CARDIOVASCULAR

DISEASES

Prepared By:

Bawar Yahya University of Suleymaniah

2015 Bawar992@yahoo.com

Anatomy of the Heart:

Physiology of the heart:

DISEASES OF THE HEART

The diseases and conditions affecting the heart

are collectively known as heart disease.

The heart consists of a muscle that pumps blood,

arteries that supply blood to the heart muscle,

and valves that ensure that the blood within the

heart is pumped in the correct direction.

Problems can arise in any of these areas.

Like cardiovascular disease, heart disease is a term

that's somewhat loose and broad, and it's often

used that way.

CAUSES OF CARDIOVASCLAR DISEASE

ORGANIC DISEASE OF HEART

1. MYOCARDIAL

A. OVERLOAD SECONDARY TO HYPERTENSON OR VALVE DISEASE

B. CORONARY (ISCHAEMIC) HEART DISEASE

C. CARDIOMYOPATHIES

2. ENDOCARDIAL

A. RHEUMATIC HEART DISEASE

B. CONGENITAL ANOMALIES

C. INFECTIVE ENDOCARDITIS

3. PERICARDIAL

A. PERICARDITIS

B. PERICARDIAL EFFUSION

C. FUNCTIONAL DISORDERS

DUE TO HYPERTENSION

DUE TO ABNORMALITIES IN HEART RATE

A. TACHYCARDIA

B. BRADICARDIA

C. OTHER DYSRTHYMIAS

CHANGES IN CIRCULATORY VOLUME

A. HYPOVOLOEMIA (SHOCH SYNDROME)

B. HYPERVOLAEMIA (CIRCULATORY OVERLOAD)

C. OTHERS

General Scheme of history taking:

A) Systems and history of present illness

1. CHEST PAIN

2. PALPITATION

3. SYNCOPE

4. COUGH WITH EXPECTORATION

5. CYANOSIS

6. RIGHT HYPOCONDRIAL PAIN, SWELLING OF FEET AND DECREASE IN THE URINE

OUTPUT

7. GASTROINTESTINAL SYMPTOMS LIKE ANOREXIA, FULLNESS OF ABDOMEN AND

VOMITING

8. FATIGABILITY

9. FEVER

10. DIABETES MELLITUS AND HYPERTENSION

B) Past History 1. RHEUMATIC FEVER

2. RECURRENT RESPIRATORY INFECTIONS SINCE CHILDHOOD

3. DETECTION OF MURMUR/CARDIAC LESION AT SCHOOL

4. RECENT DENTAL EXTRACTION

5. HYPERTENSION, DIABETES MELLITUS, ISCHAEMIC HEART DISEASE OR ANY OTHER

SIGNIFICANT MEDICAL ILLNESS

C) FAMILY HISTORY 1. HYPERTENSION

2. ISCHAEMIC HEART DISEASE

3. CONGENTAL HEART DISEASE

4. RHEUMATIC HEART DISEASE

5. SUDDEN DEATH

D) PERSONAL HISTORY 1. APPETITE

2. WEIGHT LOSS

3. DISTURBED SLEEP

4. BOWEL AND BLADDER DISTURBANCES

5. HABITS- SMOKING AND ALCOHOLISM

6. EXPOSURE TO SYPHILIS

E) TREATMENT HISTORY NIFEDIPINE- GINGIVAL HYPERPLASIA

EXAMINATION OF CARDIOVASCUAR SYSTEM

A/ GENERAL EXAMINATION

1. PALLOR 2.CYANOSIS

3. CLUBBING 4. JAUNDICE

5. Blue Sclera 6. Lymphadenopathy

B/ EXAMINATION OF MOUTH

1. Acute macroglossia:

The tongue is diffusely enlarged and bright red along its lateral portion.

The patient had bleeding into the tongue while on anticoagulants.

Acute macroglossia due to Enalapril: this 75-year-old Black female developed acute

swelling of tongue and lips after being on enalapril for 2 days. She was unable to talk or

swallow (upper photo). In lower photo, 2 days after stopping enalapril, the tongue and lips

have returned to their normal size.

2. GUM HYPERPLASIA

DUE TO DILANTIN. SIMILAR FINDINGS

MAY BE SEEN IN PATIENTS ON NIFEDIPINE

3. TANGIER DISEASE OF THE TONSILS:

THE TONSILS ARE ENLARGED WITH BRIGHT

ORANGE YELLOW STREAKS (“TIGER STRIPES”)

(PREMATURE CAD).

EXAMINATION OF:

RADIAL PULSE:-

RATE

RTHYM

VOLUME

CHARACTER

CONDITION OF VESSEL WALL

VITAL SIGNS:-

PULSE

BLOOD PRESSURE

RESPIRATORY RATE

TEMPERATURE

Common Heart Diseases:

1. Hypertension

2. Ischemic Heart disease

3. Congestive Heart Failure

Hypertension • Hypertension is defined as having systolic blood pressure

(SBP) >/= 140mm of Hg or

• diastolic blood pressure (DBP) >/= 90mm of Hg or

• As having to use antihypertensive medications.

Blood Pressure Classification SBP (mm Hg) DBP (mmHg)

• Normal <120 & <90

• Pre hypertension 120-139 & 80-89

• Stage I hypertension 140-159 & 90-99

• Stage II hypertension >/=160 & >/=100

Types of Hypertension:

PRIMARY HYPERTENSION

• Which develops gradually over many years & has no

underlying cause.

• 90% of people have this type of hypertension.

SECONDARY HYPERTENSION

• Which has an underlying cause such as renal disorders,

endocrinal disturbances, neurologic causes etc.

• 10% of people have this type of hypertension.

Other Risk Factor of Hypertension

• Lack of exercise

• Increased salt intake

• Family history

• Alcohol

• Smoking

• Stress

• Age

Diagnosis

• Physical Examination

• Laboratory and Additional Testing – it includes

Routine laboratory procedures like hemoglobin, urinalysis,

routine blood chemistries and fasting lipid profile.

• Electrocardiography

• BP Monitoring

• Radiologic testing

Dental Management for Hypertensive patients:

Before initiating dental care:

• Assess presence of hypertension

• Determine presence of target organ disease

• Determine dental treatment modifications

1. Asymptomatic BP <159/99 mm Hg, no history of target

organ disease

• No modifications needed

• Can safely be treated in dental setting

2. Asymptomatic BP 160-179/100-109 mm Hg, no history of

target organ disease

• Assessment on an individual basis with regard to type of

dental procedure BP>180/110 mm Hg, no history of

target organ disease

• No elective dental care

3. Presence of target organ disease or poorly controlled

diabetes mellitus

• No elective dental care until BP is controlled, preferable

below 140-90 mm Hg.

TREATMENT OF HYPERTENSION

NON PHARMACOLOGICAL TREATMENT LIFESTYLE

MODIFICATIONS

1. Salt restriction

2. Weight reduction

3. Stop smoking

4. Diet modifications such as:

Reduce intake of Cholesterol & Saturated fat.

• Adequate intake of Calcium & Magnesium.

• 5. Limit of alcohol intake

• 6. Relaxation such as yoga, psychotherapy etc.

7. Regular exercise.

ORAL MEDICATIONS USED FOR TREATMENT OF HYPERTENSION

• Diuretics

• Beta-Adrenergic Blockers

• Central Acting Inhibitors

• Peripheral Acting Inhibitors

• Non-Selective alpha & beta Adrenergic Inhibitors

• Vasodilators

• Angiotensin Converting Enzyme ACE Inhibitors

ORAL MANIFESTATION OF HYPERTENSION

There are no recognized manifestations of hypertension but

anti-hypertensive drugs can often cause side effects, such as:

• Xerostomia,

• Gingival overgrowth,

• Salivary gland swelling or pain,

• Lichenoid drug reactions,

• Erythema multiforme,

• Taste sense alteration,

• Paresthesia.

CORONARY (ISHAEMIC) HEART DISEASE Include disorders such as

-angina pectoris

-myocardial infarction.

ANGINA PECTORIS;

Is a system complex highlighted by chest pain, it is transient,

symptomatic, ischemic heart disease.

*Stable angina; Pain on exertion, relieved with rest.

*Unstable angina; Pain at rest or markedly changing frequency of attacks.

Oral complications;

Usually none; however no rare occasions patients may have;

(Lower jaw pain of cardiac origin (referred pain)

Causes;

Most commonly atherosclerotic of narrowing one or more

coronary vessels.

Medical evaluation of patient with angina;

- History

- Physical examination

- ECG

-exercise stress test

Treatment of patient with unstable angina pectoris; - (angina occurs irregularly or in multiple occasions without

predisposing factors), should be treated for emergency only and in

consultation with patient physician.

Treatment of patient with stable angina; (Occurs infrequently is associated with exertion or stress).

1-consultation with the patient physician

2-stress reduction

3-profound LA is vital

4-sedation is indicated for anxious patient

5-supplemental oxygen by nasal cannula also help for preventing intra

operative angina attack.

6-patient should be instructed to bring their medication to the dental

appointment nitroglycerines be kept in the office emergency medical

kit.

7-discontinues the treatment if patient fatigue or uncomfortable or

change in heart rate.

If angina attack occurs Should receive the following emergency medical treatment;

1-the periodontal procedure should be discontinuing

2-administer 1 tablet (0.3-0.6mg) of nitroglycerin sublingually

3-reassure the patient and loosen restrictive garments

4-administer oxygen with the patient in the recline position

5-if the signs and symptoms cease within 3 minutes complete the

periodontal procedure make sure that the patient is comfortable

6-if sign and symptoms do not resolve within 2-3 min. give the patient

another dose of nitroglycerin call the patient physician be ready to

take patient to the emergency department

7-third tablet can be given 3 min. after the second, if the chest pain not

relieve by 3 tablets indicates MI transport the patient to the

emergency medically facility immediately.

Myocardial Infarction It is irreversible myocardial damage as the result of prolonged ischemic

injury.

Cause;

It is most commonly the result of progressive coronary artery disease

secondary to atherosclerosis.

Prevalence;

It affects 1.3% of all patients above age 30 and 10% of all patients

above age 40.

Clinical presentation; -Severe chest pain is present in the sub sternal or left precordial area,

left arm or jaw radiation.

-Dyspnea, palpitations, nausea, and vomiting may also be part of the

presentation.

Diagnosis;

This includes;

-clinical presentation

-electrocardiographic evidence

-cardiac enzyme studies.

Dental management of patient with

-Patient with recent MI should not receive dental treatment until

condition is stabilized medically (6 months after MI).

-After 6 months MI patient can be treated in a technique similar to the

stable angina.

DENTAL ASPECTS OF MYOCARDIAL INFARCTION

• Dental clinic should have advanced cardiac life support or at least

basic cardiac life support.

• Use of pulse oximeter to determine the level oxygenation.

• Automatic external defibrillator.

• Determination of vital signs prior to dental care.

• BP & pulse rate & rhythm should be recorded & any abnormal

findings should be addressed.

• Premedication with antianxiety drugs and inhalation nitrous oxide

in anxious patients.

• Elective procedures especially those requiring GA should be

avoided for at least 4 weeks after MI. consult pt.'s physician prior

to dental therapy

CONGESTIVE HEART FAILURE

Definition: It is the inability of the heart to deliver inadequate supply of blood to meet metabolic

demand.

Signs;

-rapid shallow breathing

-jaundice

-cyanosis

-weight gain

-peripheral edema

-distended neck veins

-heart murmur

-inspiratory rates

Symptoms; -fatigue and weakness

-dyspnea (breathlessness)

- Nocturnal dyspnea

-hyperventilation followed by apnea

-low-grade fever

-anorexia

-nausea

-vomiting

-constipation

-liver pain

-insomnia

-history of weight gain

-history of increased body girth

-history of sweating

-dizziness, confusion.

Causes;

1-Decreased myocardial function; -ischemic heart disease

-infiltrative disease ex. (amyloidosis)

-metabolic disorder (hypothyroidism)

-pharmacological suppression (propanol)

2-Increased vascular resistance; -hypertension (75% of cases)

-aortic stenosis

3-Increased blood volume; -Valvular insufficiency (aortic or mitral insufficiency)

-atrial or ventricular septal defect

4-Excessive metabolic demand; -severe anemia

MEDICAL EVALUATION OF THE PATIENT WITH

CONGESTIVE HEART FAILURE; Identification of cause of C.H.F

Assess severity of C.H.F. ;

-symptoms

-ECG electrocardiogram (to assess rhythm and evidence of ischemia or infarction)

-chest x-ray (to assess heart size and pulmonary congestion)

Oral Complications;

1-infections

2-bleeding

3-petechia

4-ecchymosis

5-drug-related

a-xerostomia

b-lichnoid mucosal lesions.

Potential problems related to dental care;

1-sudden death resulting from cardiac arrest or arrythmia

2-myocardial infarction

3-CVA ( cerebro vascular accident)

4-inection

5-infective endocarditis if heart failure caused rheumatic heart disease and congenital

heart disease.

6-shortness of breath

7-drug side effects

-orthostatic hypotention (diuretics, vasodilators)

-arrythmias (digoxin, overdose)

-nausea, vomiting (digoxin, vasodilators)

-palpitations (vasodilators)

Dental management of C.H.F.;

-In poorly controlled or untreated CHF patient is not be dentally treated because those

patients are at risk of sudden death.

-In patient with treated CHF;

1-consultation with the physician

2-dental chair should be adjusted to a comfortable level partially recline position rather

than supine position

3-short appointment

4-stress reduced is profound local anesthesia

5-sedation

6-supplemental oxygen should be used.

Atherosclerosis

It is a disease of blood vessels involving the abnormal accumulation of lipids on the

walls of the arteries.

Cause; is unknown.

Impact;

Accumulations of atheromatous plaque encroach on the vascular lumen limit in the

blood flow to the affected organ.

The atheromatous plaques can act as a potential site for thrombosis (blood clot formation) and embolism.

Clinical manifestations;

1- arteriosclerotic heart disease (ASHD)

2- cerebrovascular disease 3- Peripheral vascular disease.

Oral findings;

There are no specific intraoral findings related to atherosclerosis. There are

however findings related to certain of the risk factors contributing to

atherosclerosis ex. Diabetes mellitus.

Risk factors for developing atherosclerosis;

-hyperlipidemia

-hypertension

-cigarette smoking

-diabetes

-stress

-family history

-postmenopausal state

-contraceptive pills

-obesity

-sedentary life style.

Arrhythmia Arrhythmias show electrocardiographic evidence of abnormal atrial or ventricular

electrical activity that can produce symptoms and leads to Arrhythmia.

Common symptoms;

-skipped beats

-palpitation

-dizziness

-light headedness

-dyspnea

-hypotension

-syncope

Dental evaluation of the patient with Arrhythmia;

-consult the patient s physician to ensure arrhythmia control

-minimize stress (sedation techniques)

-minimize use of epinephrine

-consider hospitalization for more stressful procedures in the higher

risk categories

-consider less complex dental treatment plans in the higher risk

categories

CONGENITAL HEART DISEASE;

great and heart is a defect in the structure of the CHD( Congenital heart defect

. Many types of heart defects exist, most of which either birth present atthat is vessels

through the flow near it, or cause blood to vessels in the heart or blood flow obstruct

heart in an abnormal pattern.

Causes:

genetic or environmental, but is The cause of congenital heart disease may be either

usually a combination of both

and maternal illness ,alcohol ,drugs ,Rubella Environmental factors include: maternal

).systemic lupus erythematosus , anddiabetes mellitus(

DENTAL MANAGEMENT OF PATIENTS WITH CONGENITAL HEART DISEASE;

1. detection by history and examination findings 2. referral for medical diagnosis and treatment 3. consultation with physician before any dental treatment is

performed 4. prophylactic antibiotic coverage before and after any dental

procedure a. patients who have just had surgery to correct congenital heart

defect coverage same as for patients with rheumatic heart disease unless special regimen is needed;

b. After consultation with physician. many patients with treated defects that have healed will no longer need coverage

5. Avoidance of dehydration in patients with oral infection 6. Bleeding time and prothrombin time tested before any surgical

procedures; consultation with physician if prolonged

7. White blood cell count; if very low. Antibiotics may be indicated for surgical procedure ; consult with physician to detection the need

Rheumatic heart disease

History of rheumatic fever during childhood or

adollescence can act as a predisposing factor

for RHD after several years.

ORAL MANIFESTATIONS • Most prominent during acute phase.

• Pharyngitis

• Increased oral temperature

• Distended neck veins and a bluish color of the skin.

DENTAL CONSIDERATIONS

- To prevent complication of infective endocarditis ,all dental

procedures should be carried under antibiotic cover.

-Amoxicillin prophylaxis-1 hour before and 6 hours after the initial

dose.

-Good oral hygiene measures ,fluoride treatment, chlorhexidine

rinses and routine cleanings to reduce harmful bacteremias.

-Proper history should be taken to identify history of rheumatic fever

during childhood.

-Suspicious cases should be referred to cardiologist for cardiac

evaluation prior to dental procedures.

-Clindamycin or erythromycin prophylaxis during dental treatment.

Elective dental treatment under physician consultation.