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Dental Management of the Medically Complex Patient > Lecture 2- Cardiovascular Disease I > Flashcards

Lecture 2- Cardiovascular Disease I Flashcards

1
Q

what is the most common cause of premature death in the world

A

cardiovascular disease

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2
Q

patients frequently have _____ CVD

A

more than one

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3
Q

what are the types of CVD

A
  • HTN
    -atherosclerosis
  • angina pectoris
  • CHF
  • arrhthmias
    -bacterial endocarditis
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4
Q

what does atherosclerosis lead to

A

coronary artery disease leading to infarction

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5
Q

what is bacterial endocarditis caused by

A

infection, inflammation and scarring

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6
Q

what is CHF

A
  • dilated ventricles with weak muscles
  • thickened myocardium
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7
Q

what is arrhythmia

A

uncoordinated electrical signals

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8
Q

what is valvular disease characterized by and what does it lead to

A
  • stenotic and not capable of full closure for blood circulation
  • leads to CHF
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9
Q

what are the conditions that are risk factors for CVD

A
  • high BP
  • high cholesterol
  • diabetes
  • rheumatic fever
  • more than one CVD
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10
Q

why is high BP a risk factor for CVD

A
  • stiffens vessels which reduces blood flow
  • risk for stroke, kidney disease and dementia
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11
Q

why is diabetes a risk factor for CVD

A

unstable glucose levels affect healthy myocardium function; angiopathy

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12
Q

what are the behaviors that are risk factors for CVD

A
  • unhealthy diet
  • physical inactivity
  • obesity
  • too much alcohol
    -tobacco use
  • stress
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13
Q

what constitutes an unhealthy diet in CVD risk factors

A
  • carbs, fat, caffeine, sodium
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14
Q

why is physical inactivity a risk factor for CVD

A

poor circulation

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15
Q

why is obesity a risk factor for CVD

A

excess weight stresses heart function, HTN, CAD

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16
Q

why is too much alcohol a CVD risk factor

A

increases BP, arrythmias

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17
Q

why is tobacco use a CVD risk factor

A

increases HR, BP, CAD

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18
Q

what family history is a risk factor for CVD

A
  • genetics
  • becoming older
  • ethnicity
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19
Q

what are predisposing etiologies for CVD

A
  • congenital
  • hypertension (positive CVD feedback cycle)
  • ischemia (positive CVD feedback cycle)
  • inflammation
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20
Q

what are the contributary anatomic abnormalities for CVD

A
  • hypertrophy
  • dilation
  • valves
  • regurgitation
  • stenosis
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21
Q

what are the late stage physiologic changes in CVD

A
  • arrhythmias
  • heart failure
  • ischemia
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22
Q

what stages do we treat in dentistry for CVD patients

A

class I or class II

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23
Q

what are some signs of CVD

A
  • elevated BP
  • irregular HR
  • abnormal RR
  • SOB
  • prolonged bleeding
  • surgical scars
  • easy bruising
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24
Q

what are symptoms of CVD

A

patient is uncomfortbale in supine position

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25
Q

what are the dental treatments in the low level intervention category

A
  • health/medical evaluation
  • exams
  • prophy
  • radiographs
  • optical oral scans
  • alginate impressions
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26
Q

what are the dental treatments that fall in the moderate intervention category

A
  • SRP
  • simple restorative procedures on 1-2 teeth
  • simple extractions on 1-2 teeth
    -restorative impressions needing retractions and longer setting times
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27
Q

what dental procedures fall under high risk intervention cateogry

A
  • complex restorative treatment on more than 2 teeth
  • multiple extractions
  • surgical extractions
  • implant placement
  • full arch impressions
  • dental care under general anesthesia
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28
Q

what does the renin-angiotensin aldosterone system do

A

maintains physiologic BP when BP is low

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29
Q

describe primary HTN

A
  • mutlifactorial, gene-environment
  • 90-95% of cases
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30
Q

what are the causes of secondary HTN

A
  • renal disease and renin-producing tumors
  • endocrine
  • cardiovascular
  • neurologic
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31
Q

what endocrine disorders can cause secondary HTN

A
  • adrenal
  • exogenous hormones
  • pregnancy
  • pheochromocytoma
  • thyroid
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32
Q

what neurologic disorders can cause secondary HTN

A
  • psychogenic
  • sleep apnea
  • intracranial vascular pressure
  • exogenous
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33
Q

what are the complications of HTN

A
  • MI
    -stroke
  • CAD
  • peripheral artery disease
  • heart failure
  • retinopathy
  • end stage renal disease
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34
Q

what is the number for normal BP

A
  • less than 120/ less than 80
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35
Q

what is the number for elevated BP

A

120-129/less than 80

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36
Q

what is the number of hypertensive crisis

A

higher than 180 and or/ higher than 120

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37
Q

how many BP readings do you need to make a dx

A

more than 2 readings on 2 separate visits

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38
Q

what is BP measured by

A

determined by indirect measurement in the upper extremities with a BP cuff and stethoscope

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39
Q

cuff should encompass ___ of the circumference of the arm

A

80%

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40
Q

center of cuff over _____

A

brachial artery

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41
Q

white coat HTN elevates BP by

A

30mmHg

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42
Q

how are pregnant patients BP affected

A

greater than 10 mmHg increase in systolic BP

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43
Q

what is the risk of high BP in pregnant patietns

A

eclampsia

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44
Q

HTN goals depend on:

A

patient age and comorbidities

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45
Q

what is the normal goal for patients with HTN

A

between less than 130-149/80-90 mmHg

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46
Q

what BP is the cut off for tx at UMKC

A

greater than or equal to 180/110 mmHg

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47
Q

what do you do if a patient presents with BP greater than 180/110 and is symptomatic

A

ER

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48
Q

what are the lifestyle modifications for HTN

A
  • diet - increase fruit intake, decrease sodium, increased potassium
  • physical exercise/weight loss
  • tobacco cessation and alcohol intake reduction
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49
Q

what is the daily limit for alcohol for men and women

A

no more than 4 for men and no more than 3 for women

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50
Q

what are the ACE inhibitor drugs and their side effects

A
  • lisinopril
    -captopril
  • angioedema, neutropenia/agranulocytosis, taste disturbances
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51
Q

what are the calcium channel blocker drugs and their side effects

A
  • nifedipine, dilitazem
  • gingival overgrowth, dry mouth, taste disturbances
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52
Q

what are the diuretic drugs and their side effects

A
  • hydrochlorothiazide
  • spironolactone
  • hydrochlorothiazide, furosemide
  • dry mouth
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53
Q

what are the alpha adrenergic blockers and their side effect

A
  • methyldopa
  • dry mouth
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54
Q

what are the beta adrenergic blockers and side effect

A
  • atenolol, oxprenolol, practolol
  • propranolol
  • dry mouth, angioedema
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55
Q

what are the side effects of pharmacotherapy for HTN

A
  • dry mouth
  • burning mouth
  • taste changes
  • angioedema
  • gingival hyperplasia
  • lichenoid reactions
  • lupus like lesions
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56
Q

what drugs cause dry mouth

A

anti adrenergic and diuretics

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57
Q

what drugs cause burning mouth

A

ACE inhibitors

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58
Q

what HTN drugs cause taste changes

A

antiadrenergics and ACE inhibitors

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59
Q

what HTN drugs cause angioedema

A

ACE inhibitors and ARB

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60
Q

what HTN drugs cause gingival hyperplasia

A

calcium channel blockers

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61
Q

what HTN drugs cause lichenoid reactions

A

thiazides, methyldopa, propranolol and labetalol

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62
Q

what HTN drugs cause lupus like lesions

A

hydralazine

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63
Q

what is the mechanism of action that causes pseudopockets in calcium channel blockers

A

stimulates fibroblasts

64
Q

what are the types of questions you should ask your HTN patients

A
  • physical activity
  • hypertension history
  • hypertension monitoring
65
Q

what are the serioud potential complications of severe uncontrolled HTN

A
  • stroke
  • angina
  • arrhythmia
  • MI
66
Q

what might increase a patients BP and lead to complications

A

stress, anxiety, and fear

67
Q

what can be a complication of patients taking nonselective beta-blockers

A

use of vasoconstrictor can cause acute rise in BP

68
Q

HTN patients may be sensitive to sudden position changes causing:

A

orthostatic hypotension

69
Q

what are the dental considerations for the hypertensive patient

A
  • pre-operative considerations
  • intra-operative considerations
  • post-operative considerations
  • ability to tolerate care
    -drug effects
70
Q

what are the pre-operative considerations for the hypertensive patient

A
  • reduce stress and anxiety
  • may need oral and/or inhalation sedation
71
Q

what are the intra-operative considerations from a HTN patient

A
  • profound anesthesia!!
  • limit epi to 2 carpules if taking a selective beta blocker- 2 carp rule
  • dont use epi gingival retraction cord
72
Q

what are the post operative considerations for HTN

A
  • avoid macrolide antibiotics with calcium channel blocker because increase in CCB levels
  • avoid long term use of NSAIDS such as more than 2 weeks
  • stage 2, monitor BP during tx
  • raise patient slowly after tx because of hypotension
73
Q

what are the general guidelines for a medical consult letter

A
  • make explicit to physician
  • ask specific questions to the physician in relation to the current disease status of patient
  • disease/patient risk factors- control and severity
  • timing risk factors- elective and emergency
  • procedure risk factors - invasive and non-invasive
74
Q

risk category of dental treatment is proportional to:

A

time of procedure

75
Q

how many times should you check BP with pt with HTN

A
  • 3 readings at 5-10 min intervals : 2 automatic and 1 manual
76
Q

what are the hypertension cardiac measures

A
  • stress reduction protocol
  • NO
  • profound anesthesia
  • cardiac epi dose = max 0.04 mg
  • articaine for maxillary blocks and maxillary or mandibular infiltrations
  • 2% lidocaine 1:100,000 epi for IANB
  • 3% mepivacaine without epi for anesthesia
77
Q

what is atherosclerosis and what categorizes it

A
  • inflammatory disorder with accumulation of lipid plaque within the aterial walls
  • thickened intima ( decreased arterial lumen)
  • decreased O2
  • decreased blood flow to the myocardium
78
Q

what does atherosclerosis lead to

A

-stenosis
- angina
- MI
- ischemic stroke
- peripheral arterial disease

79
Q

what are the main risk factors for atherosclerosis

A

depression
- family history of CVD
- insulin resistance
- DM
- hyperlipidemia

80
Q

atherosclerotic plaques can lead to:

A
  • ischemia
  • thrombosis
81
Q

what is the mechanism of atherosclerosis

A
  • chronic endothelial injury
  • endothelial dysfunction
  • smooth muscle emigration from media to intima and macrophage activation
  • macrophages and smooth muscle cells engulf lipid
  • smooth muscle proliferation, collagen and other ECM deposition, extracellular lipid
82
Q

what causes chronic endothelial injury in atherosclerosis

A
  • hyperlipidemia
  • HTN
  • smoking
  • homocysteine
  • hemodynamic factors
  • toxins
  • viruses
  • immune reactions
83
Q

what happens in endothelial dysfunction in atherosclerosis

A
  • increased permeability
  • leukocyte adhesion
  • monocyte adhesion and emigration
84
Q

what are the associated symptoms of atherosclerosis

A

chest pain and angina

85
Q

what are the complications of atherosclerosis

A
  • unstable angina
  • MI
  • thrombosis
  • embolism
  • aneurysm
86
Q

describe angina pectoris

A
  • chest pain resultant from ischemic changes
  • pain may radiate
  • pain lasts 5-15 minutes
  • vasodilation used to resolve angina
87
Q

what pain is angina pectoris described as

A
  • mid- chest pain described as aching, heavy, squeezing pressure or tightness
88
Q

where may pain radiate in angina pectoris

A

shoulder, arms and jaw

89
Q

if unstable angina, pain lasts :

A

may be more than 5-15 minutes

90
Q

describe stable angina

A
  • imbalanced cardiac perfusion
  • stable symptoms, reproducible, predictable, consistent
  • chest pain precipitated by physical activity/exertion
  • resolves with cessation of activity
91
Q

describe unstable angina

A
  • disruption of atherosclerotic plaque
  • possible partial thrombosis, embolism or vasospasm
  • symptoms increasing
  • chest pain at rest or with less intensive physical activity/exertion
92
Q

what is MI

A
  • irreversible coagulative necrosis of the myocardium
  • lose normal conduction and contraction
  • left ventricle MI is more common
93
Q

what are the symptoms of MI

A
  • similar to angina plus
    -radiation features
  • severe substernal pain with SOB, profuse sweating, and loss of consciousness
94
Q

does pain resolve in MI with vasodilators

A

no and pain is more prolonged

95
Q

what is treated/reduced in the management of modifiable risk factors and associated disease for ischemic heart disease

A
  • HTN
  • angina
  • stroke
  • revascularization
  • hyperlipidemia
96
Q

what medications are used to treat angina

A

nitrates (nitroglycerin) with stable angina

97
Q

what medications are used for stroke prevention

A

antiplatelet agents such as aspirin and clopidogrel

98
Q

what surgeries are used in revascularization

A
  • percutaneous transluminal coronary angioplasty with stening (PCI; stent)
  • coronary artery bypass grafting (CABG)
99
Q

what is the most common drug for hyperlipidemia

A
  • HMG CoA reductase inhibitor
  • statins
100
Q

is antibiotic prophylaxis required for SBE

A

no

101
Q

what should you know in the medical consult for all ischemic disease patients

A
  • severity of the disease
  • stability and cardiopulmonary reserve of the patient
  • type and magnitude of the dental procedure
102
Q

what questions do you ask for ischemic heart disease patients

A
  • same as HTN and:
  • have you had cardiac surgery
  • have you ever had MI
  • make sure you and/or patient have nitroglycerin on day of visit to use when applicable
  • be aware of signs and symptoms of MI and be prepared for emergency
  • no elective tx in patient with unstable angina or recent history of MI
  • do you bruise easily
103
Q

should you stop antiplatelet therapy with ischemic heart disease patients

A

no

104
Q

when should you consider a drug holiday with physician consult in patients with ischemic heart disease

A

if extensive surgery

105
Q

what is the protocol for recent MI less than 1 month ago

A
  • urgent dental care only
  • acute dental pain or infection
  • consult with physician
  • consider referral to specialized center
106
Q

what is the protocol for a past MI greater than 1 month

A
  • consider severity of cardiac status and comorbidities
  • ejection fraction can measure the degree of heart failure
  • consider appropriate management protocols
107
Q

what does ejection fraction measure

A
  • amount of blood that leaves the left ventricle after contraction
108
Q

what ejection fraction classes are okay to treat in dental care

A

first two levels from 40-70%

109
Q

what is the ideal stress reduction in stable angina or past MI

A
  • no ischemic symptoms
  • intermediate risk
  • no other risk factors
110
Q

what are the stress reduction protocol procedural precautions for ischemic heart disease

A
  • short appointments in the morning
  • pre-treatment vital signs
  • availability of nitroglycerin
  • oral sedation
  • NO - oxygen sedation
  • profound local anesthesia
  • limit amount of vasoconstrictor
  • avoid epinephrine-impregnated retraction cord
  • effective post-operative pain control
111
Q

what are the drug interactions and oral manifestations of ischemic heart disease

A
  • HLD: statins - avoid CYP inhibitors such as fluconazole and clarithromycin
  • limit epi
  • limit NSAIDs
112
Q

what is the SA node

A
  • primary pacemaker
  • regulates atrial function
  • produces P wave - atrial depolarization
113
Q

what is the AV node

A
  • regulates atrial impulses entering ventricles
  • slows conduction rate of SA generated impulses
114
Q

what is the QRS complex

A

simultaneous depolarization of the ventricles

115
Q

what is the T wave

A

repolarization of the ventricles

116
Q

what is an arrhythmia

A
  • disruption of the electrical impulse generation or conduction in the heart leads to abnormal cardiac function
117
Q

what qualifies an arrhythmia

A
  • formation of abnormal impulse
  • increased impulse formation
  • enhanced or abnormal impulse formation
  • delayed depolarization
  • re-excitation of the heart after refractory period
118
Q

the disruption in arrythmias may be due to an area of:

A
  • infarction
  • ischemia
  • electrolyte imbalance
  • medication
119
Q

what is the most common cause of sudden cardiac death

A

ventricular fibrillation

120
Q

what are the causes of arrhythmias

A
  • cardiovascular disorders
  • pulmonary disorders
  • autonomic disorder
  • hyperthyroidism
  • drugs
  • electrolyte imbalance
  • anxiety and anger
121
Q

what CVD cause arrhythmias

A
  • MI
  • mitral stenosis
  • valvular disease
  • ischemic heart disease
  • congestive heart failure
122
Q

what pulmonary disorders cause arrhythmias

A

-pneumonia
- obstructive lung disease

123
Q

what drugs can cause arrhythmiaas

A
  • epi
  • alcohol
  • digitalis
  • morphine
  • beta blockers
  • tricyclic antidepressants
124
Q

what are the classes of common cardiac arrhythmias

A
  • atrial tachycardias
  • heart block
  • ventricular arrhythmias
  • long QT syndrome
125
Q

what qualifies bradycardia

A
  • less than 60 beats/min
126
Q

what qualifies tachycardia

A

more than 100 beats/min

127
Q

what are the symptoms of arrhythmais

A
  • palpitations, fatigue
  • dizziness, syncope, angina
  • CHF
  • SOB
  • orthopnea
  • peripheral edema
128
Q

describe atrial fibrillation

A
  • most common arrhythmia
  • rapid uncontrolled atrial activity
  • irregularly irregular rhythm
  • risk of arterial clot formation - embolism and stroke
129
Q

what is a heart block

A

-impulse is partially or completely blocked
- prolonged or no conduction

130
Q

describe first degree, second degree and third degree heart block

A
  • first degree: longer conduction time
  • second degree: mobitz I (prolonged and no P wave) and mobitz II (repetitive and occasional sudden blocks w/o previous prolonged conduction time)
  • third degree: no impulses- complete block
131
Q

which degree of a heart block is an indication for a pace maker

A

third degree

132
Q
A
132
Q

describe ventricular arrhythmias

A
  • premature ventricular complexes (PVCs)
  • common
  • abnormal QRS complex + pause
  • increased risk of death if patients have underlying CVD
133
Q

describe ventricular tachycardia

A
  • if more than 3 consecutive PVC at 100 beats/min
  • if lasts for more than 30 seconds, requires termination
  • torsades de pointes- potentially life threateningde
134
Q

describe ventricular flutter and fibrillation

A

-lethal
- consequence of ischemic heart disease
- cardiac contraction is not sequential, chaotic

135
Q

what are the side effects of antiarrhthmics- sodium channel blockers

A
  • bitter taste
    -dry mouth
  • petechiae
  • gingival bleeding
  • oral ulcerations
  • xerostomia
  • dry mouth
  • taste abberation
  • metallic taste
136
Q

what are the side effects of beta blockers for arrhythmias

A

taste changes and lechnoid reactions

137
Q

what are the side effects for potassium channel blockers for arrhythmias

A
  • taste abberation
  • taste changes, lichenoid reaction
  • angioedema
138
Q

what are the side effects of calcium channel blockers for arrythmias

A

gingival overgrowths

139
Q

what are the oral anticoagulants

A
  • clopidogrel (Plavix)
  • Aspirin
140
Q

what is the low dose for baby aspirin

A

81 mg

141
Q

what are the oral anticoagulatns

A

warfarin (Coumadin)

142
Q

what are the direct oral anticoagulatns

A
  • direct thrombin inhibtor
  • direct factor Xa inhibitors
143
Q

what are the drugs prescribed for arrhythmias

A
  • clopidogrel
  • aspirin
  • oral anticoagulants
  • direct oral anticoagulants
144
Q

when should you stop anticoagulatns for dental tx

A

extensive surgery

145
Q

why should you not stop anticoagulation unless neccessary

A

risk of thrombosis and risk of massive bleed

146
Q

what are the non pharmacologic tx for arrhythmia

A
  • pacemakers
  • implant cardioverter- defribrillator
  • surgery
  • electrocardioversion and defribrillation
147
Q

what are the surgeries for arrhythmia

A
  • tissue resection
  • cardiac ablation
  • surgery to address underlying cause
148
Q

what is the protocol for high risk arrhythmias

A
  • defer elective dental care
  • dental tx should be limited to urgent care only such as acute pain, bleeding or infection
  • obtain medical consult
  • management may include an IV line, pulse oximeter, BP and oxygen and ECG monitoring
  • cautious use of epi
  • prophylactic nitroglycerin
149
Q

what is the protocol for intermediate and low risk arrhythmias

A
  • stress/anxiety reduction
  • assess pretreatment vital signs, have nitro available, limit epi
  • profound local anesthesia and pain control
150
Q

what is indicated with devices in arrhythmias

A
  • electrosurgery units contraindicated in patient with pacemakers and ICDs
  • ultrasonic scalers.- low risk interference
  • battery operated curing lights - low risk interference
151
Q

what type of interference is a concern in devices with arrythmias

A

electromagnetic

152
Q

what are the local measures for hemostasis/bleeding

A
  • gelatin sponges
  • oxidized cellulose
  • chitosan hemostatis products
  • sutures
  • gauze with applied pressure
  • topical tranexamic acid
  • topical amio=nocaproic acid
  • topical thrombin
  • electrocautery but not with pacemakers
153
Q

when are local measure done to control bleeding

A

when the risk of a patient coming off their medication is too great

154
Q
A

Dental Management of the Medically Complex Patient (13 decks)

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