CVD II - HF and Valv HD Flashcards

1
Q

what are the functions of the SA node

A
  • primary pacemaker
  • regulates atrial function
  • produces P wave - atrial depolarization
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2
Q

what is the function of the AV node

A
  • regulates atrial impulses entering ventricles
  • slows conduction rate of SA generated impulses
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3
Q

what is happening during the QRS complex

A

simulataneous depolarization of the ventricles

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4
Q

what happens during the T wave

A

repolarization of the ventricles

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5
Q

disruption of the electrical impulse generation or conduction in the heart leads to what abnormal cardiac functions

A
  • formation of abnormal impulse
  • increased impulse formation
  • enhanced or abnormal impulse formation
  • delayed depolarization
  • re-excitation of the heart after refractory period
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6
Q

disruption of the electrical impulse generation or conduction in the head may be due to an area of:

A
  • infarction
  • ischemia
  • electrolyte imbalance
  • medication
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7
Q

the most common cause of sudden cardiac death is:

A

ventricular fibrillation

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8
Q

what are the causes of arrhythmias

A
  • cardiovascular disorders
  • pulmonary disorder
  • autonomic disorder
  • hyperthyroidism
  • drugs
  • electrolyte imbalance
  • anxiety and anger
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9
Q

what cardiovascular disorders cause arrhythmias

A
  • MI
  • mitral stenosis
  • valvular disease
  • ischemic heart disease
  • congestive heart failure
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10
Q

what pulmonary disorders cause arrhythmias

A

-pneumonia
- obstructive lung disease

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11
Q

what drugs cause arrhythmias

A
  • epinephrine
  • alcohol
  • digitalis
  • morphine
  • beta blockers
  • tricyclic antidepressants
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12
Q

what are the supraventricular arrhythmias

A
  • sinus nodal disturbances: sinus arrhythmias, sinus tachycardia, sinus bradycardia
  • disturbances of atrial rhythm: premature atrial complexes, atrial flutter
  • ventricular tachycardia
  • ventricular fibrillation
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13
Q

what qualifies bradycardia

A

less than 60 beats/min

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14
Q

what qualifies tachycardia

A

greater than 100 bpm

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15
Q

what are the symptoms of arrhythmias

A
  • palpitations, fatigue
  • dizziness, syncope, angina
  • CHF
  • SOB
  • orthopnea
  • peripheral edema
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16
Q

describe atrial fibrillation

A
  • most common arrhythmia
  • rapid uncontrolled atrial activity
  • irregularly irregular rhythm
  • risk of arterial clot formation: embolism and stroke
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17
Q

what is a heart block

A
  • impulse is partially or completely blocked
  • prolonged or no conduction
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18
Q

what are the degrees of heart block and describe each

A
  • first degree: longer conduction time
  • second degree: Mobitz I: more prolonged and no P wave. Mobitz II: repetitive or occasional sudden blocks without previous prolonged conduction time
  • third degree: no impulses- complete block. indication for pacemaker
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19
Q

describe ventricular arrhythmias

A
  • premature ventricular complexes (PVCs)
  • common
  • abnormal QRS complex + pause
  • increased risk of death if patients have underlying CVD ( heart failure, MI, valvular heart disease)
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20
Q

describe ventricular tachycardia

A
  • if more than 3 consecutive PVS at 100 bpm
  • if lasts for more than 30 seconds, requires termination
  • torsades de pointes- potentially life threatening
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21
Q

describe ventricular flutter and fibrillation

A
  • lethal
  • consequence of ischemic heart disease
  • cardiac contraction is not sequential, chaotic
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22
Q

is there tx for arryhthmias

A

no just aimed at managing symptoms

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23
Q

what are the SE for sodium channel blockers

A
  • bitter taste
  • dry mouth
  • oral ulcerations
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24
Q

what are the SE of beta blockers

A

taste changes, lichenoid reactions

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25
Q

what are the SE of potassium channel blockers

A
  • taste abberation
  • lichenoid reactions
  • angioedema
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26
Q

what are the slow calcium channel blockers

A

gingival overgrowth

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27
Q

what are the oral anticoagulants

A
  • clopidogrel (Plavix): inhibits platelet agglutination. platelet count not affected
  • ASA (aspirin 81mg- low dose): inhibits platelet agglutination, platelet count not affected
  • warfarin: vitamin K antagonist, INR monitoring, highly variable
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28
Q

what do anticoagulants do for arrythmias

A

lower the risks of complications but dont control the arrythmias

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29
Q

what creates opportunities for atherosclerosis and blood clotting

A

turbulent blood flow and failure to move blood from the atria to the ventricles

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30
Q

what is the therapy for A-fib

A

to control ventricular rate
- diltiazem ( calcium channel blocker) slows AV nodal conduction as too many electrical signals coming from the fibrillating atria are hitting the AV node per unit time

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31
Q

what are the direct oral anticoagulants

A
  • direct thrombin inhibitor: pradaxa, reversal agent available
  • direct factor Xa inhibitors: Xarelto, Eliquis, Savaysa, reversal agents not available
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32
Q

never stop anticoagulation for dental treatment unless:

A

extensive surgery

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33
Q

what are the non pharmacologic treatments for arrhythmias

A
  • pacemakers
  • implanted cardioverter defribrillator: sets pace and shocks
  • surgery: tissue resection, cardiac ablation, surgery to address underlying cause such as stenosis
  • electrocardioversion and defribrillation: emergency situations, terminate persistant, refractory or lethal arrhythmias
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34
Q

what are the dental treatment considerations with arrhythmias

A
  • what type of arrythmia
  • assess comorbidities - CVD and pulmonary
  • ROS: palpitations, chest pain, dizziness, shortness of breath, syncope
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35
Q

what are the causes of heart failure

A
  • decreased pumping action
  • systemic fluid congestion
  • failure of vital organs
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36
Q

what are the results of right side HF

A
  • pulmonary edema
  • coughing
  • peripheral edema
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37
Q

what are the results of left side HF

A
  • affects all organ systems; decreased kidney function contributes to fluid retention
  • pulmonary edema
  • coughing
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38
Q

what is the pathophysiology of heart failure

A
  • increased workload -> problems with cardiac muscle
  • left ventricle typically fails first- can lead to right ventricular failure
39
Q

what are the features of heart failure

A
  • reduced CO
  • decreased perfusion
  • blood backed up in pulmonary vessels- SOB, foamy cough, pulmonary
  • pulmonary hypertension
  • increased workload on R ventricle
  • volume overload: venous congestion, peripheral edema, ascites
  • ventricles dilate to try to compensate: activate of RAAS and neurohormonal responses to compensate
40
Q

what is the equation for ejection fraction

A

(blood volume pumped out/blood volume in chamber) x 100

41
Q

what should you consider in past MI greater than 1 month

A
  • severity of cardiac status and comorbidities
  • ejection fraction can measure the degree of heart failure
  • appropriate management protocols
42
Q

what does EF measure

A

percentage of blood that leaves the left ventricle after contraction

43
Q

describe EF 55%-70%

A
  • pumping ability of the heart: normal
  • level of heart failure/effect on pumping: heart function may be normal or heart failure with preserved EF
44
Q

describe EF 40%-54%

A
  • pumping ability of the heart: slightly blow normal
  • level of heart failure/effect on pumping: less blood is available so less blood is ejected from the ventricles. there is a lower than normal amount of oxygen rich blood available to the rest of the body
  • may not have symptoms
45
Q

describe EF 35%-39%

A
  • pumping ability of the heart: moderately below normal
  • level of heart failure/effect on pumping: mild heart failure with reduced EF
46
Q

describe EF less than 35%

A

-pumping ability of the heart: severely below normal
- level of heart failure/effect on pumping: moderate to severe HF. severe HF increases the risk of life threatening heartbeats and cardiac dyssynchrony

47
Q

what are the types of heart failure and what is in each category

A
  • systolic failure: reduced left ventricular EF
  • diastolic failure: normal left ventricular EF
  • cardiac abnormalities: valvular disease, arrhythmias, myocardial necrosis
  • decompensation: inability to compensate, increased peripheral blood flow, increased metabolic needs
48
Q

what are the predisposing factors for HF

A
  • acute CVD: MI
  • chronic CVD: HTN, coronary artery disease, arrythmia
49
Q

what are the results/ signs and ssymptoms of HF

A
  • volume overload
  • inadequate perfusion
50
Q

what are the complications of HF

A
  • cardiac arrest
  • MI
  • stroke
51
Q

what are the signs of HF

A
  • rapid , shallow breathing
  • inspiratory rales (crackles)
  • increased HR
  • distended jugular veins
  • peripheral edema
  • ascites
  • cyanosis
  • weight gain
  • clubbing of fingers
52
Q

what are the symptoms of HF

A
  • fatigue and weakness
  • orthopnea - shortness of breath (dyspnea) in recumbent position
  • exercise intolerance
  • muscular fatigue
  • weight gain
  • GI distress- nausea, vomiting and constipation
53
Q

what are the therapies for stages of HF

A
  • stage A: ACE inhibitors
  • stage B: ACE inhibitors, beta blockers
  • stage C: diuretics for fluid retention, ACE inhibitors, beta blockers
54
Q

what is the medical management for HF

A
  • pharmacologic and non-pharmacologic
  • patients with severe HF may require cardiac transplantation
  • intermediate therapy is the LVAD
55
Q

in most cases of HF, the dentist will need to obtain a medical consultation with the patients cardiologist to determine:

A
  • the patients physical status
  • lab test results
  • level of control
  • compliance with medications and recommendations
  • overall stability
56
Q

what are the major issues for patients with symptomatic HF

A
  • symptoms can abruptly worsen
  • acute failure
  • fatal arrhythmia
  • stroke
  • MI
57
Q

describe class I HF patients

A
  • physical activity: no limitations
  • no dyspnea, fatigue or palpitations with physical activity
58
Q

describe class II HF patients

A
  • physical activity: slight limitation
  • fatigue, dyspnea, palpitations present with physical activity
59
Q

describe class III HF patients

A
  • physical activity: marked limitation
  • lesss than normal physical activity results in symptoms. comfortable at rest
60
Q

describe class IV HF patients

A
  • physical activity: severely limited, exacerabates symptoms
  • symptoms are present at rest
61
Q

how do we treat each class of HF patients

A
  • class I: routine dental care OK
  • class II: med consult required, routine dental care likely OK
  • class III and IV: consider referral to specialized care
62
Q

what are the low level interventions for medical risk categories of dental treatment

A
  • health/medical eval
  • exams
  • prophy
  • radiographs
  • optical oral scans
  • alginate impressions
63
Q

what are the moderate level interventions for medical risk categories of dental treatment

A
  • SRP
  • simple restorative procedures 1-2 teeth
  • simple extractions 1-2 teeth
  • restorative impressions needing retractions and longer setting times
64
Q

what are the high level interventions for medical risk categories of dental treatment

A
  • complex restorative procedures on more than 2 teeth
  • multiple extractions
  • surgical extractions
  • implants placement
  • full arch impressions
  • dental care under general anesthesia
65
Q

risk for time of procedure correlates with

A

risk cateogry

66
Q

what are some additional HF dental management considerations

A
  • short, stress free appointments
  • chair position: HF pt may not be able to tolerate supine position bc pulmonary edema
  • if patient is taking digitalis glycoside (digoxin) - positive inotrope: avoid epi because increases the risk for arrhythmia
67
Q

are there oral manifestations related to HF

A

no

68
Q

many of the drugs used to manage HF can cause:

A

dry mouth, altered taste and oral ulcerative lesions

69
Q

what is valvular disease

A

compromised function of the heart valves

70
Q

what are the AV valves

A

tricuspid and mitral

71
Q

what are the semilunar valves

A

aortic and pulmonary

72
Q

what is valvular stenosis

A

do not open properly

73
Q

what is valvular insufficiency and what is it associated with

A
  • do not close properly
  • associated with regurgitation
74
Q

describe fibrosis in valvular disease

A

stiff, sclerosis, stenosis causing either stenosis or insufficiency

75
Q

what is myxomatous degeneration and what does it cause

A
  • benign loose CT tumorous changes where valves become floppy, prolapse, regurgitation
  • causes insufficiency
76
Q

what are the risk factors for valvular heart disease

A
  • conditions: high BP, high cholesterol, Diabetes, rheumatic fever, more than one CVD
  • behavioral: unhealthy diet, physical inactivity, obesity, too much alcohol, tobacco use, stress
  • family hx: genetics, becoming older, ethnicity
  • calcifications
  • congenital defects
  • infective endocarditis
77
Q

why is high BP a risk factor for valvular heart disease

A
  • stiffens vessels which reduce blood flow
  • risk for stroke, kidney disease and dementia
78
Q

why is diabetes a risk factor for valvular heart disease

A

unstable glucose affects healthy myocardium function, angiopathy

79
Q

what parts of unhealthy diet are risk factors for valvular heart disease

A
  • carbs
  • fat
  • caffeine
  • Na+
80
Q

why is poor circulation a risk factor for valvular heart disease

A

poor circulation

81
Q

why is obesity a risk factor for valvular heart disease

A
  • excess weight stresses heart function
  • HTN
  • CAD
82
Q

why is alcohol a risk factor for valvular heart disease

A
  • increases BP
  • arryhtmias
83
Q

what congenital defects are risk factors for valvular heart disease

A
  • bicuspid aortic valve
  • mitral valve prolapse
84
Q

what microbe causes infective endocarditis

A

staph

85
Q

what are the signs and symptoms of valvular heart disease

A
  • signs: murmurs, syncope, heart failure, SOB
  • symptoms: HF, exercise intolerance, SOB
86
Q

what is the medical management for valvular heart disease

A
  • tx is mainly surgical
  • valve replacement - more common
  • predisposition for infective endocarditis
87
Q

what are the types of valve replacements for valvular heart disease

A
  • mechanical implants: silicone, requires long term anticoagulation
  • bioprosthetic implants: allograft, bovine graft, decellurized CT with a less antigenic structural matrix. short term anticoagulation. long term antiplatelet therapy, more preferred
88
Q

what are the questions for patients with valvular disease

A
  • screening: SOB, chest pain
  • have you ever had valve replacement surgery
  • do you take a blood thinner
  • do you take aspirin or plavix
  • does it take a long time for you to stop bleeding after a cut
  • have you ever been hospitalized due to bleeding
  • have you ever had IE
89
Q

are there oral manifestations with valvular heart disease

A

no

90
Q

what are the bleeding complications with valvular heart disease

A
  • complications from anticoagulation
  • complications from antiplatelet therapy
91
Q

what are the infections complications of valvular heart disease

A
  • risk of developing infective endocarditis
  • requires antibiotic prophylaxis when valves have been replaced
92
Q

what are the drug effects for patients with valvular heart diseae

A

potential drug interactions from CVD pharmacologic management sespecially when comorbidities are present

93
Q

what are the dental considerations for valvular heart disease

A
  • assess ability to tolerate care in context of underying condition and comorbidities
  • assess bleeding risk: obtain INR day of procedure. have local hemostatic measures in place
  • infections: determine need for AB prophylaxis and AB of choice
  • drug effects- review adverse drug effects and drug-drug interactions
94
Q
A