Cardiovascular Diseases Flashcards
(56 cards)
1
Q
Heart murmur
A
- Sound caused by blood flow through valves + chambers of heart.
- Turbulent flow results from
- Increased flow rate
- Change in viscosity (anemia)
- Stenotic/narrowed valves
- Vibration of structures
2
Q
Types of murmurs
A
-
Innocent, functional, or normal heart murmurs
- Sounds heard in the absence of any cardiac abnormality
- Since the heart is normal, no special treatment or f/u required
-
Organic or abnormal heart murmurs
- Sounds caused by pathologic abnormality in the heart
3
Q
What is the most common heart problem?
A
CHD
4
Q
CHD: L→R shunts
A
If large, may lead to too much pulmonary blood flow.
- Atrial septal defect [ASD]
- Ventricular septa defect [VSD]
- Patent ductus arteriosus [PDA]
- Atrioventricular canal or atrioventricular septal defect [AV canal]
5
Q
CHD: R→L shunts
A
May produce cyanosis
- Tetralogy of Fallot – VSD + pulmonic stenosis + aorta overrides VSD + hypertrophy of RV
- Transposition of great vessels – Pulmonary artery arises from the LV + aorta arises from the RV
- Miscellaneous
- Tricuspid atrsia
- Persistent truncus arteriosus
- Total anomalous pulmonary venous return
- Hypoplastic left heart syndrome
- Ebstein anomaly
6
Q
CHD: Obstruction of blood flow
A
- Pulmonary valve stenosis
- Aortic stenosis w/ bicuspid aortic valve
- Coarctation of aorta
7
Q
What common congenital disorders are associated w/ cardiac defects?
A
- Down
- Turner
- Noonan
- Marfan
- Ehlers-Danlos
- DiGeorge + other 22q11 microdeletion syndromes
8
Q
Symptoms of cardiac defects
A
- Dyspnea
- Syncope
- Murmur
- Cyanosis (late in L→R shunting and early in R→L shunting)
- Clubbing of fingers/toes
- Polycythemia
- Exercise intolerance
9
Q
Complications of cardiac defects
A
- CHF
- Pulmonary edema
- Growth retardation/FTT
- Infective endocarditis
- Brain abscess
10
Q
Rheumatic fever
A
- Delayed non-suppurative sequela w/ diffuse inflammation, to URI w/ group A beta-hemolytic Streptococcal infection (eg strep throat).
- Result of an autoimmune reaction arising from cross-reactivity between tissues (eg heart) and antibodies produced by the host response to Strep infection
11
Q
Rheumatic fever – Prevalence
A
- Commonly occurs b/w 5-15yo
- Prevalent in temperate zones, high altitudes, substandard living conditions
12
Q
Rheumatic fever – Symptoms
A
- Arthritis
- Carditis
- Chorea
- Erythema marginatum
- Subcutaneous nodules
13
Q
Rheumatic fever – Complciations
A
Inflammatory rxns in the heart, larger joints, skin, lungs
14
Q
Rheumatic fever – Medical management
A
Benzathine Penicllin G, salicylates, codeine
15
Q
Rheumatic heart disease
A
Carditis resulting from rheumatic fever
16
Q
Rheumatic heart disease – Prevalence
A
Uncommon in developed countries, but pockets exist in the US
17
Q
Rheumatic heart disease – Symptoms
A
Murmur, exertional dyspnea, CHF
18
Q
Rheumatic heart disease – Complications
A
- Scar tissue + deformity of affected valves (most commonly mitral and/or aortic)
- Mitral insufficiency/stenosis
- Aortic insufficiency/stenosis
- Heart failure
- Pericarditis
19
Q
Rheumatic heart disease – Medical management
A
Asymptomatic – no tx other than prevention of recurrent attacks of rheumatic fever
20
Q
Rheumatic heart disease – Dental management
A
- H/o of rheumatic fever? Send a med consult to rule out rheumatic heart disease.
- If needed, infective endocarditis prophylaxis needs to account for this rheumatic fever PCN prophylaxis regimen
21
Q
Cardiac arrhythmias – Signs + symptoms
A
- Usually asymptomatic
- Palpitations, dizziness, syncope
- Malignant ventricular arrhythmias may lead to ventricular fibrillation and cardiac arrest; other arrhythmias are typically well-tolerated
22
Q
Low risk cardiac arrhthymias
A
- Asymptomatic, not hemodynamically significant, no meds
- Most atrial arrhythmias; isolated premature ventricular beats
23
Q
Moderate risk cardiac arrhythmias
A
- Potential for symptoms + mild hemodynamic compromise
- Certain atrial or ventricular arrhythmias (eg supraventricular tachycardia SVT)
24
Q
High risk cardiac arrhythmias
A
- Potential for cardiovascular collapse
- Malignant ventricular arrhythmias, long QT syndrome, Brugada syndrome, presence of pacemaker or internal defibrillator
25
Cardiac arrhythmias – medical management
* Medication: Beta blockers, calcium channel blockers, misc agents, digoxin
* Radiofrequency ablation (for certain tachyarrhythmias)
* Pacemakers (for complete heart block)
* Internal defibrillator (for malignant ventricular arrhythmias)
26
Cardiac arrhythmias – Dental management
* Med consult to establish risk and management recommendations
* Minimize stressful situations
* Reduce anxiety w/ pre-medication, N2O, and/or sedation as indicated
* Short morning appointments
* Minimize use of epi
* Avoid GA
* Avoid electrical equipment that may interfere w/ pacemaker
27
Cardiac arrhythmias – oral complications
* Anti-arrhythmics have potential oral side effects
* Arrhythmias (most anti-arrhythmics are pro-arrhythmic), hypotension
* Ulceration, xerostomia, petechiae
28
Hypertension
Systolic pressure exceeding the 95th percentile for gender, age, and height in children (after 3 readings in a non-stressful situation)
29
Essential hypertension
More common in adolescents than children, infants
30
Secondary hypertension
* Underlying disorder: Renal, cardiac (coarctation of the aorta), endocrine
* Medication: Oral contraceptives, others
31
Hypertension – Symptoms
* Usually asymptomatic
* Headache, visual blurriness, changes in mental status, and dizziness w/ severe hypertension
32
Hypertension – Dental management
* Take BP at each visit
* Proceed w/ dental treatment in patients with controlled to mild hypertension
* Patients w/ moderate hypertension, schedule short morning appointments, consider ways to reduce anxiety
* Post-pone elective dental procedures w/ severe hypertension
33
Hypertension – Oral complications
* Xerostomia (secondary to meds)
* Lichenoid rxns associated w/ thiazides, methyldopa, propanolol
* Delayed healing and gingival healing associated w/ ACE inhibitors
* Gingival hyperplasia associated w/ calcium channel blockers
* Facial palsy associated w/ malignant hypertension
34
Congestive heart failure
Inability of heart to deliver an adequate supply of blood to meet metabolic demands.
* Etiology: Congenital heart defects, rheumatic heart disease, cardiomyopathy, vascular malformations (arteriovenous fistulae), severe anemia
* Pediatric heart failure is usually not due to pump (myocardial) failure
35
Congestive heart failure – Signs + symptoms
* Tachycardia
* Dyspnea
* Tachypnea
* Peripheral vasoconstriction
* Exercise intolerance
* Growth delay
36
Congestive heart failure – Complications
Pulmonary congestion, peripheral edema, arrhythmias
37
Congestive heart failure – Medications
Diuretics, ACE inhibitors, digoxin
38
Congestive heart failure – Dental management
* Consult w/ MD to determine ability to tolerate tx
* Avoid procedures that may cause a gag reflex
* Minimize epi use
* Prevent orthostatic hypertension
* Investigate potential bleeding problems from anticoagulant use
* INR 3.5 or less is required.
39
Congestive heart failure – Oral complications
* Infection
* Bleeding: Petechiae; ecchymoses
* Drug-related side effects: Xerostomia, lichenoid mucosal lesions
40
Infective endocarditis
Microbial infection (fungal or bacterial) of heart valves or endocardium, usually seen w/ predisposing factors (heart defects, valvulitis, prosthetic material post-surgery)
41
Acute bacterial endocarditis
* Sudden onset, can be rapidly fatal
* Causative agent *Staphylococcus aureus* can infect normal heart valves
42
Subacute bacterial endocarditis
* Slower onset, but demarcation between acute and subacute can be blurry
* *Streptococcus viridans* infects damaged heart valves, but *S. aureus* now the most important IE organism overall
* Staph + Strep species account for the large majority of cases now
43
Are pediatric patients more likely to acquire acute or subacute bacterial endocarditis?
Subacute
44
Infective endocarditis – Symptoms
* Fevers
* Weakness
* Weight loss
* Fatigue
* Chills
* Night sweats
* Anorexia
* Arthralgia
45
Infective endocarditis – Complications
* Emboli
* Cerebral abscesses
* Myocardial abscess
* Mycotic aneurysms
* Hemorrhage
* Congestive heart failure
46
Infective endocarditis – Medical management
Antibiotic therapy (type, duration) based on organism, culture and sensitivity
47
Infective endocarditis – Dental management
Antibiotic prophylaxis prior to bacteremia-inducing procedures
48
What cardiac conditions may necessitate antibiotic prophylaxis?
* Prosthetic cardiac valves
* Previous infective endocarditis
* Congenital heart disease (CHD)
* Unrepaired cyanotic CHD, including palliative shunts + conduits
* Repaired CHD w/ prosthetic material or device, whether placed by surgery or catheter intervention during the first 6m after the procedure
* Repaired CHD w/ residual defects at the site or adjacent to the site of a prosthetic device (which inhibit endothelialization)
* Cardiac transplantation recipients who develop cardiac valvulopathy
49
Cardiac conditions where antibiotic prophylaxis is **_not_** recommended
* Most congenital cardiac malformations
* Acquired valvular dysfunction (e.g. rheumatic heart disease)
* Hypertrophic cardiomyopathy
* Mitral valve prolapse w/ valvular regurgitation and/or thickened leaflets
* Isolated secundum atrial septal defect
* Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residual beyond 6m)
* Previous coronary artery bypass graft surgery
* Mitral valve prolapse w/o valvular regurgitation
* Physiologic, functional or innocent heart murmurs
* Previous Kawasaki disease w/o valvular dysfunction
* Previous rheumatic fever w/o valvular dysfunction
* Cardiac pacemakers (intravascular + epicardial) and implanted defibrillators
50
Dental procedures that may necessitate antibiotic prophylaxis in cardiac patients
* Gingival tissue manipulation
* Manipulation of periapical region of teeth
* Perforation of the oral mucosa
51
Dental procedures where endocarditis prophylaxis is **_not_** recommended
* Routine anesthetic injections through non-infected tissue
* Placement of removable prosthodontic or orthodontic appliances
* Placement of orthodontic brackets
* Taking radiographs
* Orthodontic appliance adjustment
* Shedding of primary teeth
* Bleeding from trauma to the lips or oral mucosa
52
Standard antibiotic prophylaxis – Agent, route, time and regimen
* Agent: **Amoxicillin**
* Route: **PO**
* Time: **1 hour pre-op**
* Regimen:
* Adult: **2g**
* Children: **50mg/kg**
53
Antibiotic prophylaxis when unable to take oral medications – Agent, route, time and regimen
* Agent: **Ampicillin**
* Route: **IM or IV**
* Time: **30 min pre-op**
* Regimen:
* Adult: **2g**
* Children: **50mg/kg**
54
Antibiotic prophylaxis when allergic to penicillin/ampicillin – Agent, route, time and regimen
* Agent: **Clindamycin**
* Route: **PO**
* Time: **1hr pre-op**
* Regimen:
* Adult: **600mg**
* Children: **20mg/kg**
* Agent: **Cephalexin or Cefadroxil (or other 1st or 2nd gen oral cephalosporin)**
* Route: **PO**
* Time: **1hr pre-op**
* Regimen:
* Adult: **2g**
* Children: **50mg/kg**
* Agent: **Azithromycin or Clarithromycin**
* Route: **PO**
* Time: **1hr pre-op**
* Regimen:
* Adult: **500mg**
* Children: **15mg/kg**
55
Cephalosporin contraindication
Cephalosporins should not be used in an individual w/ a h/o anaphylaxis, angioedema, or urticaria w/ penicillins or ampicillins
56
Antibiotic prophylaxis when allergic to penicillin/ampicillin **_and_** unable to take oral medications – Agent, route, time and regimen
* Agent: **Clindamycin**
* Route: **IM or IV**
* Time: **30min pre-op**
* Regimen:
* Adult: **600mg**
* Children: **20mg/kg**
* Agent: **Cefazolin or ceftriaxone**
* Route: **IM or IV**
* Time: **30min pre-op**
* Regimen:
* Adult: **1mg**
* Children: **50mg/kg**
