Caring for the Cardiac Pt Flashcards
what is the most common cause of premature death in the world
cardiovascular disease
what are the types of CVD disease
- HTN
- atherosclerosis
- CAD
- CHF
- arrhythmias
- bacterial endocarditis
- angina pectoris
pts frequently have _____ CVD
more than one
CVDs are:
interrelated
CAD leads to:
infarction
what is bacterial endocarditis characterized by
- infection
- inflammation
- scarring
what is CHF associated with
-dilated ventricles with weak muscles
- thickened myocardium
what is valvular heart disease characterized by
-stenotic and not capable of full closure for blood circulation
-leads to CHF
what are the conditions that are CVD risk factors
- high BP
- high cholesterol
- diabetes
- rheumatic fever
- more than 1 CVD
why is high BP a risk factor
stiffens vessels which reduces blood flow
why is high cholesterol a risk factor
a risk for stroke, kidney disease, and dementia
why is diabetes a risk factor
unstable glucose levels affect healthy myocardium function, angiopathy
what are the behavioral risk factors
- unhealthy diet: carbs, caffeine, fats, Na+
- physical inactivity: poor circulation
- obesity- excess weight stresses heart function, HTN, CAD
- too much alcohol- increases BP, arrythmias
- tobacco use; increases HR, BP, CAD
- stress
what are the family hx risk factors
- genetics
- becoming older
- ethnicity
what are the contributary anatomic abnormalities in CVD
- hypertrophy
- dilation
- valves
- regurgitation
- stenosis
- vascular
- heart structure
- rhythm
what are the physiologic changes in CVD
- arrhythmias
- heart failure
- ischemia
what are the signs of CVD
- elevated BP
- irregular or abnormal HR
- 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
what are the physical activity questions you should ask your patient
-do you feel shortness of breath at rest
- are you physically active?
- what kind of activities do you engage in?
- do you feel shortness of breath after exercise
- does it limit the intensity of your physical activity
what are the hypertension history questions you should ask the pt
- how long have you had high BP
- who manages your BP, primary care or cardiologist?
- how long have you been on this current antihypertenisve regimen?
- have there been any recent changes to your BP meds? Why?
what are the HTN monitoring questions you should ask
- what is your usual BP at the doctors office
- do you check your BP at home
- what are your usual readings, how high does it get>
what are the management strategies for pt with HTN
check BP - 3 readings at 5-10 min intervals- 2 automatic and 1 annual
what are the 2 things that you would do with diagnosed HTN- being treated
- elevated: 120-129/ less than 80: proceed with tx
- greater than or equal to stage 1: 130-180/greater than 120: med consult -> within BP goal proceed with tx with cardiac measures OR BP goal unmet no dental tx
what is the protocol for undiagnosed HTN
- elevated: proceed with tx but recommend med eval
- greater than or equal to stage 1: no dental tx until med eval
what BP should pt be referred to emergency room
SBP greater than 180 and/or DBP greater than 120
what is normal bp
- systolic: less than 120 AND
- diastolic: less than 80
what is elevated BP
- systolic: 120-129 AND
- diastolic: less than 80
what is high blood pressure stage 1
-systolic: 130-139 OR
- diastolic: 80-89
what is high blood pressure stage 2
- systolic: 140 or higher OR
- diastolic: 90 or higher
what is hypertensive crisis
- systolic: higher than 180 and/or
- diastolic: higher than 120
how many readings do you need to dx HTN
greater than or equal to 2 readings on greater than or equal to 2 separate visits
the less the symptoms and the better the control of risk factors then:
- the better a pt manages the stress
- the less likely the pt will have a life threatening incident during a dental procedure
- and vice versa
what are the low level interventions
- health/med eval
- exams
- prophy
- radiographs
- optical oral scans
- alginate impressions
what are the moderate interventions
- SRP
- simple restorative procedures: 1-2 teeth
- simple extractions: 1-2 teeth
- restorative impressions needing retractions and longer setting times
what are the high risk interventions
- complex restorative procedures on greater than 2 teeth
- multiple extractinos
- surgical extractions
- implant placement
- full arch impressions
- dental care under general anesthesia
time of procedure correlates to:
risk category
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 athersclerosis 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
- DEPLETION
- FAM HX OF CVD
- hyperlipidemia - high LDL
- HTN
- INSUIN RESISTANCE
- DM
athersclerotic plaques can lead to:
- ischemia
- thrombosis (vascular blockage) if they rupture
what are the steps in atherosclerosis
- chronic endothelial injury: HDL, HTN, smoking, monocysteine, hemodynamic factors, toxins, viruses, immune reactions
- endothelial dysfunction: increased permeability, leukocyte adhesion, monocyte adhesion, and emigration
- smooth muscle emigration from media to intima, macrophage activation
- macrophages and smooth muscle cells engulf lipid
- smooth muscle proliferation, collagen and other extracellular matrix deposition
what are the symptoms of atherosclerosis
- chest pain
- angina
what are the complications of atherosclerosis
- unstable angina
- MI - necrosis
- thrombosis
- embolism
- aneurysm
what does the RAA system do
maintains physiologic BP when BP is low
what does AT1 do
- smooth muscle cell contraction
- systemic vasoconstriction
- increased vascular resistance
- aldosterone release
- sodium reabsorption
- decreased renal medullary blood flow
- increased BP
what does AT2 do
- antiproliferative effects
- natriuresis
- vasodilation
- decreased BP
- pilocarpine (salagen)
what is the RAA system pathway
- angiotensinogen -> renin -> angiotensin I -> ACE -> angiotensin II -> ACE2 -> angiotensin 1-7
what causes the release of renin
- decreased sodium delivery
- decreased renal afferent perfusion pressure
- increased renal sympathetic activity
- increased vasodilation
what releases angiotensinogen
liver
what releases renin
kidney
what releases ACE
lung
what does Angiotensin II act on
adrenal gland and vessels
what does aldosterone act on
kidney
what are the complications of HTN
- CAD
- heart failure
- MI
- stroke
- Peripheral artery disease
- retinopathy
- end stage renal disease
BP is determined by:
indirect measurement in the upper extremities with a BP cuff and stethoscope
cuff should encompass ____ of the circumference of the arm
80%
center of cuff over:
brachial artery
cuff too small ->
falsely elevated values
white coat HTN ->
elevates BP by 30mmHg
pregnant pts increase systolic BP by:
greater than or equal to 10mmHg
why is HTN in pregnant pts concerning
risk of eclampsia
where should the proper arm position be when taking BP
horizontal at heart level - mid sternum
arm below heart level ->
over estimates systolic and diastolic pressures
arm above heart level ->
under estimates systolic and diastolic pressures
what are the HTN goals usually
less than 130-149/ 80-90 mmHg
no dental care at UMKC if BP is:
greater than or equal to 180/110
what is classified as a hypertensive urgency
180/120
what do you do if pt blood pressure is greater than or equal to 180/120
urgent referral to see doctor ASAP or if symptoms are present go to ER
what are the lifestyle modifications for HTN
- diet: increase fruit intake, decrease sodium, increased potassium
- physical exercise/weight loss
- tobacco cessation and alcohol intake reduction
what are the SE of ACE inhibitors
- angioedema
- neutropenia/agranulocytosis
- taste disturbances
what are the SE of sodium channel blockers
- dry mouth
- gingival overgrowth
- hypersensitivity reaction syndrome
what are the SE of calcium channel blockers
- gingival overgrowth
- dry mouth
- taste disturbances
what are the SE or diuretics
dry mouth
what are the SE of alpha adrenergic blockers
dry mouth
what are the SE of beta adrenergic blockers
dry mouth, angioedema
what are the oral manifestations of HTN meds
- dry mouth - alpha adrenergics and diuretics
- burning mouth (ACE)
- taste changes (Antiadrenergics, ACEi)
- angioedema (ACEi, ARB)
- gingival hyperplasia (calcium channel blockers and other 2
- lichenoid reactions (thiazides, methyldopa, propranolol, labetalol
-lupus like lesions ( hydralazine)
what are the oral manifestations of HTN
none - only due to meds
what are the dental considerations for the HTN Pt
- serious potential complications of severe uncontrolled HTN:
- stroke
- angina
- arrhythmia
- MI
what may increase Pt BP
stress, anxiety, fear
what should you consider for pts taking nonselective beta blockers
use of vasocontrictors can cause an acute risk in BP
pts may be sensitve to sudden position changes causing:
orthostatic hypotension
whatt are the pre operative considerations for the HTN pt
- reduce stress and anxiety
- may need oral and/or inhalation sedation
what are the intra operative considerations for the HTN pt
- profound anesthesia (most important)
- limit epi to 2 carpules if taking a selective beta blocker- 2 carp rule
- dont use Epi gingival retraction cord
what are the post operative considerations for the HTN pt
- avoid macrolide ABs with calcium channel blocker: increases CCB levels
- avoid long term use of NSAIDs ( more than 2 weeks)
- stage 2, monitor BP during tx if 180/110 stop tx
- raise pt slowly after tx bc of hypotension
