CVD part 2 Flashcards
HF defined
decreased pumping action
HF systemic effects
systemic fluid congestion and failure of vital organs
results of RSHF
➢ Pulmonary edema
➢ Coughing
➢ Peripheral edema (arms and legs mostly)
results of LSHF
➢ Affects all organ systems;decreased kidney function contributes to fluid rentention
➢ Pulmonary edema
➢ Coughing
pathophysiology of HF
*Increased workload →problems with cardiac muscle
*Left ventricle typically fails first →can lead to right ventricle failure
common signs and symptoms of HF
➢breathing
➢Inspiratory
➢heart rate
➢jugular (neck) veins
➢edema
➢Abdomen
➢skin
➢Weight
➢fingers
➢Rapid, shallow breathing
➢Inspiratory rales (crackles)
➢Increased heart rate
➢Distended jugular (neck) veins
➢Peripheral edema
➢Ascites
➢Cyanosis
➢Weight gain
➢Clubbing of fingers
pt with Hx MI <1month
consider?
mesurement?
- Consider severity of cardiac status and comorbidities
- Ejection Fraction can measure the degree of heart failure
➢Measures amount (%) of blood that leaves the left ventricle after contraction. normal=55-70%, down to 40% considered slightly below normal - Consider appropriate management protocols
systolic vs diastolic HF LVEF
*Systolic failure➢ Reduced left ventricular ejection fraction (HFrEF)
*Diastolic failure ➢ Normal left ventricular ejection fraction (HFpEF)??
cardiac abnormalities contribtuing to HF
➢ Valvular Disease
➢ Arrhythmias
➢ Myocardial necrosis
decompensation of HF
➢ Inability to compensate
➢ Increased peripheral blood flow
➢ Increased metabolic needs
predisposing factors of HF
➢ Acute CVD
oMI
➢ Chronic CVD
oHypertension
oCoronary artery disease
oArrhythmia, etc
complications of HF
➢ Cardiac arrest (stops beating)
➢ Myocardial infarction (blood flow blocked)
➢ Stroke
clubbing of fingers
shortening and rounding of the most distal phalanges
what pts may state as symptoms regarding HF
➢Fatigue and weakness
➢Orthopnea –shortness of breath (dyspnea) in
recumbent position
➢Exercise intolerance
➢Muscular fatigue
➢Weight Gain
➢GI distress - nausea, vomiting & constipation
HF stages for management
stages A-D
stage A HF, therapy
pts w/ HTN, DM, obesity, athersclerosis, metablic syndrome, using caridotoxins
ACEi or ARB
stage B HF, therapy
previous MI, LV remodel, asym valve dx
ACEi or ARB
B blocker in some pts
stage C HF, therapy
structural heart dx, SOB, fatique, reduced exercise tolerence
diuretics
ACEi
ARB
stage D HF, therapy
pts with symptoms at rest, recurrent hospitalizations
similar drugs as A,B,C
medical management of HF
- Pharmacologic and non-pharmacologic
- Patients with severe heart failure may require cardiac transplantation
- Intermediate therapy is the Left Ventricular Assist Device (LVAD)
Effect of dental treatment before cardiac valve surgery:
Results
* LVAD studies did not meet inclusion criteria
* Low certainty evidence for valvular surgery
* Data cannot support or refute efficacy of dental
treatment (clearance) prior to cardiac surgery
In most cases of HF, the dentist will need to obtain a medical consultation with the patient’s cardiologist to determine:
- The patient’s physical status
- Laboratory test results
- Level of control
- Compliance with medications and recommendations
- Overall stability
major issues for patients with symptomatic HF (risks)
- Symptoms could abruptly worsen
- Acute failure
- Fatal arrhythmia
- Stroke
- MI
Does the BENEFIT of providing dental treatment outweigh the RISK of potential complications
NYHA HF classes
which do we tx?
Class I: routine dental care ok
Class II: medical consultation required, routine dental care likely ok
Class III and IV: consider referral to specialized care
PREP for emergency CPR
Additional HF Dental Management Considerations
* appt length
* Chair position
* If patient taking digitalis glycoside (digoxin)
- Short, “stress-free” appointments
- Chair position
➢Patients with HF may not tolerate supine position (pulmonary edema) - If patient taking digitalis glycoside (digoxin) –positive inotrope
➢Epinephrine should be avoided, if possible
➢Combination increases the risk for arrhythmia
does HF have oral manifestations
- There are no oral manifestations related to HF
- Many of the drugs used to manage HF can cause dry mouth altered taste and oral ulcerative lesions (discussed previously)
valvular dx
- Compromised function of the heart valves
- Valves direct blood flow into different heart chambers
➢ Atrioventricular:
oTricuspid and Mitral
➢ Semilunar
oAortic and Pulmonary
- Valvular Stenosis
➢ Do not open properly
- Valvular Insufficiency
➢ Do not close properly
➢ Associated with regurgitation
valvular fibrosis
➢ Stiff, sclerosis, stenosis causing either stenosis or insufficency
Myxomatous degeneration
➢ Benign loose CT tumorous changes where valves become Floppy, prolapse, regurgitation
➢ Causes insufficiency
Valvular dx risk factors
same as the other conditions
additional valvular dx risk factors
- Calcifications
- Congenital defects (bicuspid aortic valve, mitral valve prolapse)
- Infections
Valvular heart dx signs
➢ Murmurs
➢ Syncope
➢ Heart failure
➢ Shortness of breath
valvular heart dx symptoms
➢ Heart failure symptoms
➢ Exercise intolerance
➢ Shortness of breath (can also be a sign)
Valvular Heart Disease
Medical Management
- Treatment is primarily surgical
- Valve replacement (more common)
➢Mechanical Implants
oSilicone
oRequires long-term anticoagulation
➢Bioprosthetic Implants
oAllograft , bovine graft, etc.; decellularized CT
with a less antigenic structural matrix
oshort-term anticoagulation
oLong-term antiplatelet therapy) - Predisposition for infective endocarditi
mechanical vs bioprosthetic valve implants Abx
mechanical: long term Abx
bioprosthetic: short term Abx
Questions for Patient with Valvular Heart Disease
screening?
replacement?
anticoag?
- Screening
➢ Shortness of breath, chest pain, etc. - Valve replacement
➢ Have you ever had valve replacement surgery ? Know type of valve and when - Anticoagulation/Bleeding
➢ Do you take a blood thinner?
➢ Do you take aspirin or clopidogrel (Plavix)?
➢ Does it take a long for you to stop bleeding after a cut?
➢ Have you ahd excessive bleeding during or after a dental appointment?
➢ Have you ever been hospitalized due to bleeding? - Previous Infective Endocarditis
➢ Have you ever had infective endocarditis? when, tx, adverse rxn to drugs?
does valcular dx have oral manifestations
no
bleeding issues with valve dx
➢ Complications from anticoagulation or
➢ Complications from antiplatelet therapy
infection risks with valve dx
➢Risk of developing infective endocarditis
➢Requires antibiotic prophylaxis when valves have been replaced
drug effects of valve dx
➢ Potential drug interactions from CVD pharmacologic management (as previously discussed), especially when comorbidities are present
Valvular Heart Disease
Dental Considerations
bleeding, infections, drugs
- Assess ability to tolerate care in context of underlying condition and comorbidities
- Assess Bleeding Risk
➢ Obtain INR the day of the invasive procedures
➢ Have local hemostatic measures in place - Infections
➢Determine need for antibiotic prophylaxis and antibiotic of choice - Drug Effects
➢ Review medication list (drug adverse effect/drug-drug interactions)
IE
infection of inner layer of the heart usually affecting the valves
IE precipitated by:
bac/fungal infection
IE death can be caused by:
emboli and valvular dx
etiology IE
blood turbulence in heart can allow microbe to infect damaged endothelial surfaces
IE pathophys diagrammed
AHA Cardiovascular Indications for Antibiotic Prophylaxis to prevent IE
- Prosthetic cardiac valves
- Prosthetic material used for cardiac valve repair
- Previous endocarditis
- Cardiac transplantation recipients with valve regurgitation due to a structurally abnormal
valve - Congenital heart disease (CHD) only in the following categories:
➢Unrepaired cyanotic CHD
➢Completely repaired congenital heart defect with prosthetic material or device, during the first six months after the procedure
➢Repaired CHD with residual shunts or valvular regurgitation at the site or adjacent to the
site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
those at high risk for IE
moderate risk for IE
low risk for IE
Antibiotic prophylaxis is recommended for ONLY AT RISK PATIENTS who have procedures that:
- Manipulate the gingival tissue
2.Manipulate the periapex of teeth
3.Perforate the oral mucosa
If the dosage of antibiotic (prophylaxis) is inadvertently not administered before the procedure, the dosage may be administered:
may be administered up
to 2 hours after the procedure.
most common prophylaxis drug and dosage
oral amoxicillin 2mg (adult), 50mg/kg (child)
pt unable to take oral Abx prophylaxis
ampicillin 2mg IV/IM OR
cefazolin/ceftriaxone 1mg IV/IM
same 50mg/kg for kid
allergy to penicillin/ampicillin, what should pt take to prophylaxis
cephalexin 2g (50mg/kg)
clindamycin 600mg (20mg/kg)
azithromycin/clarithromycin 500mg (15mg/kg)
IE Patients already taking antibiotics urgent vs elective care
If a patient is taking a beta-lactam (penicillin, amoxicillin, etc.) for an active, existing infection resistant strains have likely been selected
* If urgent/emergency dental treatment is necessary
➢ Prescribe azithromycin or clarithromycin
- If dental treatment is elective
➢ Wait 10 days after completion of the antibiotic for their active infection, then prescribe amoxicillin according to AHA guidelines
Conditions that DO NOT require Antibiotic Prophylaxis
Heart murmur
* Mitral valve prolapse
* Mitral valve prolapse with regurgitation
* Rheumatic fever
* Stent or coronary artery bypass graft (cabg)
- Note: If a heart murmur is due to specific cardiac condition (e.g., previous endocarditis, prosthetic heart valve, complex congenital cyanotic heart disease), AHA continues to recommend antibiotic prophylaxis for most dental procedures
Procedures that DO NOT require Antibiotic Prophylaxis
- Radiographs
- Placement of appliances
- Routine local injections
- Tooth shedding or trauma
predictor of IE chances
*Size of bacteremia or bacteria number is a predictor of IE chances
is IE only bacterial
*Infective endocarditis (IE) is not always caused by bacterial infection
*Continuing evidence and Abx prophylaxis
*Continuing evidence questions the validity of antibiotic prophylaxis practice to prevent IE
majority of IE due to?
*Daily exposure to bacteremias during everyday activities (toothbrushing, chewing)
likely cause most cases of IE; not dentistry
how can we help prevent IE
*Encourage good oral hygiene practices
