Chapter 67 Cardiovascular Disease Flashcards
What are the manifestations of ischemic heart disease?
Angina pectoris
Myocardial infarction
Congestive heart failure
What is Angina pectoris?
Chest pain (most common symptom of coronary atherosclerotic heart disease)
Where is Angina pectoris?
Middle of the chest and can radiate to the arms and neck or even the mandible
How long does Angina pectoris usually last?
1-5 minutes
What are the precipitating factors of stable Angina pectoris?
Exertion or exercise, emotion, or a heavy meal
What are the precipitating factors of unstable Angina pectoris?
No exertion or exercise. It can occur when the patient is at rest and intensity can vary
What is the treatment for Angina pectoris?
A vasodilator, usually nitroglycerin, placed sublingually
And BLS with supplemental oxygen
What is myocardial infarction?
The most extreme symptom of ischemic heart disease that results from a sudden reduction of coronary blood flow
What are other names for myocardial infarction?
Heart attack, coronary occlusion, and coronary thrombosis
What is the most common artery associated with MI?
The anterior descending branch of the left coronary artery
What’s the cause of MI?
Can be a thrombosis that blocks artery already narrowed by atherosclerosis. The blockage created an area of infarction which leads to necrosis of the area
Symptoms of MI
Pain (may start under sternum, with indigestion, or in mid to upper sternum) that can last for hours and feels like a pressing or crushing heavy sensation
Cold sweats, weakness, faintness, shortness of breath, nausea, vomiting
Blood pressure can drop
Women do not have the same symptoms as men!
Does nitroglycerin help MI?
NO
Onset of pain for MI
Sudden onset that can happen during sleep or exercise
Management during MI attack
Terminate treatment
Sit pt up for comfortable breathing
Give nitroglycerin and reassure pt
Get medical assistance
When nitroglycerin does not reduce pain prepare for BLS
Call emt
Use medical emergency report and record vital signs
Apply basic life support measures and transport to hospital
What is heart failure?
When there is an abnormal cardiac function tay is responsible for failure of the heart to pump blood at necessary rate to meet the oxygen needs of the body
Considered an end stage heart condition and results from many forms of cvd’s and can be related to a number of other systemic conditions
Heart failure
What are examples of diseases that contribute to heart failure?
Coronary heart disease Hypertension Diabetes Arrhythmias Congenital heart disease Thyroid disorders Alcohol or drug use such as cocaine HIV/AIDS
What do the clinical manifestations of heart failure coincide with?
The parts of the heart involved
Symptoms of heart failure
Usually different depending on which side of the heart is affected.
General effects are extreme weakness, fatigue, fear, and anxiety
What are the signs of left heart failure?
Weakness Fatigue Dyspnea Shortness of breath when lying supine and relieves when sitting up Cough or expectoration Nocturia (urinate frequently at night) Pallor. Sweating cold skin Diastolic BP increases Heart rate rapid Anxiety, fear
Symptoms of Right heart failure
Weakness, fatigue
Swelling of feet/ankles can progress to thighs and abdomen in advanced stages
Cold hands and feet
Clubbing fingers
Cyanosis of mucous membranes and nail beds
Prominent jugular veins
Congestion with edema in various organs:enlarged spleen and liver. GI distress with nausea and vomiting. Central nervous system involvement with headache and irritability
Anxiety and fear
What are the treatments of heart failure during chronic stages?
Drug therapy
Dietary control
And limitation of activity
What should people limit in the dietary control of heart failure?
Sodium intake and fluid intake
What is the emergency care for heart failure and acute pulmonary edema?
Position pt upright for comfortable breathing Call EMS Administer oxygen Monitor vitals Reassure pt
Surgical treatment of heart failure
Coronary dilation and coronary bypass
What are the types of coronary dilation?
Percutaneous transluminal coronary angioplasty and coronary stent
What is percutaneous transluminal coronary angioplasty?
Widely used to stretch the coronary blood vessel
A ballon widens the narrowed lumen
An atherectomy may be used to remove atheromatous plaque from the vessel lining
What is a coronary stent?
Placed to maintain the open vessel lumen. They are made with metal and become covered with endothelium.
The stent provides a semi-rigid scaffolding within the lumen, which helps prevent narrowing of the lumen
What is the coronary bypass?
Coronary artery bypass grafting (CABG)
What is the CABG?
Primarily for pts with significant obstruction
Purpose is to “jump pass” over arteries that have been narrowed with atherosclerosis
What are the beneficial effects of CABG?
Relief from angina, less work on the heart, and an increase of oxygen and blood supple to the heart muscle
What is the natural pacemaker?
The center where the normal heartbeat is initiated and is the sinoatrial node located in the right atrium. From that node impulses are set along the muscle walls to stimulate and regulate the contractions of the ventricles which pulp blood throughout the body
When is a pacemaker indicated?
When the natural pacemaker cells are not able to maintain a reliable rhythm, or when the impulses are interrupted because of heart block, cardiac arrest, various arrhythmias, or other disease conditions
What is a cardiac pacemaker?
An electronic stimulator used to send a specified electrical current to the heart to control or maintain a minimum heart rate
What are the parts of the pacemaker?
Has electrodes inserted transvenously to the endocardium and the electrodes are connected to the power source containing a lithium battery. The pulse generator is implanted under the skin in the thorax or upper abdomen
What is the implantable cardioverter defibrillator?
A device that is surgically placed in the chest or abdomen to treat cardiac arrhythmias
What are the parts of the implantable cardioverter defibrillator?
Wires with electrodes on the ends bat connect to the heart chambers
Are the EMIS produced from ultrasonic scalers significant enough to disrupt the function of pacemakers and ICD’s?
NO
What kind of therapy is used in the treatment of many cvds to prevent embolus and thrombus formation (clotting)
Anticoagulant therapy
What are the drugs most commonly used to prevent or delay blood coagulation?
Heparin and Coumarin derivatives
What is a test of the coagulation phase of blood clotting used to monitor therapy with anticoagulants?
INR (international normalized ratio)
Local hemostatic measures for pts on anticoagulant therapy
Instrumentation can be performed on most pts without complication provided precautions are taken to minimize tissue trauma and control bleeding and not to dismiss the other until the bleeding has stopped
How to control bleeding with someone on anticoagulant therapy
Pressure: with sponges or cotton pellets packed interdentally
Post procedural instructions for someone on anticoagulant therapy
Closely observe pts for 6-8 hours after procedure
Pt is advised to avoid vigorous brushing and rinsing on treated area for several hours or until next day
Extraoral icepacks may help
Use of a soft diet
Moderation of physical activity
Emphasize the maintenance of gingival health to prevent future bleeding problems
Cardiac surgery presurgical
Pt is brought to a state of optimum oral health with all sources of infection removed
All other dental procedures are completed
Pt needs info about the importance of OH in eliminating a potential source of infective endocarditis
Cardiac surgery postsurgical
Continuing care appointments
Prophylactic antibiotic
Immunosuppressive therapy
Side effect of cyclosporine
Gingival enlargement
Anatomical classification of patients with cardiovascular disease
Diseases of the heart; pericardium, myocardium, endocardium, heart valves. Diseases of the blood vessels and peripheral circulation
Etiology classification of a patient with cardiovascular disease
Congenital anomalies, atherosclerosis, hypertension, infectious agents and immunological mechanisms
Infective endocarditis (IE)
Serious disease, prognosis depends on the heart damage and valves involved and duration of the infection and treatment
What microorganisms are responsible for IE?
Strep and staph are MOST of the time STREP is most prevalent
Majority of IE cases related to oral cavity are caused by what?
Ransom bacteremias due to ROUTINE BRUSHING AND FLOSSING
Do dental procedures usually cause IE?
Few cares of IE result from dental procedures
Risk factors for IE:
- Artificial (prosthetic) heart valves.
- Preexisting cardiac abnormalities
- IV drug abuse
* *** if a patient had had IE previously and receives an artificial valve they are MORE susceptible to IE than a patient that has not had IE previously and has an artificial valve
Self induced bacteremia
From eating, bruxing, chewing gum, interdental aids or any activity that can force bacteria into the susceptible sulcus
Bacteremia by Infection at portals of entry
Organisms enter the blood through the periodontal and gingival pockets or an open area of infection such as ulcer or ill fitting denture and travel through the bloodstream.
Bacteremia caused by trauma to tissues by instrumentation
Bacteremias that occur during oral surgery, endo, Perio therapy, scaling, and any therapy that causes bleeding.
Disease process of bacteremia
- transient bacteremia initiated
- bacterial adherence
- proliferation of bacteria
Transient bacteremia initiated
Trauma to mucosal surface such as the sulcus during instrumentation releases the bacteria into the bloodstream
Bacterial adherence
Microorganisms cleave to damaged heart valve, prosthetic valve or other susceptible areas in the heart
Proliferation of bacteria
Microorganisms multiply to form masses of plasma cells, fibrin and bacteria
After the disease process is complete
Heart valve becomes inflamed and it’s function weakens. Clips of microorganisms can break off and spread into circulation and complicate things
Prevention of bacteremia
Pt Hx
Premed
DH care
Using Pt history to prevent bacteremia includes
Asking questions to be aware of patients who had history of congenital heart defects, cardiac transplant, prosthetic valves, valvular defects, or previous IE
Premed to decrease IE (bacteremias)
Consult with pt physician if they have a history of heart problems and need premed
Verify pt took premed before tx. Document antibiotic time type and dosage in chart
DH care to help prevent IE
Make sure pt has good OH. Use pt Ed. have pt brush floss and use oral rinse to decrease bacteria before instrumentation.
How does Perio and gingivitis effect incidence of IE
The more severe gingivitis or Perio the higher incidence of bacteremia during instrumentation
**Normal healthy heart
Blood flows one way as each chamber contracts, valves snap shut after each contraction right side of heart caries DEoxigenated bloood to Lund to be reoxigenated. Left side carries oxigenated blood from lungs to cells
***When do irregularities develop during pregnancy
Develop during the first 9 weeks in utero.
***when is fetal heart developed
By the 9th week
Diagnosing anomalies for CHD (congenital heart diseases)
Diagnosing early is important but not all defects need to be treated. If treatment is needed it require surgery
Etiology of CHD
Genetic, environmental (occurs between 5-8 weeks in utero) or combination
— viral, drugs alcohol and cocaine can Cause CHD
Types of defects
Ventricular septal defect
Atrial septal defect
Pulmonary stenosis
Patent ductus arteriosis
Defects are
Openings in septal wall that results in mixing of blood from left and right sides of heart
Ventricular and atrial septal defects
Mixing of blood between left and right side
Other defects
Mixing between main arteries and veins (oxygenated and deoxigenated blood)
2 if the MORE common defects
Ventricular septal defect
Patent Ductus arteriosis
Ventricular septal defect
Left and right side exchange blood through opening in septum (the dividing wall) oxygenated blood from lung (left side) passes to right ventricle.
—severity of symptoms DIRECTLY related to location and size of defect
Patent ductus arteriosis
Shunt is open between the 2 great arteries (aorta and pulmonary artery)
This opening usually closes a few weeks after birth. If it doesn’t close blood from aorta can pass back to the lungs.
Heart compensates to try to provide body with oxygenated blood and is overworked
Signs and symptoms of CHD
Tire easily Dyspnea Cyanosis of lips and nail beds Poor growth and development Heart murmurs and CHF (congestive heart failure)
Dental hygiene considerations for a pt with CHD
Try to prevent IE
Eliminate oral disease
AHA recommendation for pt with CHD
Premed because certain defective heart valves are at risk for IE
Rheumatic heart disease
A complication of the heart following rheumatic fever. A high percent of pts that have had rheumatic fever have heart complications from it
Rheumatic fever
More frequent in developed countries
Declined in last decades
Not common in USA
usually effects children ages 5-15
Onset of rheumatic fever
Usually 2-3 weeks after beta-hemolytic group A streptococcal pharyngeal infection. (STREP)
Prevention of rheumatic fever
Early detection of strep and pharyngeal infections because rheumatic fever following is dependent on how severe the strep was
Symptoms of rheumatic fever
Low grade fever
Abdominal pain
Shortness of breathe and chest pain related to cardiac issues joint pain with arthritis present in ankles knees wrists and elbows
Joint swelling with warmth and redness
Nose bleeds
Skin rash on trunk and upper parts of arms/legs
Emotional instability
Muscle weakness
uncontrolled jerking of face feet and hands
Rheumatic heart disease following rheumatic fever
Usually symptoms do not show except valvular deformity
Symptoms of rheumatic heart disease
Stenosis of valves
Leaky valves (usually aortic and mitral valves)
Heart murmur from scaring of valves and myocardium
Arrhythmias
LATE symptoms of rheumatic heart disease
Shortness of breath Murmur Angina pectoris Epistaxis (nose bleed) Elevation of diastolic blood pressure Enlarged left ventricle Increasing signs of congestive cardiac failure
AHA recommendation for pt with rheumatic heart disease
AHA no longer recommends premed for pt
Where is the mortal valve located
Between left ventricle and left atrium
Mitral valve prolapse
Valve becomes misaligned allowing regurgitation.
When mitral valve is damaged
Closure doesn’t work and allows OXYGENATED blood to back flow “regurgitate”
Symptoms of mitral valve prolapse
Most pts are asymptomatic
A small amount have palpitations, fatigue, atypical chest pain and systolic murmur.
MORE SEVERE CASES: increase in palpitations and a systolic click and murmur
AHA recommendation for mitral valve prolapse
No premed
**Since AHA doesn’t recommend premed for certain things can we just go ahead and begin tx?
NO!! ALWAYS check with pt physician first
Hypertension
“SILENT KILLER” abnormal elevation of BP
Contributing RISK FACTOR in many vascular diseases
**Why is hypertension called silent killer
1/3 if people who have it do not have symptoms
Hygienist and detecting hypertension
Early detection with referral to doctor for tx can save lives
Risk factors for hypertension and atherosclrosis are
Interrelated
Hypertension etiology
90% of patients with hypertension are primary or essential
Risk factors for hypertension
Tobacco use Hereditary Overweight Race Salt: in excess
Hypertension and race
Incidence is higher in African Americans than whites
Illness is more severe and morality weight is higher in younger patients
Hypertension effects on men and women
Men more effected before 45 and women in older ages
Secondary hypertension
10% is secondary to other underlying medical conditions.
Both systolic and diastolic are elevated with secondary hypertension
Causes of secondary hypertension
Oral contraceptives Renal disease Endocrine disorders Medications Decongestants Steroids
Oral contraceptives and hypertension
Elevated BP
Occurs more in overweight women and women who have hypertension during pregnancy have a family history and mild kidney disease
Endocrine disorders that effect hypertension
Hyperthyroidism
Diabetes
Cushing syndrome
Thyroid or parathyroid disease
A marked sudden drop in BP
Usually an emergency such as severe blood loss, shock myocardial infarction, sepsis
Essential hypertension
Recognized ONLY by BP readings. Condition may go unrecognized because of lack of clinical symptoms
Early symptoms of high BP
Occipital headache Dizziness Visual disturbances weakness Ringing in ears Tingling hands and feet
Major sequela of long standing elevation of BP
-Brain, eyes heart or kidney may undergo change in function
-hypertensive heart disease
enlarged heart with eventual failure
- cerebral vascular accident (stroke)
Hypertensive renal disease
Ischemic heart disease (hardening of arteries)
Malignant hypertension
Life threatening
Sudden
Diastolic above 130
Affects about 1% of patients with hypertension
Symptoms of malignant hypertension
Any early symptom of high BP Blurred vision: loss of sight possible Severe dyspnea Chest pain similar to angina pectoris Mental confusion leading to stupor coma or convulsions
If pt has malignant hypertension
Activate emergency procedures immediately because condition is life threatening is not tested quickly and can result in damage to multiple body symptoms
Goals for primary hypertension.
To have a level below 80 to lower the risk of serious complications and premature death
Goals for secondary hypertension
Medical treatment for underlying disease is needed
Children 3 years and older should have BP taken how often
At least yearly
Ischemic heart disease AKA
CHD or coronary artery disease
Ischemic heart disease
A cardiac disability
Acute and chronic
Causes by reduction of blood supply to Heart muscle
*****Ischemia
Deficiency of blood to supply oxygen resulting in either functional constriction or actual obstruction of a blood vessel
***ischemic heart disease
Result of imbalance of oxygen to the myocardium resulting in narrowing or blocking of the lumen (opening) of the coronary arteries
Main cause of ischemic heart disease
Atherosclerosis of the vessel walls which narrows the lumen and obstructs blood flow
Atherosclerosis
Inflammatory disease of medium and large arteries which deposits (atheromas) thicken the layer of the blood vessel
Atheroma
Fibro-fatty deposit or plaque containing several lipids; especially cholesterol
Risk factors for atherosclerosis
Inflammation Elevated lipid in the blood Increase in cholesterol intake carbs saturated fat alcohol and calories Tobacco use Diabetes Obesity Insufficient exercise Increased tension Stress
**** low grade chronic inflammation in other parts of the body INCLUDING CHRONIC PERIO has A relationship to adverse cardiovascular outcomes
Pathogenic microorganisms associated with Perio are associated with atheroma formation in blood.
Many risk factors for Perio are risk factors for atherosclerosis!!
