Cardiovascular 1 Flashcards
Most common cause of premature death in the world
CVD
Patients frequently have more than one
CVD
Many different types of CVD disease
(6)
- Hypertension (HTN)
- Atherosclerosis
- Angina Pectoris
- Congestive Heart Failure
- Arrhythmias
- Bacterial Endocarditis
Types of CVDs
(8)
- Atheroslerosis aka Atherosclerotic Heart Disease (ASHD)
- Hypertension (HTN)
- Coronary Artery Disease (CAD)
- Angina Pectoris
- Bacterial Endocarditis
- Congestive Heart Failure (CHF)
- Arrhythmia
- Valvular disease
- Atheroslerosis aka Atherosclerotic Heart Disease (ASHD)
- coronary artery disease leads to infarction
- Bacterial Endocarditis
- infection, inflammation and scarring
- Congestive Heart Failure (CHF)
(2)
- dilated ventricles with weak muscles
- thickened myocardium
- Arrhythmia
–uncoordinated electrical signals
Bradycardia v. Tachycardia
- Valvular disease
(2)
- stenotic and not capable of full closure for blood circulation
- leads to CHF
CVD Risk factors
conditions (5)
high BP
high cholesterol
diabetes
rheumatic fever
>1 CVD
CVD Risk factors
behavioral
(6)
unhealthy diet
physical inactivity
obesity
too much alcohol
tobacco use
stress
CVD Risk factors
family history
(3)
genetics
becoming older
ethnicity
high BP (2)
- Stiffens vessels which reduces blood flow
- also a risk for stroke, kidney disease and dementia
high cholesterol (1)
LDLs
diabetes
- Unstable glucose levels affect healthy myocardium function; angiopathy
Rheumatic fever
–valvular disease
unhealthy diet
- Carbs, fats, caffeine, Na+
physical inactivity
poor circulation
obesity
- Excess weight stresses heart function, HTN, CAD
too much alcohol
- increases BP, arrythmias
tobacco use
- increases HR, BP, CAD, etc.
Predisposing etiologies
(4)
- Congenital
- Hypertension (positive CVD feedback
cycle) - Ischemia (positive CVD feedback cycle)
- Inflammation
Contributary anatomic abnormalities
(5)
- Hypertrophy
- Dilation
- Valves
- Regurgitation
- Stenosis
Physiologic changes
(3)
- Arrhythmias
- Heart failure
- Ischemia
Staging of Cardiovascular Disease (CVD)
class 1
Physical Activity:
Symptoms:
physical activity: no limitation
no dyspnea, fatigue or palpitations with physical activity
Staging of Cardiovascular Disease (CVD)
class 2
Physical Activity:
Symptoms:
physical activity: slight limitation
fatigue, dyspnea, palpitations present with physical activity
Staging of Cardiovascular Disease (CVD)
class 3
Physical Activity:
Symptoms:
physical activity: marked limitation
less than normal physical activity results in symptoms. comfortable at rest
Staging of Cardiovascular Disease (CVD)
class 4
Physical Activity:
Symptoms:
physical activity: severely limited. exacerbates symptoms
symptoms present at rest
Signs and Symptoms of Cardiovascular Disease
Signs
(6)
- Elevated BP
- Irregular or abnormal heart rate
- Abnormal respiratory rate
- Shortness of breath upon exertion
- Prolonged bleeding/easy bruising
- Surgical scars
Signs and Symptoms of Cardiovascular Disease
Symptoms
- Patient is uncomfortable in supine position
- The less the symptoms and the better the control of risk factors
THEN - the — a patient manages the stress
AND - the — likely the patient will have a life threatening incident during a dental procedure
better
less
- The greater the symptoms and the poorer the control of risk factors
THEN - the — a patient manages the stress
AND
the — likely the patient will have a life threateningincident during a dental procedure
worse
more
Low Level Intervention
(6)
- Health/medical evaluation
- Exams
- Prophy
- Radiographs
- Optical oral scans
- Alginate impressions
Moderate Intervention
(4)
- SRP (scaling and root planning)
- Simple restorative procedures; 1-2 teeth
- Simple extractions; 1-2 teeth
- Restorative impressions needing retractions
and longer setting times
High Risk Intervention
(6)
- Complex restorative procedures on >2 teeth
- Multiple extractions
- Surgical extractions
- Implant placement
- Full arch impressions
- Dental care under general anesthesia
Primary Hypertension
(2)
- Multifactorial, gene-environment
- 90-95% of cases
Secondary hypertension
(4)
- Renal disease and renin-producing
tumors - Endocrine
- Cardiovascular
- Neurologic
- Endocrine
(5)
➢Adrenal
➢Exogenous hormones
➢Pregnancy
➢Pheochromocytoma
➢Thyroid
- Neurologic
(4)
➢Psychogenic
➢Sleep apnea
➢Intracranial vascular pressure
➢Exogenous
Complications
(7)
- Myocardial infarction
- Stroke
- Coronary artery disease
- Peripheral artery disease
- Heart failure
- Retinopathy
- End-stage renal disease
Blood Pressure
Determined by
indirect measurement in the upper extremities with a BP
cuff and stethoscope
Determined by indirect measurement in the upper extremities with a BP
cuff and stethoscope
➢ Cuff should encompass —% of the circumference of the arm.
➢ Center of cuff over
➢ Cuff too small →
➢ Cuff too large →
80
brachial artery
falsely elevated values*
falsely low values*
‘White Coat HTN’ elevate BP by
30 mm Hg*
Pregnant pts w/ ≥ 10 mm Hg increase in systolic BP from baseline
➢ Risk of
eclampsia →immediate referral
Blood Pressure
Arm position matters
➢ Horizontal at heart level (mid-sternum)
Arm below heart level
Over-Estimates systolic and diastolic pressures
Similar to Cuff too small →falsely elevated values
Arm above heart level
under-estimates systolic and diastolic pressures
Similar to Cuff too large →falsely low values
Hypertension
Goals depend on patient
age and comorbidities
Generally, goals are between <130 - 149/80-90 mm Hg
Blood Pressure
NO dental care at UMKSC SOD if BP
≥ 180/110 mmHg
➢ 180/120 is classified as a Hypertensive Urgency by the AHA based on
2017 guidelines
➢ Urgent referral →see doctor ASAP
➢ If patient is symptomatic →Emergency Room
Medical Management
* Lifestyle modifications
(3)
➢ Diet (increase fruit intake, decrease sodium, increased potassium)
➢ Physical exercise/weight loss
➢ Tobacco cessation and alcohol intake reduction
Oral Manifestations
None due to hypertension itself
* Side-effects of pharmacotherapy:
(7)
➢ Dry mouth (anti-adrenergics and diuretics)
➢ Burning mouth (ACEi)
➢ Taste changes (antiadrenergics, ACEi)
➢ Angioedema (ACEi, ARB)
➢ Gingival hyperplasia (calcium-channel blockers, what are the other 2?)
➢ Lichenoid reactions (thiazides, methyldopa, propranolol, and labetalol)
➢ Lupus-like lesions (hydralazine)
Questions to Ask Your Patient with Hypertension
Physical Activity
- Do you feel shortness of breath at rest?
- Are you physically active?
➢ What kind of physical activities do you engage in?
➢ Do you feel shortness of breath after exercise?
➢ Does it limit the intensity of your physical activity
questions
Hypertension History
- How long have you had high blood pressure?
- Who manages your blood pressure, primary care or a cardiologist?
- How long have you been on this current antihypertensive regimen?
- Have there been any recent changes to your blood pressure medication? Why?
questions
Hypertension Monitoring
(3)
- What is your usual BP level at the doctor’s office?
- Do you check your BP at home?
- What are your usual readings, how high does it get?
Dental Considerations for the Hypertensive Patient
Serious potential complications of severe uncontrolled HTN:
(4)
- Stroke
- Angina
- Arrhythmia
- Myocardial infarction
(3) may increase the patient’s BP and lead to complications
Stress, anxiety, fear
Patients taking nonselective beta-blockers
➢Use of vasoconstrictor can cause an acute rise in BP
Patients may be sensitive to sudden position changes causing
orthostatic hypotension
Dental Considerations for the Hypertensive Patient
Pre-operative considerations
- Reduce Stress and Anxiety
➢ May need oral and/or inhalation sedation
Intra-operative considerations
(3)
- Profound anesthesia!!!! (MOST IMPORTANT)
- Limit epi to 2 carpules if taking a selective beta-blocker, (2 carp rule)*
- Don’t use epinephrine-gingival retraction cord
Post-operative considerations
(4)
- Avoid macrolide antibiotics with calcium channel blocker (↑ CCB levels)
- Avoid long-term use of NSAIDs (>2 weeks)
- Stage 2, monitor BP during treatment, if 180/110 stop tx!
- Raise patient slowly after treatment b/c of hypotension
MEDICAL CONSULT LETTER –GENERAL GUIDELINES
(2)
Make explicit to physician when writing a medical consult (categorize procedure risks not dental details)
Ask very specific questions to the physician in relation to the current disease status of the patient
time of procedure -
risk category
Hypertension Medical Consult Questions*
(4)
- What is the patient’sBP goal (range)
- What have been patient’sin-office BP readings?
- Does the patient have any end-organ damage?
- Current medications prescribed to manage
Hypertension
Cardiac measures**
(4)
- Stress reduction protocol
- Nitrous oxide
- Profound anesthesia
- Cardiac epi dose = max 0.04mg
- Cardiac epi dose = max 0.04mg
✓Articaine for
✓2% lidocaine 1:100,00 epi for
✓3% mepivacaine without epi for
maxillary blocks and maxillary or mandibular infiltrations
IANB
anesthesia
Atherosclerosis
- Inflammatory disorder with accumulation of
lipid plaque within the arterial walls
➢ Thickened intima (decreased arterial lumen)
➢ Decreased oxygen
➢ Decreased blood flow to the myocardium
Atherosclerosis
* Leads to
(5)
➢ Stenosis
➢ Angina (stable ischemic disease)
➢ MI
➢ Ischemic stroke (acute ischemic disease)
➢ Peripheral arterial disease
Atherosclerosis –Risk Factors
➢Depression
➢Family history of CVD
➢Insulin resistance
➢Diabetes mellitus
➢Male sex
➢Age
➢Smoking
➢Lack of exercise
➢Obesity
➢Stress
➢Depression
➢Family history of CVD
➢Hyperlipidemia
(↑LDL)
➢Hypertension
➢Insulin resistance
➢Diabetes mellitus
Atherosclerotic plaques can lead to:
(2)
- ischemia
- thrombosis, (vascular blockage) if they
rupture
Atherosclerosis of the Circulatory System (Heart)
* Associated symptoms
(2)
➢ Chest pain
➢ Angina
Atherosclerosis of the Circulatory System (Heart)
* Complications
(5)
➢ Unstable angina
➢ Myocardial infarction (necrosis)
➢ Thrombosis
➢ Embolism
➢ Aneurysm
Angina Pectoris
* Chest pain resultant from
ischemic changes
➢Mid-chest pain described as
o“aching, heavy squeezing pressure or tightness”
Angina Pectoris
* Pain may radiate (3)
* Pain lasts
* — used to resolve angina
➢Shoulder, arms, jaw
5-15 minutes
➢ If unstable angina, may be longer
Vasodilation
Angina Pectoris
May be stable or unstable
* Stable
(4)
➢Imbalanced cardiac perfusion
➢Stable symptoms, reproducible, predictable, consistent
➢Chest pain precipitated by physical activity/exertion
➢Resolves with cessation of activity
- Unstable
(4)
➢Disruption of atherosclerotic plaque
➢Possible partial thrombosis, embolism or vasospasm
➢Symptoms increasing
➢Chest pain at rest or with less intense physical activity/exertion
Myocardial Infarction
* Definition
➢Lose normal (2)
➢— ventricle MI more common
Irreversible coagulative necrosis of the myocardium
conduction and contraction
Left
Myocardial Infarction
* Symptoms similar to angina, plus
➢— features
➢Severe — pain with (3)
Radiating
substernal
shortness of breath, profuse sweating, and loss of consciousness
Myocardial Infarction
Pain does not resolve with — and is more prolonged
vasodilators
Medical Management
Treatment/reduction of modifiable risk factors and associated disease
Hypertension
(2)
➢Beta-blockers
➢Calcium channel blockers
Angina
(1)
➢Nitrates (nitroglycerin) –stable angina
Stroke
(1)
➢Antiplatelet agents (aspirin, clopidogrel) –stroke prevention
Revascularization (interventional)
(2)
➢ Percutaneous transluminal coronary angioplasty with stenting (PCI;
stent)
➢ Coronary artery bypass grafting (CABG)
Hyperlipidemia
(5)
➢Fibrates
oGemfibrozil
➢Niacin
oNiaspan
➢Omega-3 fatty acids
oLovaza
➢HMG-CoA reductase inhibitor
oStatins
➢Cholesterol absorption
inhibitor
oEzetimibe
➢Bile acid sequestrants
oCholestyramine
oColestipol
FOR ALL ISCHEMIC DISEASE
(3)
- Severity of the disease
- Stability and cardiopulmonary reserve of the patient
(i.e., the ability to tolerate dental care) - Type and magnitude of the dental procedure
Ischemic Heart Disease
Same questions as HTN + :
(6)
- Do you have chest pain?
- Do you get chest pain after exercise or at rest?
- How often? When was the last time?
- Has there been any change in frequency or intensity of your chest
pain? - Do you take anything to make it stop?
- Have you ever had cardiac surgery?
- Which procedure(s)
- How long ago was it?
- Have you ever had a MI?
- How long ago?
- Make sure you and/or patient have — on day of visit to use
where applicable. - Be aware of signs and symptoms of MI and be prepared for an
emergency - No elective treatment in patient with unstable angina or recent
history of MI (major risk)
nitroglycerin
Do you bruise easily?
(3)
- Are you taking aspirin or clopidogrel (antiplatelet meds)?
- When you cut yourself how long does it take to stop bleeding?
- Have you ever been hospitalized for bleeding?
- Increased bleeding expected, have local measures ready
- In general, no need to stop
- If extensive surgery, may consider
antiplatelet therapy
drug holiday with physician
consultation
Recent Myocardial Infarction <1
month
(3)
- Urgent dental care only
➢ACUTE dental pain or infection - Consultation with physician
- Consider referral to specialized center
Past Myocardial Infarction
>1 month
* Consider severity of cardiac status and
comorbidities
* — can measure the
degree of heart failure
➢Measures amount (%) of
* Consider appropriate management
protocols
Ejection Fraction
blood that
leaves the left ventricle after
contraction.
Past Myocardial Infarction
>1 month
* Consider severity of
* Consider appropriate management
protocols
cardiac status and
comorbidities
* Ejection Fraction can measure the
degree of heart failure
➢Measures amount (%) of blood that
leaves the left ventricle after
contraction.
- Ejection Fraction (EF) %: 55% to 70%
- Pumping Ability of the Heart:
- Level of Heart Failure/Effect on Pumping:
Normal
Heart function may be normal or you may have heart failure with preserved EF (HF-pEF).
- Ejection Fraction (EF) %: 40% to 54%
- Pumping Ability of the Heart:
- Level of Heart Failure/Effect on Pumping:
Slightly below normal
Less blood is available so less blood is ejected from the ventricles. There is a lower-than-normal amount of oxygen-rich blood available to the rest of the body. You may not have symptoms.
- Ejection Fraction (EF) %: 35% to 39%
- Pumping Ability of the Heart:
- Level of Heart Failure/Effect on Pumping:
- Pumping Ability of the Heart: Moderately below normal
- Level of Heart Failure/Effect on Pumping: Mild heart failure with reduced EF (HF-rEF).
- Ejection Fraction (EF) %: Less than 35%
- Pumping Ability of the Heart:
- Level of Heart Failure/Effect on Pumping:
- Pumping Ability of the Heart: Severely below normal
- Level of Heart Failure/Effect on Pumping: Moderate-to-severe HF-rEF. Severe HF-rEF increases the risk of life-threatening heartbeats and cardiac dyssynchrony/desynchronization (right and left ventricles do not pump in unison).
Stress Reduction in Stable Angina or Past Myocardial Infarction
* Ideal
(3)
➢No ischemic symptoms
➢Intermediate risk
➢No other risk factors
Stress Reduction in Stable Angina or Past Myocardial Infarction
Procedural Precautions
➢Short appointments in the –
➢Pre-treatment –
➢Availability of –
➢– sedation
➢– –oxygen sedation
➢Profound –
➢Limit amount of –
➢Avoid –
➢Effective post-operative – control
morning
vital signs
nitroglycerin
Oral
Nitrous oxide
local anesthesia
vasoconstrictor
epinephrine-impregnated retraction cord
pain
Pre op sedation: (2)
short acting benzodiazepine (triazolam 0.125-0.25 mg)
1 hr before appointment and possibly the night before the day of the appointment
Ischemic Heart Disease
Drug interactions and oral manifestations
Same as HTN + :
(3)
- HLD
- Limit epinephrine as discussed earlier
- Bleeding as discussed earlier –limit NSAIDs.
- HLD
- Statins –avoid CYP inhibitors (fluconazole, clarithromycin
- ↑ statin levels
SA node
(3)
- Primary pacemaker
- Regulates atrial function
- Produces P wave (atrial
depolarization)
AV node
(2)
- Regulates atrial impulses entering
ventricles - Slows conduction rate of SA
generated impulses
QRS complex
- Simultaneous depolarization of the
ventricles
T wave
- Repolarization of the ventricles
Arrhythmia
Disruption of the electrical impulse generation or conduction in the heart that
leads to abnormal cardiac function
Arrhythmia
* Formation of
* Increased
*(2) impulse formation
* Delayed —
* — of the heart after refractory period
abnormal impulse
impulse formation
Enhanced or abnormal
depolarization
Re-excitation
Arrhythmia
The disruption may be due to an area of:
(4)
- Infarction
- Ischemia
- Electrolyte imbalance
- Medication
The most common cause of sudden cardiac death is
ventricular fibrillation*
Causes of arrhythmias
(6)
- Cardiovascular disorders
- Pulmonary disorder
- Autonomic disorder
Arrhythmia - Hyperthyroidism
- Drugs
- Electrolyte imbalance
- Anxiety and anger
- Cardiovascular disorders
(5)
- Myocardial infarction
- Mitral stenosis
- Valvular disease
- Ischemic heart disease
- Congestive heart failure
- Pulmonary disorder
(2)
➢Pneumonia
➢Obstructive lung disease
- Drugs
(6)
➢ Epinephrine
➢ Alcohol
➢ Digitalis
➢ Morphine
➢ Beta-blockers
➢ Tricyclic antidepressants, and
others
Bradycardia
Tachycardia
- <60 beats/min
- > 100 beats/min
Arrhythmia
Symptoms
(6)
- Palpitations, fatigue
- Dizziness, syncope, angina
- Congestive heart failure
- Shortness of breath
- Orthopnea
- Peripheral edema
Atrial Fibrillation
(4)
- Most common arrhythmia
- Rapid uncontrolled atrial activity
- Irregularly irregular rhythm
- Risk of arterial clot formation
➢ Embolism and stroke
Heart Block
- Impulse is partially or completely blocked
➢Prolonged or no conduction
- First-degree
➢ Longer conduction time
- Second-degree
➢ Mobitz I
➢ Mobitz II*
oMore prolonged and no P wave
oRepetitive or occasional sudden blocks w/o previous prolonged
conduction time
- Third-degree
(2)
➢ No impulses –COMPLETE BLOCK *
➢ Indication for pacemaker
Ventricular Arrhythmias
(4)
- Premature ventricular complexes (PVCs)
- Common
- Abnormal QRS complex + pause
- Increased risk of death if patients have underlying CVD (heart failure,
MI, valvular heart disease
Ventricular tachycardia
(3)
- If more than 3 consecutive PVC at 100 beats/min
- If lasts for more that 30 seconds, requires termination
- Torsades de pointes –potentially life-threatening
Ventricular flutter and fibrillation
(3)
- Lethal
- Consequence of ischemic heart disease
- Cardiac contraction is not sequential, chaotic
Pharmacotherapy
- Antiarrhythmics
Pharmacotherapy
* Oral anticoagulants
➢ Clopidogrel (Plavix)
(2)
oInhibits platelet agglutination
oplatelet count not affected
Pharmacotherapy
* Oral anticoagulants
➢ ASA (Aspirin 81mg - low dose)
(2)
oInhibits platelet agglutination
oplatelet count not affected
Drugs that cause gingival hyperplasia (3)
Ca channel blockers (20% of pt affected)
-nifedipine
-verapamil
Immunosuppressants (30% of pt affected)
-cyclosporin
-tacrolimus
Anticonvusants (50% of pt affected)
-phenytoin
Pharmacotherapy
* Oral anticoagulants
➢ Warfarin (Coumadin)
(3)
oVitamin K antagonist
oINR monitoring
oHighly variable
Pharmacotherapy
Direct Oral Anticoagulants (DOACs)
➢ Direct thrombin inhibitor
(2)
oDabigatran (Pradaxa)
oReversal agent available
Pharmacotherapy
Direct Oral Anticoagulants (DOACs)
➢ Direct Factor Xa inhibitors
(4)
oRivaroxaban (Xarelto)
oApixaban (Eliquis)
oEdoxaban (Savaysa)
oReversal agents not available
NEVER STOP ANTICOAGULATION FOR DENTAL TREATMENT UNLESS
RISK OF THROMBOSIS — RISK OF MASSIVE BLEED
CONSULT PHYSICIAN IF EXTENSIVE SURGERY NECESSARY
CONSIDER REFERRAL TO SPECIALIZED CENTER
EXTENSIVE SURGERY
>
Non-pharmacologic
(4)
- Pacemakers
- Implanted Cardioverter-Defibrillator (ICD)
- Surgery
- Electrocardioversion and defibrillation
- Implanted Cardioverter-Defibrillator (ICD)
(1)
➢ Sets pace and shocks
- Surgery
(3)
➢ Tissue resection
➢ Cardiac ablation
➢ Surgery to address underlying cause such as stenosis
Dental Treatment Considerations
* What type of arrhythmia?
questions
(5)
➢ When diagnosed? How frequent?
➢ How treated?
➢ Do you have a pacemaker or
defibrillator?
➢ Have you ever required emergency
intervention for arrhythmia?
➢ Is your arrhythmia stable now?
Dental Treatment Considerations
(3)
- What type of arrhythmia?
Assess comorbidities (CVD, pulmonary) - ROS: palpitations, chest pain, dizziness,
shortness of breath, syncope
If severity, nature, treatment of C.A. is unclear obtain
Med Consult
High Risk Arrhythmia
* – elective dental care
* Dental treatment should be limited to – care only
- Treatment of (3)
* If necessary treatment, obtain a –
* Management may include an (4)
* Cautious use of — (contraindicated if taking –)
* Prophylactic –
Defer
urgent
ACUTE pain, bleeding, or infection, only
medical consult
IV line, pulse oximeter, BP and oxygen, electrocardiogram monitoring
epinephrine, digoxin
nitroglycerin
**Limit Local Anesthetics.
2 Carp or < Rule (Lido 1:100 epinephrine)
Intermediate and Low Risk Arrhythmia
Elective care can be provided with following management protocols:
(4)
*Stress/Anxiety reduction:
*Assess pretreatment vital signs, have nitroglycerin available, limit
epinephrine (LA and gingival cord)
*Profound local anesthesia and pain control
*Devices
*Stress/Anxiety reduction:
➢Oral sedative &/or inhalation sedative
Devices
(3)
➢Electrosurgery units contraindicated in patient with pacemakers and ICDs
➢Ultrasonic scalers –low risk interference
➢Battery operated curing lights –low risk interference
Dental Treatment Considerations
* Do you take a blood thinner?
(5)
➢ How often do you have your INR measured?
➢ What was your last reading? What has been your range? (Ideal: < 3)
➢ When is your next reading?
➢ Does it take a long for you to stop bleeding after a cut?
➢ Have you ever been hospitalized due to bleeding?
Local measures for hemostasis/
*Gelatin sponges (Gelfoam)
*Oxidized cellulose
*Chitosan hemostatic products
*Sutures
*Gauze with applied pressure
*Topical tranexamic acid
*Topical aminocaproic acid (Amicar)
*Topical thrombin
Electrocautery - not with pacemakers
