Cardiovascular Diseases Flashcards
Heart murmur
- 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
Types of murmurs
-
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
What is the most common heart problem?
CHD
CHD: L→R shunts
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]
CHD: R→L shunts
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
CHD: Obstruction of blood flow
- Pulmonary valve stenosis
- Aortic stenosis w/ bicuspid aortic valve
- Coarctation of aorta
What common congenital disorders are associated w/ cardiac defects?
- Down
- Turner
- Noonan
- Marfan
- Ehlers-Danlos
- DiGeorge + other 22q11 microdeletion syndromes
Symptoms of cardiac defects
- Dyspnea
- Syncope
- Murmur
- Cyanosis (late in L→R shunting and early in R→L shunting)
- Clubbing of fingers/toes
- Polycythemia
- Exercise intolerance
Complications of cardiac defects
- CHF
- Pulmonary edema
- Growth retardation/FTT
- Infective endocarditis
- Brain abscess
Rheumatic fever
- 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
Rheumatic fever – Prevalence
- Commonly occurs b/w 5-15yo
- Prevalent in temperate zones, high altitudes, substandard living conditions
Rheumatic fever – Symptoms
- Arthritis
- Carditis
- Chorea
- Erythema marginatum
- Subcutaneous nodules
Rheumatic fever – Complciations
Inflammatory rxns in the heart, larger joints, skin, lungs
Rheumatic fever – Medical management
Benzathine Penicllin G, salicylates, codeine
Rheumatic heart disease
Carditis resulting from rheumatic fever
Rheumatic heart disease – Prevalence
Uncommon in developed countries, but pockets exist in the US
Rheumatic heart disease – Symptoms
Murmur, exertional dyspnea, CHF
Rheumatic heart disease – Complications
- Scar tissue + deformity of affected valves (most commonly mitral and/or aortic)
- Mitral insufficiency/stenosis
- Aortic insufficiency/stenosis
- Heart failure
- Pericarditis
Rheumatic heart disease – Medical management
Asymptomatic – no tx other than prevention of recurrent attacks of rheumatic fever
Rheumatic heart disease – Dental management
- 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
Cardiac arrhythmias – Signs + symptoms
- Usually asymptomatic
- Palpitations, dizziness, syncope
- Malignant ventricular arrhythmias may lead to ventricular fibrillation and cardiac arrest; other arrhythmias are typically well-tolerated
Low risk cardiac arrhthymias
- Asymptomatic, not hemodynamically significant, no meds
- Most atrial arrhythmias; isolated premature ventricular beats
Moderate risk cardiac arrhythmias
- Potential for symptoms + mild hemodynamic compromise
- Certain atrial or ventricular arrhythmias (eg supraventricular tachycardia SVT)
High risk cardiac arrhythmias
- Potential for cardiovascular collapse
- Malignant ventricular arrhythmias, long QT syndrome, Brugada syndrome, presence of pacemaker or internal defibrillator
Cardiac arrhythmias – medical management
- 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)
Cardiac arrhythmias – Dental management
- 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
Cardiac arrhythmias – oral complications
- Anti-arrhythmics have potential oral side effects
- Arrhythmias (most anti-arrhythmics are pro-arrhythmic), hypotension
- Ulceration, xerostomia, petechiae
Hypertension
Systolic pressure exceeding the 95th percentile for gender, age, and height in children (after 3 readings in a non-stressful situation)
Essential hypertension
More common in adolescents than children, infants
Secondary hypertension
- Underlying disorder: Renal, cardiac (coarctation of the aorta), endocrine
- Medication: Oral contraceptives, others
Hypertension – Symptoms
- Usually asymptomatic
- Headache, visual blurriness, changes in mental status, and dizziness w/ severe hypertension
Hypertension – Dental management
- 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
Hypertension – Oral complications
- 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
Congestive heart failure
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
Congestive heart failure – Signs + symptoms
- Tachycardia
- Dyspnea
- Tachypnea
- Peripheral vasoconstriction
- Exercise intolerance
- Growth delay
Congestive heart failure – Complications
Pulmonary congestion, peripheral edema, arrhythmias
Congestive heart failure – Medications
Diuretics, ACE inhibitors, digoxin
Congestive heart failure – Dental management
- 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.
Congestive heart failure – Oral complications
- Infection
- Bleeding: Petechiae; ecchymoses
- Drug-related side effects: Xerostomia, lichenoid mucosal lesions
Infective endocarditis
Microbial infection (fungal or bacterial) of heart valves or endocardium, usually seen w/ predisposing factors (heart defects, valvulitis, prosthetic material post-surgery)
Acute bacterial endocarditis
- Sudden onset, can be rapidly fatal
- Causative agent Staphylococcus aureus can infect normal heart valves
Subacute bacterial endocarditis
- 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
Are pediatric patients more likely to acquire acute or subacute bacterial endocarditis?
Subacute
Infective endocarditis – Symptoms
- Fevers
- Weakness
- Weight loss
- Fatigue
- Chills
- Night sweats
- Anorexia
- Arthralgia
Infective endocarditis – Complications
- Emboli
- Cerebral abscesses
- Myocardial abscess
- Mycotic aneurysms
- Hemorrhage
- Congestive heart failure
Infective endocarditis – Medical management
Antibiotic therapy (type, duration) based on organism, culture and sensitivity
Infective endocarditis – Dental management
Antibiotic prophylaxis prior to bacteremia-inducing procedures
What cardiac conditions may necessitate antibiotic prophylaxis?
- 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
Cardiac conditions where antibiotic prophylaxis is not recommended
- 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
Dental procedures that may necessitate antibiotic prophylaxis in cardiac patients
- Gingival tissue manipulation
- Manipulation of periapical region of teeth
- Perforation of the oral mucosa
Dental procedures where endocarditis prophylaxis is not recommended
- 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
Standard antibiotic prophylaxis – Agent, route, time and regimen
- Agent: Amoxicillin
- Route: PO
- Time: 1 hour pre-op
- Regimen:
- Adult: 2g
- Children: 50mg/kg
Antibiotic prophylaxis when unable to take oral medications – Agent, route, time and regimen
- Agent: Ampicillin
- Route: IM or IV
- Time: 30 min pre-op
- Regimen:
- Adult: 2g
- Children: 50mg/kg
Antibiotic prophylaxis when allergic to penicillin/ampicillin – Agent, route, time and regimen
- 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
Cephalosporin contraindication
Cephalosporins should not be used in an individual w/ a h/o anaphylaxis, angioedema, or urticaria w/ penicillins or ampicillins
Antibiotic prophylaxis when allergic to penicillin/ampicillin and unable to take oral medications – Agent, route, time and regimen
- 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
