Lecture 2- Cardiovascular Disease Flashcards
(189 cards)
1
Q
- The number of conditions
- The complexity of conditions
- The number of medications
These are DIRECTLY proportional to:
A
combinations and permutations of dental treatments
2
Q
Many chronic disorders or their treatments necessitate modification of dental treatments. 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 medication 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 the diseases
6
Q
Patients with cardiovascular disease frequently have:
A
more than one CVD
7
Q
List some examples of CVDs:
A
- HTN
- Atherosclerosis
- Angina pectoris
- CHF
- Arrhythmias
- Bacterial endocarditis
8
Q
Of the following, which is the least likely to progress?
- HTN
- Atherosclerosis
- Angina pectoris
- CHF
- Arrhythmias
- Bacterial endocarditis
A
Bacterial endocarditis- an infectious disease process that is more related to the risk of getting certain bacteria and also a genetic predisposition to it as well
9
Q
Coronary artery disease that leads to infarction:
A
Athersclerosis (Atherosclerotic Heart Disease) (ASHD)
10
Q
Type of CVD characterized by infection, inflammation, and scarring of cardiac tissues
A
bacterial endocarditis
11
Q
Type of CVD characterized by dilated ventricles with weak muscles and thickened myocardium
A
CHF
12
Q
Type of CVD characterized by uncoordinated electrical signals
A
Arrhythmia
13
Q
Common arrhythmias include:
A
bradycardia and tachycardia
14
Q
Type of CVD characterized by stenotic heart that is not capable of full closer 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
- high blood pressure
- high cholesterol
- diabetes
- 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, and dementia
19
Q
How does the condition DM serve as a risk factor for CVD?
A
unstable glucose levels affect healthy myocardium 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 and 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 BP & 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:
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)
1. arrhythmias
2. heart failure
3. ischemia
30
In terms of cardiac classification, which patients would we treat at UMKC?
Only Class I or Class II
31
New York Heart Association Heart Failure Classification (Symptom Based)
Physical Activity: No limitation
No dyspnea, fatigue or palpitations with physical activity
Class I
32
New York Heart Association Heart Failure Classification (Symptom Based)
Physical activity: Slight limitation
Fatigue, dyspnea, & palpitations are present with physical activity
Class II
33
New York Heart Association 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 Association Heart Failure Classification (Symptom Based)
Physical activity: Severely limited (exacerbates symptoms)
Symptoms present at rest
Class IV
35
As a dentist a stage 4 patient is a patient we don't want to treat at all unless:
dental emergency (treat only in hospital setting)
36
Categorize the following as a sign or symptoms of CVD:
Elevated BP
sign
37
Categorize the following as a sign or symptoms of CVD:
Irregular or abnormal HR
sign
38
Categorize the following as a sign or symptoms of CVD:
abnormal respiratory rate
sign
39
Categorize the following as a sign or symptoms of CVD:
Pt is uncomfortable in supine position
symptom
40
Categorize the following as a sign or symptoms of CVD:
SOB upon exertion
sign
41
Categorize the following as a sign or symptoms of CVD:
prolonged bleeding/easy bruising
signs
42
Categorize the following as a sign or symptoms of CVD:
surgical scars
signs
43
The sign - prolonged bleeding/bruising - we see in patients with cardiac disease, is often times attributed to:
medications the patient may be taking to control cardiac disease
44
The less symptoms and 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 and 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
Medication risk categories of dental treatment:
1. Low level intervention
2. Moderate intervention
3. High risk intervention
47
List some examples of LOW LEVEL INTERVENTION dental treatments:
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 dental treatments:
1. SRP
2. Simple restorative procedures; 1-2 teeth
3. Simple extractions (1-2 teeth)
4. Restorative impressions needing retractions and longer setting times
49
List some examples of HIGH RISK LEVEL INTERVENTION dental treatments:
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 and personnel
51
Blood pressure =
CO x peripheral resistance
52
What are some factors that affect cardiac output?
Cardiac factors: HR & contractility
Blood volume: Na, Mineralcorticoids, ANP
53
____ & ____ factors affect peripheral resistance
humoral & neural
54
A complex physiological arrangement that functions to maintain physiologic BP when BP is low:
Renin-Angiotensin-Aldosterone System
55
FINB
A: Angiotensinogen
B: Angiotensin I
C: Angiotensin II
C1: AT1
C2: AT2
D: Angiotensin (1-7)
56
FINB
A: Renin
B: ACE
C: ACE2
57
FINB
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 hypertension is being described?
- Multifactorial, gene-enviornment
- 90-95% of cases
Primary hypertension
(not 100% sure what causes it)
60
What type of hypertension is being described?
- renal disease and renin-producing tumors
- endocrine issues
- cardiovascular issues
- neurologic issues
Secondary hypertension
(other disease processes cause it)
61
What are some endocrine conditions that may cause hypertension?
1. adrenal (hormones)
2. exogenous hormones
3. pregnancy
4. pheochromocytoma
5. thyroid
62
Blood pressure in pregnant 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 hypertension?
1. psychogenic
2. sleep apnea
3. intracranial vascular pressure
4. exogenous
64
What are the two main things that HTN can lead to?
1. coronary artery disease
2. atherosclerosis
65
Complications of HTN include:
1. MI
2. Stroke
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 over 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 blood pressure (HTN Stage 1)
72
Categorize the following BP:
systolic: 140 o higher
diastolic: 90 or higher
High blood pressure (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 BP, you must take it more than 2 times on 2 separate visits
true
75
BP thresholds and recommendations for treatment and follow up - come up with goals that depend on:
patient age & comorbidities
76
General goals for HTN management are between:
Less than 130 -149/80-90 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 hypertension includes lifestyle modifications. List some examples:
1. diet (increase fruit, decrease sodium, increase potassium)
2. physical exercise/weightloss
3. tobacco cessation
4. alcohol intake reduction
80
How much alcohol is too much?
4 drinks or day or more is too much (male)
more than 3 drinks per day is too much (female)
81
T/F: a lifestyle modification in regards to diet the might help to manage HTN included increasing sodium, and decreased potassium
false- decrease sodium & increase potassium
82
List two types of ACE inhibitors and their dental implication:
1. Lisinopril- dry mouth
2. Captopril- lichenoid drug eruption
83
What are 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-arrhythmics class I)
1. dry mouth
2. gingival overgrowth
3. hypersensitivity reaction syndrome
85
List 3 types of calcium-channel blockers and their dental implications:
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 distrubances
87
List some diuretics and their dental implications:
1. hydrochlorothiazide- agranulocytosis & thrombocytopendia
2. spironolactone- EM, SJS, TEN & drug hypersensitivity rxn
3. Furosemide- hypersensitivity reaction, angioedema
88
Lisinopril and Captopril are examples of:
ACE inhibitors
89
Nifedipine, Diltiazem, and Amlodipine are examples of:
Calcium channel blockers
90
Hydrochlorothiazide, Spironolactone, & Furosemide are examples of:
Diuretics
91
Give an example of an alpha adrenergic blocker and its dental implication:
Methyldopa- dry mouth
92
Give some examples of a beta adrenergic blockers and their dental implications:
1. Atenolol
2. Propranolol
(dry mouth & angioedema)
93
Methyldopa is an example of
alpha adrenergic blocker
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 pharmacy therapy used to treat HTN include:
1. Dry mouth (anti-adrenergic & diuretics)
2. Burning mouth (ACEi)
3. Taste changes (Antiadrenergics & ACEi)
4. Angeioedema (ACEi & ARB)
5. Gingival Hyperplasia (Calcium channel blockers, sodium channel blockers)
6. Lichenoid reactions (thiazides, methyldopa, propranolol, and labetalol)
7. Lupus-like lesions (hydralazine)
97
What can be seen in the following image? What may be the cause of this?
calcium channel blocker (stimulates the fibroblasts)
98
T/F: Gingival hyperplasia seen in patient taking calcium channel blockers is due to an inflammatory process
False- due to stimulation of fibroblasts (not a true inflammatory rxn)
(eventually may become an inflammatory reaction)
99
What can be seen in the following image? What may be the cause of this?
lichenoid reaction due to HTN medications
(anular/linear pattern with white striations, alteration of the maturation of the tissues where it may be thicker or thinner, and where its thinner its symptomatic)
100
Dental considerations for the hypertensive patient (SERIOUS POTENTIAL COMPLICATIONS OF SEVERE UNCONTROLLED HTN):
1. stroke
2. angina
3. arrhythmia
4. myocardial infarction
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 an ___
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 is an INTRA-OPERATIVE consideration for a 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 is an POST-OPERATIVE consideration for a hypertensive patient?
1. avoid macrolide antibiotics with calcium channel blockers
2. avoid long-term 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 and max/mand infiltration
2. 2% lidocaine 1:100,000 epi for IANB
3. 3% mepivacaine 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 in arterial walls in atherosclerosis results in:
1. thickened intimacy (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. ischemia stroke
5. peirpheral arterial disease
114
stable ischemic disease:
angina
115
acute ischemia disease:
ischemia stroke
116
Risk factors for atherosclerosis:
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 40M & under 50F
118
AT RISK level of-
Total cholesterol:
LDL:
HDL:
Total cholesterol: 200-239
LDL: 100-159
HDL: 40-59M & 50-59F
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 include:
1. unstable angina
2. MI (necrosis)
3. thrombosis
4. embolism
5. aneurysm
123
When atherosclerosis is affecting the 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 lead to more plaques = bad cycle)
126
Chest pain resultant from ischemic changes:
angina pectoris
127
Describe how a patient with angina pectoris may present:
with mid chest pain described asa chin, heavy squeezing pressure or tightness
128
Pain from angina pectoris may radiate to ___ and last ___, unless unstable, then may be longer
should, arms, jaw; 5-15 minutes
129
What is used to resolve angina?
medications that result in vasodilation (nitroglycerine)
130
What type of angina is being described?
- imbalanced cardiac perfusion
- stable symptoms, 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:
MI
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 build up of atherosclerotic plaques to ultimately prevent ___.
Antiplatelet agents (aspirin, clopidogrel); stroke
140
List some antiplatelet agents that may be indicated in a patient with ischemic heart 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 inhibitor
3. Bile acid sequestrants
142
The following classes of medications may be used to treat HLP in patients with ischemic heart disease. Name an example of each:
1. HMG-CoA reductase inhibitor
2. Cholesterol absorption inhibitor
3. Bile acid sequestrants
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
ejection fracture- in patient who has past history of MI greater than 1 month ago
146
Measures the amount (%) of blood the t leaves the left ventricle after contraction:
Ejection fraction
147
Normal Ejection Fraction:
55-75%
148
For 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 & 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 off the issues with hyperlipidemia is that these plaques can cause mineralizations in the intima. One of these places this occurs is the carotid furcation (C3 & C4), why is this significant? And 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
Responsible for 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 condition 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
More 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?
AF
166
What are the main risks of A-fib?
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 are 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 taste/ 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 reaction
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 anticoagulant
175
ASA:
(acetyl salicylic acid) aspirin 81mg (low dose)
176
What are the benefits of taking aspirin 81mg (low dose) for anticoagulation for an arrhythmia?
1. inhibits platelet agglutination
2. platelet count not affected
177
Oral anticoagulants for arrhythmias include:
1. clopidogrel (plavix)
2. ASA (asprin)- 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 anticoagulant
182
DOACs include:
1. direct thrombin inhibitors
2. Direct factor 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?
because the risk of thrombosis is greater than the risk of a massive bleed
185
T/F: The risk of a massive bleed is greater than 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 surgery?
1. consult physician
2. consider referral to specialized center
187
What are some local measures for hemostasis?
1. gelatin sponges (gel foam)
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
