Cardiovascular Disease Flashcards
What is the most common cause of premature death in the world?
cardiovascular disease (CVD)
What are the different types of CVD disease?
- Hypertension (HTN)
- Atherosclerosis
- Angina Pectoris
- Arrhythmias
- Bacterial Endocarditis
- Congestive Heart Failure
- Valvular disease
Patients frequently have more than ____ CVD
one
What is valvular disease?
- stenotic and not capable of full closure for blood circulation
- leads to CHF
What does high blood pressure do to the cardiovascular system?
- Stiffens vessels which reduces blood flow
- also a risk for stroke, kidney disease and dementia
What does diabetes do to the cardiovascular system?
Unstable glucose levels affect healthy myocardium function; angiopathy
What behavioral issues are bad for the cardiovascular system?
- unhealthy diet
- physical inactivity
- obesity
- too much alcohol
- tobacco use
- stress
What are the types of predisposing etiologies for CVD?
- Congenital
- Hypertension (positive CVD feedback cycle)
- Ischemia (positive CVD feedback cycle)
- Inflammation
What are the contributary anatomic abnormalities for CVD?
- Hypertrophy
- Dilation
- Valves
- Regurgitation
- Stenosis
What is a class I heart failure classification (symptom based)?
Physical activity = no limitation
No dyspnea, fatigue, or palpitations with physical activity
What is a class II heart failure classification (symptom based)?
Physical activity = slight limitation
Dyspnea, fatigue, palpitations present with physical activity
What is a class III heart failure classification (symptom based)?
Physical activity = marked limitation
Less than normal physical activity results in symptoms. Comfortable at rest.
What is a class IV heart failure classification (symptom based)?
Physical activity = severely limitation
Symptoms present at rest
What are the signs of CVD?
- elevated BP
- irregular or abnormal heart rate
- abnormal respiratory rate
- shortness of breath upon exertion
- prolonged bleeding/easy bruising
- surgical scars
What are the symptoms of CVD?
- patient is uncomfortable in supine position
The less the symptoms and the better the control of risk factors then…
- the better a patient manages the stress
AND - the less likely the patient will have a life threatening incident during a dental procedure
The greater the symptoms and the poorer the control of risk factors then…
- the worse a patient manages the stress
AND - the more likely the patient will have a life threatening incident during a dental procedure
What are low risk interventions/ dental treatments?
- Health/medical evaluation
- Exams
- Prophy
- Radiographs
- Optical oral scans
- Alginate impressions
What are moderate risk interventions/ dental treatments?
- SRP (scaling and root planning)
- Simple restorative procedures; 1-2 teeth
- Simple extractions; 1-2 teeth
- Restorative impressions needing retractions and longer setting times
What are high risk interventions/ dental treatments?
- Complex restorative procedures on >2 teeth
- Multiple extractions
- Surgical extractions
- Implant placement
- Full arch impressions
- Dental care under general anesthesia
What are the factors that contribute to hypertension?
- Cardiac Output (sodium, natriuretic peptides, heart rate, contractility)
- Peripheral Resistance (constrictors, dilators, local factors)
Blood pressure equation
Blood pressure = cardiac output x peripheral resistance
What system allows for blood pressure regulation?
renin-angiotensin-aldosterone system
What is primary hypertension?
- Multifactorial, gene-environment
- 90-95% of cases
What is secondary hypertension?
- Renal disease and renin-producing tumors
- Cardiovascular
- Endocrine
➢Adrenal
➢Exogenous hormones
➢Pregnancy
➢Pheochromocytoma
➢Thyroid - Neurologic
➢Psychogenic
➢Sleep apnea
➢Intracranial vascular pressure
➢Exogenous
other disease processes affecting BP
What are complications with hypertension?
- Myocardial infarction
- Stroke
- Coronary artery disease
- Peripheral artery disease
- Heart failure
- Retinopathy
- End-stage renal disease
How do you measure blood pressure?
Determined by indirect measurement in the upper extremities with a BP cuff and stethoscope
‘White Coat HTN’ elevate BP by ___ mm Hg
30
What are the non-pharmacologic hypertension managment?
- Diet
- Exercise
- Biofeedback
- Tobacco cessation
- Alcohol intake reduction
- EtOH limitation
What is the normal bp?
< 120/80 mm Hg
What is an elevated bp?
120 - 129/< 80 mm Hg
What is a stage 1 bp?
130-139 or 80-89 mm Hg
What is a stage 2 bp?
≥ 140 or 90 mm Hg
What is a hypertensive crisis?
≥ 180 and/or >120
NO dental care at UMKSC SOD if BP ≥ _________ mmHg
180/110
What are the side effects of pharmacotherapy for hypertension?
➢ Dry mouth (anti-adrenergics and diuretics)
➢ Burning mouth (ACEi)
➢ Taste changes (antiadrenergics, ACEi)
➢ Angioedema (ACEi, ARB)
➢ Gingival hyperplasia (calcium-channel blockers)
➢ Lichenoid reactions (thiazides, methyldopa, propranolol, and labetalol)
➢ Lupus-like lesions (hydralazine)
Serious potential complications of severe uncontrolled HTN are…
- Stroke
- Angina
- Arrhythmia
- Myocardial infarction
What may increase the patients BP and lead to complications?
- stress
- anxiety
- fear
Use of vasoconstrictor can cause?
acute rise in BP
Patients may be sensitive to sudden position changes causing…
orthostatic hypotension
What are pre-operative considerations for HTN?
- Reduce Stress and Anxiety
➢ May need oral and/or inhalation sedation
What are intra-operative considerations for HTN?
- 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
What are post-operative considerations for HTN?
- 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
What are the kind of questions you ask in a med consult for hypertension?
- What is the patient’s BP goal (range)
- What have been patient’s in-office BP readings?
- Does the patient have any end-organ damage?
- Current medications prescribed to manage Hypertension
What is 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
What does atherosclerosis lead to?
➢ Stenosis
➢ Angina (stable ischemic disease)
➢ MI
➢ Ischemic stroke (acute ischemic disease)
➢ Peripheral arterial disease
What are the risk factors for atherosclerosis?
➢Male sex
➢Age
➢Smoking
➢Lack of exercise
➢Obesity
➢Stress
➢Depression
➢Family history of CVD
➢Hyperlipidemia (↑LDL)
➢Hypertension
➢Insulin resistance
➢Diabetes mellitus
What are heart-healthy levels of cholesterol?
total = under 200
LDL = under 100
HDL = 60 and higher
What are at-risk levels of cholesterol?
total = 200-239
LDL = 100-159
HDL = 40-59 (male) 50-59 (female)
What are dangerous levels of cholesterol?
total = 240 and higher
LDL = 160 and higher
HDL = under 40 (male) under 50 (female)
Atherosclerotic plaques can lead to:
- ischemia
- thrombosis, (vascular blockage) if they rupture
What are the associated symptoms of atherosclerosis?
- chest pain
- angina
What are the complications of atherosclerosis?
➢ Unstable angina
➢ Myocardial infarction (necrosis)
➢ Thrombosis
➢ Embolism
➢ Aneurysm
What are the characteristics of angina pectoris?
- Chest pain resultant from ischemic changes
➢ Mid-chest pain described as
o “aching, heavy squeezing pressure or tightness” - Pain may radiate
➢Shoulder, arms, jaw - Pain lasts 5-15 minutes
➢ If unstable angina, may be longer - Vasodilation used to resolve angin
What is stable angina pectoris?
➢Imbalanced cardiac perfusion
➢Stable symptoms, reproducible, predictable, consistent
➢Chest pain precipitated by physical activity/exertion
➢Resolves with cessation of activity
What is unstable angina pectoris?
➢Disruption of atherosclerotic plaque
➢Possible partial thrombosis, embolism or vasospasm
➢Symptoms increasing
➢Chest pain at rest or with less intense physical activity/exertion
What is myocardial infarction?
Irreversible coagulative necrosis of the myocardium
➢Lose normal conduction and contraction
➢Left ventricle MI more common
What are the symptoms of myocardial infarction?
Symptoms similar to angina, plus
➢Radiating features
➢Severe substernal pain with shortness of breath, profuse sweating, and loss of consciousness
What is the medical management for hypertension?
➢Beta-blockers
➢Calcium channel blockers
What is the medical management for angina?
➢Nitrates (nitroglycerin) – stable angina
What is the medical management for stroke?
➢Antiplatelet agents (aspirin, clopidogrel) – stroke prevention
What is the medical management for revascularization (interventional)?
➢ Percutaneous transluminal coronary angioplasty with stenting (PCI; stent)
➢ Coronary artery bypass grafting (CABG)
What is the medical management for hyperlipidemia?
➢HMG-CoA reductase inhibitor
o Statins
➢Cholesterol absorption inhibitor
o Ezetimibe
➢Bile acid sequestrants
o Cholestyramine
o Colestipol
➢Fibrates
o Gemfibrozil
➢Niacin
o Niaspan
➢Omega-3 fatty acids
o Lovaza
Do NOT require antibiotic prophylaxis for what?
SBE
subacute bacterial endocarditis
What do you need to know for all ischemic disease?
- 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
What dental care can you do on a patient with a recent myocardial infarction <1 month?
- Urgent dental care only
➢ACUTE dental pain or infection - Consultation with physician
- Consider referral to specialized center
What dental care can you do on a patient with a past myocardial infarction >1 month?
- Consider severity of cardiac status and comorbidities
- Ejection Fraction can measure the degree of heart failure
➢Measures amount (%) of blood that leaves the left ventricle after contraction. - Consider appropriate management protocols
What are the procedural precaustions for stress reduction for stable angina or past myocardial infarction?
➢Short appointments in the morning
➢Pre-treatment vital signs
➢Availability of nitroglycerin
➢Oral sedation
➢Nitrous oxide–oxygen sedation
➢Profound local anesthesia
➢Limit amount of vasoconstrictor
➢Avoid epinephrine-impregnated retraction cord
➢Effective post-operative pain control
What drugs should you limit in someone with ischemic heart disease or hypertension?
- HLD
– Statins- avoid CYB inhibitors (fluconazole, clarithromycin) - Limit epinephrine as discussed earlier
- Bleeding as discussed earlier – limit NSAIDs.
Carotid Atheromas
Lymphatic or tonsillar dystrophic calcifications
What is the SA node?
- primary pacemaker
- regulates atrial function
- produces P wave (atrial depolarization)
What is AV node?
- regulates atrial impulses entering ventricles
- slows conduction rate of SA generate impulses
What is QRS complex?
simulataneous depolarization of the ventricles
What is T wave?
repolarizarion of the ventricles
What is an arrhythmia?
Disruption of the electrical impulse generation or conduction in the heart that leads to abnormal cardiac function
What abnormal cardiac function is caused by arrhythmia?
- Formation of abnormal impulse
- Increased impulse formation
- Enhanced or abnormal impulse formation
- Delayed depolarization
- Re-excitation of the heart after refractory period
The disruption of heart beat (arrhythmia) may be due to an area of:
- Infarction
- Ischemia
- Electrolyte imbalance
- Medication
The most common cause of sudden cardiac death is…
ventricular fibrillation
- most common arrhythmia in general is atrial fibrillation
What are the causes of arrhythmia?
- Cardiovascular disorders
➢ Myocardial infarction
➢ Mitral stenosis
➢ Valvular disease
➢ Ischemic heart disease
➢ Congestive heart failure - Pulmonary disorder
➢Pneumonia
➢Obstructive lung disease - Autonomic disorder
- Hyperthyroidism
- Drugs
➢ Epinephrine
➢ Alcohol
➢ Digitalis
➢ Morphine
➢ Beta-blockers
➢ Tricyclic antidepressants, and others - Electrolyte imbalance
- Anxiety and anger
What is bradycardia?
<60 beats/min
What is tachycardia?
> 100 beats/min
What are the symptoms of arrhythmia?
- Palpitations, fatigue
- Dizziness, syncope, angina
- Congestive heart failure
- Shortness of breath
- Orthopnea
- Peripheral edema
What is atrial fibrillation?
- Most common arrhythmia
- Rapid uncontrolled atrial activity
- Irregularly irregular rhythm
- Risk of arterial clot formation
➢ Embolism and stroke
What is a heart block?
Impulse is partially or completely blocked
➢Prolonged or no conduction
What is a 1st degree heart block?
Longer conduction time
What is a 2nd degree heart block?
➢ Mobitz I
o More prolonged and no P wave
➢ Mobitz II*
o Repetitive or occasional sudden blocks w/o previous prolonged conduction time
What is a 3rd degree heart block?
➢ No impulses – COMPLETE BLOCK
➢ Indication for pacemaker
What is ventricular arrhythmia?
- Premature ventricular complexes (PVCs)
- Common
- Abnormal QRS complex + pause
- Increased risk of death if patients have underlying CVD (heart failure, MI, valvular heart disease
What is ventricular tachycardia?
- 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
What is ventricular flutter and fibrillation?
- Lethal
- Consequence of ischemic heart disease
- Cardiac contraction is not sequential, chaotic
What are pharmacotherapy options for arrhythmia?
- Oral anticoagulants
➢ Clopidogrel (Plavix)
o Inhibits platelet agglutination
➢ ASA (Aspirin 81mg - low dose)
o Inhibits platelet agglutination
➢ Warfarin (Coumadin)
o Vitamin K antagonist
o INR monitoring
o Highly variable - Direct Oral Anticoagulants (DOACs)
➢ Direct thrombin inhibitor
o Dabigatran (Pradaxa)
o Reversal agent available
➢ Direct Factor Xa inhibitors
o Rivaroxaban (Xarelto)
o Apixaban (Eliquis)
o Edoxaban (Savaysa)
o Reversal agents not available
DOACs are the more commonly used drugs
NEVER STOP _____________ FOR DENTAL TREATMENT UNLESS EXTENSIVE SURGERY
ANTICOAGULATION
risk of thrombosis > risk of massive bleed
What are the non-pharmacologic ways to treat arrhythmia?
- Pacemakers
- Implanted Cardioverter-Defibrillator (ICD)
- Surgery
➢ Tissue resection
➢ Cardiac ablation - Electrocardioversion and defibrillation
➢ Emergency situations
What should you do if your patient has high risk arrhythmia?
- Defer elective dental care
- Dental treatment should be limited to urgent care only
— Treatment of ACUTE pain, bleeding, or infection, only - If necessary treatment, obtain a medical consult
- Management may include an IV line, pulse oximeter, BP and oxygen, electrocardiogram monitoring
- Cautious use of epinephrine (contraindicated if taking digoxin)
- Prophylactic nitroglycerin
What should you do if your patient has intermediate or low risk arrhythmia?
Elective care can be provided with following management protocols:
* Stress/Anxiety reduction:
➢Oral sedative &/or inhalation sedative
*Assess pretreatment vital signs, have nitroglycerin available, limit epinephrine (LA and gingival cord)
*Profound local anesthesia and pain control
*Devices
➢Electrosurgery units contraindicated in patient with pacemakers and ICDs
What are the 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
