CARDIOVASCULAR DISEASES

• ACQUIRED HEART DISEASE• CONGENITAL HEART DISEASES• VALVULAR HEART DISEASE • INFECTIVE ENDOCARDITIS• RHEUMATIC FEVER

AQUIRED HEART DISEASE

• ISCHAEMIC HEART DISEASE (CORONARY ARTERY DISEASE)

• ANGINA PECTORIS

• MYOCARDIAL INFARCTION

• HYPERTENSION

CORONARY (ISCHAEMIC) HEART DISEASE

CAUSE• Atherosclerosis: it is the

accumulation of lipids in the arterial walls due to variety of factors.

• It can lead to vascular thrombosis (clots) and result in embolism

ATHEROSCLEROSIS

CORONARY (ISCHAEMIC) HEART DISEASE

Clinical features:• Cardiac ischaemia in itself is

symptomless. Its presence is manifested only by its dramatic complications namely:-

• ANGINA PECTORIS• MYOCARDIAL INFARCTION• IHD often comes without warning or

history of heart disease.

CORONARY (ISCHAEMIC) HEART DISEASE

Dental considerations:• Stress, anxiety, exertion or pain can

provoke angina.• Patient should receive dental care in

short, minimally stressful appointments.

• Patients are best treated in the late mornings.

• Effective painless local anesthesia is essential.

CORONARY (ISCHAEMIC) HEART DISEASE

Dental considerations…..:• Confirm negative aspiration before

injection.• Vasoconstrictor-containing local

anesthetics should not be given to patients taking B-blockers.

ANGINA PECTORIS

• It is a severe paroxysmal chest pain caused due to higher myocardial oxygen demand.

Cause: ruptured coronary atherosclerotic plaques.

ANGINA PECTORIS

Clinical features:• Strangling, or tightness, heaviness,

compression of the chest sometimes radiating to the left arm or jaw.

• Precipitated by physical exertion especially in cold weather and emotional stress.

• Pain is relieved by rest. (unlike AMI)

ANGINA PECTORIS

SIGNS & SYMPTOMS

ANGINA PECTORIS

Dental considerations:• Pre-operative glyceryl trinitrate &

oral sedation with timazepam are adviced.

• Dental care should carried out with minimal anxiety & monitor oxygen saturation, BP & pulse.

• Effective local anesthesia is essential.

• Ready access to medical help, oxygen & nitroglycerin is essential

ANGINA PECTORIS

Management of acute attack during Dental treatment :

• Stop the treatment immediately.• Give 0.3-0.6mg sublingual glyceryl

trinitrate.• Give oxygen & seat the patient upright.• Monitor vital signs.• Pain should be relieved in 2-3 minutes.

Patient should then rest & be accompanied home

ANGINA PECTORIS

Management of acute attack during Dental treatment :

• Pain that persists after 3 doses of nitroglycerin given every 5 minutes & that lasts for more than 15-20 minutes or that is associated with nausea, vomiting, syncope or hypertension is highly suggestive of MI

• Continue oxygen & chew 300 mg aspirin & insert IV cannula.

• Nitrous oxide/oxygen or 5-10mg of morphine sulphate IV to relieve pain & anxiety

MYOCARDIAL INFARCTION(CORONARY THROMBOSIS

OR HEART ATTACK)Clinical features:• Sometimes it is preceded by angina.• Strangling, or tightness, heaviness,

compression of the chest sometimes radiating to the left arm or jaw.

• Precipitated by physical exertion and emotional stress.

• Pain is NOT relieved by rest.• Persist for a few hours if death does not

supervene.

MYOCARDIAL INFARCTION(CORONARY THROMBOSIS

OR HEART ATTACK)Clinical features…:• The pain of MI may sometimes start

at rest and is not relieved by nitrates.

• Vomiting, facial pallor, sweating, restlessness, apprehension are common.

• Restlessness, cough , loss of consciousness may also occur.

MYOCARDIAL INFARCTION(CORONARY THROMBOSIS

OR HEART ATTACK)Dental considerations:• Dental intervention can precipitate

dysrhythmias or aggravate cardiac ischaemia especially patients within 6 months of an MI attack (ASA IV).

• Simple emergency dental treatment under LA can be given but opinion of the physician should be sought first.

• In asymptomatic patients with previous older MI ( >6months & <12 months), pain & anxiety should be minimized.

• In symptomatic patients but older MI (>12 months), elective dental care can be carried out safely, but pain & anxiety should be minimized.

MYOCARDIAL INFARCTION(CORONARY THROMBOSIS

OR HEART ATTACK)Dental considerations…..:• Monitor BP, ECG, pulse & oxygen saturation.• Dental care should be stopped if there is

/are: - chest pain - dyspnoea - rise in HR>40beats/minute - rise in ST segment displacement > 0.2mv on

ECG - dysrhythmias - rise in systolic BP >20mmHg• There should be ready access to oxygen &

medical help

MANAGEMENT OF MI AS AN EMERGENCY IN DENTAL

SURGERY

• Assess the situation : shake the person & ask in a loud voice “Are you OK?” If there is no response-

• Call for medical help• Begin basic life support & CPR &

continue until help arrives.

CARDIO PULMONARY RESUSCITATION

EXTERNAL CARDIAC MASSAGE

HYPERTENSION

• When either or both systolic or diastolic pressure are persistently raised, & on remeasurement ,

with systolic pressure >140 & diastolic >90 mm Hg, it is generally regarded as

hypertension.

Features of advanced hypertension

SYMPTOMS• Headaches• Visual

disorders• Tinnitus• Dizziness• Angina

SIGNS• Hypertension

on testing• Retinal

changes • Left

ventricular hypertrophy

• Proteinuria• hematuria

ASA grading & dental management considerations for

hypertension BP (mmHg) systolic,diastolic

ASA grade

Hypertension stage

Key considerations

<140,<90

140-159,90-99

160-179,95-109

>180,>110

I

II

III

IV

-

1

2

3

•Routine dental care

•Recheck BP before starting. Routine dental care

•Recheck BP before starting .Medical advice before routine dental care. Restrict use of epinephrine

•Recheck BP after 5 mins. quiet rest. Only emergency care until BP controlled. Medical advice before routine dental care. Avoid vasoconstrictor.

HYPERTENSIONDental considerations:• BP should be controlled before elective dental

treatment.• Appointments should be short & minimally

stressful.• Avoid anxiety & pain.• Pre-operative assurance is important. sedation with

10mg temazipam may be helpful.• Patients are best treated in the late morning.• Continuous BP monitoring is indicated.• Do not raise the patient suddenly from the supine

position as it may cause postural hypotension & loss of consciousness.

• Some NSAIDS can reduce the efficacy of anti hypertensive agents.

HYPERTENSION

Dental considerations….:• Adequate analgesia must be

provided.• confirm negative aspiration• Vasoconstrictor containing LA

should not be given in large doses to patients taking beta blockers.

• Epinephrine effect may be reversed in patients taking beta blockers causing vasodilatation.

CONGENITAL HEART DISEASE

Clinical features• Most striking feature: CYANOSIS• Shunting of deoxygenated blood from the

right ventricle directly into the left side of the heart & systemic circulation leads to chronic hypoxemia.

• Chronic hypoxemia causes severely impaired development & often gross clubbing of fingers & toes.

• Hemorrhagic or thrombotic tendencies may develop.

CLUBBING

CONGENITAL HEART DISEASE

Dental considerations:• Confirm negative aspiration before injection

of LA.• Adequate analgesia must be provided.• Oral abnormalities associated are:• Delayed eruption of both dentitions, greater

frequency of positional anomalies, enamel hypoplasia, greater caries & periodontal disease activity.

• Patient with congenital cardiac defects are often liable to infective endocarditis & other complications.

RHEUMATIC FEVER• It is a disease which sometimes follows a sore

throat caused by certain strains of beta-haemolytic streptoccoci (strep.pyogenes)

Clinical features• A sore throat maybe followed after 3 weeks by an

acute febrile illness with pain flitting from one joint to another.

• Usually resolves within 6-12 weeks• Other effects: cerebral involvement causing

spasmodic involuntary movements (sydenham’s chorea), a characteristic rash (erythema marginatum), lung involvement, subcutaneous nodules usually around the elbows.

• Essential features of c/c rheumatic heart disease are fibrotic stiffening & distortion of heart valves often causing mitral stenosis.

ERYTHEMA MARGINATUM

RHEUMATIC FEVER

Dental considerations:• Acute rheumatic fever patients are

exceedingly unlikely to be seen during an attack, but emergency dental treatment maybe necessary.

• No special precautions should be necessary as there appears to be little risk of infective endocarditis at this stage.

• Treatment can be done under LA in consultation with the physician.

INFECTIVE ENDOCARDITIS

• It is a rare but dangerous, potentially lethal infection predominantly affecting the heart valves.

• Causative organisms: viridans streptococci such as strep.mutans & S.sanguis

• It results from two main predisposing factors-bacteraemia and a cardiac lesion where there is turbulent blood flow.

INFECTIVE ENDOCARDITIS

Clinical features:• In a previously healthy patient who

acquires endocarditis,3-4 weeks after dental operation there is insidious onset of low fever & malaise. palor, café-au-lait pigmentation of the skin, joint pains, hepatosplenomegaly are typical.

• Main effects include progressive heart damage, infection or embolic damage of many organs especially kidneys.

PROPHYLAXIS OF INFECTIVE ENDOCARDITISSituation Medication Dosage

Standard prophylaxis AmoxicillinAdult-2 gm Children-50 mg/kg orally 1 hr before procedure

Unable to take oral medication Ampicillin

Adult-2gm IM/IV Children-30 mg/kg IM/V30min before procedure

Allergic to pencillin

Clindamycin

OR Cephalexin or cefadroxil

OR Azithromycin or clarithromycin

Adult-600mg, children-20 mg/kg orally 1 hour before procedure Adult-2 gm children-50mg/kg orally 1 hr before procedure Adult -500mg, children-15mg/kg Orally 1 hr before procedure

Allergic to pencilin &unable to take oral medication

ClindamycinOR cefazolin

Adult-600mg, children-20mg/kg IV with 30min before procedureAdult-1gm, children-25mg/kg IM/IV with 30min before procedure

HEART FAILURE

• Heart failure is when the pumping action of the heart is insufficient to meet the body’s demand.

• Lack of tissue & organ perfusion results.

• Most common cause :IHD

HEART FAILURE

Clinical features• Left sided heart failure: lying down

worsens pulmonary congestion,oedema, dyspnoea, makes respiration less effective ,cyanosis, coughing, pink frothy sputum

• Right sided heart failure: congestion of systemic & portal venous system causing peripheral oedema ,fatigue, hepatomegaly&ascites.

HEART FAILURE

Dental considerations:• It is dangerous to lay any person with left sided

heart failure supine. dental chair should be kept in a partially reclining or erect position.

• Dental treatment may precipitate dysrhythmias, angina & heart failure.

• Mild controlled cardiac failure: routine dental care can usually be provided

• Anxiety & pain must be minimised• Poorly controlled or uncontrolled cardiac

failure: attain medical attention before dental treatment.

• Elective dental treatment should be delayed until the condition has been stabilized medically.

• Emergency dental care with analgesics & antibiotics.

HEART FAILUREDental considerations:• Late morning appointments are recommended.• Confirm negative aspiration before injection.• Vasoconstrictor-containing local anesthetics should

not be given to patients taking B-blockers.• Effective analgesia must be provided.• Diuretic drugs may cause orthostatic

hypotension.thus patient should be raised slowly to upright position.

• NSAIDs other than aspirin should be avoided in those patients taking ACE inhibitors as they increase risk of renal damage.

• Monitor BP & ECG especially in patients taking digoxin.

• Drugs that can complicate dental treatment: Digitalis - (vomiting) ACE inhibitors - (coughing) itraconazole - (cardiac failure)

CARDIMYOPATHIES

• It is a disease of the heart muscle commonly caused by alcoholism

Clinical features• Frequently there are no symptoms

until complications develop.• Alcoholic effects on the heart:

precordial pain, palpitations, dysrhythmias, pulmonary hypertension, right ventricular failure.

CARDIMYOPATHIESDental considerations• Heart muscle enlargement may restrict the

movement of the mitral valve leaflets leading to valvular insufficiency & regurgitation. Hence patient is susceptible to Infective endocarditis.Antibiotic prophylaxis must be given.

• Use epinephrine only in limited amounts• Nitroglycerines or similar drugs are

contraindicated• If angina pectoris, MI or fibrillation occurs,

oxygen should be administered & CPR must be given. Activate the medical emergency response system

DYSRHYTHMIAS

Clinical features• They are disturbances of the heart rhythm

or gross disturbances of heart rate resulting from disturbed cardiac impulse generation or conduction.

• Dysrhythmias may arise from cardiac, respiratory autonomic or endocrine disease, fever, hypoxia or electrolyte disturbances.

• May be symptomless.• Reduce cardiac efficiency & cardiac output.• Causes dyspnoea, palpitations & syncope

DYSRHYTHMIAS

Dental considerations• Appointments must be made for late

mornings or early afternoon.• Confirm negative aspiration before injection.• Vasoconstrictor-containing local anesthetics

should not be given to patients taking B-blockers.

• Effective analgesia must be provided.• Epinephrine & other vasoconstrictors should

be used with caution (lower dose & careful monitoring) in patients with pacemakers & implanted cardioverter,defibrillators.

THYROID-RELATED HEART DISEASE

Clinical features• Untreated thyrotoxicosis:

tachycardia, dysrhythmias leading to cardiac failure & MI especially in elderly.

• Hypothyroidism: slows heart rate• Myxoedema: hypercholestremia

associated with atherosclerosis.

THYROID-RELATED HEART DISEASE

Dental considerations• Sedation is desirable as they have

heightened anxiety, hyperexcitabilty & excessive sympathetic activity.

• Hypothyroidism patients with IHD are at increased risk in the dental surgery

• In severe myxoedema diazepam & other CNS depressants can precipitate coma.

• Confirm negative aspiration before injection.• Vasoconstrictor-containing local anesthetics

should not be given to patients taking B-blockers.

• Effective analgesia must be provided.

PULMONARY HEART DISEASE

Clinical features• Right ventricular hypertrophy leads

to right sided failure with systemic venous congestion & persistent hypoxia.

• In early stages: dyspnoea, chronic cough, wheezing, often cyanosis

PULMONARY HEART DISEASE

Dental considerations• Ipratropium bromide can cause dry

mouthContraindicated drugs:• Diazepam or midazolam • IV barbituarates-due to their respiratory depressant

effects