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JournalofIMABAnnualProceeding(ScientificPapers)2015,vol.21,issue1

LOCALANESTHETICSINPATIENTSWITHCARDIOVASCULAR
DISEASES.
HristoDaskalov,AtanaskaDinkova,MartinDrangovDepartmentofOralSurgery,FacultyofDentalMedicine,
MedicalUniversityPlovdiv,Bulgaria
728http://www.journalimabbg.org/JofIMAB.2015,vol.21,issue1/
SUMMARYAsignificantprobleminthedentalmedicineispainalleviation.Manystudiesinthedental
anesthesiologyresultintheproductionofnewagentsforlocoregionalanesthesia.Objective:Thisarticleaimto
presenttheresultsofthelaststudiesontheeffectofthelocalanestheticsusedintheoralsurgeryonpatientswith
cardiovasculardiseases.Material:Ageneralreviewoftheexistingliteratureontheeffectoftheadrenaline,included
asvasoconstrictorinthelocalanesthetics,usedinpatientswithcardiovasculardiseasesismade.Thebenefitsof
vasoconstrictorsforthequalityoftheanestheticeffectareproven.Conclusion:Asmallamountofadrenalinein
theanestheticsolutiondoesnotresultincomplicationsdevelopmentinpatientswithcontrolledcardiovascular
diseases.Articaineisrecommendedagentoffirstchoiceforlocalanesthesiaintheoralsurgery.
Keywords:locoregionalanesthesia,adrenaline,cardiovasculardiseases,Articaine
INTRODUCTIONPainmanagementhaslongbeenanimportantprobleminmedicine.Itbecomesparticularly
importantwhentheroleofpainalleviationforthefavorableoutcomeofthehealingprocessisdiscussed.Pain
managementindentalmedicinewheremostofproceduresarepainfulisofsuperiorimportance.Numberof
studiesinthefieldofdentalanesthesiaresultedinthedevelopmentofnewagentsforlocoregionalanesthesiaand
newmethodsforpainmanagement.
OBJECTIVE:Theaimofthisarticleistopresenttheresultsofthelaststudiesontheeffectofthelocalanesthetics
usedintheoralsurgeryonpatientswithcardiovasculardiseases.
MATERIAL:Inthelastdecadethereareagrowingnumberofstudiesoftheuseofanestheticscontaining
vasoconstrictorsforpatientswithcardiovasculardiseases.Ingreatnumberofcontemporaryanesthetics
vasoconstrictorsareaddedforimprovementofanestheticeffect.Thereiswidespreadallegationthatinpatients
withcardiovasculardiseases,theanestheticsshouldnotcontainvasoconstrictors.Manyauthorsstudiedthe
influenceofadrenalineonthecardiovascularsystem.Themajorpartofthestudiesisonpatientswith
cardiovasculardiseases.
Migliau[1]definesthemainfactorshavingeffecton

http://dx.doi.org/10.5272/jimab.2015211.728
patients heart during oralsurgery treatment. They include the psychological stress, the anesthesia and the
momentarymedicaltherapy.Ontheotherhand,studyingthecomplicationsintheoralsurgeryinpatientover65
years,AmadoCuestaetal.[2]cometotheconclusion,thatinelderlypatientsthemostoftenconcomitantdiseases
arehypertension,cerebrovascularandcardiacdiseases,aswellasdiabetes.Therearenumberofstudiesaimingthe
developmentofprotocolsfordentaltreatmentofpatientswithcardiovasculardiseases[3,4,5].
Frabettietal.[6]conductedastudywith14patientswhethertheepinephrineinthelocalanestheticscarries
cardiovascularrisks.Thesystolicandthediastolicbloodpressurewereanalyzed,aswellastheaverageandthe
maximalheartrate.Thecomparisonoftheinitialbloodpressureandtheoneafterthepostanestheticperiod
showedinsignificanttendencytowardsincreasingthesystolicpressureandslightlymorestatisticallysignificant
increaseddiastolicbloodpressure.Theheartfrequencyincreasesonlyinsmallnumberofthepatients,however,not
morethan10beatsperminute.Ingeneral,thegroupofthestudiedpatientsshowedastatisticallydecreaseinthe
averageandthemaximalheartratefromthebeginningtotheendofthesession.Thus,thedosagesofepinephrine
administeredtothesepatientsresultininsignificantchangesintheheartrateandbloodpressure.Thedecreaseofthe
heart rate at the end of the therapy un derlines the important role of the autonomic nervous sys tem inthe
modulationofthecardiovascularresponseduringdentaltherapy.
DavenportR.etal.[7]studiedninepatientswithstablecardiovasculardiseases,whichwereevaluatedin
statisticalcrossoverstudyduringperiodontalsurgeryusing2%lidocainewithadrenaline1:100000orlidocaine
withoutvasoconstrictor.Inthegroup,anesthetizedwithlidocainewithadrenaline,thelevelsofadrenalineincreased
from198/54pg/mlto592/166pg/ml2minutesaftertheinjection.Inthegroup,whichwereanesthetizedwith
lidocaine,thelevelsofadrenalineincreasedfrominitiallevelof115/34pg/mlto150/34pg/mlwithin2minutes
aftertheinjection.Regardlessoftheincreasedadrenalinelevel,therewerenosignificantchangesintheheartrateor
theaveragearterialbloodpressure.Thelidocainewithoutvasoconstrictordidnotprovidesatisfactoryhemostasisor
anesthesiaduringtheperiodontalsurgery.Thestudyregistersfastincreaseoftheadrenalineplasmalevelsasaresult
of oral local anesthesia for periodontal surgery. These increases however, could not provoke significant
cardiovascularresponseinthegroupof
patients with stable cardiovascular diseases. This suggests that the effects on cardiovascular system of the
anesthetics containing adrenaline are small and they safely can be used in patients with stable cardiovascular
diseases.
KnollKoeleretal.[8]studiedtheeffectofthedifferentconcentrationofadrenaline.Theobjectiveofthis
studywastodefinetowhatextendthesurgicalstressandtheadrenalineintheanestheticsaffectthelevelsofthese
rum catecholamines, the level of the potassium ions and the change in the cardiachemodynamic parameters.
ArticaineHydrochloride(4ml,4%)withtwodifferentconcentrationsofadrenalinewasrandomlyusedinpatients
forextractionofretainedwisdomtooth.Theresultsshowedthattheexogenouslyobtainedadrenalineduringthe
anesthesiaincreasestheserumlevelsofthecatecholamines.Theincreasedleveloftheserumadrenalinedidnot
correlatewiththecardiachemodynamicchangesduringthestudy.Theserumlevelsofthecatecholamineschanges
relatedtoadrenaline,whilethelevelofthepotassiumionsremainedunchanged.
LippM.etal.[9]offeredaninterestingmethodfortestingthecatecholaminesplasmalevels.Heusedtritium
markedepinephrinetoestablishtheserumlevelsofthevasoconstrictorafterlocalanesthesiain20malehealthy
patients.TheusedanestheticwasArticaine4%with20gepinephrineasvasoconstrictor.Ofthewholequantityof
theusedepinephrinewasconsideredthat 1.2%(100 icroCi)istritiummarked.Abloodsamplewasfollowed
throughcentralvenouscatheterbeforeandinequalintervalsafteradministrationoflocalanesthetic.Significant
increaseoftheexogenousepinephrinewasobservedin4patientsduringtheinjection(upto6937pg/ml).Theother
16patientsshowedgradualincreaseoftheappliedepinephrine,whichreachedpeakvaluesontheseventhminute
(631.5+/41.4pg/ml).Thesecondincreaseoccurredafterthestartofthedentalprocedure.Theleveloftheaverage
totalepinephrinewasalwayshigherthantheleveloftheadministeredepinephrine.Extrasystoleswereobservedin2
of4,andtachycardiain3of4patientswithhighplasmaleveloftheappliedepinephrine.
DaublaenderM.etal.[10]studiedtherateofcomplicationsresultingfromlocalanesthesia.Inthestudy
wereincluded2731patientswhoreceiveddentalanesthesia.Riskfactorswereevaluatedwithaquestionnaireas
wellasthetypeanddoseofthelocalanesthetic,typeanddurationofthetherapyandcomplicationsresultingfrom
the local anesthesia. In the medical history of 45.9% of the patients was revealed at least one risk factor as
cardiovascular dis eases and allergies were most common. The overall rate of complications was 4.5% and
significantlyhigherinpatientswithriskfactors(5.7%),comparedtononriskpatients(3.5%).Themostcommon
complications(dizziness,tachycardia,overexcitement,nauseaandtremor)weretransitoryanddidnotrequire
specifictreatment.Othercomplications(fainting,bronchospasm)wereobservedonlyintwocases(0,07%).Itwas
establishedthatArticaineisusedin90%ofthecasesrequiringdentalanesthesiainGermany,althoughthereisa
greatvarietyofdifferenttypesofanesthetics,andalso,thatArticainewithEpinefrine1:100
000causesmoresympathomimeticeffectscomparedwithArticainewithEpinefrine1:200000.
HirotaY.etal.[11]investigatedthecardiacfunctionofninepatientswithvariouscardiovasculardiseasesby
echocardiographyduringdentaltreatment.HecomparedtheeffectofLidocainewithadrenalineandPrilocainewith
Felypressin.Changesintheheartratewereobservedonlyinonecase.
LevinerE.etal.[12]studiedtheperioperativehemodynamicchangesin20patientswithstableIschemic
HeartDiseaseinfunctionalclassIIIV,subjecttodentaltreatment.Calculuswasremovedin7patientswithoutuse
oflocalanesthesia.13hadreconstructionsunderlocalanesthesiaofwhich7weretreatedwithepinephrinecon
taininganestheticandin6withoutepinephrinecontaininganesthetic.Duringthedentalproceduretheheartrate,the
bloodpressureandtheelectrocardiographywereconstantlymonitored.Duringthedentaltreatmentinallpatients
wasregisteredincreasedsystolicbloodpressure.Inthegroupofpatientstreatedwithoutepinephrinecontaining
anesthetic,theincreaseofthesystolicpressureandtheheartrateweresignificantlybelowthethresholdofischemia.
ArrhythmiaorSTsegmentdepressionof1mmwasnotregisteredinnoneofthepatients.
Cintron G. et al. [13] conducted a study with 40 pa tients who underwent uncomplicated myocardial
infarction, using Lidocaine with 1:100 000 adrenaline. He monitored the pulse, blood pressure and
electrocardiographyanddidnotregistersignificanthemodynamicchangesduringtheprocedures.
Intheliteraturehasbeendiscussedcorrespondencebetweenthelocalanesthesiainjectionmethodandcardio
vascular effects [14, 15]. There is number of studies trying to introduce new and different methods of local
anesthesia[16,17].In2005Vianaetal.[18]publishedastudyinwhichtheyinvestigatedthechangesintheserum
catecholamineslevelsafterconventional mandibularblockandGowGatesanesthesiamethod.Theauthorsuse
Lido caine with 1:100 000 epinephrine. In the study were in cluded 18 patients divided in two groups
(conventional man dibular anesthesia and GowGates), as well a control group of nine people, where pure
Mepivacainewasused.Thebloodpressure,pulseandtheserumcatecholamineslevelsweremeasured.Theresults
wereprocessedwithvariationanalysis,whichshowedthattheplasmalevelsoftheadrenalinewerestatistically
significantly higher in the group with conventional mandibular block, than in the patients with GowGates
anesthesia.Atthesametime,therewassignificantdifferencebetweenthecontrolgroupandtheGowGates
group.Theauthorscometotheconclusion,thattheabsorptionoftheexogenousadrenalineisinfluencedbythe
injectionanesthesiamethod.
Anumberofstudiestrytoestablishthesafetyofthenewanesthetics,aswell astomakecomparative
analysisofthedifferenttypesofanesthetics[19,20,21].AfteritsintroductioninGermanyin1976,Articaine
quicklybecameusedworldwide.Itisestablishedthatitismedicineoffirstchoicefor90%ofthedoctorsofdental
medicineinGermany[10].
/JofIMAB.2015,vol.21,issue1/http://www.journalimabbg.org729
 In2000Malamedetal.[22]madecomparativeanalysisofLidocaineandArticaine.Theyconcludedthat4%
Articaineisbettertoleratedbythepatientsandhasbetterpaincontrol.Thebeginningandthedurationoftheeffect
arecomparabletotheothermostpopularandstudiedanesthetics.
Anisimovaetal.[23]conductedalargesurveywith615patientsinwhichtheeffectofthelocalanesthetics
with vasoconstrictors was studied. Patients were divided into six groups: using Lidocaine 2% without
vasoconstrictor; Lido caine 2% with adrenaline 1: 100 000; Mepivacaine 3% with out vasoconstrictor;
Mepivacaine2%withadrenaline1:100000;Articainewithadrenaline1:100000andArticaine4%withadrenaline
1:200000.Afterdiscussionoftheresults,theauthorsconcludedthatArticain1:200000istheoptimalanesthetic
solutionformostdentalprocedures.Theyrecommendtheadrenalineconcentrationof1:100000tobeusedas
backupoptionforpatientswithverylowthresholdofsensitivityandwhereintentionalischemiaofthetissuesis
wanted.
Nevesetal.[24]studiedtheeffect ofadrenalineonpatientswithcoronarydiseases.Inthestudywere
included62patientsagedfrom39to80years.Inthefirstgroupwasusedlidocainesolutionwithoutvasoconstrictor;
inthesecondgroupwasusedlidocainewithadrenaline1:100000.Thebloodpressurewasanalyzedwith24hour
recordanddynamicelectrocardiography.Thecomparisonofthetwogroupsdidnotshowstatisticallysignificant
differenceinthebloodpressure.Theanalysisofthe24hourelectrocardiographyshowedSTdepressionin10cases
six(20.7%)inthegroupreceivedsolutionwithoutadrenalineandfour(14.8%)inthegroupreceivedsolutionwith
adrenaline.Nostatisticallysignificantdifferencewasfoundbetweenthegroups(p=0.731).Theanalysisofthe
cardiacarrhythmiasalsodidnotshowstatisticallysignificantdifferencebetweenthetwogroups(p=1.00).The
authorsconcludedthattherewasnodifferenceinthechangeofthearterialpressureintwogroups,related
totheuseofvasoconstrictor.Moreovertherewerenocasesofcardiacarrhythmiaormyocardialischemiaduringthe
useofbothtypesofanestheticsolutions.
Inthesearchofanestheticswithoptimal effect,studiesarecomparingnot onlythedifferent typesof
anesthetics,butalsothedifferenttypesofvasoconstrictors[25].InstudyofSumeretal[26]wascomparedthepain
frominjectionduringadministrationofArticainewithadrenaline,PrilocainewithFelypressin,andLidocainewith
adrenaline.497patientsanesthetizedintraoralywithdifferentsolutionswereincluded.Thepatientswereevaluated
subjectivelyandaskedtoratetheirinjectionpainonasixpointscale.Afteranalyzingtheresults,theauthors
concludedthattherewasnostatisticallysignificantdifferencebetweenthepainfeltduringinjectionofthreetypesof
solutions.Referringtoliteraturesources,accordingtowhichsolutionswithlowpHaretakenmuchmorepainfully,
authorsconsideredthattheresultisduetothesimilarpHofthesolutions.Manyauthorsemphasizetheroleofthe
injection method for more successful anesthesia of patients [27, 28], and other con duct research aiming at
optimisationoftheprotocolsforworkwithmedicallycompromisedpatients[29,30,31].
CONCLUSION:Basedonthecontemporaryliteraturereview,wecanconcludethatmanystudiesaimedat
improvingthelocoregionalanesthesiaofpatientswithcardiovasculardiseases.Thebenefitsfromvasoconstrictors
inanestheticsolutionsforthequalityoftheanesthesiawerebeingproven.Numberofauthorsmaintainsthetheory
thatasmallamountofadrenalineintheanestheticsolutiondoesnotresultincomplicationsforpatientswith
controlledcardiovasculardiseases,whileatthesametimesignificantlyincreasestheeffectoftheusedanesthetic.
MainsubjectofstudyistheanestheticArticaine,assomeauthorsrecommenditasafirstchoiceagentforlocal
anesthesiaintheoralsurgery.
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Pleasecitethisarticleas:DaskalovH,DinkovaA,DrangovM.LOCALANESTHETICSINPATIENTS
WITHCARDIOVASCULARDISEASES.JofIMAB.2015JanMar;21(1):728731.DOI:
http://dx.doi.org/10.5272/jimab.2015211.728
Received:16/01/2015;Publishedonline:19/03/2015

Addressofcorrespondingauthor:HristoDaskalov,DMD,DDS,PhD.OralSurgeryDepartment,FacultyofDental
Medicine,MedicalUniversity,Plovdiv,Bulgaria11,OpalchenskaStr.,4000Plovdiv,BulgariaTel.:+359/8885892
42Email:hdaskalov@hotmail.com,
/JofIMAB.2015,vol.21,issue1/http://www.journalimabbg.org731