EXAM I Management of the Cardiac Patient in Oral Surgery Flashcards
what is the cause of essential hypertension?
the cause of essential hypertension is unknown
also called primary hypertension
what are the systolic and diastolic values of mild-moderate essential hypertension, and what are the oral surgery implications?
- systolic <200, diastolic <110
- usually no contraindications to ambulatory oral surgery
what are the systolic and diastolic values of severe essential hypertension, and what are the oral surgery implications?
- systolic >200, diastolic >110
- postpone oral surgery until pressure is better controlled
- emergency procedures can be performed in a controlled setting
what is a hypertensive event/emergency?
someone who is experiencing symptoms of hypertension
symptoms MUST be present in order for it to be considered a hypertensive emergency, no matter how high the BP is
what population is most affected by angina?
primarily men >40yo and post-menopausal women
what is angina
mismatch in myocardial oxygen demand and oxygen supply
angina is a symptom of ___
ischemic heart disease
if your patient has symptoms of ischemic heart disease, what questions should you ask them?
frequency, duration, severity, response to medications
this can help determine if your patient is stable vs. unstable
what is nitroglycerin given for?
causes venodilation, so it supplies more oxygen to blood and tissues, and decreases the preload of the heart (aka the amount of blood going to the heart, aka the demand of the heart)
is angina an acceptable reason to exclude oral surgery?
no
if the patients angina arises to moderately vigorous exertion and responds readily to rest and nitroglycerin administration, then ambulatory oral surgery procedures are usually safe when performed with proper precautions
what precautions should you take when performing ambulatory oral surgery on a patient with angina?
- lower the myocardial oxygen demand
- anxiety reduction protocol
- profound local anesthesia
- epinephrine - max dose for an adult patient with ischemic heart disease is 0.04mg every 30 minutes = 2 carps
cardiac functional status can be expressed in ___
metabolic equivalents (METs)
what is a metabolic equivalent (MET)?
1 MET is defined as 3.5ml oxygen uptake/kg per minutes, which is the resting oxygen uptake in a sitting person
what MET is considered poor functional capacity?
<4
if a person is out of breath performing activities such as doing light housework (dusting), walking one or two blocks on level ground at 2-3 miles per hour, or eating, dressing, cooking, or using the toilet, about what MET range are they in?
MET 2-4
if a person is out of breath watching television, what MET is that?
1
if a person is out of breath climbing a flight of stairs, walking on level ground at 4 miles per hour, or running a short distance, about what MET range do they fall under?
about 4-6
if a person is out of breath doing heavy chores around the house or playing moderately strenuous sports, what MET range do they fall under?
about 7-9
if a person doesn’t get out of breath unless they are playing strenuous sports, what is their MET?
>10
___ results when an oxygen supply-demand mismatch results in myocardial cell death/dysfunction
myocardial infarction
what is the difference between angina and myocardial infarction?
there is cell death in MI
if a patient has suffered an MI, elective surgeries should be deferred for how long? what is that based on? what if emergency oral surgery is necessary?
- at least 6 months
- based on statistical data showing the risk of reinfarction is as low as it will ever be at 6 months
- if emergency surgery is necessary, a consultation with the patients cardiologist is required
what are some important considerations in the management of the patient with a history of MI?
- consult with primary care physician
- check with physician if invasive dental care is needed within 6 months of the MI
- check whether the patient is using anticoagulants, including aspirin
- use an anxiety-reduction protocol
- have nitroglycerin available
- administer supplemental oxygen
- provide profound local anesthesia
- consider nitrous oxide administration
- monitor vital signs, maintain verbal contact with the patient
- consider possible limitation of epi (0.04mg)
- consider referral to oral-maxillofacial surgeon
dual antiplatelet therapy (DAPT) is recommended for ___ months following percutaneous intervention and stenting procedures
12
(DAPT is basically anticoagulant therapy)
what are 4 common anticoagulants?
- aspirin - antiplatelet
- plavix - antiplatelet
- coumadin - the formation of vitamin K–dependent clotting factors in the liver
- Xa inhibitors (xabans)
which anticoagulant decreases production of vitamin K dependent clotting factors?
coumadin
cardiac dysrhythmias are common in patients with history of ___
ischemic heart disease
patients that have had a MI are at risk for cardiac ___
dysrhythmias
patients with cardiac dysrhythmias commonly have ___, are often ___, do not require ___, and should be carefully monitored
- pacemakers
- anticoagulated
- antibiotic prophylaxis
___ is a condition in which a problem with the structure or function of the heart impairs its ability to supply sufficient blood flow to meet the body’s needs
heart failure
what are 3 common causes of heart failure?
ischemic heart diseases, hypertension, valvular disease
what are the symptoms of congestive heart failure?
- coughing
- tiredness and shortness of breath
- pulmonary edema (excess fluid in lungs)
- pulmonary effusion (excess fluid around lungs)
- pumping action of the heart grows weaker
- swelling in abdomen (ascites)
- swelling in ankles and legs
what are 5 things you can do in the management of the patient with congestive heart failure (hypertrophic cardiomyopathy)?
- defer treatment until heart function has been medically improved and the patient’s physician believes treatment is possible
- use an anxiety-reduction protocol
- consider possible administration of supplemental oxygen
- avoid using the supine position
- consider referral to an oral-maxillofacial surgeon
what is the difference between ischemic and hemorrhagic cerebrovascular accidents?
ischemic refers to a clogged artery, and hemorrhagic refers to a ruptured artery
hemorrhagic events are deadly
patients who have had a cerebrovascular accident (stroke) are at increased risk for ___
future cerebrovascular accidents
patients who have had cerebrovascular accidents (stroke) are often prescribed ___
anticoagulants
what are 4 precautions you should take when treating a patient who has had a cerebrovascular accident (stroke)?
- anticoagulation
- beware of hypertension
- assess baseline neurologic status preoperatively
- consult patients primary care physician prior to proceeding
___ is an infection of the internal cardiac surface (heart chambers or valves)
infective endocarditis
___ following dental procedures have been shown to cause infective endocarditis
bacteremias
which bacteria is the most common cause of infective endocarditis?
streptococcus viridans
s. viridans is susceptible to the antibiotics recommended for prophylaxis
what are 4 cardiac conditions that increase the risk of infective endocarditis, and for which prophylaxis with dental procedures is recommended?
- prosthetic cardiac valve
- previous infective endocarditis
- congenital heart disease
- cardiac transplant recipients who have cardiac valvulopathy
what is the oral antibiotic regimen for prophylaxis of bacterial endocarditis?
amoxicillin 2g (adults) or 50mg/kg (children)
what is the parenteral antibiotic regimen for prophylaxis of bacterial endocarditis?
- ampicillin 2g IM or IV (adults) or 50 mg/kg IM or IV (children)
- cefazolin/ceftriaxone 1g IM or IV (adults) or 50mg/kg IM or IV (children)
what is the oral antibiotic regimen for prophylaxis of bacterial endocarditis in patients with a penicillin allergy?
- cephalexin 2g (adults) or 50mg/kg (children)
- clindamycin 600mg (adults) or 20mg/kg (children)
- azithromycin/clarithromycin 500mg (adults) or 15mg/kg (children)
what is the parenteral antibiotic regimen for prophylaxis of bacterial endocarditis for patients who are allergic to penicillin?
- cefazolin/ceftriaxone 1g IM or IV (adults) or 50mg/kg IM or IV (children)
- clindamycin 600mg IM or IV (adults) or 20mg/kg IM or IV (children)
a 36 year old male admits to doing cocaine the morning of your appointment. his initial blood pressure is 210/125. you take a repeat blood pressure after laying him supine and see it is 205/120. he reports no symptoms. what is the best course of action?
call his primary physician and notify him/her personally and sent up an appointment for that day; arrange for transfer
your patient presents for removal of tooth no. 14 today under local anesthesia. during your H&P she states she gets short of breath just walking indoors at her home. how many METs is this, approximately? should you proceed with removal of tooth no. 14?
- <4 METs, so cardiac function is not good
- you should not proceed with the extraction; refer to physician
- “defer and refer”
a 58 year old male patient presents with a recent history of coronary stent placed 5 months ago. after talking to his physician, you find out it was a drug-eluting stent. you forgot to ask the physician if the patient was taking anti-coagulants still. the patient does not know. what is the likelihood that the patient is still taking anticoagulants?
very likely because the patient should be on anticoagulants at least 12 months post stent placement
a patient with a mechanical cardiac valve that was placed 3 years ago presents for extraction of tooth no. 6, which is a surgical extraction. the patient is taking augmentin for a resolving sinus infection. what is your course of action?
- want to give antibiotic prophylaxis prior to procedure
- amoxicillin 2g prior to the procedure
your patient has a mechanical prosthetic cardiac valve which was placed 10 years ago. is it likely that the patient is still taking anticoagulants?
yes
for mechanical valves, anticoagulation is generally required for life
a 67 year old female presents to the oral surgery clinic for removal of her remaining mandibular dentition. during your H&P, you note the patient has a history of atrial fibrillation and is currently anticoagulated with coumadin (aka warfarin) 5mg daily. how do you want to proceed?
- you should never take a patient off of coumadin without getting the patients primary care physician’s permission first
- normal INR is 1, but patients taking coumadin will have an increased INR (decrease in clotting efficiency)
- coumadin blocks the production of vitamin K clotting factors II, VII, IX, and X, so if they are losing blood, you can give your patient vitamin K
a 54 year old male presents to the clinic for removal of his remaining maxillary teeth. the patient has a past medical history of smoking and periodic chest pain. you have elected to proceed under local anesthesia and have injected 6 carps of lidocaine 1:100,000 epi. midway through the procedure, the patient begins to complain of severe chest pain. how do you proceed?
- call 911 first, then proceed with “MONA”
- M - give the patient morphine (decreases pain and thus decreases heart rate)
- O - put patient on oxygen
- N - give the patient nitroglycerin sublingually for vasodilation
- A - give the patient aspirin so they don’t clot - improves survival of these patients
