Cardiovascular 2 Flashcards
HF
Causes (3)
decreased pumping action
systemic fluid congestion
failure of vital organs
Results of right side HF
(3)
pulmonary edema
coughing
peripheral edema (arms and legs mostly)
Left side HF
(3)
affects all organ systems; decrease kidney function contributes to fluid retention
pulmonary edema
coughing
Heart Failure
Pathophysiology
*Increased workload →problems with
cardiac muscle
*— ventricle typically fails first →can lead to — ventricle failure
Left
right
Heart Failure
reduced –
decreased –
blood backed up in –
pulmonary –
increased workload on – ventricle
volume overload (3)
ventricles – to try to compensate
activation of – to compensate
cardiac output
perfusion
pulmonary vessels (SOB, foamy cough, pulmonary)
hypertension
R
venous congestion, peripheral edema, ascites
dilate
RAAS and neurohormonal responses
Past Myocardial Infarction
>1 month
* Consider
(2)
severity of cardiac status and
comorbidities
appropriate management
protocols
- 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: Normal
- Level of Heart Failure/Effect on Pumping: 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: Slightly below normal
- Level of Heart Failure/Effect on Pumping: 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: 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: 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).
EF =
blood vol. pumped out x 100
blood vol. in chamber
normal EF
50-70% is pumped out
during each contraction (usually comfortable during activity)
borderline EF
41-49% is pumped out
during each contraction (symptoms may become noticeable during activty)
reduced EF
< 40% is pumped out
during each contraction (symptoms may become noticeable even during rest)
*Systolic failure
➢ Reduced left ventricular ejection fraction (HFrEF)
*Diastolic failure
➢ Normal left ventricular ejection fraction (HFpEF)??
*Cardiac abnormalities
(3)
➢ Valvular Disease
➢ Arrhythmias
➢ Myocardial necrosis
*Decompensation
(3)
➢ Inability to compensate
➢ Increased peripheral blood flow
➢ Increased metabolic needs
Predisposing Factors
➢ Acute CVD
(1)
➢ Chronic CVD
(3)
oMI
oHypertension
oCoronary artery disease
oArrhythmia, etc
HF
Result (signs and symptoms)
(2)
➢ Volume overload
➢ Inadequate perfusion
HF
Complications
(3)
➢ Cardiac arrest (stops beating)
➢ Myocardial infarction (blood flow blocked)
➢ Stroke
Heart Failure
Signs
➢Rapid, shallow breathing
➢Inspiratory rales (crackles)
➢Increased heart rate
➢Distended jugular (neck) veins
➢Peripheral edema
➢Ascites
➢Cyanosis
➢Weight gain
➢Clubbing of fingers
Heart Failure
Symptoms
(6)
➢Fatigue and weakness
➢Orthopnea - shortness of breath (dyspnea) in recumbent position
➢Exercise intolerance
➢Muscular fatigue
➢Weight gain
➢GI distress
(nausea, vomiting & constipation)
Heart Failure Medical Management
* Pharmacologic and non-pharmacologic (see previous slide info)
STAGE A
STAGE B
STAGE C
STAGE D
* Patients with severe heart failure may require –
* Intermediate therapy is the –
ACE inhibitor
ACE inhibitor, beta blocker
ACE inhibitor, beta blocker, diuretic for fluid retention
ACE inhibitor, beta blocker, diuretic for fluid retention, decision ab appropriate level of care
cardiac transplantation
Left Ventricular Assist Device (LVAD)
Effect of dental treatment
before cardiac valve surgery:
Systematic review and meta-analysis
Looked at effect dental treatment (clearance)
prior to cardiac valve surgery or LVAD
implantation
Outcomes:
Morbidity (IE, post-surgical infection, length of
hospital stay) and mortality (all cause)
Results
(3)
- LVAD studies did not meet inclusion criteria
- Low certainty evidence for valvular surgery
- Data cannot support or refute efficacy of dental
treatment (clearance) prior to cardiac surgery
In most cases of HF, the dentist will need to obtain a medical
consultation with the patient’s cardiologist to determine
(5)
- The patient’s physical status
- Laboratory test results
- Level of control
- Compliance with medications and recommendations
- Overall stability
A major issue for patients with symptomatic HF
(5)
- Symptoms could abruptly worsen
- Acute failure
- Fatal arrhythmia
- Stroke
- MI
HF
class 1
physical limitation: no limitation
no dyspnea, fatigue or palpitations with physical activity
HF
class 2
physical activity: slight limitation
fatigue, dyspnea, palpations present w physical activity
HF
class 3
physical activity: marked limitation
less than normal physical activity results in symptoms, comfy at rest
HF
class 4
physical activity: severely limited, exacerbates symptoms
symptoms present at rest
Class I:
routine dental care ok
Class II:
medical consultation required, routine dental care likely ok
Class III and IV:
consider referral to specialized care
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
(5)
*Complex restorative procedures on >2 teeth
*Multiple extractions
*Surgical extractions
*Implant placement
*Full arch impressions
*Dental care under general anesthesia
Heart Failure
Additional HF Dental Management Considerations
(3)
- Short, “stress-free” appointments
- Chair position
- If patient taking digitalis glycoside (digoxin) –positive inotrope
- Chair position
➢Patients with HF may not tolerate supine position (pulmonary edema)
- If patient taking digitalis glycoside (digoxin) –positive inotrope
(2)
➢Epinephrine should be avoided, if possible
➢Combination increases the risk for arrhythmia
There are no — manifestations related to HF
oral
Many of the drugs used to manage HF can cause
dry mouth
altered taste and oral ulcerative lesions (discussed previously)
Valvular Disease
* Compromised function of the
* Valves direct blood flow into
heart valves
different heart chambers
➢ Atrioventricular:
➢ Semilunar
oTricuspid and Mitral
oAortic and Pulmonary
Valvular Disease
* Valves open and close
~
85,000/QD @ 60/min
100,800/QD @ 70/min
- Valvular Stenosis
➢ Do not open properly
- Valvular Insufficiency
(2)
➢ Do not close properly
➢ Associated with regurgitation
Fibrosis
➢ Stiff, sclerosis, stenosis causing either stenosis or insufficency
Myxomatous degeneration
(2)
➢ Benign loose CT tumorous changes where valves become Floppy, prolapse, regurgitation
➢ Causes insufficiency
Valvular Heart Disease
Risk Factors (other)
(3)
- Calcifications
- Congenital defects (bicuspid aortic valve, mitral valve prolapse)
- Infections
Valvular Heart Disease
Signs
(4)
➢ Murmurs
➢ Syncope
➢ Heart failure
➢ Shortness of breath
Valvular Heart Disease
Symptoms
(3)
➢ Heart failure
➢ Exercise intolerance
➢ Shortness of breath (can also be a sign)
Valvular Heart Disease
Medical Management
(2)
- Treatment is primarily surgical
- Valve replacement (more common)
Valve replacement (more common)
➢Mechanical Implants
(2)
oSilicone
oRequires long-term anticoagulation
Valve replacement (more common)
➢Bioprosthetic Implants
(3)
oAllograft , bovine graft, etc.; decellularized CT
with a less antigenic structural matrix
oshort-term anticoagulation
oLong-term antiplatelet therapy)
Predisposition for
infective endocarditis
Questions for Patient with Valvular Heart Disease
* Screening
➢ Shortness of breath, chest pain, etc.
Questions for Patient with Valvular Heart Disease
* Valve replacement
➢ Have you ever had valve replacement surgery ?
oWhat type? When?
oWhat kind of valve do you have (mechanical or bioprosthetic)
Questions for Patient with Valvular Heart Disease
* Anticoagulation/Bleeding
➢ Do you take a blood thinner?
oHow often do you have your INR measured?
oWhat was your last reading? What has been your range?
oWhen is your next reading?
➢ Do you take aspirin or clopidogrel?
➢ Does it take a long for you to stop bleeding after a cut?
➢ Have you ever been hospitalized due to bleeding?
Questions for Patient with Valvular Heart Disease
* Previous Infective Endocarditis
➢ Have you ever had infective endocarditis?
oWhen?
oAre you allergic to any antibiotics?
oIf, so what type of reaction occurs?
Questions for Patient with Valvular Heart Disease
Oral manifestations
- No specific oral manifestations of Valvular Heart Disease
Questions for Patient with Valvular Heart Disease
* Bleeding
➢ Complications from anticoagulation or
➢ Complications from antiplatelet therapy
Questions for Patient with Valvular Heart Disease
* Infections
➢Risk of developing infective endocarditis
➢Requires antibiotic prophylaxis when valves have been replaced
Questions for Patient with Valvular Heart Disease
* Drug Effects
➢ Potential drug interactions from CVD pharmacologic management (as
previously discussed), especially when comorbidities are present
Dental Considerations
(4)
- Assess ability to tolerate care in context of underlying condition and
comorbidities - Assess Bleeding Risk
- Infections
- Drug Effects
- Assess Bleeding Risk
(2)
➢ Obtain INR the day of the invasive procedures
➢ Have local hemostatic measures in place
- Infections
(1)
➢Determine need for antibiotic prophylaxis and antibiotic of choice
- Drug Effects
➢ Review medication list
oDrug adverse effects
oDrug-drug interactions
Infective Endocarditis
infection of inner layer of heart- usually affects cardiac valves
Infective Endocarditis
was almost always fatal until development of
penicillin
15000 cases diagnosed in US each year
endocarditis
precipitated by —; potential death from —
bacteria/fungal infection
emboli and valvular disturbance
Infective Endocarditis
etiology and pathophysiology
key-
blood turbulence within heart allows causative agent to infect previously damaged valves or other endothelial surfaces
AHA Cardiovascular Indications for Antibiotic Prophylaxis
(4)
- Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts
- Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords
- Previous endocarditis
- Cardiac transplantation recipients with valve regurgitation due to a structurally abnormal
valve
Congenital heart disease (CHD) only in the following categories:
(3)
➢Unrepaired cyanotic CHD, including those with palliative shunts and conduits
➢Completely repaired congenital heart defect with prosthetic material or device, whether
placed by surgery or catheter intervention, during the first six months after the procedure
➢Repaired CHD with residual shunts or valvular regurgitation at the site or adjacent to the
site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
Infective Endocarditis
high risk
(5)
mechanical prosthetic heart valve
natural prosthetic heart valve
prior IE
valve repair with prosthetic material
most congenital heart diseases
Infective Endocarditis
moderate risk
(4)
valve repair without prosthetic material
hypertrophic cardiomyopathy
mitral valve prolapse with regurgitation
acquired valvular dysfunction
Infective Endocarditis
low risk
(4)
innocent heart murmurs
mitral valve prolapse without regurgitation
coronary artery disease
people with pacemakers / defibrilators
prophylactic ab are generally recommend only for people in the
high risk category
Antibiotic prophylaxis is recommended for
ONLY AT RISK PATIENTS who have
procedures that:
(3)
- Manipulate the gingival tissue
2.Manipulate the periapex of teeth
3.Perforate the oral mucosa
OBS.:If the dosage of antibiotic is
inadvertently not administered before the
procedure, the dosage may be administered
up
to 2 hours after the procedure.
Patients already taking antibiotics
If a patient is taking a beta-lactam (penicillin, amoxicillin, etc.) for an
active, existing infection resistant strains have likely been selected
- If urgent/emergency dental treatment is necessary
➢ Prescribe azithromycin or clarithromycin
- If dental treatment is elective
➢ Wait 10 days after completion of the antibiotic for their
active infection, then prescribe amoxicillin according to
AHA guidelines
Conditions that DO NOT require Antibiotic Prophylaxis
(5)
- Heart murmur
- Mitral valve prolapse
- Mitral valve prolapse with regurgitation
- Rheumatic fever
- Stent or coronary artery bypass graft (cabg)
Note: If a heart murmur is due to specific cardiac condition (e.g., previous
endocarditis, prosthetic heart valve, complex congenital cyanotic heart
disease), AHA continues to recommend
antibiotic prophylaxis for most
dental procedures
Procedures that DO NOT require Antibiotic Prophylaxis
(4)
- Radiographs
- Placement of appliances
- Routine local injections
- Tooth shedding or trauma
These procedures are unlikely to:
(3)
- Manipulate the gingival tissue
2.Manipulate the periapex of teeth
3.Perforate the oral mucosa
*— of bacteremia or bacteria — is a predictor of IE chances
Size, number
*Infective endocarditis (IE) is not always caused by
bacterial infection
*Continuing evidence questions the validity of
antibiotic prophylaxis practice to
prevent IE
*Daily exposure to — during everyday activities (toothbrushing, chewing)
likely cause most cases of IE; not —
bacteremias
dentistry
*Encourage good oral hygiene practices
