Chapter 2: Dental Management Of The Patient With Cardiovascular Pathologies Flashcards
1
Q
Hypertension corresponds to BP of?
A
140/90 mmHg
2
Q
80-90% of the patients are asymptomatic, the remaining 10% present initial symptomatology such as:
A
- occipital headache
- blurred vision
- paraesthesia of lower limbs
- tinnitus
BOPT
3
Q
Posterior lesions in the heart because of hypertension?
A
- congestive heart failure
- Ischemic cardiopathy
4
Q
Posterior lesions in the arteries because of hypertension?
A
Hemorrhage
5
Q
Posterior lesions in the kidneys because of hypertension ?
A
Renal disease
6
Q
Posterior lesions in the brain because of hypertension?
A
Stroke, encephalitis, hemorrhages
7
Q
Posterior lesions in the eyes because of hypertension?
A
Blindness, hypertension in the eye (glaucoma)
8
Q
Types of hypertension: primary or essential. What are the predisposing factors
A
- age
- dietary sodium
- hereditary
- obesity
- stress
90% of the cases
9
Q
Types of hypertension: secondary. Secondary to a systemic pathology such as?
A
- renal, endocrine, neurological, eclampsia, and alcoholic disease
10% of the cases
10
Q
When does eclampsia occur?
A
20th week: 2nd trimester.
11
Q
What is the definition of a hypertensive crisis?
A
Acute decompensation of hypertension.
Greater than 200/120mmHg
12
Q
3 types of hypertensive crises:
A
- Hypertensive urgency
- Hypertensive emergency
- Hypertensive pseudo-crisis
13
Q
Hypertensive urgency:
A
Absence of acute lesion of target organs, asymptomatic or with mild and non specific symptoms (mild headache, dizziness). Should be gradually corrected in 24-48 hours with oral medication.
14
Q
Hypertensive emergency:
A
Acute or progressive lesions of the target organs that may be irreversible and of poor vital prognosis (anticoagulants), requires immediate reduction (less than 1 hour) of the blood pressure with hospital treatment.
15
Q
Hypertensive pseudo-crisis:
A
elevation of blood pressure, asymptomatic, and without damage to target organs, secondary to anxiety, pain, hypoxia, that does not require hypotensive treatment but casual treatment.
16
Q
Non-pharmacological measures for hypertension?
A
- correct overweight. No fats or cholesterol.
- reduce salt intake.
- daily exercise: 45 mins/day.
- reduce alcohol intake.
- avoid other risk factors (tobacco, diabetes).
- avoid stressful situations.
17
Q
Pharmacological measures of hypertension?
A
- diuretics
- beta blockers
- calcium channel blockers
- ACE inhibitors
18
Q
Diuretics MOA?
A
Low renal absorption of sodium and calcium
Helps rid ur body of sodium and water
19
Q
Types of diuretics:
A
- Thiazides: chlorthalidone (HIGOTRONE).
- Indapamide (TERTENSIF), Hydrochlorothiazide (ESIDREX, HIDROSAUTERIL).
- Felt: Furosemide (SEGURIL).
- K -Spacer : (ALLDACTONE).
20
Q
Beta blocker MOA?
A
they antagonise the cardiovascular action of catecholamines.
Block effect of adrenaline/epinephrine
21
Q
2 types of beta blockers:
A
Cardio electives
Non cardio selectives
LOLs
22
Q
Cardio electives:
A
Atenolol, tenormin
Without interaction or contraindication to dental treatment
23
Q
Non-cardio selectives:
A
Propranolol (sumial), may increase the pressure response to adrenaline and cause reflex brachycardia
24
Q
ACE inhibitors MOA?
A
Vasodilation
25
Types of ACE inhibitors:
Captopril, enalapril (renitec), fosinopril, lisinopril
PRILS
26
Caution with ACE inhibitors and NSAIDs? Alternatives?
Interaction With INDOMETHACIN (NSAID derived from Acetic Acids), resulting in less hypotensive effect. Solution: use IBUPROFEN.
27
Calcium antagonists MOA?
Depression of myocardial function, slowing of electrical impulses and reduction of coronary and systemic vascular tone.
28
Types of calcium antagonists?
Dilitiazem, Nicardipine (ADALAT), Nifedipine, Nimodipine, and Verapamil.
PINE
29
Side effects of diuretics:
Xerostomia, nausea
30
Side effects of beta blockers:
Xerostomia, depression, sedation, sialadenosis.
Lichenoid reaction
31
ACEIs side effects?
Lichenoid reactoin, burning mouth, loss of taste.
32
Calcium antagonists side effects?
Xerostomia, gingival hyperplasia.
33
Other vasodilators (Hydralazine, nitroprusside, minoxidil) side effects?
Cephalgia, nausea
34
When does the greatest increase in BP occur?
during extractions, surgeries, and restorative treatments performed ** without anesthesia. **
35
What concentration of LA do u use for controlled hypertension?
1:1 with VC
36
Patients on MAOi (iproniazide), VC could trigger?
Hypertensive crisis
37
Patients who are stressed or anxious?
value premedication with oral sedatives or sedatives.
38
Why should you be careful with sprays (topical anaesthesia)for dental pain?
these carry local anaesthetics like benzocaines or lidocaine, which can be absorbed sublingually and cause risk of bronchospasm, ischemic heart disease and even myocardial infarction has been described.
39
Patient with controlled hypertension and under treatment with iproniazide?
WITHOUT VC
40
Protocol of patient with hypertension?
- determine BP before Tx (diastolic < 100mmHg).
- diazepam
- Anaesthesia with adrenaline 1:100,000, maximum 2 carpules- if you have to use more. we will use without a vasoconstrictor.
- Avoid intravascular injection (always aspirate).
- Avoid sudden changes of position so they don't get scared.
41
What to do in a hypertensive crisis:
- If the pt is feeling anxious randomly during the visit:
* Delay start of treatment. 10-15 min, relax, remain semi-seated (45%).
* Furosemide - a diuretic (SEGURIL) 40mg, and if it is not enough, CAPTOPRIL 25mg sublingually (fast reaction).
* DO NOT use SUBLINGUAL ADALAT (nifedipine) because from going from a level of 200 to 80 (one extreme to another) the patient will into shock therefore we need to lower it gradually!!!
42
When arteriosclerosis presents symptoms at the level of the heart, it’s known as?
Caridopathy
43
Ischemic cardiopathy symptoms?
Pain, ischemia.
Angina pectoris—> myocardial infarction. Sudden death.
44
Non-reversible risk factors of ischemic heart disease?
- age
- male sex
- family history
45
Reversible risk factors of ischemic heart disease?
Tobacco (very high risk).
Hyper-caloric diet rich in saturated fats. Foods with cholesterol (LDL).
Obesity/ overweight.
Inactivity / sedentary lifestyle.
Stressful situations.
Hypothyroidism, diabetes and hypertension.
46
Other risk factors for ischemic heart disease?
Low socioeconomic status.
Race (lower risk African and Asian).
Postmenopausal women.
Women on oral contraceptive (low risk).
Blood clotting disorder.
periodontal disease.
47
What risk factor of ischemic heart disease can we control as dentists?
Peridontal disease
48
What type of patients with ischemic heart disease are always taking medications? And what are the medications?
- patients with stents
- anticoagulants and antiaggregants.
49
What is a stent and what are it’s two types:
- Metal device that is inserted into the lumen of a vessel, increasing it’s light.
- conventional (metallic, chrome cobalt)
- pharmacoactive (drug-coated, drug-eluting)
50
Double anti-aggregatants:
Aspirin and clopidogrel
If you had to suspend 1: suspend clopidogrel and keep aspirin
51
Patient with previous infarction:
wait at least 6 months to 1 year and ask the cardiologist for a report -especially for high risk treatments eg extraction, surgery, etc
52
Protocol of action in patient with ischemic cardiopathy:
• Semi-upright position. Beware of orthostatic hypotension.
• Perform a correct technique of local anesthesia : anaesthetic with adrenaline 1:100,000, max 2 carpules. Aspirate and avoid intravascular injection. If you need more, use without Vc.
• Monitor the patient before and during the dental treatment, measure BP and pulse oximeter. (Heart rate and peripheral 02 pressure).
• Check coagulation. If anticoagulants intake—> INR of the day (between 2 and 2.5) and control
bleeding after exodontia or surgery—> local hemostasis. If pt is taking anticoag, we can go up to 3.5.
53
Precordial pain:
- stop procedure
- sublingual nitrates immediately (cafinitrin), 0.4, if BP is <100mmHg , dont give more doses
- O2 mask
- diazepam
- if it’s not relieved in 3 mins:
* 300mg of aspirin to avoid thrombosis
* Metamizole or morphine
54
Angina that is relived in 2-3 minutes?
Rest
55
If chest pain is not relived within 3 minutes:
AMI: pain lasts longer than 15-20 mins,
associated with sweating, nausea, vomiting, syncope, or hypertension
56
Congestive heart failure is?
Inability of the heart to pump blood necessary to meet the metallic needs of peripheral tissues —> increased plasma volume of liquids.
57
Treatment of CHF?
1. Medical rest
2. Improve the heart performance:
• Improving contractility: digitalis glycosides: DIGOXIN (DISUSE)
• Decrease in the after-load:
Nitroglycerine —> CAFINITRIN.
ACE inhibitor—> CAPTOPRIL, ENALAPRIL.
• Decease preload—> CAFINITRIN.
3. Reduce retention of H2O and electrolytes: Diuretics —> SEGURIL 40mg.
58
Cardiac arrhythmias:
- Variations in the normal rhythm of the heartbeat due to disturbances of the own rhythm, the frequency or the cardiac contraction.
- Normal—> 60 to 80 beats per minute. Less= bradycardia /more= tachycardia.
- Stress + anxiety + dental treatment: triggers potentially lethal arrhythmias.
59
The most common awareness of an abnormal heart beat?
Palpitations
60
Signs and symptoms of cardiac arrhythmias?
• Palpitatoins.
• Shortness of breath (DYSPNEA) .
• Thoracic pain.
• Altered state of consciousness.
• Dizziness.
61
Etiology of cardiac arrhythmias
• Cardiovascular diseases.
• Thyroid disorders.
• Respiratory disorders.
• Alterations in vegetative nervous system.
• Arrhythmias secondary to anxiety.
• Drugs
62
Cardiac arrhythmias caused by drugs that cause bradycardia?
Morphine, digoxin, beta blockers, calcium blockers
63
Cardiac arrhythmias caused by drugs that cause tachycardia?
Atropine, adrenaline, caffeine, nicotine, alcohol, tricyclic antidepressants.
64
Antiarrythmic drugs:
- digoxin
- propranolol
- quinidine
- verapamil
65
3 ways of treating cardiac arrhythmias?
- surgery
- antiarryhtmic drugs
- pacemakers
66
Old vs new pacemakers?
• New generation bipolar pacemaker—> NO PROBLEM FOR US. NO PROPHYLACTIC ENDOCARDITIS.
• Old pacemakers - interferes with ultrasound.
- might need ATB prophylaxis but not IE prophylaxis
67
What to do in the clinic with an arrythmic patient?
• Suspend intervention, TRANQUILLISE.
• Valuing vital signs.
• Administer oxygen if necessary.
• Sublingual nitrites if there's precordial pain.
• Place in Trendelenburg position (feet higher than the head).
• Be prepared to initiate basic cardiopulmonar resuscitation manoeuvres (CPR).
• Evacuation protocol.
68
Is IE frequent?
NO
69
IE:
Colonisation by microorganisms on pre-existing vegetative lesions —> ADHESION OF
PLATELETS AND FIBRIN = septic embolias (obstruction of blood vessels caused by an infected thrombosis that will then travel to the bloodstream).
70
Indications for ATB prophylaxis for IE:
!!!
1. Prophylactic cardiac valve
2. Previous infective endocarditis
3. Congenital heart disease:
* unrepaired cyanotic
* during first 6 months after complete repair by prosthetic material
* repaired but with residual defect
4. Cardiac transplant recipients who develop valvulopathy
71
In which cases is there a significant risk of bacteremia and what is needed?
- exodontia
- oral surgery
- endodontics
- periodontal tx (probing, maintenance, root scaling, sx, retractor thread)
- implants
- placement of orthodontic band (not braces)
- intraligamentary anaesthesia
- ultrasound prophylaxis (where bleeding is expected)
PROPHYLAXIS RECOMMENDED
72
In which cases is there a insignificant risk of bacteremia and what is needed?
- restorative dentistry, other anaesthesia, placement of rubber dams, removal of sutures, placement of prosthesis, impression taking.
No prophylaxis needed
73
ATB REGIMEN FOR DENTAL PROCEDURES:
- Time: single dose, 30-60mins before procedure
- Oral: amoxicillin 2g for adults, 50mg/kg for children
- Allergy to penicillin/ampicillin:
Oral:
* cephalexin 2g for adults, 50mg/kg for children
* clindamycin 600mg for adults, 20mg/kg for children
* azithromycin/clarithromycin 500mg for adults, 15mg/kg for children
- allergy to penicillin/ampicillin and unable to intake meds:
Injectable:
* cefazolin/ceftriaxone 1g IM/IV for adults, 50mg/kg IM IV for children
* clindamycin 600mg IM/IV for adults, 20mg/kg IM/IV for children
74
If inadvertently omitted before the procedure?
Could be administered up to 2 hours later with some benefit.
75
Major predictors that suspend or delay surgery for a patient with cardiac risk:
- Unstable coronary changes.
- Decompensated congestive heart failure.
- Severe cardiac arrhythmias.
- Angina and recent stable acute myocardial infarction (<1 month).
76
Intermediate predictors that suggest a consult with the doctor for a patient with cardiac risk:
- Compensated congestive heart failure.
- Long term diabetes mellitus.
77
Lower predictors that suggest oral surgery can be performed for a patient with cardiac risk:
- Old age.
- Minor electrocardiogram abnormalities.
- Non-sinus rhythms.
- Exertional dyspnea.
- Old heart attacks.
- Uncontrolled hypertension.
78
If a patient of 50 years of age goes to a consultation for the accomplishment of a root canal after a half hour of treatment, the patient begins to notice an early pain. How can we differentiate between a myocardial infarction and an angina pectoris?
a. It is typical that in the infarction it hurts the little finger and / or the jaw
b. The infarct yields with nitrites and angina does not
c. In the angina there is always perioral cyanosis
d. Nitrites improve painful symptomatology and in AMI, it usually does not
D?
79
Of the following statements only one is true:
a. A patient with ischemic heart disease needs prophylaxis of endocarditis
b. In the prevention of endocarditis, good dental hygiene and periodic review by the dentist are important.
c. All dental procedures have the same risk of bacteremia
d. Patients with accurate pacemaker prophylaxis of endocarditis
e. Prophylaxis of endocarditis in patients at risk and dental extraction is not necessary
B
80
The pathology that cardiovascular patients don’t present is?
A. Hypertensive crisis
B. Arteriosclerosis at a cardiac level
C. Alteration of the rhythm and frequency of the heart rate
D. Bacterial endocarditis due to valvular heart disease
E. Congestive heart failure because there’s enough pumping of the blood to the peripheral tissues
E
81
When treating patients who have pharmacoactive stents, we must?
A. Antibiotic prophylaxis for tooth extraction, if the stent was placed less than 6 months ago
B. Suspend treatment in case of dental surgeries
C. Go ahead with all the treatments from 6 month onwards
D. Suspend clopidogrel (antiaggregant) before tooth extraction
E. Carry on using ASA treatment that causes bleeding
B?
82
A PATIENT COMES TO THE CONSULT TO GET A
RECONSTRUCTION OF TOOTH 47. THE PATIENT HAD A HEART TRANSPLANT 15 YEARS AGO , CONTROLLED
HYPERTENSIVE. ITS TRUE THAT:
A. WE WONT TREAT UNTIL THE ENOUGH TIME AFTER THE TRANSPLANT HAS PASSED
B. WE WILL ALLWAYS PLACE MEPIVACAINE WITHOUT
VASOCONSTRICTOR FOR ANESTHETIC
C. WE WILL PRESCRIBE ENDOCARDITIS PROPHYLAXIS
D. IT IS NOT NECESSARY TO PRESCRIBE ENDOCARDITIS PROPHYLAXIS
E. THEY ARE ALL TRUE
C
* WHAT ANESTHETIC WILL YOU USE? Lidocaine 1:1 w/ Vc max 2 carpules, if more needed then without Vc
83
IN WHICH OF THE NEXT SITUATIONS WILL WE BE LOOKING ANT ARTERIAL HYPERTENSION AND NOT HYPERTENSIVE CRISIS
A. > or equal to 210/140 mmHg
B. 120mmHg/ PAD 90mmHg
C. PAS > or equal 140 mmHg/ PAD > or equal to 90 mmHg
D. 180 mmHg/ PAS 100 mmHG in an anticoagulated patient
E. B and c are correct
C
84
Which of the following factors indicates that
a patient with hypertension has not yet controlled its disease?
A. Type of hypertension
b. Alcohol consumption
c. Uncontrolled anxiety
d. Taking various antihypertensive drugs
e. Presenting another systemic disease: diabetes or heart disease
D
85
if a cardiac patient comes to the consult for dental preparation and begins to notice a precordial pain that is relieved after 2 or 3 minutes of rest, we should suspect of a?
A. tachycardia
B. angina
C. myocardial infarction
D. hypertensive pseudo crisis
E. cardiac arrhythmia
B
