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Human Diseases > 17.3 Management of dental patients taking anticoagulant and antiplatelet drugs > Flashcards

17.3 Management of dental patients taking anticoagulant and antiplatelet drugs Flashcards

1
Q

Give examples of antiplatelets.

A
  • Aspirin
  • Clopidogrel
  • Prasugrel
  • Ticagrelor

NB: we never interrupt antiplatelet drugs for dental treatment.

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2
Q

What is the most common antiplatelet?

A

Aspirin
- 75mg OTC
- 150mg prescribed

We don’t stop aspirin for dental treatments

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3
Q

What is dual antiplatelet therapy?

A

For patients who have had an MI, they will be on dual therapy for 12 months- aspirin with clopidogrel/prasugrel/ticagrelor.

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4
Q

What is the ASA system?

A

Categorises the physical status of patients.
ASA 1 and 2 are treated in primary care.
Patients who have had a heart attack, stroke or ministroke in the past 3 months are classed as ASA 4.

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5
Q

Describe the action of warfarin.

A

Vitamin K anatognist
- Reduces liver’s production of clotting factors 2,7,9 and 10

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6
Q

What is the typical dose of warfarin?

A

1-10mg single dose per day (normally at night)

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7
Q

How long does warfarin take to reach its maximum effect?

A

48 hours

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8
Q

What is the normal INR for a healthy patient?

A

0.8-1.1

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9
Q

What is the typical INR target for a DVT patient?

A

2.2-2.5

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10
Q

What is the typical INR target for a pt with atrial fibrillation?

A

2.2-2.3

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11
Q

What is the typical INR target for a pt with recurrent DVT?

A

High e.g. 3 - 4

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12
Q

What is the INR limit for a dental extraction?

A

INR must be below 4
INR 4 and greater = high risk of catastrophic bleed

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13
Q

Should you ask a patient taking warfarin to change their dose for dental treatment?

A

No, never.

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14
Q

Name the 4 DOACs.

A
  • Apixaban
  • Rivaroxaban
  • Dabigatran
  • Edoxaban

Taken once or twice a day

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15
Q

Describe the action of DOACs.

A
  • Apixaban, rivaroxaban and edoxaban are all factor Xa inhibitors
  • Dabigatran is a direct thrombin inhibitor
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16
Q

What is clexane?

A

A LMWH (anticoagulant), used as a bridging therapy onto other anticoagulants.
Injected into pts admitted to hospital who are deemed high risk for a DVT.

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17
Q

Why may patients be taking anticoagulants or antiplatelets?

A
  • Previous MI
  • Previous CVA (cerebrovascular accident, stroke), TIA (transient ischaemic attack, mini stroke)
  • Atrial fibrillation
  • Ischemic heart disease
  • DVT/PE
  • Valvular heart disease, patients who have had mechanical or biological heart valve replacement
  • Factor V Leiden syndrome, genetic condition
  • Protein C deficiency, genetic
  • Protein S deficiency, genetic
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18
Q

What is ischaemic heart disease?

A

Aka. coronary heart disease.
Condition where oxygen suppply does not meet the myocardial oxygen demand.

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19
Q

Give examples of ischaemic heart disease/coronary heart diseases.

A
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20
Q

What medication will patients with stable angina carry on themselves?

A

GTN spray, used sublingually.
Glyceryl trinitrate.

21
Q

How does GTN spray work?

A

Causes vasodilation of BVs, thus increasing supply of oxygenated blood to the heart.
Can cause a headache.

22
Q

What is the difference between stable and unstable angina?

A

Stable angina: central chest pain on exertion e.g. during exercise, which responds to rest or medication

Unstable angina: chest pain at rest or with minor exertion, doesn’t respond to medication or rest

23
Q

What are STEMI and NSTEMI?

A

STEMI: myocardial infarction caused by complete occlusion of a major coronary artery

NSTEMI: myocardial infarction caused by a block in a minor artery or the partial obstruction of a major artery

Different ECG traces, treated differently.

24
Q

What diagnostic test is used to confirm an MI?

A

Troponin
- Protein produced by breakdown of cardiac muscle

25
Q

What should you do in dental practice if you suspect that a patient has an MI?

A
  • Give GTN spray
  • High flow oxygen via non-rebreathe mask at 15 litres
  • Give aspirin
  • Call 222
26
Q

How long following an MI should a patient postpone routine dental treatment?

A

6 months

27
Q

What type of anaesthesia may be indicated for previous MI patients who are anxious?

A

Sedation.
Stress can trigger cardiac events, sedation can prevent this.

28
Q

What are the 2 types of valvular heart disease?

A
  • Regurgitation: valves don’t close properly and blood leaks backwards, often occurs due to valve prolapse, can cause clots= increased stroke risk.
  • Stenosis: valve flaps become thick/stiff. Results in narrowed opening and reduced blood flow through the heart.
29
Q

What are the consequences of valvular heart disease?

A
  • Heart failure
  • Dyspnoea
  • Chest pain
  • Irregular pulse
  • Syncope
30
Q

What are the 2 types of valve replacements?

A
  • Biological: tend to be for older patients
  • Mechanical: tend to be for younger patients, require lifelong anticoagulants, last longer than biological replacement valves
31
Q

What is a TAVI?

A

Transcatheter aortic valve implantation
- May see older patients with this
- Replacement valve with cow or pig tissue
- Minimally invasive

32
Q

What is infective endocarditis?

A

A life threatneing infection of the endocardium of the heart.
Rare, affects less than 1 in every 10,000.
50% of pts have no underlying cardiac condition.

33
Q

Which guidelines are followed with regards to antibiotic prophylaxis and infective endocarditis risk in dentistry?

A

SDCEP guidance

34
Q

What patients are at a higher risk of IE?

A
  • Acquired valvular heart disease with stenosis or regurgitation
  • Hypertrophic cardiomyopathy
  • Previous IE
  • Structural congenital heat disease
  • Valve replacement
35
Q

Which sub-group of pts have been identified in the SDCEP guidance as potentially requiring antibiotic prophylaxis due to IE risk?

A
  • Prothetic valve
  • Previous IE
  • Congenital heart disease

Abx for invasive dental procedures e.g. extractions, incision and drainage of abscess, flap raising, dental implants.

  • Liaise with cariologist
  • If not recommended by cardio team then follow advice for routine management
  • Ensure consent is gained and recorded in notes
36
Q

What abx do you prescribe for a high risk IE patient before dental treatment?

A
  • 3g amoxicillin 60 minutes before procedure

Penicillin allergy:
- 600mg clindamycin (2 capsules) unless the cardiac team recommend an alternative

37
Q

Why are dental procedures considered high risk for IE?

A
  • Theory that bacteria from the mouth can enter the blood stream (bacteraemia) and colonise on the heart, causing IE
  • Research has also found that even brushing your teeth can cause the same type of bacteraemia
  • Poor evidence of what definitely causes a bacteraemia and what doesn’t
38
Q

What are the signs and symptoms of IE that you should inform a patient to look out for and visit their GP?

A

Popular SBA question!

39
Q

What BP is classed as hypertension?

A

> 140/90mmHg

40
Q

What BP is classed as severely hypertensive?

A

> 160/100mmHg

41
Q

What BP is classed as a hypertensive crisis?

A

> 200/100mmHg

42
Q

Give examples of common antihypertensive drugs.

A
  • Ramipril
  • Amlodipine
  • Lisinopril
43
Q

What does hypertension put you at a higher risk for?

A

Thrombo-embolic events e.g. stroke, MI

44
Q

What are the effects of sedative drugs on BP?

A

All sedative drugs cause hypotension.

45
Q

Which BP reading is more important?

A

Systolic (top number)

46
Q

What guidelines are followed for the management of dental patients taking anticoagulants or antiplatelets in dental practice?

A

SDCEP 2022

47
Q

What is the general advice in the SDCEP 2022 guidance?

A
  • Plan treatments for early in the day or week
  • Use appropriate local measures
  • Ensure haemostasis has been achieved before patient is discharged
48
Q

When can DOAC medication be adjusted?

A

For higher bleeding risk dental procedures e.g. surgical extraction.
Pt taking apixaban twice a day- ask them to miss morning dose and take normal evening dose at least 4 hours post extraction.

49
Q

DOAC medication interruption for dental treatment.

A

Human Diseases (47 decks)

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