W14 51 treatment of cardiovascular disease

Question 1

What can drugs target to do with cardiovascular activity?

Answer 1

Drugs affecting the heart - alter rate of contraction, conductivity or force of contraction
Drugs affecting the vasculature - arteriolar dilatation, venodilatation
Drugs working centrally - various mechanisms, on the brain

Question 2

What cardiovascular conditions can be targeted?

Answer 2

Angina
Arrhythmias
Cardiovascular disease
Heart failure
Hypertension
Myocardial infarction

Question 3

Examples of ADRs to cardiac drugs

Answer 3

ACE inhibitors can cause angioedema
Calcium channel blockers (eg nifedipine, amlodipine) cause gingival hyperplasia
Oral ulceration to nicorandil and captopril
ACE inhibitors and thiazide diuretics can cause lichenoid reactions

Question 4

What are the stages of management of hypertension?

Answer 4

A = ACE inhibitor, C = calcium channel blocker, D = thiazide-like diuretics
Step 1 - A (for under 55) or C (for over 55)
Step 2 - A + C
Step 3 - A + C + D
Step 4 - resistance hypertension. Consider addition of beta blockers.

Question 5

What are some complications of high blood pressure?

Answer 5

MI, stroke, renal disease
Increased risk of bleeding

Question 6

What things in practice can increase blood pressure?

Answer 6

Anxiety, vasoconstrictors

Question 7

Why might patients on hypertensive treatment experience orthostatic hypotension?

Answer 7

Vasodilation agents will keep blood vessels open all the time, causing orthostatic hypotension.
Make position or chair changes slowly, and assist patient into and out of the chair.

Question 8

What common drugs can increase blood pressure?

Answer 8

NSAIDs

Question 9

What should you do if their BP is above 160/100mmHg?

Answer 9

Only operate if necessary
Haemostatic agent post-op (haemostatis more difficult due to pressure in blood vessels)
IV sedation may be preferable (esp if or really anxious)
Don’t want blood vessels to pop and cause haemorrhagic stroke

Question 10

What treatments are there for patients with cardiovascular risk?

Answer 10

Aspirin, statins, BP treatment

Question 11

Which patients are at risk for coronary heart disease?

Answer 11

Those with type 1 or 2 diabetes mellitus
Cigarette smokers (with high lifetime exposure)
Patients over 75yrs

Question 12

How do you manage acute angina pectoris attacks?

Answer 12

Sublingual glyceryl trinitrate (GTN)

Question 13

How might angina be induced in a dental setting?

Answer 13

Stress might cause tachycardia which might cause angina

Question 14

How do you treat mild-moderate stable angina?

Answer 14

Treat with beta blockers
Alternatives include long-acting nitrates, rate-limiting CCBs (eg diltiazem) or nicorandil

Question 15

How do you treat an acute angina pectoris attack?

Answer 15

Ensure patient is sitting or lying down
Use 2 sprays of GTN SUBLINGUAL every 5 mins as necessary

Question 16

When is hospital admission with angina needed?

Answer 16

Hospital admission is not necessary if symptoms are mild and resolve rapidly with the patients own medication (may not be unusual)
Pain not resolved with second GTN should prompt emergency admission (20 min rule)

Question 17

What is the aim of management of acute myocardial infarction?

Answer 17

To provide supportive care and pain relief, to promote reperfusion and reduce mortality

Question 18

What drugs are involved in the medical management of AMI? (And drug acronym)

Answer 18

Morphine
Oxygen
Nitrates
Aspirin
Re-perfusion (percutaneous coronary intervention)
MONAR!

Question 19

What is the dental management of MI during treatment?

Answer 19

Call immediately for medical assistance and an ambulance, as appropriate (inform MI is suspected)
Rest patient in a comfortable position - usually sitting if breathless, or flat if feeling faint
Oxygen may be administered
Sublingual GTN may relieve pain
Reassure patient to relieve anxiety
Aspirin (300mg) dispersible should be given where available

Question 20

What drugs should be given post-MI?

Answer 20

Treatment with low-dose aspirin (75mg daily), clopidogrel, prasugrel, or dipyridamole should not be stopped routinely, nor should the dose be altered before dental procedures.

Question 21

When are patients still vulnerable following a MI or following any sudden increase in angina symptoms?

Answer 21

At least 4 weeks following these events

Question 22

How do you manage arrhythmias?

Answer 22

Precisely diagnose the type of arrhythmia first for treatment:
- ectopic (skipped beat) - reassurance
- atrial fibrillation - on rate control, long term Anticoagulation
- ventricular fibrillation - DC shock

Question 23

What should you consider when treating patients with cardiac arrhythmias?

Answer 23

Goal is to provide dental treatment whilst minimising the risk of precipitating a harmful arrhythmia, not changing heart rate.
Determine the severity and extent of the disease by obtaining a thorough history, performing a proper examination, enquiring about the presence of the pacemaker and taking a medication history.
Provide a non-stressful environment, short appointments, anxiolytic therapy when appropriate, to reduce the risk of precipitating an arrhythmia.
Consider monitoring ECG during procedures or surgical interventions (so better to be in hospital)
Minimise the use of epinephrine
Be aware of potential use of anticoagulants

Question 24

What information should you know about a patient with cardiac arrhythmias?

Answer 24

Type of arrhythmia treated
Presence of other cardiac disease
Medication prescribed
Type of pacemaker worn by the patient
Type of arrhythmia to be anticipated if the pacemaker malfunctions

Question 25

What are pacemakers used for?

Answer 25

To prevent asystole or severe bradycardia

Question 26

What dental considerations should be made for patients with pacemakers?

Answer 26

Some electrical dental equipment (eg ultrasonic scalers) interfere with the normal function of pacemakers (including shielded pacemakers) and should not be used

Question 27

What should you do if severe bradycardia occurs in a patient with a pacemaker?

Answer 27

If severe bradycardia occurs in a patient fitted with a pacemaker, electrical equipment should be switched off and patient placed in supine with legs elevated

Question 28

What should you do if a pt with pacemaker loses consciousness and the pulse remains slow or is absent?

Answer 28

Start CPR

Question 29

Occasionally, instead of pacemakers, they have cardioverted defibrillators that will shock people’s hearts and there have been occasional cases where they get shocked in the dental chair, usually due to them having an arrhythmia. What should you do in this case?

Answer 29

Stop treatment and refer to hospital

Question 30

What is the aim for heart failure treatment?

Answer 30

To relieve symptoms, improve exercise tolerance, reduce the incidence of acute exacerbations and reduce mortality.

Question 31

What medications can be used in heart failure management?

Answer 31

ACE inhibitors (titrated to a target dose) and beta blockers are key to this aim
Diuretics often required to reduce symptoms due to fluid overload
Digoxin improves symptoms, helping with contractility and exercise tolerance
Spironolactone (aldosterone antagonist) in moderate-severe heart failure

Question 32

How does the dental chair impact heart failure patients?

Answer 32

Use semi supine or upright chair position (avoid flat) - orthostatic breathlessness when lying flat
Watch for orthostatic hypotension, make position or chair changes slowly and assist patient into and out of chair

Question 33

What is the NYHA classification system for heart failure?

Answer 33

Class I = shortness of breath on major exertion
Class IV = shortness of breath at rest

Question 34

What drugs should you avoid/consider in heart failure?

Answer 34

Avoid epinephrine (especially in those on digoxin)
For patients with NYHA class III and IV congestive HF, avoid vasoconstrictors
Avoid NSAIDS (other than aspirin) - since salt and water retention make HF worse
Avoid itraconazole, a systemic antifungal (can precipitate or cause heart failure)

Question 35

What drugs interact with digoxin that should be avoids in heart failure due to digoxins narrow therapeutic index?

Answer 35

Erythromycin and tetracycline (antibiotics) should be avoid in patients taking digoxin as they may cause digoxin toxicity

Question 36

What does NBM mean?

Answer 36

Nil by mouth

Question 37

Perioperative care of cardiovascular patients - what should you do for patients who are NBM?

Answer 37

Should receive treatment on the morning of surgery
Oral anticoagulants require special consideration depending on indication - IV heparin cover may be necessary

Question 38

What can abrupt cessation of beta blockers or CCBs precipitate?

Answer 38

Abrupt cessation of beta-blockers or CCBs can precipitate peri-operative ischaemia/MI, from reflex tachycardia