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Cardiovascular Diseases Flashcards

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1
Q

Heart murmur

A
  • Sound caused by blood flow through valves + chambers of heart.
  • Turbulent flow results from
    • Increased flow rate
    • Change in viscosity (anemia)
    • Stenotic/narrowed valves
    • Vibration of structures
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2
Q

Types of murmurs

A
  • Innocent, functional, or normal heart murmurs
    • Sounds heard in the absence of any cardiac abnormality
    • Since the heart is normal, no special treatment or f/u required
  • Organic or abnormal heart murmurs
    • Sounds caused by pathologic abnormality in the heart
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3
Q

What is the most common heart problem?

A

CHD

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4
Q

CHD: L→R shunts

A

If large, may lead to too much pulmonary blood flow.

  • Atrial septal defect [ASD]
  • Ventricular septa defect [VSD]
  • Patent ductus arteriosus [PDA]
  • Atrioventricular canal or atrioventricular septal defect [AV canal]
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5
Q

CHD: R→L shunts

A

May produce cyanosis

  • Tetralogy of Fallot – VSD + pulmonic stenosis + aorta overrides VSD + hypertrophy of RV
  • Transposition of great vessels – Pulmonary artery arises from the LV + aorta arises from the RV
  • Miscellaneous
    • Tricuspid atrsia
    • Persistent truncus arteriosus
    • Total anomalous pulmonary venous return
    • Hypoplastic left heart syndrome
    • Ebstein anomaly
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6
Q

CHD: Obstruction of blood flow

A
  • Pulmonary valve stenosis
  • Aortic stenosis w/ bicuspid aortic valve
  • Coarctation of aorta
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7
Q

What common congenital disorders are associated w/ cardiac defects?

A
  • Down
  • Turner
  • Noonan
  • Marfan
  • Ehlers-Danlos
  • DiGeorge + other 22q11 microdeletion syndromes
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8
Q

Symptoms of cardiac defects

A
  • Dyspnea
  • Syncope
  • Murmur
  • Cyanosis (late in L→R shunting and early in R→L shunting)
  • Clubbing of fingers/toes
  • Polycythemia
  • Exercise intolerance
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9
Q

Complications of cardiac defects

A
  • CHF
  • Pulmonary edema
  • Growth retardation/FTT
  • Infective endocarditis
  • Brain abscess
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10
Q

Rheumatic fever

A
  • Delayed non-suppurative sequela w/ diffuse inflammation, to URI w/ group A beta-hemolytic Streptococcal infection (eg strep throat).
  • Result of an autoimmune reaction arising from cross-reactivity between tissues (eg heart) and antibodies produced by the host response to Strep infection
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11
Q

Rheumatic fever – Prevalence

A
  • Commonly occurs b/w 5-15yo
  • Prevalent in temperate zones, high altitudes, substandard living conditions
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12
Q

Rheumatic fever – Symptoms

A
  • Arthritis
  • Carditis
  • Chorea
  • Erythema marginatum
  • Subcutaneous nodules
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13
Q

Rheumatic fever – Complciations

A

Inflammatory rxns in the heart, larger joints, skin, lungs

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14
Q

Rheumatic fever – Medical management

A

Benzathine Penicllin G, salicylates, codeine

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15
Q

Rheumatic heart disease

A

Carditis resulting from rheumatic fever

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16
Q

Rheumatic heart disease – Prevalence

A

Uncommon in developed countries, but pockets exist in the US

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17
Q

Rheumatic heart disease – Symptoms

A

Murmur, exertional dyspnea, CHF

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18
Q

Rheumatic heart disease – Complications

A
  • Scar tissue + deformity of affected valves (most commonly mitral and/or aortic)
  • Mitral insufficiency/stenosis
  • Aortic insufficiency/stenosis
  • Heart failure
  • Pericarditis
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19
Q

Rheumatic heart disease – Medical management

A

Asymptomatic – no tx other than prevention of recurrent attacks of rheumatic fever

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20
Q

Rheumatic heart disease – Dental management

A
  • H/o of rheumatic fever? Send a med consult to rule out rheumatic heart disease.
  • If needed, infective endocarditis prophylaxis needs to account for this rheumatic fever PCN prophylaxis regimen
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21
Q

Cardiac arrhythmias – Signs + symptoms

A
  • Usually asymptomatic
  • Palpitations, dizziness, syncope
  • Malignant ventricular arrhythmias may lead to ventricular fibrillation and cardiac arrest; other arrhythmias are typically well-tolerated
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22
Q

Low risk cardiac arrhthymias

A
  • Asymptomatic, not hemodynamically significant, no meds
  • Most atrial arrhythmias; isolated premature ventricular beats
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23
Q

Moderate risk cardiac arrhythmias

A
  • Potential for symptoms + mild hemodynamic compromise
  • Certain atrial or ventricular arrhythmias (eg supraventricular tachycardia SVT)
24
Q

High risk cardiac arrhythmias

A
  • Potential for cardiovascular collapse
  • Malignant ventricular arrhythmias, long QT syndrome, Brugada syndrome, presence of pacemaker or internal defibrillator
25
Q

Cardiac arrhythmias – medical management

A
  • Medication: Beta blockers, calcium channel blockers, misc agents, digoxin
  • Radiofrequency ablation (for certain tachyarrhythmias)
  • Pacemakers (for complete heart block)
  • Internal defibrillator (for malignant ventricular arrhythmias)
26
Q

Cardiac arrhythmias – Dental management

A
  • Med consult to establish risk and management recommendations
  • Minimize stressful situations
  • Reduce anxiety w/ pre-medication, N2O, and/or sedation as indicated
  • Short morning appointments
  • Minimize use of epi
  • Avoid GA
  • Avoid electrical equipment that may interfere w/ pacemaker
27
Q

Cardiac arrhythmias – oral complications

A
  • Anti-arrhythmics have potential oral side effects
    • Arrhythmias (most anti-arrhythmics are pro-arrhythmic), hypotension
    • Ulceration, xerostomia, petechiae
28
Q

Hypertension

A

Systolic pressure exceeding the 95th percentile for gender, age, and height in children (after 3 readings in a non-stressful situation)

29
Q

Essential hypertension

A

More common in adolescents than children, infants

30
Q

Secondary hypertension

A
  • Underlying disorder: Renal, cardiac (coarctation of the aorta), endocrine
  • Medication: Oral contraceptives, others
31
Q

Hypertension – Symptoms

A
  • Usually asymptomatic
  • Headache, visual blurriness, changes in mental status, and dizziness w/ severe hypertension
32
Q

Hypertension – Dental management

A
  • Take BP at each visit
  • Proceed w/ dental treatment in patients with controlled to mild hypertension
  • Patients w/ moderate hypertension, schedule short morning appointments, consider ways to reduce anxiety
  • Post-pone elective dental procedures w/ severe hypertension
33
Q

Hypertension – Oral complications

A
  • Xerostomia (secondary to meds)
  • Lichenoid rxns associated w/ thiazides, methyldopa, propanolol
  • Delayed healing and gingival healing associated w/ ACE inhibitors
  • Gingival hyperplasia associated w/ calcium channel blockers
  • Facial palsy associated w/ malignant hypertension
34
Q

Congestive heart failure

A

Inability of heart to deliver an adequate supply of blood to meet metabolic demands.

  • Etiology: Congenital heart defects, rheumatic heart disease, cardiomyopathy, vascular malformations (arteriovenous fistulae), severe anemia
    • Pediatric heart failure is usually not due to pump (myocardial) failure
35
Q

Congestive heart failure – Signs + symptoms

A
  • Tachycardia
  • Dyspnea
  • Tachypnea
  • Peripheral vasoconstriction
  • Exercise intolerance
  • Growth delay
36
Q

Congestive heart failure – Complications

A

Pulmonary congestion, peripheral edema, arrhythmias

37
Q

Congestive heart failure – Medications

A

Diuretics, ACE inhibitors, digoxin

38
Q

Congestive heart failure – Dental management

A
  • Consult w/ MD to determine ability to tolerate tx
  • Avoid procedures that may cause a gag reflex
  • Minimize epi use
  • Prevent orthostatic hypertension
  • Investigate potential bleeding problems from anticoagulant use
    • INR 3.5 or less is required.
39
Q

Congestive heart failure – Oral complications

A
  • Infection
  • Bleeding: Petechiae; ecchymoses
  • Drug-related side effects: Xerostomia, lichenoid mucosal lesions
40
Q

Infective endocarditis

A

Microbial infection (fungal or bacterial) of heart valves or endocardium, usually seen w/ predisposing factors (heart defects, valvulitis, prosthetic material post-surgery)

41
Q

Acute bacterial endocarditis

A
  • Sudden onset, can be rapidly fatal
  • Causative agent Staphylococcus aureus can infect normal heart valves
42
Q

Subacute bacterial endocarditis

A
  • Slower onset, but demarcation between acute and subacute can be blurry
  • Streptococcus viridans infects damaged heart valves, but S. aureus now the most important IE organism overall
    • Staph + Strep species account for the large majority of cases now
43
Q

Are pediatric patients more likely to acquire acute or subacute bacterial endocarditis?

A

Subacute

44
Q

Infective endocarditis – Symptoms

A
  • Fevers
  • Weakness
  • Weight loss
  • Fatigue
  • Chills
  • Night sweats
  • Anorexia
  • Arthralgia
45
Q

Infective endocarditis – Complications

A
  • Emboli
  • Cerebral abscesses
  • Myocardial abscess
  • Mycotic aneurysms
  • Hemorrhage
  • Congestive heart failure
46
Q

Infective endocarditis – Medical management

A

Antibiotic therapy (type, duration) based on organism, culture and sensitivity

47
Q

Infective endocarditis – Dental management

A

Antibiotic prophylaxis prior to bacteremia-inducing procedures

48
Q

What cardiac conditions may necessitate antibiotic prophylaxis?

A
  • Prosthetic cardiac valves
  • Previous infective endocarditis
  • Congenital heart disease (CHD)
    • Unrepaired cyanotic CHD, including palliative shunts + conduits
    • Repaired CHD w/ prosthetic material or device, whether placed by surgery or catheter intervention during the first 6m after the procedure
    • Repaired CHD w/ residual defects at the site or adjacent to the site of a prosthetic device (which inhibit endothelialization)
    • Cardiac transplantation recipients who develop cardiac valvulopathy
49
Q

Cardiac conditions where antibiotic prophylaxis is not recommended

A
  • Most congenital cardiac malformations
  • Acquired valvular dysfunction (e.g. rheumatic heart disease)
  • Hypertrophic cardiomyopathy
  • Mitral valve prolapse w/ valvular regurgitation and/or thickened leaflets
  • Isolated secundum atrial septal defect
  • Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residual beyond 6m)
  • Previous coronary artery bypass graft surgery
  • Mitral valve prolapse w/o valvular regurgitation
  • Physiologic, functional or innocent heart murmurs
  • Previous Kawasaki disease w/o valvular dysfunction
  • Previous rheumatic fever w/o valvular dysfunction
  • Cardiac pacemakers (intravascular + epicardial) and implanted defibrillators
50
Q

Dental procedures that may necessitate antibiotic prophylaxis in cardiac patients

A
  • Gingival tissue manipulation
  • Manipulation of periapical region of teeth
  • Perforation of the oral mucosa
51
Q

Dental procedures where endocarditis prophylaxis is not recommended

A
  • Routine anesthetic injections through non-infected tissue
  • Placement of removable prosthodontic or orthodontic appliances
  • Placement of orthodontic brackets
  • Taking radiographs
  • Orthodontic appliance adjustment
  • Shedding of primary teeth
  • Bleeding from trauma to the lips or oral mucosa
52
Q

Standard antibiotic prophylaxis – Agent, route, time and regimen

A
  • Agent: Amoxicillin
  • Route: PO
  • Time: 1 hour pre-op
  • Regimen:
    • Adult: 2g
    • Children: 50mg/kg
53
Q

Antibiotic prophylaxis when unable to take oral medications – Agent, route, time and regimen

A
  • Agent: Ampicillin
  • Route: IM or IV
  • Time: 30 min pre-op
  • Regimen:
    • Adult: 2g
    • Children: 50mg/kg
54
Q

Antibiotic prophylaxis when allergic to penicillin/ampicillin – Agent, route, time and regimen

A
  • Agent: Clindamycin
  • Route: PO
  • Time: 1hr pre-op
  • Regimen:
    • Adult: 600mg
    • Children: 20mg/kg
  • Agent: Cephalexin or Cefadroxil (or other 1st or 2nd gen oral cephalosporin)
  • Route: PO
  • Time: 1hr pre-op
  • Regimen:
    • Adult: 2g
    • Children: 50mg/kg
  • Agent: Azithromycin or Clarithromycin
  • Route: PO
  • Time: 1hr pre-op
  • Regimen:
    • Adult: 500mg
    • Children: 15mg/kg
55
Q

Cephalosporin contraindication

A

Cephalosporins should not be used in an individual w/ a h/o anaphylaxis, angioedema, or urticaria w/ penicillins or ampicillins

56
Q

Antibiotic prophylaxis when allergic to penicillin/ampicillin and unable to take oral medications – Agent, route, time and regimen

A
  • Agent: Clindamycin
  • Route: IM or IV
  • Time: 30min pre-op
  • Regimen:
    • Adult: 600mg
    • Children: 20mg/kg
  • Agent: Cefazolin or ceftriaxone
  • Route: IM or IV
  • Time: 30min pre-op
  • Regimen:
    • Adult: 1mg
    • Children: 50mg/kg

* (22 decks)

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