepivacaine HCl 3%, an increase in the number or severity of dysrhythmias or ST-segment depression was noted in 35% of the participants during exodontia. Eighty-six percent of patients who had received digoxin showed electrocardiographic (ECG) changes, suggesting the existence of a previously unknown drug interaction between it and mepivacaine. A literature review failed to shed any light on this potential interaction.3 In the current study, both the addition of a vasopressor, epinephrine (l:lOO,OOO), and use of a different local anesthetic, lidocaine HC12%, failed to prevent the same approximate percentage of patients (37.5%) from showing similar cardiovascular changes during equivalent surgical procedures Fifty-three percent of digitalis-receiving patients showed postoperative ECG changes.

It is not surprising that transient tachycardia was the most oft-noted complication associated with the inclusion of epinephrlne in a local anesthetic (53.3% vs 7.1% with “plain” mepivacaine).1,2 Lipp et al* have shown that exogenous epinephrine does provoke changes such as those seen in this study. Fortunately, these changes are normally mild and prove to be innocuous, even in more severely cardiovascularly compromised persons5 Yagiela states that, “in most individuals, even those with heart disease, the cardiovascular effects of conventional doses of adrenergic vasopressors are of little practical concern.“” When one considers that the primary purpose for inclusion of a vasopressor is to decrease local anesthetic toxicity, it becomes imperative to compare the benefits to be gained from its inclusion with any added risk that might develop because of its presence. Risk versus benefit represents the ultimate consideration in drug selection. Benefits obtained from the inclusion of a vasopressor in most local anesthetics include 1) an increased duration of pulpal anesthesia, 2) increased depth of anesthesia, and 3) decreased systemic toxicity. The intraoral administration of a local anesthetic without a vasopressor provides peak plasma levels in approximately 10 minutes after injection, whereas inclusion of a vasopressor delays onset of peak anesthetic levels for approximately 30 minutes. Peak blood levels observed with vasopressorcontaining lidocaine and mepivacaine are also considerably lower than those with “plain drugs.“6 Additionally, by providing increased depth and duration of anesthesia, vasopressors enable a greater percentage of dental procedures to