Lecture 2- Cardiovascular disease Flashcards
(189 cards)
1
Q
- The number of conditions
- The complexity of conditions
- The number of medications
Are DIRECTLY proportional to:
A
Combinations and permutations of dental treatments
2
Q
Many chronic disorders or their treatments necessitate modification of dental treatment. The following conditions brought forth what changes in the dental field:
- hepatitis (1982)
- AIDs (1990)
- Covid-19 (2019)
A
- gloves
- PPE
- PPE & vaccines
3
Q
Clinicians must practice so that the ____ of dental treatment will ______ of a medical complication occurring either during treatment or as a result of treatment
A
benefit; outweigh the risks
4
Q
Most common cause of premature death in the world:
A
CVD
5
Q
T/F: It is rare that a person will have just one type of cardiovascular disease
A
True- often they have a combination of multiple
6
Q
Patients with cardiovascular disease frequently have:
A
more than one CVD
7
Q
List some examples of CVDs: (6)
A
- HTN
- Atherosclerosis
- Angina pectoris
- CHF
- Arrythmias
- Bacterial endocarditis
8
Q
Of the following conditions, which is the least likely to progress
- HTN
- Atherosclerosis
- Angina pectoris
- CHF
- Arrythmias
- bacterial endocarditis
A
Bacterial endocarditis
(An infectious disease process that is more related to the risk of getting certain bacteria and also genetic predisposition to it as well)
9
Q
Coronary artery disease that leads to infarction:
A
Atherosclerosis (Atherosclerotic heart disease) (ASHD)
10
Q
Type of CVD characterized by infection, inflammation & scarring of cardiac tissues:
A
Bacterial endocarditis
11
Q
Type of CVD characterized by dilated ventricles with weak muscle & thickened myocardium:
A
CHF
12
Q
Type of CVD characterized by uncoordinated electrical signals:
A
Arrhythmia
13
Q
Common arrhythmias include:
A
Bradycardia & tachycardia
14
Q
Type of CVD characterized by stenotic heart that is not capable of full closure for blood circulation and leads to CHF:
A
Valvular disease
15
Q
What can valvular disease lead to?
A
CHF
16
Q
List the categories of CVD risk factors:
A
- conditions
- behavioral
- family history
17
Q
What are some conditions that serve as risk factors for CVD:
A
- HTN
- High cholesterol
- DM
- Rheumatic fever
- greater than 1 CVD
18
Q
How does the condition HTN serve as a risk factor for CVD?
A
- Stiffens vessels which reduces blood flow
- puts patient at risk for stroke, kidney disease & dementia
19
Q
How does the condition diabetes serve as a risk factor for CVD?
A
unstable glucose levels affect healthy mycocardium function; angiopathy
20
Q
What are some behavioral factors that serve as risk factors for CVD:
A
- unhealthy diet
- physical inactivity
- obesity
- excessive alcohol
- tobacco use
- stress
21
Q
What aspects of an unhealthy diet may contribute to risk factors for CVD?
A
- carbs
- fats
- caffeine
- sodium
22
Q
Why is obesity a risk factor for CVD?
A
Excessive weight stresses heart function, and leads to HTN & CAD
23
Q
How does physical inactivity lead to CVD?
A
Poor circulation
24
Q
How does too much alcohol put one at risk for CVD?
A
increases blood pressure and arrhythmias
25
How does tobacco use put one at risk for CVD?
Increases HR, BP, CAD, etc.
26
List some components of family history that serve as risk factors for CAD?
1. Genetics
2. Ethnicity
3. Aging
27
What are some contributory anatomic abnormalities that puts one at risk for CVD?
1. Hypertrophy
2. Dilation
3. Valves
4. Regurgitation
5. Stenosis
28
When the heart has to work harder to pump blood, leading to a larger, less efficient heart:
Cardiac hypertrophy
29
What are some physiologic changes that occur in the heart due to prior abnormalities (atherosclerosis, HTN, HLP)
Asking for more advanced heart conditions due to the earlier conditions not being treated properly)
1. Arrhythmias
2. heart failure
3. ischemia
30
In terms of cardiac classification, which patients will we treat at UMKC?
Only Class I or II
31
New York Heart Associatiation Heart Failure Classification (Symptom Based):
Physical activity: no limitation
No dyspnea, fatigue or palpitations with physical activity
Class I
32
New York Heart Associatiation Heart Failure Classification (Symptom Based):
Physical activity: slight limitation
Fatigue, dyspnea & palpitations are present with physical activity
Class II
33
New York Heart Associatiation Heart Failure Classification (Symptom Based):
Physical activity: marked limitation
Less than normal physical activity results in symptoms. Comfortable at rest
Class III
34
New York Heart Associatiation Heart Failure Classification (Symptom Based):
Physical activity: severely limited (exacerbates symptoms)
Symptoms present at rest
Class IV
35
As a dentist a stage IV patient is a patient we don't want to treat at all unless:
dental emergency (best done in hospital setting)
36
Categorize the following as a sign or symptom of cardiovascular disease:
Elevated BP
Sign
37
Categorize the following as a sign or symptom of cardiovascular disease:
Irregular or abnormal heart rate
Sign
38
Categorize the following as a sign or symptom of cardiovascular disease:
Abnormal respiratory rate
Sign
39
Categorize the following as a sign or symptom of cardiovascular disease:
Patient is uncomfortable in supine position
Symptom
40
Categorize the following as a sign or symptom of cardiovascular disease:
Shortness of breath upon exertion
Sign
41
Categorize the following as a sign or symptom of cardiovascular disease:
Prolonged bleeding/easy bruising
Sign
42
Categorize the following as a sign or symptom of cardiovascular disease:
Surgical scars
Sign
43
The sign- prolonged bleeding/easy bruising we see in patients with cardiac disease, is often times attributed to:
medications the patient may be taking to control their cardiac disease
44
The less symptoms & the better the control of risk factors:
THEN The ____ a patient manages the stress
AND the ____ likely the patient will have a life threatening incident during a dental procedure
better; less
45
The greater symptoms & the poorer the control of risk factors:
THEN The ____ a patient manages the stress
AND the ____ likely the patient will have a life threatening incident during a dental procedure
worse; more
46
Medical risk categories of dental treatment:
1. low level intervention
2. moderation intervention
3. high risk intervention
47
List some examples of LOW LEVEL intervention of dental treatment:
1. health/medical evaluation
2. exams
3. prophy
4. radiographs
5. optical oral scans
6. alginate impressions
48
List some examples of MODERATE LEVEL intervention of dental treatment:
1. SRP
2. simple restorative procedures; 1-2 teeth
3. simple extractions; 1-2 teeth
4. restorative impressions needing retractions & longer setting times
49
List some examples of HIGH RISK LEVEL intervention of dental treatment:
1. complex restorative procedures; 2+ teeth
2. multiple extractions
3. surgical extractions
4. implant placement
5. full arch impressions
6. dental care under general anesthesia
50
It is ideal if high risk intervention procedures are done in facilities with:
more medical support (in terms of equipment & personnel)
51
Blood pressure =
CO x Peripheral resistance
52
What are some factors that affect cardiac output:
Cardiac factors: HR & contractility
Blood volume: sodium, mineralocorticoids, ANP
53
Both ___ & ___ factors effect peripheral resistance
humoral & neural
54
A complex physiologic arrangement that functions to maintain physiologic BP when BP is low:
Renin-angiotensin-aldosterone system
55
FITB
a) angiotensinogen
b) angiotensin I
c) angiotensin II
c1) AT1
c2) AT2
d) angiotensin (1-7)
56
FITB
a) renin
b) ACE
c) ACE2
57
FITB
a) raises BP
b) lowers BP
58
ACE inhibitors:
Type of medication patients take to prevent the renin-angiotensin-aldosterone system from raising BP
(ultimately lower BP)
59
What type of HTN is being described?
-multi-factorial
-gene-environemnt
-90-95% of cases
Primary HTN
(not 100% sure what causes it)
60
What type of HTN is being described?
-renal disease and renin-producing tumors
-endocrine issues
-cardiovascular issues
-neurologic issues
Secondary HTN
(other disease processes cause it)
61
What are some endocrine conditions that may cause HTN?
1. Adrenal (hormones)
2. Exogenous hormones
3. Pregnancy
4. Pheochromocytoma
5. Thyroid (can also decrease BP)
62
Blood pressure in pregnancy patients can be anywhere from ____ to ____ higher than their baseline BP due to increased physiologic demands
10; 20
63
What are some neurologic conditions that may cause HTN?
1. Psychogenic
2. Sleep apnea
3. Intracranial vascular pressure
4. Exogenous
64
What are the two main things HTN can lead to?
CAD & Atherosclerosis
65
Complications of HTN include:
1. MI
2. Stoke
3. CAD
4. Peripheral artery disease
5. Heart failure
6. Retinopathy
7. End-stage renal disease
66
The following may all result from:
-stroke
-vision loss
-heart failure
-heart attack
-kidney disease/failure
-sexual dysfunction
HTN
67
T/F: BP categories contain some overlap and are not an exact science
True
68
T/F: 120/80 is considered normal BP
False- less than 120/ less than 80
69
Categorize the following BP:
Systolic: less than 120
Diastolic: less than 80
Normal
70
Categorize the following BP:
Systolic: 120-129
Diastolic: less than 80
Elevated
71
Categorize the following BP:
Systolic: 130-139
Diastolic: 80-89
High (HTN stage 1)
72
Categorize the following BP:
Systolic: 140 or higher
Diastolic: 90 or higher
High (HTN Stage 2)
73
Categorize the following BP:
Systolic: higher than 180
Diastolic: higher than 120
Hypertensive crisis
74
T/F: In order to categorize a patients blood pressure you must take it more than 2 times on 2 separate visits
True
75
BP threshold & recommendations for treatment & follow-up- come up with goals that depend on:
patient age & comorbidities
76
General goals for HTN management are between:
Less than 130 to 149 / 80 to 90 mmHg
77
No dental care at UMKC if BP is:
greater than or equal to 180/110
78
A BP of 180/120 is classified as _____ by the AHA based on the 2017 guidelines
hypertensive emergency
79
Medical management of HTN includes lifestyle modifications. List some examples:
1. diet (increase fruit, decrease sodium, increase potassium)
2. physical exercise/weight loss
3. tobacco cessation
4. alcohol intake reduction
80
How much alcohol is too much?
4 drinks a day or more is too much (male)
More than 3 a day is too much (female)
81
T/F: A lifestyle modification in regards to diet that may help to manage HTN includes increasing sodium and decreasing potassium
False- decrease sodium & increase potassium
82
List two types of ACE inhibitors & their dental implication:
1. Lisinopril- dry mouth
2. Captopril- lichenoid drug eruption
83
What are some common side effects of ACE inhibitors?
1. angioedema
2. neutropenia/agranulocytosis
3. taste disturbances
84
What are some common side effects of sodium channel blockers (anti-arrhythnics class I)?
1. dry mouth
2. gingival overgrowth
3. hypersensitivity reaction syndrome
85
List three types of Calcium channel blockers & their dental implication:
1. Nifedipine- angioedema
2. Diltiazem- angioedema
3. Amlodipine- lichenoid drug eruption
86
List some common side effects of Calcium channel blockers:
1. gingival overgrowth
2. dry mouth
3. taste disturbances
87
List some diuretics & their dental implications:
1. Hydrochlorothyazide- thrombocytopenia & agranulocytosis
2. Spironolactone- EM, SJS, TEN & drug hypersensitivity reaction
3. Furosemide- hypersensitivity reaction, angioedema
88
Lisinopril & Captopril are examples of:
ACE inhibitors
89
Nifedipine, Diltiazem & Amlodapine are examples of:
Calcium-channel blockers
90
Hydrochlorothyazide, Spironolactone & Furosemide are examples of:
Diuretics
91
Give an example of an alpha-adrenergic blocker & its dental implication:
Methyldopa- dry mouth
92
List some examples of beta adrenergic blockers & their dental implications:
1. Atenolol
2. Propanolol
Dry mouth & angioedema
93
Methyldopa is an example of:
alpha adrenergic blockers
94
Atenolol & Propranolol are examples of:
Beta adrenergic blockers
95
Oral manifestations seen in patients with HTN are due to ____ not ____
side effects of pharmacotherapy not HTN itself
96
Oral manifestations of pharmacotherapy used to treat HTN include:
1. dry mouth (anti-adrenergics & diuretics)
2. burning mouth (ACEi)
3. taste changes (anti-adrenergic & ACEi)
4. Angioedema (ACEi, ARB)
5. Gingival hyperplasia (calcium-channel blockers & sodium-channel blockers)
6. lichenoid reactions (thiazides, methyldopa, propranolol, labetalol)
7. lupus-like lesions (hydralazine)
97
What can be seen in the following image, what may be the cause of this
Gingival hyperplasia: Calcium channel blocker (stimulates the fibroblasts)
98
T/F: Gingival hyperplasia seen in patients taking calcium channel blockers is due to an inflammatory process
False- due to stimulation of fibroblasts, not a true inflammatory reaction
(secondarily it becomes inflammatory)
99
What can be seen in the following image, what may be the cause of this?
Lichenoid reaction due to HTN medications
(Annular pattern with white striations, ultimately an alteration of the maturation of the tissue where it may be a little thicker or thinner & where its thinner its symptomatic)
100
Dental considerations for the hypertension patient:
(serious potential complications of severe uncontrolled HTN)
1. Stroke
2. Angina
3. Arrhythmia
4. MI
101
What may increase the patients BP and lead to complications?
Fear, stress, anxiety
102
For patients taking _____ for HTN, use of a vasoconstrictor can cause an acute rise in BP
Nonselective beta blockers
103
For patients taking nonselective beta blockers for HTN, use of a ____ can cause ____
Vasoconstrictor; acute rise in BP
104
If patients are sensitive to sudden position changes, this is a sign of:
orthostatic hypotension
105
What is a PRE-OP consideration for a hypertensive patient?
Reduce stress & anxiety (may need oral or inhalation sedation)
106
What an INTRA-OPERATIVE consideration for hypertensive patient?
1. profound anesthesia*
2. limit epi to 2 carpules if taking a selective beta-blocker
3. don't use epi gingival retraction cord
107
For a patient taking a selective beta blocker, don't exceed 2 carpules of epi. This is the guidelines for what rule?
2-Carp rule
108
What an POST-OPERATIVE consideration for hypertensive patient?
1. Avoid macrolide antibiotics with calcium channel blockers
2. Avoid longterm use of NSAIDs
3. Stage 2, monitor BP during treatment and if 180/110 stop
4. Raise patient slowly after treatment
109
List some cardiac measures regarding anesthetics that you would take for a patient with HTN:
1. Articaine for maxillary blocks & max/mand infiltrations
2. 2% lidocaine 1:100,000 epi for IANB
3. 3% Mepivicaine without epi for anesthesia
110
What is the MAX cardiac epi dose?
0.04 mg
111
Inflammatory disorder with accumulation of lipid plaque within the arterial walls:
atherosclerosis
112
The accumulation of lipid plaque within the arterial walls in atherosclerosis results in:
1. thickened intimal (decreased arterial lumen)
2. decreased oxygen
3. decreased blood flow to the myocardium
113
Basically, the decreased blood flow in atherosclerosis can lead to:
1. stenosis
2. angina
3. MI
4. ischemic stroke
5. peripheral arterial disease
114
Stable ischemic disease:
angina
115
Acute ischemic disease:
ischemic stroke
116
Risk factors for atherosclerosis include:
1. depression
2. family history of CVD
3. insulin resistance
4. DM
117
DANGEROUS level of
total cholesterol:
LDL:
HDL:
total cholesterol: 240+
LDL: 160+
HDL: Under 40 M; Under 50 F
118
AT RISK level of
total cholesterol:
LDL:
HDL:
total cholesterol: 200-239
LDL: 100-159
HDL: 40-59 M; 50-59 F
119
HEART HEALTHY level of
total cholesterol:
LDL:
HDL:
total cholesterol: under 200
LDL: under 100
HDL: 60+
120
Atherosclerotic plaques can lead to:
1. ischemia
2. thrombosis (vascular blockage if they rupture)
121
Associated symptoms of atherosclerosis of the circulatory system:
1. chest pain
2. angina
122
Complications of atherosclerosis of the circulatory system:
1. unstable angina
2. MI (necrosis)
3. thrombosis
4. embolism
5. aneurysm
123
When atherosclerosis is affecting coronary arteries:
CAD
124
Ischemic heart disease occurs when:
heart is not getting enough oxygen
125
If a person has atherosclerotic plaques in their coronary arteries this will ____ BP
increase
(the increased BP will then lead to more plaques = bad cycle)
126
Chest pain resultant form ischemic changes:
angina pectoris
127
Describe how a patient with angina pectoris may present:
With mid-chest pain described as aching, heavy, squeezing pressure or tightness
128
Pain from angina pectoris may radiate to ____ and lasts _____ unless unstable and then may be longer
shoulder, arms, jaw; 5-15 minutes
129
what is used to resolve angina?
medications that result in vasodilation (nitroglycerin)
130
What type of angina is being described?
-imbalanced cardiac perfusion
-stable symtoms, reproducible, predictable, consistent
-chest pain precipitated by physical activity/exertion
-resolves with cessation of activity
Stable
131
What type of angina is being described?
-disruption of atherosclerotic plaque
-possible partial thrombosis, embolism or vasospasm
-symptoms increasing
-chest pain at rest or with less intense physical activity
unstable
132
Irreversible coagulative necrosis of the myocardium:
MI
133
Irreversible coagulative necrosis of the myocardium is characterized by loss of:
normal conduction & contraction
134
What ventricle is more common to have an MI?
Left
135
Symptoms of an MI are similar to angina +
1. radiating features
2. severe substernal pain
3. SOB
4. profuse sweating
5. loss of consciousness
136
A person is experiencing angina pain but the pain does NOT resolve with vasodilators and is more prolonged, this is likely:
Myocardial infarction
137
If a patient has ischemic heart disease, treatment for HTN may be indicated. What are common HTN medications used to treat ischemic heart disease?
1. Beta-blockers
2. Calcium channel blockers
138
Calcium channel blockers affect what system?
Renin-angiotensin-aldosterone system
139
in a patient with ischemic heart disease ______ agents are used to prevent the buildup of the atherosclerotic plaques to ultimately prevent _____
antiplatelet agents (Aspirin & Clopidogrel); stroke
140
List some antiplatelet agents that may be indicated in a patient with ischemic hear disease?
Aspirin & Clopidogrel
141
In a patient with ischemic heart disease, what medications may be used to treat HLP?
1. HMG-CoA reductase inhibitor
2. Cholesterol absorption inhinitors
3. Bile acid sequesterants
142
The following classes of medications may be used to treat HLP in patients with ischemic heart disease. Name an examples of each:
1. HMG-CoA reductase inhibitor
2. Cholesterol absorption inhinitors
3. Bile acid sequesterants
1. Statins
2. Ezetimibe
3. Cholestyramine & Colestipol
143
Statins are examples of:
HMG-CoA reductase inhibitors
144
Recent myocardial infarction of less than one month indicates:
Urgent dental care only!! (acute dental pain or infection)
145
What can be used to measure the degree of heart failure. When might we measure this?
In patient who has past history of MI (greater than 1 month ago); Ejection fraction
146
Measures the amount (%) of blood that leaves the left ventricle after contraction:
Ejection fraction
147
Normal ejection fraction:
55-70%
148
In patients on statins, certain ____ will NOT work well
CYP inhibitors (fluconazole & clarithromycin)
149
If you give a patient on statins a CYP inhibitor such as fluconazole or clarithromycin, this may:
increase statin levels
150
Some of the issues with hyperlipidemia is that these plaques can cause:
mineralizations in the intima
151
Some of the issues with hyperlipidemia is that these plaques can cause mineralizations in the intimal. One of these places this occurs in the carotid furcation (C3, C4). Why is this significant? What is this called?
Because as a dentist, we may be able to pick this up on a pano; called a carotid atheroma
152
What can be seen in this image?
Carotid atheroma
153
-primary pacemaker
-regulates atrial function
-produces P wave (atrial depolarization)
SA node
154
-regulates atrial impulses entering ventricles
-slows conduction rate of SA generated impulses
AV node
155
Simultaneous depolarization of the ventricles:
QRS complex
156
What test is used to determine if a patient has an arrhythmia?
electrocardiogram
157
Disruption of the electrical impulse generation or conduction in the heart leads to abnormal cardiac function including:
1. formation of abnormal impulse
2. increased impulse formation
3. enhanced or abnormal impulse formation
4. delayed depolarization
5. re-excitation of the heart after refractory period
158
Arrhythmias may be due to disruption of an area caused by:
1. infarction
2. ischemia
3. electrolyte imbalance
4. medication
159
The most common cause of cardiac death is:
ventricular fibrillation
160
In addition to cardiovascular disorders causing arrhythmias, pulmonary disorders can also contribute to arrhythmias, including:
1. pneumonia
2. obstructive lung disease
161
What are the most common classifications of arrhythmias that we will see?
1. atrial tachycardias
2. heart block
3. ventricular arrhythmias
162
Less than 60 BPM:
Bradycardia
163
Greater than 100 BPM:
Tachycardia
164
List some symptoms of arrhythmias:
1. palpitations
2. fatigue
3. dizziness
4. syncope
5. angina
6. CHF
7. SOB
8. orthopnea
9. peripheral edema
165
What is the most common arrhythmia?
AFIB
166
What are the main risks of AFIB?
Embolism & Stroke
167
What type of heart block is considered a complete block and an indication for a pacemaker?
Third degree
168
What are the classes of anti-arrhythmics?
Class I: Fast sodium channel blockers
Class II: Beta Blockers
Class III: Potassium channel blockers
Class IV: Slow calcium channel blockers
169
List the oral side effects of the following anti-arrhythmic drug:
Class I: Fast sodium channel blockers
1. bitter/metallic taste
2. dry mouth
3. petechiae
4. gingival bleeding
5. oral ulcerations
170
List the oral side effects of the following anti-arrhythmic drug:
Class II: Beta blockers
1. Taste changes
2. Lichenoid reactions
171
List the oral side effects of the following anti-arrhythmic drug:
Class III: Potassium channel blockers
1. bitter taste
2. lichenoid reactions
3. angioedema
172
List the oral side effects of the following anti-arrhythmic drug:
Class IV: Slow calcium channel blockers
Gingival overgrowth
173
List the oral side effects of the following anti-arrhythmic drug:
Class V: Variable mechanisms
1. metallic taste
2. burning sensation
3. hyper salivation (toxicity)
174
Baby aspirin is used as an:
oral antivoagulant
175
ASA:
(acetyl salicylic acid) Aspirin 81mg (low dose)
176
What are the benefits of taken aspirin (81mg - low dose) for anticoagulation for an arrhythmia?
1. inhibits platelet agglutination
2. platelet count not affected
177
Oral anticoagulant for arrhythmias include:
1. Clopidogrel (Plavix)
2. ASA (aspirin- low dose)
3. Warfarin (Coumadin)
178
Plavix is an example of:
oral anticoagulant (Clopidogrel)
179
What oral anticoagulant is being described below:
-Vitamin K antagonist
-Requires INR monitoring
-Highly variable
Warfarin (Coumadin)
180
Coumadin is another name for:
Warfarin
181
DOACs:
Direct oral anticoagulants
182
DOACs include:
1. direct thrombin inhibitors
2. direct factors Xa inhibitors
183
T/F: Never stop anticoagulation for dental treatment unless extensive surgery
True
184
Why do we NEVER stop anticoagulation for dental treatment unless its an extensive surgery?
Risk of thrombosis > Risk of massive bleed
185
T/F: The risk of a massive bleed > the risk of thrombosis
False- thrombosis risk is greater
186
What should you do if your patient is on an anticoagulant and they need extensive dental surgery?
1. consult physician
2. consider referral to specialized center
187
What are some local measures for hemostasis?
1. gelatin sponges (Gelfoam)
2. oxidized cellulose
3. chitosan hemostatic products
4. sutures
5. gauze with applied pressure
6. topical tranexamic acid
7. topical aminocaproic acid (Amicar)
8. topical thrombin
9. electrocautery- NOT WITH PACEMAKERS
188
Electrocautery to control local bleeding is contraindicated for:
pacemaker patients
189
