CVD - valvular heart disease, congenital heart disease and infective endocarditis Flashcards
What part of the heart is most commonly affected by valvular heart disease?
What is the most common cause of valvular heart disease?
Any other causes?
Left side of the heart most commonly affected:
- aortic valve
- mitric valve
Most commonly age-related
- congenital
- infective endocarditis
- rheumatic fever - complication of streptococcus infection
Explain the pathophysiology of valvular heart disease:
- Regurgitation:
- loss of valve integrity, becomes floppy and leaks –> heart failure - Stenosis:
- narrowing of valve, obstruction of flow –> inadequate cardiac output –> heart failure
How to treat valvular heart disease?
- Medication - treat heart failure
- Surgery:
- open heart surgery valve replacement: biological (anticoagulant short term post op) or mechanical (warfarin for life)
- transcatheter aortic valve implantation (TAVI) - biological valve so no warfarin but need lifelong antiplatelet therapy
What are some dental aspects of valvular heart disease?
Anticoagulation
- warfarin and other anticoagulants
- INR for metal valves usually >3 (range 2.5-4.0 depending on valve and patient factors)
Risk of infective endocarditis
- can be induced by invasive procedures (e.g. toothbrushing)
- can occur spontaneously (caries and gingivitis)
What is congenital heart disease?
- atrial spetal defect: hole in atrial septum - NOT at increased risk of IE
- ventricular septal defect: hole in ventricular septum - at increased risk of IE
- patent ductus arteriosus: part of foetal circulation, usually closes at birth - at increased risk of IE
- co-arctation of the aorta: narrowing of aorta at site of embryonic ductus arteriousus - increased risk of IE
- tetralogy of fallot - increased risk of IE
What are dental aspects of congenital heart disease?
- risk of infective endocarditis
- if severe, can have problems lying flat (breathlessness)
- seek advice from cardiologist if unsure how to proceed
- dental treatment in hospital in those with cyanotic heart disease advised
What is infective endocarditis?
Infection of heart valves caused by bacterial vegetation on the heart valve
- usually occurs on diseased or prosthetic valves
- due to (often trivial) bacteraemia: strep viridans, strep faecalis, staph aureus
What are the clinical features of IE?
How is IE diagnosed?
How is it treated?
- prolonged febrile illness
- valve degeneration and failure
- embolic disease: brain, skin, anywhere
- immune complex formation: kidneys
Diagnosis: lots of blood cultures in hospital and echocardiogram
Treatment: prolonged course of IV antibiotics (4 weeks or more) or valve replacement surgery
What increases risk of infective endocarditis?
- acquired valvular heart disease with stenosis or regurgitation
- valve replacement
- hypertrophic cardiomyopathy
- previous endocarditis
structural congenital heart disease (including surgically corrected structural conditions but excluding isolated ASD, fully repaired VSD and PDA, and closure devices judged to be endothelialised)
Dental aspects of valvular heart disease?
Any special considerations?
- maintain high standards of oral hygiene
- avoid surgery if possible, minimise risks when it is necessary
- prophylaxis is no longer routinely given
Patients who may need to consider prophylaxis:
- patients with any prosthetic valve, of those whom any prosthetic matierial was used for cardiac valve repair
- patients with previous episode of infective endocarditis
- patients with congenital heart disease
What antibiotics should you use if prophylaxis is required?
If no penicillin allergy - 3mg, 60 mins before procedure of amoxicillin
If known penicillin allergy - 600mg, 60 mins before procedure of clindamycin
Both antibiotics risk of C.difficile
