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CARDIOVASCULAR DISEASES
ACQUIRED HEART DISEASE
CONGENITAL HEART DISEASES
VALVULAR HEART DISEASE INFECTIVE ENDOCARDITIS
RHEUMATIC FEVER
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AQUIRED HEART DISEASE
ISCHAEMIC HEART DISEASE(CORONARY ARTERY DISEASE)
ANGINA PECTORIS
MYOCARDIAL INFARCTION
HYPERTENSION
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CORONARY (ISCHAEMIC)
HEART DISEASECAUSE
Atherosclerosis: it is the accumulation of
lipids in the arterial walls due to variety offactors.
It can lead to vascular thrombosis (clots)and result in embolism
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ATHEROSCLEROSIS
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CORONARY (ISCHAEMIC)
HEART DISEASEClinical features:
Cardiac ischaemia in itself is symptomless.
Its presence is manifested only by itsdramatic complications namely:-
ANGINA PECTORIS
MYOCARDIAL INFARCTION IHD often comes without warning or
history of heart disease.
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CORONARY (ISCHAEMIC)
HEART DISEASEDental 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.
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CORONARY (ISCHAEMIC)
HEART DISEASEDental considerations..:
Confirm negative aspiration before
injection. Vasoconstrictor-containing local
anesthetics should not be given to patientstaking B-blockers.
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ANGINA PECTORIS
It is a severe paroxysmal chest pain caused
due to higher myocardial oxygen demand.Cause: ruptured coronary atherosclerotic
plaques.
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ANGINA PECTORIS
Clinical features:
Strangling, or tightness, heaviness,
compression of the chest sometimesradiating to the left arm or jaw.
Precipitated by physical exertion especiallyin cold weather and emotional stress.
Pain is relieved by rest. (unlike AMI)
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ANGINA PECTORIS
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SIGNS & SYMPTOMS
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ANGINA PECTORIS
Dental considerations:
Pre-operative glyceryl trinitrate & oralsedation with timazepam are adviced.
Dental care should carried out withminimal anxiety & monitor oxygensaturation, BP & pulse.
Effective local anesthesia is essential. Ready access to medical help, oxygen &
nitroglycerin is essential
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ANGINA PECTORIS
Management of acute attack during Dentaltreatment :
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. Patientshould then rest & be accompanied home
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ANGINA PECTORIS
Management of acute attack during Dentaltreatment :
Pain that persists after 3 doses of nitroglyceringiven every 5 minutes & that lasts for more than15-20 minutes or that is associated with nausea,
vomiting, syncope or hypertension is highlysuggestive of MI
Continue oxygen & chew 300 mg aspirin & insert
IV cannula. Nitrous oxide/oxygen or 5-10mg of morphinesulphate IV to relieve pain & anxiety
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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 armor jaw.
Precipitated by physical exertion and emotionalstress.
Pain is NOT relieved by rest. Persist for a few hours if death does not
supervene.
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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 consciousnessmay also occur.
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MYOCARDIAL INFARCTION(CORONARY THROMBOSIS OR
HEART ATTACK)Dental considerations: Dental intervention can precipitate dysrhythmias or
aggravate cardiac ischaemia especially patientswithin 6 months of an MI attack (ASA IV).
Simple emergency dental treatment under LA canbe given but opinion of the physician should besought first.
In asymptomatic patients with previous older MI
( >6months & 12
months), elective dental care can be carried outsafely, but pain & anxiety should be minimized.
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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
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MANAGEMENT OF MI AS ANEMERGENCY IN DENTAL
SURGERY
Assess the situation : shake the person &
ask in a loud voice Are you OK? If thereis no response-
Call for medical help
Begin basic life support & CPR& continueuntil help arrives.
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CARDIO PULMONARYRESUSCITATION
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EXTERNAL CARDIAC MASSAGE
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HYPERTENSION
When either or both systolic or diastolicpressure are persistently raised, & onremeasurement ,
with systolic pressure >140 &
diastolic >90 mm Hg,
it is generally regarded as hypertension.
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Features of advanced hypertension
SYMPTOMS
Headaches
Visual disorders Tinnitus
Dizziness
Angina
SIGNS
Hypertension on
testing Retinal changes
Left ventricular
hypertrophy Proteinuria
hematuria
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ASA grading & dental management considerations for hypertension
BP (mmHg)
systolic,diastolic
ASA
grade
Hypertension
stage
Key considerations
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. quietrest. Only emergency care until
BP controlled. Medical advice
before routine dental care. Avoid
vasoconstrictor.
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HYPERTENSIONDental considerations:
BP should be controlledbefore elective dental treatment.
Appointments should be short & minimally stressful.
Avoid anxiety & pain.
Pre-operative assurance is important. sedation with 10mgtemazipam 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 positionas it may cause postural hypotension & loss ofconsciousness.
Some NSAIDS can reduce the efficacy of anti hypertensiveagents.
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HYPERTENSION
Dental considerations.:
Adequate analgesia must be provided.
confirm negative aspiration Vasoconstrictor containing LA should notbe given in large doses to patients takingbeta blockers.
Epinephrine effect may be reversed inpatients taking beta blockers causingvasodilatation.
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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 impaireddevelopment & often gross clubbing of fingers &
toes. Hemorrhagic or thrombotic tendencies may
develop.
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CLUBBING
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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, enamelhypoplasia, greater caries & periodontal disease
activity.
Patient with congenital cardiac defects are oftenliable to infective endocarditis & other
complications.
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RHEUMATIC FEVER
It is a disease which sometimes follows a sore throat causedby certain strains ofbeta-haemolytic streptoccoci(strep.pyogenes)
Clinical features
A sore throat maybe followed after 3 weeks by an acutefebrile illness with pain flitting from one joint to another. Usually resolves within 6-12 weeks Other effects: cerebral involvement causing spasmodic
involuntary movements (sydenhams chorea), a
characteristic rash (erythema marginatum), lunginvolvement, subcutaneous nodules usually around theelbows.
Essential features of c/c rheumatic heart disease are fibroticstiffening & distortion of heart valves often causing mitralstenosis.
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ERYTHEMA MARGINATUM
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RHEUMATIC FEVER
Dental considerations:
Acute rheumatic fever patients are exceedinglyunlikely to be seen during an attack, but
emergency dental treatment maybe necessary.
No special precautions should be necessary asthere appears to be little risk of infectiveendocarditis at this stage.
Treatment can be done under LA in consultationwith the physician.
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INFECTIVE ENDOCARDITIS
It is a rare but dangerous, potentiallylethal infection predominantly affectingthe heart valves.
Causative organisms:viridans streptococcisuch as strep.mutans &S.sanguis
It results from two main predisposingfactors-bacteraemia and a cardiac lesionwhere there is turbulent blood flow.
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INFECTIVE ENDOCARDITIS
Clinical features:
In a previously healthy patient who acquiresendocarditis,3-4 weeks after dental operation
there is insidious onset of low fever & malaise.palor, caf-au-lait pigmentation of the skin, jointpains, hepatosplenomegalyare typical.
Main effects include progressive heart damage,infection or embolic damage of many organsespecially kidneys.
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PROPHYLAXIS OF INFECTIVE ENDOCARDITIS
Situation Medication Dosage
Standard prophylaxis Amoxicillin
Adult-2 gm
Children-50 mg/kg orally 1 hr before
procedure
Unable to take oral
medicationAmpicillin
Adult-2gm IM/IV
Children-30 mg/kgIM/V
30min before procedure
Allergic to pencillin
Clindamycin
OR
Cephalexin orcefadroxil
OR
Azithromycin orclarithromycin
Adult-600mg, children-20 mg/kg orally 1
hour before procedure
Adult-2 gm children-50mg/kg orally 1
hrbefore procedure
Adult -500mg, children-15mg/kg Orally
1 hr before procedure
Allergic to pencilin &unable
to take oral medication
Clindamycin
OR
cefazolin
Adult-600mg, children-20mg/kg IV with
30min before procedure
Adult-1gm, children-25mg/kg IM/IV
with 30min before procedure
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HEART FAILURE
Heart failure is when the pumping actionof the heart is insufficient to meet thebodys demand.
Lack of tissue & organ perfusion results.
Most common cause :IHD
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HEART FAILURE
Clinical features
Left sided heart failure: lying down worsenspulmonary congestion,oedema, dyspnoea,
makes respiration less effective ,cyanosis,coughing, pink frothy sputum
Right sided heart failure: congestion ofsystemic & portal venous system causingperipheral oedema ,fatigue,hepatomegaly&ascites.
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HEART FAILURE
Dental considerations: It is dangerous to lay any person with left sided heart
failure supine. dental chair should be kept in apartially reclining or erect position.
Dental treatment may precipitate dysrhythmias,angina & heart failure.
Mild controlled cardiac failure: routine dental care canusually 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 thecondition has been stabilized medically.
Emergency dental care with analgesics & antibiotics.
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HEART FAILURED
ental 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)
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CARDIMYOPATHIES
It is a disease of the heart musclecommonly caused by alcoholism
Clinical features
Frequently there are no symptoms untilcomplications develop.
Alcoholic effects on the heart: precordial
pain, palpitations, dysrhythmias,pulmonary hypertension, right ventricularfailure.
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CARDIMYOPATHIESDental considerations
Heart muscle enlargement may restrict themovement of the mitral valve leaflets leading to
valvular insufficiency & regurgitation. Hence patient
is susceptible to Infective endocarditis.Antibioticprophylaxis must be given.
Use epinephrine only in limited amounts
Nitroglycerines or similar drugs are contraindicated
If angina pectoris, MI or fibrillation occurs, oxygenshould be administered & CPRmust be given.
Activate the medical emergency response system
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DYSRHYTHMIAS
Clinical features
They are disturbances of the heart rhythm or grossdisturbances of heart rate resulting from disturbed
cardiac impulse generation or conduction. Dysrhythmias may arise from cardiac, respiratory
autonomic or endocrine disease, fever, hypoxia orelectrolyte disturbances.
May be symptomless.
Reduce cardiac efficiency & cardiac output.
Causes dyspnoea, palpitations & syncope
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DYSRHYTHMIAS
Dental considerations
Appointments must be made for late mornings orearly afternoon.
Confirm negative aspiration before injection.
Vasoconstrictor-containing local anesthetics shouldnot be given to patients taking B-blockers.
Effective analgesia must be provided. Epinephrine & other vasoconstrictors should be
used with caution (lower dose & carefulmonitoring) in patients with pacemakers &
implanted cardioverter,defibrillators.
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THYROID-RELATED HEARTDISEASE
Clinical features
Untreated thyrotoxicosis: tachycardia,
dysrhythmias leading to cardiac failure &MI especially in elderly.
Hypothyroidism: slows heart rate
Myxoedema: hypercholestremiaassociated with atherosclerosis.
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THYROID-RELATED HEARTDISEASE
Dental considerations
Sedation is desirable as they have heightenedanxiety, hyperexcitabilty & excessive sympathetic
activity. Hypothyroidism patients with IHD are at increased
riskin the dental surgery
In severe myxoedema diazepam & other CNS
depressants can precipitate coma. Confirm negative aspiration before injection.
Vasoconstrictor-containing local anesthetics shouldnot be given to patients taking B-blockers.
Effective analgesia must be provided.
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PULMONARY HEART DISEASE
Clinical features
Right ventricular hypertrophy leads to
right sided failure with systemic venouscongestion & persistent hypoxia.
In early stages: dyspnoea, chronic cough,wheezing, often cyanosis
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PULMONARY HEART DISEASE
Dental considerations
Ipratropium bromide can cause dry mouth
Contraindicated drugs: Diazepam or midazolam
IV barbituarates
-due to their respiratory depressant effects
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