Cardiovascular Disease II (HF, Valvular Heart Disease, Infectious Endocarditis) Flashcards
What are the causes of heart failure?
➢ Decreased pumping action
o Systemic fluid congestion
o Failure of vital organs
What are the results of right side heart failure?
➢ Pulmonary edema
➢ Coughing
➢ Peripheral edema (arms and legs mostly)
What are the results of left side heart failure?
➢ Affects all organ systems
— decreased kidney function contributes to fluid rentention
➢ Pulmonary edema
➢ Coughing
What is the pathophysiology of heart failure?
*Increased workload → problems with cardiac muscle
*Left ventricle typically fails first → can lead to right ventricle failure
- reduced CO
- decreased perfusion
- blood backed up in pulmonary vessels
- SOB, foamy cough
- pulmonary hypertension
- increased workload on R ventricle
- volume overload
- venous congestion, peripheral edema, ascities
- ventricles dilate to try to compensate
- activation of RAAS and neurohormonal responses to compensate
What are the effects of chronic heart failure?
- coughing
- pleural effusion
- swelling in abdomen
- swelling in ankles/legs
- tiredness
- shortness of breath
- pulmonary edema
- pumping action of the heart grows weaker
- congested lung
- enlarged heart
What is the ejection fraction?
(amount of blood pumped out/amount of blood in chamber)*100
What can measure the degree of heart failure?
ejection fraction
- Measures amount (%) of blood that leaves the left ventricle after contraction.
What is a normal ejection fraction?
50-70%
or 55-70 (slides are contradicting)
What is a borderline ejection fraction?
41-49%
What is a reduced ejection fraction?
less than 40%
or less than 35 (slides are contradicting)
What is systolic failure?
➢ Reduced left ventricular ejection fraction (HFrEF)
What is diastolic failure?
➢ Normal left ventricular ejection fraction (HFpEF)
What are cardiac abnormalities assocaited with heart failure?
➢ Valvular Disease
➢ Arrhythmias
➢ Myocardial necrosis
What are the decompensations associated with heart failure?
➢ Inability to compensate
➢ Increased peripheral blood flow
➢ Increased metabolic needs
What are the predisposing factors of heart failure?
➢ Acute CVD
o MI
➢ Chronic CVD
o Hypertension
o Coronary artery disease
o Arrhythmia, etc
What are the results of heart failure?
➢ Volume overload
➢ Inadequate perfusion
What are the complications with heart failure?
➢ Cardiac arrest (stops beating)
➢ Myocardial infarction (blood flow blocked)
➢ Stroke
What are the signs of heart failure?
➢Rapid, shallow breathing
➢Inspiratory rales (crackles)
➢Increased heart rate
➢Distended jugular (neck) veins
➢Peripheral edema
➢Ascites
➢Cyanosis
➢Weight gain
➢Clubbing of fingers
What are the symptoms of heart failure?
➢Fatigue and weakness
➢Orthopnea – shortness of breath (dyspnea) in recumbent position
➢Exercise intolerance
➢Muscular fatigue
➢Weight Gain
➢GI distress - nausea, vomiting & constipation
distended jugular veins
ascites
What is stage A heart failure and its therapy?
- at high risk for HF but without structural heart disease or symptoms
- ACE inhibitor or ARB
What is stage B heart failure and its therapy?
- structural heart disease but without signs of symptoms of HF
- ACE inhibitor or ARB in appropriate patients; beta-blockers
What is stage C heart failure and its therapy?
- structural heart disease with prior or current symptoms of HF
- diuretics for fluid retention; ACE inhibitor; beta-blocker
What is stage D heart failure and its therapy?
- refractor HF requiring specialized interventions
- appropriate measures under stages A, B, and C; decision about appropriate level of care
What is the medical management options for heart failure?
- Pharmacologic and non-pharmacologic (see previous slide info)
- Patients with severe heart failure may require cardiac transplantation
- Intermediate therapy is the Left Ventricular Assist Device (LVAD)
In most cases of HF, the dentist will need to obtain a medical consultation with the patient’s cardiologist to determine…
- The patient’s physical status
- Laboratory test results
- Level of control
- Compliance with medications and recommendations
- Overall stability
The major issues for patients with symptomatic HF are…
- Symptoms could abruptly worsen
- Acute failure
- Fatal arrhythmia
- Stroke
- MI
What classes of heart failure do you see at UMKC?
class I and II
What dentistry can you do with class I HF?
routine dental care ok
What dentistry can you do with class II HF?
medical consultation required, routine dental care likely ok
What dentistry can you do with class III and IV HF?
consider referral to specialized care
What are HF dental management considerations?
- Short, “stress free” appointments
- Chair position
- patients with HF may not tolerate supine position (pulmonary edema)
What should you do with a HF patient taking digitalis glycoside (digoxin)?
➢Epinephrine should be avoided, if possible
➢Combination increases the risk for arrhythmia
What are the oral manifestations associated with heart failure?
There are no oral manifestations related to HF
BUT…
many of the drugs used to manage HF can cause dry mouth, altered taste, and oral ulcerative lesions
What is valvular heart disease?
- Compromised function of the heart valves
What is valvular stenosis?
➢ Do not open properly
What is valvular insufficiency?
➢ Do not close properly
➢ Associated with regurgitation
At what frequency do valves open and close?
~ 85,000/QD @ 60/minute
~100,800/QD @ 70/minute
What is fibrosis of valves?
➢ Stiff, sclerosis, stenosis causing either stenosis or insufficency
What is myxomatous degeneration of valves?
➢ Benign loose CT tumorous changes where valves become floppy, prolapse, regurgitation
➢ Causes insufficiency
What are the conditions that are risk factors for valvular heart disease?
- high blood pressure
- high cholesterol
- diabetes
- rheumatic fever
- > 1 CVD
- other
— Calcifications
— Congenital defects (bicuspid aortic valve, mitral valve prolapse)
— Infections
What are the signs of valvular heart disease?
➢ Murmurs
➢ Syncope
➢ Heart failure
➢ Shortness of breath
What are the symptoms of valvular heart disease?
➢ Heart failure
➢ Exercise intolerance
➢ Shortness of breath (can also be a sign)
What is the medical management of valvular heart disease?
- Treatment is primarily surgical
- Valve replacement (more common)
➢Mechanical Implants
o Silicone
o Requires long-term anticoagulation
➢Bioprosthetic Implants
o Allograft , bovine graft, etc.; decellularized CT with a less antigenic structural matrix
o short-term anticoagulation
o Long-term antiplatelet therapy)
What are oral manifestations of valvular heart disease?
no specific oral manifestations
What are the dental considerations for those with valvular heart disease?
- Assess ability to tolerate care in context of underlying condition and comorbidities
- Assess Bleeding Risk
- Infections
- Drug Effects
What is infective endocarditis?
- infection of inner layer of heart
- usually affects cardiac valves
- was almost always fatal until development of penicillin
What is the etiology of infective endocarditis?
- precipitated by an infectious agent
- turbulent cardiac blood flow and damaged endothelium or heart valves permit congregation of and infection by the microbes
Morbidity from infective endocarditis accrues from…
- thrombus formation and emboli
- valvular dysfunction
What is a thrombus versus an embolism?
thrombus - big clot (platelets or bacteria) in an area of endothelial damage
embolism - part of a thrombus that broke off and travels
What are the high risks for infective endocarditis?
- mechanical prosthetic heart valve
- natural prosthetic heart valve
- prior infective endocarditis
- valve repair with prosthetic material
- most congenital heart disease
What are the moderate risks for infective endocarditis?
idk if we need to know this
- valve repair without prosthetic material
- hypertrophic candiomyopathy
- mitral valve prolapse with regurgitation
- acquired valvular dysfunction
What are the low risks for infective endocarditis?
idk if we need to know this
- innocent heart murmers
- mitral valve prolapse without regurgitation
- coronary artery disease
- people with pacemakers/defibrillators
Prophylactic antibiotics are generally recommended for only people with IE in the _________ category
high risk
What are the conditions that DO require antibiotic prophylaxis?
What are the conditions that DO NOT require antibiotic prophylaxis?
What are the five main conditions that require antibiotic prophylaxis?
- Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts.
- Prosthetic material used for heart valve repair, such as annuloplasty rings, chords or clips (but not pledgets).
3.Previous IE.
4.Unrepaired cyanotic congenital heart defect or repaired congenital heart defect, with residual shunts or valvular regurgitation at the site adjacent to the site of a prosthetic patch or prosthetic device.
5.Cardiac transplant with valve regurgitation due to a structurally abnormal valve.
CHD, CNS, previous IE
What are the five main conditions that do not need antibiotic prophylaxis?
- Heart murmur (BUT!! If a heart murmur is due to specific cardiac condition, then antibiotic prophylaxis recommended)
- Mitral valve prolapse
- Mitral valve prolapse with regurgitation
- Rheumatic fever
- Stent or coronary artery bypass graft (cabg)
For prosthetic joint implants…
Prophylactic antibiotics __________ recommended prior to dental procedures to prevent prosthetic joint infection
are not
What is the oral medication of choice for antibiotic prophylaxis in at risk patients during procedures that…
1.Manipulate the gingival tissue
2.Manipulate the periapex of teeth
3.Perforate the oral mucosa
KNOW THIS
amoxicillin (2g for adults)
If the dosage of antibiotic is inadvertently not administered before the procedure, the dosage maybe administered up to ___ hours after the procedure
2
What is the medication of choice for antibiotic prophylaxis in at risk patients that are unable to take oral medication?
Ampicillin (2g)
Cefazolin/Ceftriaxone (1g)
What is the medication of choice for antibiotic prophylaxis in at risk patients that are allergic to penicillins or ampicillin?
KNOW THIS
Cephalexin (2g)
Azithromycin/Clarithromycin (500 mg)
Doxycycline (100 mg)
What is the medication of choice for antibiotic prophylaxis in at risk patients that are allergic to penicillins or ampicillin and unable to take oral medication?
Cefazolin/Ceftriaxone (1 g)
What medication is no longer recommended due to gastric side effects?
clindamycin
If a patient is already taking a beta-lactam (penicillin, amoxicillin, etc.) for an active, existing infection then __________ strains have likely been selected
resistant
If urgent/emergency dental treatment is necessary and the patient is taking a beta-lactam for an active, existing infection what do you do?
Prescribe azithromycin or clarithromycin
If elective dental treatment and the patient is taking a beta-lactam for an active, existing infection what do you do?
Wait 10 days after completion of the antibiotic for their active infection, then prescribe amoxicillin according to AHA guidelines
What is the written prescription for amoxicillin (one appt dose prophylaxis)?
What procedures are antibiotic prophylaxis recommended due to liklihood of induced bleeding and bacteremia?
all dental procedures that involve…
- manipulation of gingival tissue
- manipulation of the periapical region of teeth
- perforation of the oral mucosa
What procedures are not antibiotic prophylaxis recommended?
- anesthetic injections through noninfected tissue
- taking dental radiographs
- placement of removable prosthodontic or orthodontic applicances
- adjustment of orthodontic appliances
- placement of orthdontic brackets
- shedding of primary teeth
- bleeding from trauma to the lips or oral mucosa
- simple impressions (alginate)
- optical spans
What types of “intervention” would potentially require antibiotic prophylaxis?
Moderate Intervention
and
High Risk Intervention
What is more likely to cause most cases of IE…
- Daily exposure to bacteremias during everyday activities (toothbrushing, chewing)
- dental treatments from dental providers
- Daily exposure to bacteremias during everyday activities (toothbrushing, chewing)
