Title Epinephrine Use With Local Anesthesia in Post Myocardial Infarction Patients
Clinical Question In a patient who has had a MI, how long after their cardiac event is it safe to use standard levels of epinephrine in local anesthesia?
Clinical Bottom Line There is no clearly specific period of time to wait after a patient has had an MI for it to be safe to use standard levels of epinephrine in local anesthesia, but these studies suggest that the amount of risk and the length of time needed to wait are not as great as previous thought.
Best Evidence  
PubMed ID Author / Year Patient Group Study type
(level of evidence)
17589623Conrado/2007Fifty-four patients with coronary artery disease (excluding patients with a MI within the previous 3 months).Cohort Study
Key resultsIn this study there was no chest pain, arrhythmias, occurrence or worsening of left ventricular segmental hypocontractility or mitral regurgitation observed. The study concluded that: “dental extraction performed under anesthesia with 1:100,000 epinephrine does not imply additional ischemic risks, as long as performed with good anesthetic technique and maintenance of the pharmacological treatment prescribed by the cardiologist.”
3778050Cintron/1986Forty male patients with recent uncomplicated MI (6-20 days prior) with an average age of 60 years oldCase Series
Key resultsHalf of the patients were subjected to only a dental examination with local anesthesia (with 1:100,000 epi) while the other half were received either vigorous prophylaxis or a single extraction with local anesthesia (with 1:100,000 epi). No significant change in heart rate or blood pressure was noted during or after the dental anesthesia nor did any of the patients develop angina or other symptoms of myocardial infarction. Only one patient in the second group experienced an asymptomatic eight-beat run of ventricular tachycardia two hours after the dental extraction, but this was unassociated with dental or chest pain.
Evidence Search "Myocardial Ischemia"[Mesh] AND "Anesthesia, Dental"[Mesh] NOT (Review[ptyp] OR Case Reports[ptyp] OR Editorial[ptyp])
Comments on
The Evidence
Validity: The study design of Conrado’s article was a case control study where 54 patients were evaluated. The groups were similar at the start of the study but it doesn't appear to have been a double-blind study. The study design Cintron’s article was a case report where 40 male patients who had a previous uncomplicated MI were evaluated. There was no control group to compare to, but there was a >80% completion rate. Perspective: It is apparent the guidelines we have for time to wait after a patient has had a MI in order to use epinephrine in local anesthesia are, in fact, guidelines and should be treated as such and not as absolute rules. They tend to lean more to the conservative desiring to be better safe than sorry; however these guidelines are based more on the medical use of epinephrine, which uses much higher concentrations of epinephrine than that used in dental local anesthesia. It is important to go on a case-by-case basis and base decisions on a good clinical evaluation and history rather than strictly adhering to standard guidelines.
Applicability This applies to any patient undergoing local anesthesia with epinephrine who has had a previous myocardial infarction.
Specialty (General Dentistry) (Oral Surgery) (Dental Hygiene)
Keywords Epinephrine, myocardial infarction, dental anesthesia, local anesthesia, coronary disease
ID# 2664
Date of submission 03/17/2014
E-mail flandersd@livemail.uthscsa.edu
Author David Flanders
Co-author(s) e-mail
Faculty mentor Gregory K. Spackman, DDS, MBA
Faculty mentor e-mail spackman@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
None available
Comments and Evidence-Based Updates on the CAT
None available