Guided By:DR. NEELKAMALDR. VERMA

Submitted By:Nishtha Singhal (45)Nidhi Nagar (46)Neha Sachdeva (47)Pallavi Singh (48)BDS Final Year Batch 2005-06

CARDIOVASCULAR DISEASES

A)SYMPTOMS AND HISTORY OF PERSENT ILLNESSA)SYMPTOMS AND HISTORY OF PERSENT ILLNESS

B)PAST HISTORYB)PAST HISTORY

C)FAMILY HISTORY

D)PERSONAL HISTORY

E)TREATMENT HISTORY

SCHEME OF HISTORY TAKING

A)SYMPTOMS AND HISTORY OF PERSENT ILLNESS1. DYSPNOEA2. CHEST PAIN3. PALPITATION4. SYNCOPE5. COUGH WITH EXPECTORATION AND HAEMOPTYSIS6. CYANOSIS7. RIGHT HYPOCONDRIAL PAIN, SWELLING OF FEET AND DECREASE IN THE URINE

OUTPUT8. GASTROINTESTINAL SYMPTOMS LIKE ANOREXIA, FULLNESS OF ABDOMEN AND

VOMITING9. FATIGABILITY10. FEVER11. DIABETES MELLITUS AND HYPERTENSION

B)PAST HISTORY1. RHEUMATIC FEVER2. CYANOTIC SPELLS3. RECURRENT RESPIRATORY INFECTIONS SINCE CHILDHOOD4. DETECTION OF MURMUR/CARDIAC LESION AT SCHOOL5. RECENT DENTAL EXTRACTION, GENITOURINARY INSTRUMENTATIONS6. HYPERTENSION, DIABETES MELLITUS, ISCHAEMIC HEART DISEASE OR ANY OTHER

SIGNIFICANT MEDICAL ILLNESS

C)FAMILY HISTORY1. HYPERTENSION2. ISCHAEMIC HEART DISEASE3. CONGENTAL HEART DISEASE4. RHEUMATIC HEART DISEASE5. SUDDEN DEATH

D)PERSONAL HISTORY1. APPETITE2. WEIGHT LOSS3. DISTURBED SLEEP4. BOWEL AND BLADDER DISTURBANCES5. HABITS- SMOKING AND ALCOHOLISM6. EXPOSURE TO SYPHILIS

E)TREATMENT HISTORYNIFEDIPINE- GINGIVAL HYPERPLASIA

APPROACH TO A PATIENT OF CARDIAC DISEAASEANALYSIS OF PRESENTING SYMPTOMS

1)DYSPNOEADEFINITION:- ABNORMAL AWARENESS OF BREATHING WITH DISCOMFORT.DYSPNOEA IS A SIGNIFICANT MANIFESTATION OF CARDIAC FAILURE.DYSPNOEA IS MORE COMMONLY DUE TO LEFT-SIDED CARDIAC FAILURE

THAN DUE TO RIGHT HEART FAILURE.SEVERITY (GRADING)FUNCTIONAL GRADING OF DYSPNOEAGRADE I : NO LIMITATN OF ANY PHYSIAL ACTIVITY BUT DYSPNOEA

OCCURS ON MORE THAN ORDINARY (UNOCCUSTOMED) EXERTION.

GRADE II: DYSPNOEA ON ORDINARY DAILY ACTIVITYGRADE III : DYSPNOEA ON LESS THAN ORDINARY DAILY ACTIVITIES.GRADE IV : LIMITATIONS OF ALL ACTIVITIES( DYSPNOEA AT REST)

2)ORTHOPNOEADEFINITION: DYSPNOEA THAT OCCURS USUALLY ON LYING DOWN.CHARACTERISTIC FEATURES: USALLY OCCURS WITHIN MINUTES OF

ASSUMPTION OF RECUMBENCY.OCCURS WHEN A PATIENT IS AWAKE.INDICATES THE PRESENCE OF SEVERE LEFT HEART FAILRE (PULMONARY

OEDEMA).MANIFESTS LATER THAN PND. (IN SLOWLY PROGRESSIVE LEFT HEART

DISEASE).

3)PLATYPNEA: DYSPNOEA OCCURS ON SITTING (UPRIGHT) RATHER THAN ON LYING DOWN POSITION.EXAMPLE: LEFT ATRIAL MYXOMA,LEFT ATRIAL BALL VALVE THROMBUS

4)TREPOPNEA: OCCURS ON BREATHLESSNESS ONLY WHEN LYING DOWN IN LATERAL POSITION.

MAY BE DUE TO VENTILATION PERFUSION RELATIONSHIP ALTERATION IN CERTAIN BODY POSITION.

5)PROXIMAL NOCTURNAL DYSPNOEAATTACK OF BREATHLESSNESS AT NIGHT.SIGN OF SEVERE DEGREE OF LEFT HEART FAILURE.

6)CHEYNES-STROKE BREATHINGTHERE IS SEVERE PERIODS OF HYPERVENTILATION FOLLWEDBY PERIODS OF

APNOEA.SIGN OF SEVERE HEART FAILURE.

7)CYANOSISA)CYANOSIS APPEARING IN INFANCY INDICATES THE PRESENCE OF CONGENITAL

CARDIAC ANOMALIES WITH RIGHT TO LEFT SHUNT(TERATOLOGY OF FALLOT)B)CYANOSIS BEGINNING TO APPEAR AFTER 6 WEEKS OF AGE MAY BE AN INDICATION

OF VSD WITH SLOWLY PROGRESSIVE RIGHT VENTRICUAR OUTFLOW OBSTRUCTION.

C)HISTORY OF CYANOSIS IN A SUSPECTED PATIENT OF CONGENITAL HEART DISEASE BETWEEN THE AGE OF 5-20 YEARS INDICATES REVERSAL OF LEFT TO RIGHT SHUNT(EISENMEGER)

8)SWELLING OF FEET (PEDAL ODEMA)RIGHT HEART FAILURE CAUSES SYSTEMIC VENOUS CONGESTION WITH INCREASED HYDROSTATIC PRESURE IN THE LOWER LIMB VEINS. THIS RESULT IN THE TRANSUDATION OF FLUID CAUSING EDEMA.ANKLE EDEMA IS MORE COMMON IN AMBULATORY PATIENTS. BED-RIDDEN

PATIENT DEVELOP SACRAL EDEMA.

9) RIGHT HYPOCHODRAL PAINTHIS IS DUE TO ENLARGED AND CONGESTED LIVER AND STREACHING OF ITS

CAPSULE.

10) DECREASED URINE OUTPUTIN THE PRESENCE OF CARDIAC FAILURE DUE TO DECREASED CARDIAC

OUTPUT, RENAL BLOOD FLOW DECREASES WITH DECREASE IN THE GLOMERULAR FITRATION RATE, THIS CAUSES DECREASE OF URNE OUTPUT IN PATIENTS WITH CARDIAC FAILURE.

11)SYNCOPETRANSIENT LOSS OF CONSCIOUSNESS WITH POSTURAL COLLAPSE.

12)COUGH AND EXPECTORATION

13)PALPITATIONSUGGESTS AWARENESS OF HEARTBEAT,WHCH MAY BE UNPLEASANT.

EXAMINATION OF CARDIOVASCUAR SYSTEM

SCHEME OF EXAMINATIONGENERAL EXAMINATION

1. BUILD2. NOURISHMENT3.PALLOR4.CYANOSIS5. CLUBBING6. JAUNDICE7. PEDAL ODEMA8. LYMPHADENOPATHY

EXTERNAL MARKERS OF CARDIAC DISEASE

EXAMINATION OF :-FACEEYESEARS

SKIN AND MUCOSAEXTREMITIES

VITAL SIGNS:-PULSE

BLOOD PRESSURERESPIRATORY RATE

TEMPERATURE

EXAMINATION OF PERIPHERAL CARDIOVASCUAR SYSTEM

RADIAL PULSE:-RATE

RTHYMVOLUME

CHARACTERCONDITION OF VESSEL WALL

EXAMINATION OF:-THE CAROTIDS

THEIR PERIPHERAL PULSESJUGULAR VENOUS PULSE AND PRESSURE

PERIPHERAL SIGNS OF WIDE PULSE PRESSURE(IN RELEVANT SITUATION)PERIPHERAL SIGNS OF INFECTIVE

ENDOCARDITISPERIPHERAL SIGNS OF RHEUMATIC FEVER

EXAMINATION OF THE PRECORDIUM

INSPECTION1. PRECORDIAL BULGEPOSITION OF APICAL IMPULSEPULSATIONS IN THE:-A. LEFT PARASTERNAL REGIONB. 2ND LEFT INTERCOSTAL SPACEC. 2ND RIGHT INTERCOSTAL SPACED. EPIGASTRIC PULSATIONE. SUPRASTERNAL PULSATIONF. ENGORGED VEINS OVER THE CHESTG. SPINE(KYPHOSCOLIOSIS)

• PALPATION1)APICAL IMPULSE- POSITION AND

CHARACTER2)LEFT PARASTERNAL HEAVE3) OF EPIGASTRIC PULSATIONTHRILLS4)PALPABLE SOUNDS

PERCUSSION1)RIGHT CARDIAC BORDER2)LEFT CARDIAC BORDER3)LEFT AND RIGHT 2ND INTERCOSTAL SPACE.

• AUSCULTATION• MITRAL, TRICUSPID, AORTIC, PULMONARY AND OTHER

ADDITIONAL AREAS FOR:-• A. 1ST AND 2ND HEART SOUNDS• B. ADDITOINAL SOUNDS• C. MURMURS

EXAMINATION ALSO INCLUDES THE FOLOWING SIGNS

A)PALLOR

SEVERE ANEMIA MAY BE ASSOCIATED WITH:1. CHRONIC CCF2. INFECTIVE ENDOCARDITISSEVERE ANEMIA CAN ITSELF CAUSE- CARDIAC FAILURE OR

AGGRAVATE THE UNDERLYING HEART DISEASE.PATIENTS WITH CYANOTIC CONGENITAL HEART DISEASE MAY

HAVE POLYCYTHEMIA WITH SUFFUSED CONJUNCTIVA.

B)CYANOSIS:

CENTRAL CYANOSIS OCCURS IN:• 1. CYANOTIC CONGENITAL HEART DISEASE• 2. REVERSAL OF LEFT TO RIGHT SHUNT• 3. INTRAPULMONARY RIGHT TO LEFT SHUNT• 4. PULMONARY EDEMA (LEFT HEART FAILURE)

• PERIPHERAL CYANOSIS OCCURS IN:• 1. CONGENITAL CARDIAC FAILURE• 2. PERIPHERAL VASCULAR DISEASE

• DIFFERENTIAL CYANOSIS:• 1. FEET AND TOES ARE BLUE BUT HANDS AND FINGERS ARE NOT CYNOSED.• E.G. PDA WITH PULMONARY HYPERTENSION WITH REVERSAL OF SHUNT.

• REVERSE DIFFERENTAL CYANOSIS:• 1. FINGERS ARE MORE CYANOSED THAN TOES.• E.G. TRANSPSITION OF GREAT VESSELS WITH PULMONARY HYPERTENSION

WITH PREDUCTAL COARCTATION WITH REVERSED FLOW THROUGH PDA.

C))CLUBBING

CARDIAC CAUSES:1. CYANOTIC CONGENTAL HEART DISEASE2. REVERSAL OF LEFT TO RIGHT SHUNT3. INFECTIVE ENDOCARDITIS

CYANOTIC CONGENITAL HEART DISEASE MAY BE ASSOCIATED WITH HYPERTROPHIC PULMONARY OSTEOARTHROPATHY.

D)JAUNDICE

FOLLOWING CARDIAC CONDITIONS MAY BE ASSOCIATED WITH JAUNDICE:

1. CONGESTIVE CARDIAC FAILURE WITH CONGESTIVE HEPATOMEGALY

2. CARDIAC CIRRHOSIS3. PULMONARY INFARCTION

E)PEDAL EDEMAPITTING EDEMA OF FEET CAN OCCUR IN:1. CONGESTIVE CARDIAC FAILURE2. CONSTRICTIVE PERICARDITIS3. TRICUSPID VALVE DISEASE

F)LYMPHADENPATHY:CONDITION ASSOCIATED WITH GENERALIZED

LYMPHADENOPATHY MAY INVOLVE THE CARDIOVASCULAR SYSTEM. E.G. LYMPHOMA, SLE ETC.

EXAMINATION OF FACE

• FOLLOWING FEATURES MAY BE INDICATIVE OF UNDERLYING CAARDIAC ABNORMALITY WHILE EXAMINATION OF FACE.

ABNORMALITIES CONDITION ASSOCIATED

ELFIN FACIES RECEDING JAWS,

FLARED NOSTRILS,

POINTED EARS

SUPRAVENTRICULAR AORTIC STENOSIS

HIGH ARCHED PALATE MARFAN SYNDROME

MITRAL FACIES MALAR FLUSH AND PINKISH PURPLE PATCHES OVER THE CHEEK

MITRAL STENOSIS WITH DECREASED CARDIAC OUTPUT AND SYSTEMIC VASOCNSTRICTION

MALAR FLUSH

MARFAN SYNDROME

TERATOLGY OF FALLOT

Acute macroglossia:the tongue is diffuselyenlarged and bright red along its lateral portion. The patient had bleeding into the tongue while on anticoagulants.

Acute macroglossia due to Enalapril: this75-year-old Black female developed acute swelling oftongue and lips after being on enalapril for 2 days. She was unable to talk or swallow (upper photo). In lower photo, 2 days after stopping enalapril, the tongue and lips have returned to their normal size.

EXAMINATION OF MOUTH

GUM HYPERPLASIA DUE TO DILANTIN. SIMILAR FINDINGSMAY BE SEEN IN PATIENTS ON NIFEDIPINE

TANGIER DISEASE OF THE TONSILS:THE TONSILS ARE ENLARGED WITH BRIGHTORANGE YELLOW STREAKS (“TIGER STRIPES”)(PREMATURE CAD).

EXAMINATION OF EAR:EXAMINATION OF EAR:

PRESENCE OF CREASE IN THE PINNA OF THE EAR- PRESENCE OF CREASE IN THE PINNA OF THE EAR-

ASSOCIATED WITH INCREASED INCIDENCE OF CORONARY ARTERY ASSOCIATED WITH INCREASED INCIDENCE OF CORONARY ARTERY DISEASE.DISEASE.

• EXAMINATION OF EYES:

• EXOPTHALMUS: ASSOCIATED WITH THYROID ARTERY DISEASE.• BLUE SCLERA: OSTEOGENESIS IMPERFECTA WITH AORTIC

REGULTATION.• OPTHALMIC FUNDUS: LOOK FOR• A. ARTERIOSCLEROTIC CHANGES• B. HYPERTENSIVE RETINOPATHY• C. ROTH’S SPOTS( OF INFECTIVE ENDOCARDITIS)• D. ARTERIAL PULSATION IN AR• E. CORK SCREW ARTERIES- COARCTATION OF AORTA.

BLUE SCLERA ROTHS SPOT

EXAMINATION OF FINGER

CLUBBING

CLUBING NEGATIVE

OSLERS NODE IN ENDOCARDITIS

SUBUNGAL HAEMORRHAGES

JANEWAY LESIONS

CAUSES OF CARDIOVASCLAR DISEASE

ORGANIC DISEASE OF HEART1. MYOCARDIALA. OVERLOAD SECONDARY TO HYPERTENSON OR VALVE DISEASEB. CORONARY( ISCHAEMIC) HEART DISEASEC. CARDIOMYOPATHIES

2. ENDOCARDIALA. RHEUMATIC HEART DISEASEB. CONGENITAL ANOMALIESC. INFECTIVE ENDOCARDITIS

3. PERICARDIALA. PERICARDITISB. PERICARDIAL EFFUSIONC. FUNCTIONAL DISORDERS

DUE TO HYPERTENSION

DUE TO ABNORMALITIES IN HEART RATEA. TACHYCARDIAB. BRADICARDIAC. OTHER DYSRTHYMIAS

CHANGES IN CIRCULATORY VOLUMEA. HYPOVOLOEMIA (SHOCH SYNDROME)B. HYPERVOLAEMIA ( CIRCULATORY OVERLOAD)C. OTHERS

FUNCTIONAL CAPACITY OBJECTIVE ASSESSMENT

CLASS I. PATIENTS WITH CARDIAC DISEASE BUT WITHOUT RESULTING LIMITATION OF PHYSICAL ACTIVITY. ORDINARY PHYSICAL ACTIVITY DOES NOT CAUSE UNDUE FATIGUE, PALPITATION, DYSPNEA, OR ANGINAL PAIN.

A. NO OBJECTIVE EVIDENCE OF CARDIOVASCULAR DISEASE.

CLASS II. PATIENTS WITH CARDIAC DISEASE RESULTING IN SLIGHT LIMITATION OF PHYSICAL ACTIVITY. THEY ARE COMFORTABLE AT REST. ORDINARY PHYSICAL ACTIVITY RESULTS IN FATIGUE, PALPITATION, DYSPNEA, OR ANGINAL PAIN.

B. OBJECTIVE EVIDENCE OF MINIMAL CARDIOVASCULAR DISEASE.

CLASS III. PATIENTS WITH CARDIAC DISEASE RESULTING IN MARKED LIMITATION OF PHYSICAL ACTIVITY. THEY ARE COMFORTABLE AT REST. LESS THAN ORDINARY ACTIVITY CAUSES FATIGUE, PALPITATION, DYSPNEA, OR ANGINAL PAIN.

C. OBJECTIVE EVIDENCE OF MODERATELY SEVERE CARDIOVASCULAR DISEASE.

CLASS IV. PATIENTS WITH CARDIAC DISEASE RESULTING IN INABILITY TO CARRY ON ANY PHYSICAL ACTIVITY WITHOUT DISCOMFORT. SYMPTOMS OF HEART FAILURE OR THE ANGINAL SYNDROME MAY BE PRESENT EVEN AT REST. IF ANY PHYSICAL ACTIVITY IS UNDERTAKEN, DISCOMFORT IS INCREASED.

D. OBJECTIVE EVIDENCE OF SEVERE CARDIOVASCULAR DISEASE.

NYHA CLASSIFIACTION

HYPERTENSIONHypertension is known as Silent Killer of mankind.

Most of the sufferers (85 %) are asymptomatic and hence early diagnosis is a problem.

More than 65 lakh Americans and over 1 billion worlwide suffer with hypertension.

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Definition• Hypertension is defined as

having systolic blood pressure (SBP) >/= 140mm of Hg or

• diastolic blood pressure (DBP) >/= 90mm of Hg or

• as having to use antihypertensive medications.

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Classification

The Seventh Joint National Committee Criteria (JNC VII) classifies hypertension for adults aged 18 years and older into following stages:

Blood Pressure Classification SBP(mm Hg) DBP(mmHg)•Normal <120 & <90•Pre hypertension 120-139 & 80-89•Stage I hypertension 140-159 & 90-99•Stage II hypertension >/=160 & >/=100

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Types

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Other Risk Factor of Hypertension

•Lack of exercise

•Increased salt intake

•Family history

•Too little potassium

•Alcohol

•Smoking

•Stress &

•Age

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Effect of hypertension

The common target organs damaged by long standing hypertension are:

•Brain

•Heart

•Kidneys

•Eyes &

•Peripheral arteries. 32

Complications of hypertension

Left ventricular hypertrophyHeart failureCerebral hemorrhageRenal insufficiencyAortic dissectionAtherosclerotic disease

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SymptomsSymptoms due to hypertension:

1.Headache - usually in morning hours.

2.Dizziness

3.Epistaxis

Symptoms due to affection of target organs:

1.CVS:

a.Dyspnea on exertion

b.Anginal chest pain

c.Palpitations34

2. Kidneys: Hematuria , nocturia , polyuria .

3.CNS:

a.Transient ischemic attacks ( TIA or Stroke)

b.Hypertensive encephalopathy(headache , vomiting etc.)

c.Dizziness, Tinnitus & syncope.

4. Retina:

a.Blurred vision or

b.sudden blindness.35

Diagnosis

• Physical Examination • Laboratory and Additional Testing – it includes

Routine laboratory procedures like hemoglobin, urinalysis, routine blood chemistries and fasting lipid profile.

• Electrocardiography • Ambulatory BP Monitoring• Plasma renin activity testing• Radiologic testing

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WHITE COAT HYPERTENSION

‘’White coat hypertension’’ is a phenomenon in which individuals present with persistent elevated BP in a clinical setting but present with non-elevated BP in an ambulatory setting.

•20% of mild hypertensive individuals may present with white coat hypertension. 37

Dental Management• Measure and record BP at initial visit

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Recheck :-•Every 2 yrs for patient with BP <120/80 mm Hg.•Every 1 yr for patient with BP 120-139/80-89 mm Hg.•Every visit for patient with BP >140-90 mm Hg.•Every visit for patient with established coronary artery disease, diabetes mellitus or chronic renal disease with BP >135-85 mm Hg.•Every visit for patient with established hypertension. Before initiating dental care:•Assess presence of hypertension•Determine presence of target organ disease•Determine dental treatment modifications

1. Asymptomatic BP <159/99 mm Hg, no history of target organ disease

• No modifications needed• Can safely be treated in dental setting

2. Asymptomatic BP 160-179/100-109 mm Hg, no history of target organ disease

• Assessment on an individual basis with regard to type of dental procedure BP>180/110 mm Hg, no history of target organ disease

• No elective dental care

3. Presence of target organ disease or poorly controlled diabetes mellitus

• No elective dental care until BP is controlled , preferable below 140-90 mm Hg.

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TREATMENT OF HYPERTENSION

NON PHARMACOLOGICAL TREATMENT LIFESTYLE

MODIFICATIONS

1.Salt restriction

2.Weight reduction

3. Stop smoking

4. Diet modifications such as:• Reduce intake of Cholesterol

& Saturated fat.• Adequate intake of Calcium &

Magnesium.41

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5. Limit of alcohol intake

6. Relaxation such as yoga, psychotherapy etc.

7. Regular exercise.

ORAL MEDICATIONS USED FOR TREATMENT OF HYPERTENSION

•Diuretics

•Beta-Adrenergic Blockers

•Central Acting Inhibitors

•Peripheral Acting Inhibitors

•Non-Selective alpha & beta Adrenergic Inhibitors

•Vasodilators

•Angiotensin Converting Enzyme ACE Inhibitors

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ORAL MANIFESTATION OF HYPERTENSION

There are no recognized manifestations of hypertension but anti-hypertensive drugs can often cause side affects , such as:•Xerostomia,•Gingival overgrowth,•Salivary gland swelling or pain,•Lichenoid drug reactions,•Erythema multiforme,•Taste sense alteration,•Paresthesia.

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CONCLUSION

• HYPERTENSION has no cure, but it can be controlled with proper diet, lifestyle changes, and if necessary medications.

• Get regular health check ups. Think about the consequences of untreated high blood pressure.

• Do not take chances with the disease that can be controlled.

• Lastly, Hypertension is a silent disease, but its silence is not golden.

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CORONARY (ISHAEMIC)

ARTERY DISEASE

• Atherosclerosis is the most common cause of CAD

ETIOPATHOGENESIS

Various risk factors include:

1. lipids (especially HDL)

2. hypertension

3. diabetes mellitus & glucose intolerance

4. cigarette smoking

5. lifestyle & dietary factors

6. exercise

7. obesity

8. vitamins & homocystiene

9. plasma fibrinogen

10. endothelial dysfunction

11. antioxidants

12. estrogen deficiency

RISK FACTORS Induce variety of pathological processes

Interaction & disruption of vascular endothelium

Plaque formation

Effective arterial luminal area compromised

Myocardial ischaemia acute plaque rupture

thrombus formation angina M I

DIAGNOSIS

1) Based on clinical presentation : chest tightness Jaw discomfort Left arm pain Dyspnea Epigastric distress

2) E.C.G.

3) Exercise E.C.G.

4) Coronary Angiography

5) P.C.I.(Percutaneous Coronary Intervention)

MANAGEMENT

Management of CAD depends on:• Extent and severity of ischemia• Exercise capacity• Prognosis based on exercise testing• Overall LV function• Associated features such as diabetes mellitus Patients with a small ischemic burden, normal exercise

tolerance, and normal LV function may be safely treated with pharmacologic therapy.

Selected use of aspirin, β-blockers, ACEIs, and HMG CoA reductase inhibitors.

Nitrates and calcium channel blockers may be added to primary agents to relieve symptoms of ischemia in selected patients.

• Percutaneous coronary intervention (PCI) with percutaneous transluminal coronary angioplasty (PTCA) and intra coronary stenting relieves symptoms chronic ishchemia.

• Patient with complex multivessel CAD require PCI with medical therapy of surgical revascularization.

• Patients with reduced LV function and severe ischemia, often associated with left main or multivessel CAD, are best served by coronary artery bypass graft (CABG) surgery.

DENTAL ASPECTS

• STRESS, ANXIETY, EXERTION or PAIN can provoke angina

• Short, minimally stressful dental appointments

• Late morning appointments• Excessive dose of LA containing adrenaline

to be avoided in patients taking beta blockers

• More severe dental caries and periodontal disease in pts of IHD

Acute Coronary Syndromes

• Represent a continuous spectrum of disease ranging from unstable angina to MI

Angina pectoris• Name given to paroxysms of severe chest pain

CLINICAL FEATURES1) 40 TO 60 years , M > F2) pain often described as sense of Strangling, choking , Tightness,

Heaviness ,Compression, or Constriction of chest3) PAIN MAY RADIATE TO JAW or left arm4) rarely pain in mandible, teeth or other tissues

PRECIPITATING FACTORS• Physical exertion(main) particularly in cold weather• Emotion(anger or anxiety) & stress caused by fear or pain

TYPICALLY RELEIVED BY REST

Dental aspects

Preoprerative glyceryl trinitrate & oral sedation advised sometimes

dental care carried with minimal anxiety & oxygen saturation

Monitor pulse & B.P. POST ANGIOPLASTY elective dental care deffered for 6

months , emergency dental care in a hospital setting PTS with BYPASS GRAFTS – no anti biotic cover

against infective endocarditis

- LA containing adrenaline is contraindicated (may ppt dysrhythmia)

PTS with vascular stents – no antibiotic cover

except during 1st 6 week postop for emergency dental care

DRUGS used in t/t of angina may cause oral adverse effects like :

-lichenoid reaction Ca channel

- gingival swelling blockers

- ulcers (nicorandil)

Gingival hyperplasia in patient consuming Ca channel blockers

Myocardial infarction• Synonyms – coronary thrombosis or heart attack

CLINICAL FEATURES1. Clinical picture is variable2. More than 50% patients are symptomless3. MI may be preceded by angina often felt as indigestion like pain4. any anginal attack lasting longer than 30 minutes is considered

MI5. Tachycardia &irregular pulse6. nausea, vomitting, sweating ,restlessness, facial pallor7. breathlessness, cough8. Loss of conciousness, shock & even death9. Many pts die within 1st hour to few days after attack THUS, MI is a MEDICAL EMERGENCY

DIAGNOSIS

I. Based on clinical features

II. Elevated TLC & ESR during 1st wk

III. ECG changes

IV. Rise in serum “cardiac” enzymes ( CPK)

V. Rise in troponin T within 4-8 hours

VI. echocardiography

General Precautions during Dental Procedures

• Dental clinic should have advanced cardiac life support or at least basic cardiac life support.

• Use of pulse oximeter to determine the level oxygenation.• Automatic external defibrillator.• Determination of vital signs prior to dental care.• BP & pulse rate & rhythm should be recorded & any

abnormal findings should be addressed.• Premedication with antianxiety drugs and inhalation

nitrous oxide in anxious patients.• Elective procedures esp those requiring GA should be

avoided for atleast 4 wks aftr MI. consult pt’s physician prior to dental therapy

Management on dental chair1. Terminate all dental treatment2. Position pt in semirecline position3. Give nitroglycerin(TNG) (abt 0.4 mg) tablet or spray4. Administer oxygen5. Check pulse & B.P.

Discomfort relieved Discomfort continues 3 mins after 2nd TNG 6. Assume angina pectoris is 6. give 2nd TNG dose present 7. monitor vital signs. 7. Slowly taper oxygen over 5 mins8. Modify t/t to prevent recurrence discomfort discomfort continues relieved 3 mins after

TNG

8. give 3rd TNG dose

9. Monitor vitals

10. Call for medical assistance

Discomfort relieved discomfort continues 3 mins after 3 rd TNG dose

11. Refer pt for medical 12.assume MI is in progress

evaluation before 13. start i.v. line with drip of a crystalloid solution

further dental care at 30 mL/ hr

14. If discomfort severe titrate morfine sulphate 2mg s/c or i/v every 3 mins until relief is obtained

15. Transport to emergency care. Administer Basic Life Support ,if necessary.

Anticoagulation Therapy & Dental Care• Anticoagulant therapy is used both to treat & to

prevent throboembolism.• 2 major types : 1. antiplatlet medications 2. antithrombin medications• Acetylsalicylic acid (ASA) + clopidogrel

( anticoagulant) given for 4 weeks after stent implantation

• daily aspirin typically continued lifelong.• May increase risk of oral bleeding following

surgical procedures• Associated conditions which predispose patient to

uncontrolled hemostasis : uraemia or liver diseases or use of NSAIDS

• If emergency surgery needs to be done,DDAVP(1- desamino-8-D-arginine vasopressin) is administered{0.3 micro kg/body wt parenterally} within 1 hr of surgery

• Antithrombin medications are dicumarols ( eg. Warfarin), it inhibits biosynthesis of vit. – K dependent coagulations protein.

- Efficacy monitored by prothrombin time or the international normalized ratio (INR), which is calculated on the basis of international sensitivity index (ISI).

- INR ranges from 2.0 – 3.5 & it should be performed within 24 hrs of surgery.

- If INR is < 3.5, anticoagulation therapy should be discontinued before minor surgical procedures.

3 different protocols used to treat patients with elevated INR :

• Ist protocol – warfarin not discontinued (minimizes thromboembolic events & increases risk of bleeding after surgery).

• IInd protocol – warfarin discontinued (drug should be discontinued 2-3 days prior to surgery, during this period patient is at risk of developing thromboembolic event but not bleeding).

• IIIrd protocol – warfarin discontinued & patient placed on alternative anticoagulant therapy (thromboembolic event minimized).

• We always plan a t/t by comparing potential risk for excessive bleeding after procedures if anticoagulation therapy is not reduced or stopped v/s risk of pt experiencing a thromboembolic event if anticoagulation therapy is altered.

Rheumatic fever is an inflammatory disease that may develop two to three weeks after a

Group A streptococcal infection (such as strep throat or scarlet fever). It is believed to be caused by antibody cross-reactivity and

can involve the heart, joints, skin, and

Brain

Acute rheumatic fever commonly appears in children ages 5 through 15, with only 20% of

first time attacks occurring in adults

Rheumatic fever

• What are the symptoms of strep throat?

• sudden onset of sore throat (streptococcal oropharyngitis)

• pain on swallowing • fever, usually 101–104°F • Headache • Red and edematous soft palate

and oropharynx.

• Areas of tonsillar ulceration and exudation.

• abdominal pain, nausea and vomiting may also occur, especially in children

• What are the symptoms/clinical features of rheumatic fever?

• Symptoms may include:• fever • painful, tender, red swollen joints • pain in one joint that migrates to another one • heart palpitations • chest pain  • shortness of breath • skin rashes • fatigue • small, painless nodules under the skin 

• Diagnosis• Two major criteria, or

one major and two minor criteria,

• Major criteria(jones)• Joints (Migratory

polyarthritis): • O [imagine heart-shaped

O] (carditis): • Nodules (subcutaneous

nodules - a form of Aschoff bodies):

• Erythema marginatum: • Sydenham's chorea

• mnemonic: C.A.N.C.ER

• C: Carditis

• A: Arthritis

• N: Nodules (sub cutaneous)

• C: Chorea

• ER: ERythema Marginatum

• Another way of remembering it is CASES

• Minor criteria

• Fever:

• Arthralgia

• Laboratory abnormalities: increased Erythrocyte sedimentation rate

• Electrocardiogram abnormalities

• Evidence of Group A Strep infection: elevated or rising Antistreptolysin O titre,

• LAB INVESTIGATIONS-• raised ESR• culture studies of throat

swabs is always negative in RF

• High anti sterptolysin o(ASO)titre-!300 todd units

• Chest radiograph-enlargement of heart

• ECG-prolonged PR interval

• Echocardiogram-confirms ventricular dilatation n pericardial effusion

• TREATMENT-• Oral phenoxymthylpenicillin 500 mguntil

age of 20 yrs.• Allergic to penicillin,sulfadimidine by

mouth.• Aspirin for fever and pain 50mg/kg bwt in 4

hrly doses• Corticosteroids 60-80mg prednisolone• Digoxin and diuretics for heart failure• Ballon valvuloplasty,using inoue balloon,if

mitral valves damage.

• DENTAL CONSIDERATION-

• Dental extractions and local anesthesia in consent with physician.

• The prophylactic use of antibiotics prior to a dental procedure is now recommended ONLY for those patients with the highest risk of adverse outcome resulting from endocarditis

• No2 used with approval of physician.

• GA shd be avoided if essential must be given in hospital.

• Rheumatic heart disease-

• History of rheumatic fever during childhood or adollescence can act as a predisposing factor for RHD after several years.

• Common signs-murmur due to valvular damage n later enlargement of heart.

• ORAL MANIFESTATIONS

• Most prominent during acute phase,

• Pharyngitis• Inc oral temperature• Distended neck veins

and a bluish color of the skin.

• DENTAL CONSIDERATIONS-• To prevent complication of infective

endocarditis ,all dental procedures should be carried under antibiotic cover.

• Amoxicillin prophylaxis-1 hour before and 6 hours after the initial dose.

• Good oral hygiene measures ,fluoride treatment, chlorhexidine rinses and routine cleanings to reduce harmful bacteremias.

• Proper history should be taken to identify history of rheumatic fever during childhood.

• Suspicious cases should be referred to cardiologist for cardiac evaluation prior to dental procedures.

• Clindamycin or erythromycin prophylaxis during dental treatment.

• Elective dental treatment under physician consultation.

• HEART FAILURE-• Heart failure (HF) is a

condition in which a problem with the structure or function of the heart impairs its ability to supply sufficient blood flow to meet the body's needs .

• Common causes of heart failure –

• ischemic heart diseases• Hypertension• Valvular diseases

• Left-sided failure(MORE COMMON)• Backward failure of the left ventricle causes congestion

of the pulmonary vasculature, and so the symptoms are predominantly respiratory in nature. The patient will have dyspnea (shortness of breath) on exertion and in severe cases, dyspnea at rest. Increasing breathlessness on lying flat, called orthopnea.

• Another symptom of heart failure is paroxysmal nocturnal dyspnea also known as "cardiac asthma", a sudden nighttime attack of severe breathlessness, usually several hours after going to sleep

• Inadequate cerebral oxygenation leads to loss of concentration,restlessness and irritability.

• Right-sided failure

• Backward failure of the right ventricle leads to congestion of systemic capillaries. This helps to generate excess fluid accumulation in the body. This causes swelling under the skin (termed peripheral edema or anasarca)

• IF occurs with MS is called congestive heart failure.

• Biventricular failure ,faiure of one side of heart leads to failure of other.

• CLINICAL FEATURES• pedal edema• Dyspnea• Congestion of neck veins• Cynosis• Fatigue

• DIAGNOSIS• Imaging

Echocardiography• Electrophysiology

electrocardiogram (ECG/EKG)

• Blood tests• Angiography • Monitoring

• TREATMENT MODALITIES-• Diet and lifestyle measures • Weight reduction • Monitor weight• Sodium restriction -excessive sodium intake may

precipitate or exacerbate heart failure • Fluid restriction – patients with CHF have a

diminished ability to excrete free water load • stress reduction,rest• Stop smoking

• Pharmacological management • diuretic • Loop diuretics (e.g. furosemide, bumetanide)

• ACE inhibitor/ Angiotensin II receptor antagonist Positive inotropes

• Digoxin • Beta blockers • Alternative vasodilators• The combination of isosorbide

dinitrate/hydralazine

ORAL MANIFESTATIONS

• Distention of the external jugular viens.

• Compensatory polycythemia –ruddy complexion and bleeding tendencies.

• Abnormal production of clotting factors

• Bleeding can be spontaneous or extravasational.

• DENTAL ASPECTS-• The dental chair should be kept in partially

reclining or erect position and patient should be raised slowly in upright position.

• Emergency dental care should be conservative ,principally with analgesics and antibiotics.

• Appointments should be short

• Non stressful appointments

• Patients are best treated in late morning because of epinephrine levels peak in early morning.

• Bupivacaine should be avoided as it is cardiotoxic.

• An aspirating syringe should be used to give local anesthetic

• Epinephrine containing LA should be not given in large doses to patients taking beta blockers.

• Gingival retraction cords containing epinephrine should be avoided

• Supplemental o2 shd be available

• Rubber dam is contraindicated when it contributes to breathing difficulty.

• NSAIDS other than aspirin shd be avoided in pts taking ACE inhibitors(renal damage).

• Erythromycin and tetracycline to be avoided as they may induce digitalis toxicity

• GA is contraindicated in cardiac failure.until under control(venous thrombosis and pulmonary embolism)

• ACE inhibitors can sometimes cause erythema multiforme,angioedema or burning mouth.

• Antibiotic prophylaxis req for dental care

• History of recent MI ,req delay of elective dental care for 6 months

Ortho static hypotension

• CARDIAC ARRHYTHMIA -Cardiac arrhythmia (also dysrhythmia) is a term for any of a large and heterogeneous group of conditions in which there is abnormal electrical activity in the heart. The heart beat may be too fast or too slow, and may be regular or irregular

• Accordingly there r 2 types-

• Atrial arrhythmia• Ventricular arrhythmia• More fatal than AA

• TACHYCARDIA-

• Any heart rate faster than 100 beats/minute is labelled tachycardia. BRADYCARDIAS

• A slow rhythm, (less than 60 beats/min), can lead to syncope.

• HEART BLOCK-blockage of cardiac impulse anywhere in the conduction system.

TREATMENT

• AA-• Digoxin• Propanolol• qUinidine sulphate• Anticoagulant such as

warfarin

• VA-• Procainamide• Phenytoin• Dispyramide• Propanolol

• Physical maneuvers• Antiarrhythmic drugs • Electricity • Electrical cautery

ORAL MANIFESTATIONS

• Procainamide can cause agranulocytosis,oral ulcerations

• Quinidine-infrequent oral ulcerations

• Disopyramide is anticholinergic agent capable of producing xerostomia.

• verapamil,enalapril can cause gingival hyperplasia.

• DENTAL CONSIDERATIONS-

• A proper history to be taken

• Stress and anxiety• be minimized• Short appointments• Use of epinephrine to be

minimized• Proper chair position is

important, SUPINE• At end of appointment

chair should be raised slowly to minimize orthostatic hypotension.

• Use of vasoconstrictors should be minimized in pts taking digitalis glycosides.

• The equipments like pulp testers ,ultrasonic scalers ,electrosurgical units ,should not be in close proximity.

• Prophylactic antibiotics before and after treatment in recently placed pacemaker patients.

• Pts who report palpitations or skipped beats must be evaluated by physician

• Sustained sinus tachycardia above 100 beats/min in resting position is indicative of sinus tachycardia

• Dental treatment shd not be carried out in patients with irregular pulse

• Long use of procainamide can cause a lupus like syndrome

• Drug like quinidine can cause erythema multiforme

• CA may be induced by general anesthesia and vagal reflex

ORAL HEALTH CONSIDERATION & ORAL MANIFESTATION

• Valvular heart disease that compromises cardiac output produces signs of hypoxemia.

• Cyanosis of lips and oral mucosa is the most prominent oral sign of tissue hypoxia.

• According to American heart association guidelines: Antibiotic prophylaxis should be administered to patitents who have undergone mitral or aortic valve repair or replacement.

• Patients with a prior history of infective endocarditis.

• Patients with mitral or aortic regurgigation or stenosis.

• Patients with mitral valvular prolapse with valvular regurgigation.

• Prosthetic heart valves.

• Previous bacterial endocarditis.

• Acquired valvular dysfunction.

• Complex cyanotic congenital heart disease.

• Surgically constructed systemic pulmonary shunts.

ORAL PROCEDURES & NEED FOR ANTIBIOTIC PROPHYLAXIS TO MINIMISE RISK OF

BACTERIAL ENDOCARDITIS

• Extractions.• Periodontal procedures including

surgery,subgingival,placement of antibiotic fibers or Strips,scaling &root planning.

• Implant placement.• Tooth reimplantation.• Placement of orthodontic bands(not brackets).• Endodontic instrumentation.• Intra ligamentary injection.• Prophylatic cleaning of teeth where bleeding is anticipated.• Other procedure in which significant bleeding is anticipated.

STANDARD REGIMENS FOR PROPHYLAXIS TO MINIMISE RISK OF BACTERIAL

ENDOCARDITIS

• Oral medication.

• Adults & children not allergic to penicillin-amoxicillin.

• Adults & children allergic to penicillin-clindamycin.

• Non oral medication.

• Adults & Childrens not allergic to penicillin-iv or im ampicillin.

• Adults & children alergic to penicillin-iv clindamycin.