cardiac neuro stuff Flashcards
invasive dental procedure, cardiac at risk patient, gave AB prophy but 3 weeks after got fever, lethargy, petechiae, what do we think about, what signs and symptoms
how to manage
think about IE (prosthetic heart valve got highest risk for IE)
signs:
- roth spots (in ocular)
- splinter hemorrhages
- osler nodes (painful, on fingers/toes)
- janeway lesions (not painful, on palms/soles)
mx: give amox 4-6 weeks
if suspect IE need to do blood culture to identify organism
common cardiac complication that we think about when we hear rheumatic fever
what are the dental implications and how to manage
atrial fibrillation, means might be wafarinised, but some are on NOACs instead
if warfarin, check INR. if too high (above 2-3) then need to bridge?
what are the risk categories for IE and what does it mean
high, intermediate and low risk
it is NOT high risk of getting IE but rather high risk of ADVERSE EFFECTS after getting IE
what condition do we think about for patient on furosemide
its a diuretic, so can be CHF
condition we think about when patient has erythropoietin injections
anemia
what do we have to be careful about in cardiac patients if we want to give AB
avoid macrolides because they can cause arrhythmias, increase QT intervals
possible causes of falls if its a diabetic patient
- hypoglycemia
- postural hypotension
- vasovagal syncope
- stroke
what factors should we be looking out for when we think about things affecting bleeding risk
- meds
- systemic problems like liver failure (means no production of clotting factors and platelets)
what is the livers function in the aspect of blood
produce clotting factors like fibrinogen, prothrombin, factor V, VII, IX, X, XI, XII, and protein C and S
liver also produces bile salts which help the intestines absorb vit K, and Vit K is required for synthesis of some clotting factors like factor II, VII, IX and X
difference between valvular and non valvular AF
valvular is caused by a problem with heart valve like narrowed or leaky valve
non valvular means Afib not caused by heart valve issue, usually triggered by other factors like high blood pressure or stress
reversal agent for apixaban
some recombinant form of human factor Xa protein, called Andexanet alfa, binds to apixaban and reverses anticoag effect
other blood products that can be used to reverse anticoagulation are prothrombin complex concentrates
what is the reversal agent for warfarin
- in urgent situations, more concentrated product like prothrombin complex concentrate is preferred for faster reversal
- fresh frozen plasma
dental implications of CHF
- need to put patient semi upright because if supine will become breathless
- aka paroxysmal nocturnal dyspnea
how can epilepsy affect us
- might be on carbamazepine
- but to be on carbamazepine need to do HLA genotype testing and if its positive then susceptible to SJS TEN
SJS TEN dental implications:
- severe oral mucosal ulcerations
- xerostomia
Definition of IE and classification
Is a microbial infection of the heart valves or the mural endocardium that leads to the formation of vegetations composed of thrombotic debris and organisms, often associated with destruction of the underlying cardiac tissues
Classified into:
1) acute: tumultuous and destructive infection involving highly virulent organisms eg Staph aureus
2) subacute: caused by less virulent organisms eg Strep viridians. Slow progressing, typically on already abnormal valves
pathophysio of IE
- caused by staphylococci, strep, enterococci
- staph aureus is associated with injecting drug users, usually affects the right side of the heart (tricuspid valve)
- viridians group strep are a group of bacteria found in oral cavity and can cause IE as a result of transient bacteremia from daily activities or after dental procedures
what are the risk factors of IE
GENERAL
- poor OH
- immunosuppression
- Injecting drug users
- DM
- long term hemodialysis (indwelling IV lines)
LOCAL
factors which increase an individuals thrombotic risk including:
- cardiac abnormalities
- previous prosthetic valve
- vascular procedures because these are foci for disrupted blood flow and bacterial seeding
clinical presentation of IE
- symptoms usually start 2 weeks after initiating bacteremia (aka after dental tx)
signs
- fever
- dyspnoea (difficult breathing)
- flu like symptoms
- heart murmur
- positive blood culture
- vegetative mass seen on echocardiography
- petechiae on extremities
- splinter hemorrhages
- roth spots (oval retinal hemorrhages with clear centres)
- janeway lesions (soles and palms)
- osler nodes (painful nodules on digits, fingers and toes)
how can diagnosis of IE be made
using modified Duke criteria
definite diagnosis made by 2 major criteria or one major and 3 minor criteria or 5 minor criteria
MAJOR
1) blood cultures positive for infective endocarditis
2) evidence of endocardial involvement
MINOR
1) predisposing factor (eg IV drug user or a predisposing heart condition)
2) temperature >38 degrees
3) vascular phenomena (septic emboli, pulmonary infarcts, janeway lesions)
4) immunologic phenomena (eg glomerulonephritis, oslers nodes, roth spots)
5) microbiologic evidence
what patients are at risk for IE and need AB prophylaxis
1) prosthetic heart valves
2) prior hx of IE
3) unrepaired cyanotic congenital heart disease including palliative shunts and conduits
4) completely repaired congenital heart defects with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure
5) repaired congenital heart disease with residual defects at the site or adjacent to the site of the prosthetic patch
6) valve regurgitation due to structurally abnormal valve in transplanted heart
what procedures require AB prophy for patients at risk for IE
any procedure that involves the manipulation of gingival tissue or perf of oral mucosa
what is the ab prophy regime for IE for adults
1) amoxicillin 2g
2) if unable to take oral meds, ampicillin 2g IM or IV OR
cefazolin/ceftriaxone 1g IM or IV
3) if allergic to ampicillin/ penicillins:
- cephalexin 2g (but this is still a beta lactam)
- azithro/ clarithro 500mg
- doxycycline 100mg
what is the ab prophy regime for IE for children
1) amoxicillin 50mg/kg
2) if unable to take oral meds,
- ampicillin 50mg/kg IM or IV
- cefazolin/ ceftriaxone 50mg/kg IM or IV
3) if allergic to penicillin or ampicillin,
- cephalexin 50mg/kg
- azithro/ clarithro 15mg/kg
- doxycycline (2.2mg/kg for kids less than 45kg and 100mg for kids above 45kg)
symptoms of AF
- heart palpitations
- dizziness
- chest pain
- SOB
- irregularly irregular pulse
but AF can also be asymptomatic
what is AF
- most common type of cardiac arrhythmia
- characterised by rapid, disorganised and ineffective atrial contractions
- irregularly irregular pulse
- a type of supraventricular tachycardia
- because atria do not contract effectively, this promotes formation of intraarterial clots and risk of embolism and stroke
risk factors of AF
- HTN
- valvular heart disease
- heart failure
- DM
- stroke
- old age
