From the Guidelines
Epinephrine can be used cautiously in dental procedures for patients with severe aortic stenosis (AS), but with important limitations, as its use may increase myocardial oxygen demand and cause peripheral vasoconstriction, which can be problematic in AS patients. When considering the use of epinephrine in dental procedures for patients with severe AS, it is essential to weigh the potential benefits against the risks. The primary concern with epinephrine in severe AS patients stems from its potential to increase myocardial oxygen demand through its beta-adrenergic effects while simultaneously causing peripheral vasoconstriction through alpha-adrenergic effects, as noted in the 2017 ACC expert consensus decision pathway for transcatheter aortic valve replacement in the management of adults with aortic stenosis 1.
Key Considerations
- Local anesthetics containing epinephrine should be administered in minimal effective doses, typically not exceeding 0.04 mg (equivalent to about 2 cartridges of 1:100,000 epinephrine) per appointment.
- Slow injection technique with careful aspiration is essential to avoid intravascular administration.
- For patients with severe AS, consider using 1:200,000 epinephrine concentration rather than 1:100,000 when possible.
- Vital signs should be monitored before, during, and after the procedure, with oxygen and emergency medications readily available.
High-Risk Patients
For very high-risk patients with symptomatic severe AS, it is recommended to consult with the patient's cardiologist before the procedure and potentially perform dental work in a hospital setting where advanced cardiac monitoring is available, as suggested by the 2017 ACC/AATS/AHA/ASE/EACTS/HVS/SCA/SCAI/SCCT/SCMR/STS appropriate use criteria for the treatment of patients with severe aortic stenosis 1. The management of hypertension in patients with aortic stenosis is also crucial, as noted in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.
Monitoring and Emergency Preparedness
Given the potential risks associated with epinephrine use in severe AS patients, it is crucial to have emergency medications readily available and to monitor vital signs closely throughout the procedure. The goal is to minimize the risk of adverse outcomes while providing necessary dental care, prioritizing the patient's morbidity, mortality, and quality of life.
From the FDA Drug Label
Epinephrine should be used with caution in patients with cardiac arrhythmias, coronary artery or organic heart disease, hypertension, or in patients who are on medications that may sensitize the heart to arrhythmias, e.g., digitalis, diuretics, or anti-arrhythmics. In such patients, epinephrine may precipitate or aggravate angina pectoris as well as produce ventricular arrhythmias.
The use of epinephrine in dental procedures for patients with severe Aortic Stenosis (AS) should be approached with caution. Patients with cardiac arrhythmias, coronary artery disease, or organic heart disease may be at increased risk of adverse reactions, including angina pectoris and ventricular arrhythmias.
- Key considerations include:
- Cardiac conditions: Epinephrine may exacerbate existing cardiac conditions, such as hypertension or coronary artery disease.
- Medication interactions: Patients taking medications that may sensitize the heart to arrhythmias, such as digitalis, diuretics, or anti-arrhythmics, should be closely monitored.
- Dose and administration: Epinephrine should be administered with caution, and patients should be closely monitored for signs of adverse reactions 2, 2, 2.
From the Research
Considerations for Using Epinephrine in Dental Procedures
Patient Conditions
- Severe Aortic Stenosis (AS) is a significant risk factor for perioperative cardiac events in patients undergoing noncardiac surgery, including dental procedures 3
- Patients with severe AS may have symptoms such as dyspnea, angina, syncope, or presyncope, which can impact the management of anesthesia and epinephrine use 3, 4
Anesthetic Management
- Intraoperative hypotensive events should be treated promptly, primarily with phenylephrine, to maintain stable blood pressure 3
- The use of antihypertensive treatment, including β-blockers, may be safe and beneficial in patients with severe AS, but requires careful consideration and monitoring 5
- Neuraxial anesthesia (NA) may not be contraindicated in carefully selected patients with AS, but significant data heterogeneity prevents formal metanalysis 6
Epinephrine Use
- Epinephrine administration may be necessary in cases of anaphylactic shock, but should be used with caution and in combination with landiolol to suppress excessive tachycardia 7
- The use of epinephrine in patients with severe AS requires careful consideration of the potential risks and benefits, including the risk of inducing left ventricular dysfunction and hemodynamic compromise 5, 7
Preoperative Assessment
- Clinical assessment should search for signs of aortic stenosis, and echocardiographic examination should be considered, particularly in elderly patients or those undergoing high-risk surgery 4
- Preoperative cardiac risk assessment should include evaluation of the severity of aortic stenosis, measurement of functional capacity, and estimation of surgical risk of cardiac events 4