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Contents
Introduction Anatomy & physiology Ischaemic heart disease Anticoagulation therapy and dental care Acute coronary syndromes Congenital heart diseases
Examination of CVS
Questionnare ECG & JVP Infective endocarditis Rheumatic fever Hypertension
Introduction
Cardiovascular diseases (CVD) are very common in India , though more frequent and severe in the later stages of life, can also affect young
individuals.
They have high mortality rate and the associated morbidity affects all walks of life impacting the quality of life . A thorough knowledge of CVD is necessary because of its implications in dentistry and also the initial measures to be taken by the dentists in case of
Questionnare
Have you experienced chest pain or shortness of breath The quality of chest discomfort should be determined by asking the patient to describe the nature of the episode and the usual radiation pattern associated with it .
Where does the pain ,hurt or radiate Anginal pain is usually substernal , across both sides of the chest . Pain may radiate to various regions. Common sites of radiation of ischemic chest pain include the neck and jaw , the upper epigastric region (stomach ) , intracapsular
Have you experienced swollen ankles or shortness of breath Bilateral swelling of the legs ,is a common feature of chronic CVDs Shortness of breath is a major symptom of CVDs . Dyspnea may vary in severity from an uncomfortable awareness of breathing to a frightening sensation of
How long do your anginal episode lasts If the episode or discomfort ,normally ceases within 2-10 mins by taking rest Chest pain lasting with a brief duration commonly points to a noncardiac origin such as musculoskeletal pain , hiatal hernia
ECG
3 distinct waves are produced during cardiac cycle P wave caused by atrial depolarization QRS complex caused by ventricular depolarization T wave results from ventricular repolarization
ECG interpretation
P waves are absent in atrial fibrillation and before ventricular premature beats. Normally, all P waves are followed by QRS complexes but in third degree A-V block, P waves do not bear any relation to QRS complexes. Morphology and duration of P waves are important to determine left and
The P-R interval (normally 0.12-0.20 seconds) reflects intra-atrial, AV nodal and His-Purkinje conduction. It is the interval between the beginning of P wave and the beginning of QRS complex. The QRS complex, has a normal duration of 0,04-0.10 seconds. Abnormal Q
ST segment elevation or depression is seen in ischaemic heart disease, cardiomyopathies, myocarditis and conduction blocks. Some drugs like digitalis can also produce ST segment depression. T waves represent ventricular repolarisation.
Inverted T waves are frequently seen in cases with ischaemic heart disease,
bundle branch blocks, atrial fibrillation with rapid ventricular rate and in PS VT due to relative coronary insufficiency. QT interval is abnormal in hypokalemia and hypocalcaemia
Electrocardiography is useful in the following situations: Effects of drugs (digitalis). Hypothermia, pericarditis. Myocardial ischaemia and infarction. Cardiac arrhythmias. Conduction defects. Chamber hypertrophy.
between the top of the venous column and the sternal angle, regardless of the
body position. Normally, it is less than 3 cm. By convention, jugular venous pressure is measured from the sternal angle with the patient reclining at 45.
Central venous pressure can be accurately estimated from the jugular venous pressure. For this, the sternal angle is taken as the reference point The centre of the right atrium lies 5 cm below the sternal angle, regardless of body position. The central venous pressure is calculated as 5+jugular venous
The various waves on JVP reflect the phasic pressure changes in the right atrium. Normal JVP has three positive waves, namely, a, c and v waves, and two negative descents namely x descent and y descent a wave is due to right atrial contraction The c wave is due to bulging of the tricuspid valve into the right atrium and impact of the adjacent carotid artery during ventricular systole. v wave is due to passive right atrial filling during ventricular systole. The x descent ('systolic collapse9) is due to atrial relaxation and downward displacement of tricuspid valve during systole. a The y descent ('diastolic collapse') is due to opening of the tricuspid valve and the rapid flow of blood into
Infective endocarditis (IE) is a microbial infection of the endothelial surface of the heart or heart valves that most often occurs in proximity to congenital or acquired cardiac defects.
Previously, IE was classified as acute and subacute, to reflect the rapidity of onset and duration of symptoms prior to diagnosis. It has now largely been replaced by a classification that is based on the causative microorganism (e.g., streptococcal endocarditis, staphylococcal
endocarditis, candidal endocarditis) and the type of valve that is infected (e.g.,
native valve endocarditis [NVE], prosthetic valve endocarditis [PVE]). IE is also classified according to the source of infection, that is, whether community acquired or hospital acquired, or whether the patient is an intravenous drug user.
Etiology
A total of 80% to 90% of cases of identified IE are due to Viridans streptococci (alpha-hemolytic streptococci)and staphylococci. This variation depends on the type of valve infected (i.e., native or prosthetic), whether the infection is community acquired or hospital acquired (nosocomial).
The species that most commonly cause endocarditis are Streptococcus sanguis,
Streptococcus oralis (mitis), Streptococcus salivarius, Streptococcus mutans, and Gemella morbillorum formerly called Streptococcus morbillorum). Group D streptococci, which include Streptococcus bovis and the enterococci (Enterococcus faecalis)
Other microbial agents that less commonly cause IE include the HACEK group (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella),
similar frequently indistinguishable A Flow fromand a highto a low-pressure chamber condition is found in some patients with systemic lupus erythematosis and is called Libman-Sacks Flow acrossendocarditis a narrowed orifice at high velocity Fibrin and platelets then verrucous
adhere to the roughened endothelial surface and form small clusters or masses
The clinical outcome of IE depends upon several factors, including the following: Local destructive effects of intracardiac (valvular) lesions Embolization of vegetative fragments to distant sites, resulting in infarction or
infection
Hematogenous seeding of remote sites during continuous bacteremia Antibody response to the infecting organism with subsequent tissue injury caused by deposition of preformed immune complexes or
Complications
Heart failure that results from severe valvular dysfunction. This most commonly occurs as a problem with aortic valve involvement followed by mitral and then tricuspid valve infection. Embolization of vegetation fragments leads to complications in up to 35% of
much longer than 2 weeks (sometimes months) unlikely that the initiating
bacteremia was associated with dental treatment. Peripheral manifestations of IE due to emboli and/or immunologic responses are less frequently seen since the advent of antibiotics. These include petechiae of the palpebral conjunctiva, the buccal and palatal mucosa, and extremities.
Osler's nodes (small, tender, subcutaneous nodules that develop in the pulp of the digits), Janeway lesions (small, erythematous or hemorrhagic, macular contender lesions on the palms and soles), splinter hemorrhages in the nail beds, and Roth spots, retinal hemorrhages with pale centers)
DUKES CRITERIA
The Duke criteria were developed and later modified to facilitate the definitive diagnosis of IE. This set of diagnostic criteria assesses the presence or absence of major and minor criteria. MAJOR CRITERIA
MINOR CRITERIA Predisposing heart condition or IV drug use Fever Vascular phenomena Immunologic phenomena Microbiologic evidence other than positive blood culture Definitive diagnosis of IE requires the presence of two major criteria, one major and three minor criteria, or five minor criteria.
LABORATORY FINDINGS
Complete blood count with differential, electrolytes, renal function tests, urinalysis, chest x-ray, and electrocardiogram (ECG). Patients with IE frequently have a normocytic, normochromic anemia that tends to worsen as the disease progresses. The white blood cell count may or may not be elevated.
ECG may show evidence of conduction block with myocardial involvement or infarction. Other abnormal findings may include an elevated erythrocyte sedimentation rate, increased immune globulins, circulating immune complexes, and positive rheumatoid factor.
Dental considerations
Antibiotic Prophylaxis Dental treatment has long been implicated as a significant cause of IE. It was most often due to a bacteremia that resulted from an invasive dental procedure, and that through the administration of antibiotics prior to those procedures, IE
could be prevented.
CURRENT AMERICAN HEART ASSOCIATION RECOMMENDATIONS (2007) AHA cites the following reasons for revision of the previous recommendations: IE is much more likely to result from frequent exposure to random bacteremia associated with daily activities than from bacteremia caused by a dental procedure
Special Situations
Patients Already Taking Antibiotics Patients who are already taking penicillin or amoxicillin for eradication of an
be used.
Patients Who Undergo Cardiac Surgery. It is recommended that a preoperative dental evaluation be performed and necessary dental treatment provided whenever possible prior to cardiac valve surgery or replacement or repair of congenital heart disease.
Prolonged Dental Appointment. The length of a dental appointment in relation to the effective plasma concentration of an administered antibiotic is not addressed in these recommendations.
With amoxicillin, which has a half-life of approximately 80 minutes, the average peak plasma concentration of 4 (mg/mL is reached about 2 hours after oral administration of a 250-mg dose. Most of the penicillin-sensitive viridans group streptococci have an MIC requirement of 0.2 mg/mL. Thus, a 2-g dose of
Other Considerations No evidence suggests that coronary artery bypass graft surgery is associated with long-term risk for infection; thus, antibiotic prophylaxis is not recommended for these individuals. Patients who have had a heart transplant
Rheumatic fever
Rheumatic fever is an inflammatory disease occurring as a delayed sequale to pharyngeal infection with group A Streptococci. It primarily involves the heart, joints, central nervous system skin and subcutaneous tissues. Etiology
Acute rheumatic fever is characterised by exudative and proliferative inflammatory lesions of the connective tissues. It mainly involves the heart, joints and subcutaneous tissues.
Minor manifestations Fever Arthralgia Previous rheumatic fever or rheumatic heart disease Raised ESR Positive CRP Prolonged PR interval
Two major manifestations or one major and two minor manifestations indicate a high probability, with one supporting evidence of preceding streptococcal infection
MANAGEMENT
Bedrest Antistreptococcal therapy A course of antibiotic should be given to eradicate the streptococci, even if the throat culture is negative. One of the following regimens may be used:
days.
c. Oral erythromycin 20-40 mg/kg/day in three divided doses, in patients who are sensitive to penicillin.
Salicylates Aspirin is effective in providing symptomatic relief. Aspirin is started at doses of 60 mg/kg/day in 6 divided doses. Dose is increased gradually until the drug produces either a clinical improvement or systemic
Corticosteroids Patients who have severe carditis manifested by congestive heart failure not responding to aspirin.
Patients with severe arthritis whose symptoms and signs are not adequately
suppressed by aspirin. Prednisolone is given orally at a dose of 60-120 mg/day in four divided doses until the ESR is normal. It is then gradually tailed off over a period of 2 weeks. 4 To prevent a 'post-steroid rebound' an 'overlap course of aspirin may be added
Prevention
Primary prevention can be summarised as accurate diagnosis and treatment of group A streptococcal pharyngeal infection. An outbreak of rheumatic fever in a closed population is best treated by mass penicillin prophylaxis.
Duration of prophylaxis is controversial. Broad outlines are: Those under the age of 18 years should receive continuous prophylaxis. Those who are over 18 years who develop rheumatic fever without carditis should receive prophylaxis for a minimum period of 5 years.
4 Regimens: One of the following regimens may be used: Intramuscular injection of 1.2 million units of benzathine penicillin G every 3 weeks (most efficient regimen). Oral penicillin V 250 mg twice a day. Sulphadiazine 1 g/day orally as a single dose (in those allergic to penicillins). Erythromycin 250 mg twice a day orally (in those allergic to penicillins and sulpha)
Regulation of BP
HYPERTENSION
Hypertension is an abnormal elevation in arterial pressure that can be fatal if sustained and untreated. People with hypertension may not display symptoms for many years but eventually can experience symptomatic damage to several target organs, :ncluding kidneys, heart, brain, and eyes. In adults, a sustained
The dental patient with hypertension poses several potentially significant management considerations. These include identification of disease,
Etiology
About 90% of patients have no identifiable cause for their disease, which is referred to as essential, primary, or idiopathic hypertension. For the remaining 10% of patients, an underlying cause or condition may be identified; for these patients, the term secondary hypertension is applied. The most common cause of secondary hypertension is renal parenchymal disease,
Physiologic factors may have an effect on blood pressure. Increased viscosity of the blood (e.g., polycythemia) may cause an elevation in blood pressure that results from an increase in resistance to flow. A decrease in blood volume or tissue fluid volume (e.g., anemia, hemorrhage) reduces blood pressure. Conversely,
Diastolic pressure represents the total resting resistance in the arterial system
after passage of the pulsating force ventricle. The difference between diastolic and systolic pressures is called pulse pressure. Labile hypertension is the term that was previously used to Mean arterial pressure is roughly definedwith as the sum of the diastolic pressure describe a subgroup of patients wide variability in blood pressures plus one-third the pulse pressure. produced by contraction of the left
About 15% to 20% of patients with untreated stage 1 hypertension have what is called white coat hypertension, which is defined as persistently elevated blood pressure only in the presence of a health care worker but not elsewhere. Before the age of 50, hypertension is typically characterized by an elevation in
Deflate cuff slowly while listening with the stethoscope over the brachial artery over the skin Record the systolic pressure as and when the first tapping sound appears ( korotkoff sounds )
Deflate cuff further until the tapping sounds become muffled i.e diastolic
pressure and then disappear.
The "ideal" cuff should have a bladder length that is 80% and a width that is at least 40% of arm circumference (a length-to-width ratio of 2:1). The recommended cuff sizes are: For arm circumference of 22 to 26 cm, the cuff should be "small adult" size:
12X22 cm
27 to 34 cm, "adult" size: 16X30 cm 35 to 44 cm, "large adult" size: 16X36 cm 45 to 52 cm, "adult thigh" size: 16X42 cm
Laboratory Findings
The INC 7 recommends that patients who have sustained hypertension should be screened through routine laboratory tests, including 12-lead electrocardiogram, urinalysis, blood glucose, hematocrit, and a serum potassium, creatinine, calcium, and lipid profile.
Additional tests should be ordered if clinical and laboratory findings suggest the
presence of an underlying cause for hypertension.
DENTAL CONSIDERATIONS
The first task of the dentist is to identify patients with hypertension, both diagnosed and undiagnosed. A medical history, including the diagnosis of hypertension, how it is being treated, identification of antihypertensive drugs, compliance of the patient, the presence of symptoms associated with
Blood pressure measurements should be routinely performed for all new patients and at recall appointments. When a patient with upper level stage 2 blood pressure is treated, consideration should be given to leaving the blood pressure cuff on the patient's arm and periodically checking pressure during the
appointment.
The primary concern when one is providing dental treatment for a patient with hypertension is that during the course of treatment, the patient might experience an acute elevation in blood pressure that could lead to a serious outcome such as stroke or MI.
This acute elevation in blood pressure could result from the release of endogenous catecholamines in response to stress and anxiety, from injection of exogenous catecholamines in the form of vasoconstrictors in the local anesthetic, or from absorption of a vasoconstrictor from the gingival retraction cord.
Drug interactions Some NSAIDS ( indomethacin , ibuprofen , naproxen ) can reduce the efficacy of antihypertensive agents. Sodium based analgesics should be avoided
Because some antihypertensive agents tend to produce orthostatic hypotension, sudden changes in chair position during dental treatment should be avoided. After patients have had time to adjust to the change in posture, they should be physically supported while slowly getting out of the chair and should have
References Burkets oral medicine 10th & 11th edition. Essentials of medical physiology 3rd edition. Sembulingam. Davidsons principles & practice of medicine 20th edition. Current medical diagnosis & treatment. Lange 2004 Dental management of medically compromised patients. 7th edition. Little Medicine prep manual for undergraduates 3rd edition George mathew
In the later stages , the atherosclerotic plaque ruptures and exposes the arterial blood to the plaque contents and stimulates the formation of haemostatic plug . This occlusive thrombus may cause myocardial infaction. Atherosclerosis is the most common underlying cause of not only coronary an
Risk factors
Male gender, older age, a family history of cardiovascular disease, hyperlipidemia, hypertension, cigarette smoking, physical inactivity, obesity, insulin resistance and diabetes mellitus, mental stress, and depression. In addition to these conventional risk factors, markers of inflammation such as C-
ANGINA PECTORIS
Defined as a temporary inability of the coronary arteries to supply the
Variants of angina
Duration Stable Chronic , classic , exertional 1-15mins Due to obstruction of coronaries by atheroma.
Variant angina
Unstable
Preinfarction ,crescendo
The atypical attack of classic angina usually follows physical exertion or emotion stress . The patient is seized with a viselike crushing pain in the substernal region . The pain radiates characteristically to the left shoulder and down the arm to the
4th and 5th finger tips , but it may radiate to other areas , including the neck
region and even the jaws . Jaw pain has been reported to occur in the absence of precordial or substernal pain . This crushing pain lasts a few seconds to minutes, seldom longer .
Diagnosis
Electrocardiography ECG is normal in these pts at rest and in between attacks . Evidence, is demonstration of reversible ST segment depression or
Dental considerations
Acute anginal attack may occur as a result of the stress associated with dental services , particularly extractions . It is speculated that because of the over lapping of the 5th cranial nerve , 3rd cervical nerve and 1st thoracic nerve cardiac pain may be transmitted to the jaw
MYOCARDIAL INFARCTION
Synonyms coronary occlusion and heart attack .
MI - Types
Sub-endocardial Inner 1/3 to half of ventricular wall Decreased circulating blood volume( shock, Hypotension, Lysed thrombus) Circumferential
Symptoms Pain severe & intolerable , prolonged 30 mins , crushing , choking , retrosternal , radiates to left arm , hand epigastrium shoulders neck and jaws Nausea and vomiting weakness , dizziness palpitations ,cold perspiration
Investigations
ECG useful in conforming the diagnosis ST segment elevation Appearance of pathologic Q waves i.e initial negative deflections .
Detectable by changes in S-T segment of ECG Myocardial infarction (MI) is diagnosed by high
Plasma enzymes 1 . Creatine kinase (CK) More specific and starts to rise at 4-6 hrs , reaches peak 12 hrs , falls back to normal in 48-72 hrs 2. aspartate aminotransferase (AST)
Troponins (I and T )
Dental considerations
Prevention
Dental considerations
Several considerations need to be addressed when treating dental patients with CAD . The primary concern is to prevent ischemia or infraction The use of pulse oximeter to determine the level of oxygenation and the availability of an automatic external defibrillator are also advantageous .
Studies have indicated the influence of circadian variation on the triggering of acute coronary events , occur between 6 am and noon . It has been proposed that sympathetic nervous system activation and an increased coagulative state may be precipitating factors
Therefore , dental care for high risk pts might ideally be provided in the late
morning or the early afternoon . Consultation with the patients primary physicians or cardiologists prior to dental therapy is recommended.
Anticoagulation therapy and dental care Patients with CAD may require the use of aspirin or other antiplatelet drug , such as clopidogrel . The combination of acetylsalicylic acid and clopidogrel is usually continued for a minimum period of 4 weeks after stent placement
Data that address the risk of bleeding from dental extractions in pts who
use antiplatelet agents are limited although a bleeding time test is often recommended to evaluate the qualitative defect in platelets If emergency surgery needs to be performed and there is concern about
300 mg /kg
Studies suggest that there is no need to discontinue or alter anticoagulation therapy prior to routine oral surgical procedures for patients taking antiplatelet medications other than aspirin There seems to be a consensus that the risk to the patient ( thromboembolism)
if these drugs are discontinued , which far exceeds the problem of prolonged
bleeding
The most commonly used antithrombin medications are the dicumarols ( e.g.warfarin) , which inhibit the biosynthesis of vitamin K dependent coagulation proteins ( factors II, prothrombin , VII ,IX and X) The full therapeutic effect of warfarin is reached after 48 72 hrs and lasts
There is minimal indication for discontinuation of anticoagulation therapy , before minor oral surgical procedures when pts INR is <3.5
Thus , the minimal increase of intraoral bleeding can be stopped with local
measures and the potentially devastating consequenses of thromboembolic events are prevented . 3 different protocols can be used to treat patients with marked elevation in INR .
3) warfarin therapy is discontinued and the patient is placed on an alternative anticoagulation therapy Advantage pts risk for developing thromboembolic events is minimized by comparision with the 2nd protocol .
Unfractionated heparin is used for bridging the warfarin free period and
vitamin K is administrated . Heparin is continued , approximately to about 6hrs before surgery and is reinstituted after surgery with in combination woth oral anticoagulants until desirable INR has been achieved .
The advantage of using heparin are its short half life of 4-6 hrs and the availability of antidote , protamine sulfate . Patient can also self administer a subcutaneous injection of low molecular
The diagnosis of an ACS is usually made on the basis of clinical data .the patients history suggests a change in anginal pattern at rest Acutely ,the ECG is important to risk stratify the patient and to
Step -1 termination of the dental procedure Step 2 : P (position ) the anginal patient is consciuos and usually apprehensive . The pt is allowed to position themselves in the most comfortable manner . Commonly sitting or standing upright . The supine
If the patient experiences an anginal attack while in the dental chair , a nitroglycerine tablet should be placed immediately under the tongue or the patient should inhale amyl nitrate . These medications are not useful in patients known to be having a myocardial infraction.
Emergency management
In the dental office , the use of nitrolingual spray is preferred to the sublingual tablets because of the relative insability of the tablets One or two metered sprays are recommended intially with no more than 3 metered doses within a 15 min period , whereas sublingual nitoglycerine
tablets are recommended at 0.3 0.6 mg every 5 mins as needed with no more
than 3 tablets every 15 mins
Nitroglycerine normally reduces or eliminates anginal discomfort dramatically within 2 4 mins ,commonly seen side effects are fullness or pounding in the head,flushing,tachycardia and possible hypotension . Represents a contraindication to nitroglycerine administration
Congenital heart diseases Are the common heart disease among children , present in 1% of live births Cyanotic transposition of great vessels , tetralogy of Fallot
Acyanotic
Atrial and ventricular septal defect , pantent ductus arteiosus,
Dental considerations
Antimicrobial prophylaxis Dental bacteria may cause cerebral abscess Bleeding tendencies due to platelet dysfunction and excessive fibrinolytic activity .
DENTAL CONSIDERATIONS
According to AHA 2007 , antimicrobial prophylaxis is now recommended only for people defined as being in higher risk for a poor outcome Prophylaxis is recommended because endothelialization of prosthetic material occurs within 6 months after the procedure.
Pacemakers
These are small implanted electronic devices that stimulates the heart to beat and pace the heart rate when it is too slow Bipolar , implanted transvenously in the subclavian or cephalic vein and typically located in right ventricle .
Cardiac Arrhythmias
Refers to any variation in the normal heartbeat, and includes disturbances of rhythm, rate, or the conduction pattern of the heart. Cardiac arrhythmias are present in a significant percentage of the population, many of whom will seek
dental treatment. Most arrhythmias are of little concern to the patient or die
dentist; however, some can produce symptoms, and a few may be life threatening.
The normal pattern of sequential depolarization consists of (1) sinoatrial (SA) node (2) atrioventricular (AV) node (3) bundle of His (4) right and left bundle branches (5) subendocardial Purkinje network.
Normal cardiac function depends on cellular automaticity (impulse forrnation), conductivity, excitability, and contractiiity. Disorders in automaticity and conductivity form the basis of the vast majority of cardiac arrhythmias. Disorders of conductivity (block or delay) paradoxically may lead to rapid
cardiac rhythm.
Investigations
The electrocardiogram (ECG) is the primary tool used in the identification and diagnosis of cardiac arrhythmias. Additional tests that may be used include exercise or stress testing, long-term or ambulatory ECG (Holter) recording, baroreceptor reflex sensitivity testing, body surface mapping, and
Drugs in arrhythmias
Dental considerations
Heart failure
HF represents the end stage of many of the cardiovascular diseases. The American College of Cardiology/ American Heart Association 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult1 defines HF as a complex clinical syndrome that may result from any
When right-sided ventricular enlargement occurs as the result of a lung . (e.g., emphysema), pulmonary hypertension is produced; this disorder condition is called corpulmonale
Conclusion
References Burkets oral medicine 10th & 11th edition Davidsons principles & practice of medicine 20th edition. Current medical diagnosis & treatment. Lange 2004 Dental management of medically compromised patients. 7th edition. Little Medicine prep manual for undergraduates 3rd edition George mathew
References Burkets oral medicine 10th & 11th edition. Essentials of medical physiology 3rd edition. Sembulingam. Davidsons principles & practice of medicine 20th edition. Current medical diagnosis & treatment. Lange 2004 Dental management of medically compromised patients. 7th edition. Little Medicine prep manual for undergraduates 3rd edition George mathew