* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Cardiovascular Diseases and its dental implications
Remote ischemic conditioning wikipedia , lookup
Cardiovascular disease wikipedia , lookup
Heart failure wikipedia , lookup
Electrocardiography wikipedia , lookup
Cardiac contractility modulation wikipedia , lookup
Infective endocarditis wikipedia , lookup
Hypertrophic cardiomyopathy wikipedia , lookup
Arrhythmogenic right ventricular dysplasia wikipedia , lookup
Lutembacher's syndrome wikipedia , lookup
Rheumatic fever wikipedia , lookup
Management of acute coronary syndrome wikipedia , lookup
Antihypertensive drug wikipedia , lookup
Quantium Medical Cardiac Output wikipedia , lookup
Coronary artery disease wikipedia , lookup
Dextro-Transposition of the great arteries wikipedia , lookup
Cardiovascular Diseases and its dental implications Dr Elsanousi M Taher BDS, MSc., FFDRCSI E-mail: [email protected] Signs of cardiac diseases – Cyanosis – Finger clubbing – Leg oedema – Distended neck veins and elevated jugular venous pressure Symptoms of cardiac diseases – Chest pain: Angina pectoris MI Pericarditis – Dyspnea (Lt. side heart failure is the most common heart cause of it) – Orthopnea – Paroxysmal nocturnal dyspnea – Palpitation – Syncope and dizziness as a result of failure to maintain an adequate circulation to the brain Distended neck veins in CVD occur in Rt. Side heart failure and abnormalities of tricuspid valve when Rt. Atrium contract against narrow or closed valve Severe central cyanosis Severe central & peripheral cyanosis Central cyanosis may be seen in the oral cavity Drum stick like finger tips Note the bluish discoloration of nail beds Leg edema in cardiac patient Bilateral pitting leg edema is indicative of heart failure Cardiovascular Diseases Congenital heart diseases: a) non cyanotic b) cyanotic What is cyanosis ? Non-cyanotic diseases which include: Ventricular septal defect (VSD): – The most common (1l3 of all malformations) – Lt to Rt. shunt Atrial septal defect (ASD): – 10% of cases – May be asymptomatic – Cause arrhythmias Non-cyanotic diseases which include: Patent ductus arteriosus: – is caused by failure of closure of the communication between the pulmonary artery and descending aorta after birth – Cause continuous shunting from aorta to pulmonary artery increasing the pulmonary venous return to the left heart to increase Lt ventricular cardiac load and Lt heart failure Coarctation of aorta: narrowing of the lumen of the arch of aorta distal to the origin of the left subclavian artery: – Cause secondary hypertension – Delay between the radial and femoral pulses ASD VSD Coarctation of aorta Tetralogy of Fallot’s Cyanotic diseases: Fallot’s tetralogy: – pulmonary stenosis – VSD – Right Ventricular hypertrophy – Dextroposition of aorta to overlies the outflow tracts of both ventricles Rheumatic Fever Is immunologically mediated disease caused by cross reactivity between the antibodies formed against M protein of the cell wall of the Lancefield group A ß-hemolytic streptococci and human connective tissues It is usually follows sore throat and pharyngitis Affects children (5-15 years old) The patient usually hospitalized for many weeks After recovery, the patient will be kept under antibiotic until he/she is no longer at risk (early twenties) Its complicated sequel may result in rheumatic heart disease (stenosis & incompetence) 60% of patients with caraditis develop chronic rheumatic heart disease Major criteria Revised Jones criteria for the diagnosis of rheumatic fever (two major or one major and two minor) - caraditis - migratory polyarthritis - Sydenham’s chorea - erythema marginatum - subcutaneous nodules Minor criteria - fever raised ESR arthralgia leukocytosis characteristic ECG changes (prolonged P-R interval) Plus - evidence of preceding streptococcal infection: positive throat swab culture and raised streptolysin O Rheumatic Heart Disease Develops subsequently in at least 50-60% of patients affected by rheumatic fever with caraditis The mitral valve is affected in > 90% of cases Many patients may not be aware that they have had rheumatic heart disease, in that case, active inquiry must be made for history of chorea, migratory polyarthropathy or growing pains in childhood Patients with H/O rheumatic fever should be considered to have rheumatic heart disease and at risk to develop infective endocaraditis until proved otherwise Heart murmurs “Abnormal heart sounds that result from vibrations caused by turbulent blood flow through the valves or chambers of the heart“ – They are classified into: II. Innocent, functional or physiological murmur: – – as in children and pregnancy no need for antibiotic cover II. Organic or pathological murmur: – There is valvular or other cardiac abnormality – Need antibiotic cover – Infective endocarditis (IE) is defined as an infection of the endocardial surface of the heart which may include one or more heart valves. – Its intracardiac effects include severe valvular insufficiency, which may lead to intractable congestive heart failure and myocardial abscesses. – If left untreated, IE is generally fatal. – It is caused by infectious agents, or pathogens, which are usually bacterial but other organisms can also be responsible. Infective Endocaraditis • Its incidence is 10-50 cases per million (uncommon) • 50% of all endocaraditis occurs in normal valves (acute course) • At risk patients are 100 times higher chance to get the disease than general population after dental procedure Risk factors for infective endocaraditis VSD PDA Coarctation of aorta Rheumatic and other acquired valvular disease Persistent murmur ASD repaired with a patch Hypertrophic cardiomyopathy Mitral valve prolapse with regurgitation Tetralogy of Fallot’s cases Others High risk patient for infective endocaraditis H/O infective endocaraditis Prosthetic valve Patients not at risk from infective endocaraditis Pulmonary stenosis Mitral valve prolapse without a murmur/ regurgitation Six months after surgery for: ligated ductus arteriosus surgically closed atrial or septal defects (without dacron patches) Pathogenesis of endocaraditis damage to cardiac endothelium: congenital or acquired circulating platelets adhere to the exposed collagen fibrin incorporated into the clot bactermia organisms adhere to the clot vegetations grows and damage cardiac tissues dissolution of the vegetations & occurrence of embolic phenomenon only 5-10 % of endocaraditis cases are due to dental causes 65% are due to St. viridians and enterococci 10% are caused by staphylococcal bacteria 0-5% are due to anaerobic bacteria (G- bacilli) 0-15 are due to other organisms (fungi, chlamydia and rickettsia) it has 100% mortality rate if untreated and more than 30% if treated Infective endocaraditis Clinical features: are mainly due to cardiac infection and embolic phenomenon General: night sweating, myalgia, joint pain,weakness, wt. Loss, anemia, finger clubbing Cardiac: failure, murmur and dysrrythemia Eye: Conjunctival hemorrhage, Roth spots in retina Lung: cough, dyspnea and bloody sputum Skin : petechiae, splinter hemorrhage and Osler’s nodules (painful pulp infarcts in fingers and toes) Kidney: hematuria and acute renal failure Infective endocaraditis Infective endocaraditis Splinter hemorrhage Osler's nodules Subcutaneous nodules Diagnosis of infective endocaraditis – Blood culture: four sets of cultures should be taken in the first 24 hrs – CBC: normochromic, normocytic anemia, leukocytosis, raised ESR – CXR: cardiomegally – ECG – Echocardiography – Urinalysis: hematuria and proteinuria Infective endocaraditis prevention Prevention depends on: – Identification of at risk patients – Deciding which dental procedure require prophylaxis – Giving appropriate prophylaxis at appropriate time Procedures that require antibiotic prophylaxis Extraction and minor OS procedures Incision of an abscess Scaling, curettage and root planning Full mouth periodontal probing Implant placement Placement and removal of orthodontic bands (not brackets) Procedures for which it may be prudent to give antibiotic prophylaxis Root Canal Therapy !!! Procedures that do not require antibiotic prophylaxis Temporary or permanent restoration Adjustment of orthodontic appliance Placement of matrix band Exfoliation of primary teeth Invective endocaraditis prophylaxis a) Preventive role: Inform the at risk patient about importance of his/her oral health Advise regular checkups and maintaining of good oral hygiene (to maintain healthy dentition for life) b) Local measures Use antiseptic like chlorhexidine gel (1%) or as mouth wash (0.2%) 5 minutes before dental treatment Use povidone iodine application if chlorhexidine is not available c) Systemic measures (prophylaxis regime) Invective endocaraditis prophylaxsis Basic principles: Follow the recommended regime in your area (Libya, Europe, USA, Australia) The antibiotic must target the tissue before the dissemination of the micro-organisms The antibiotic must be used on the basis of the most likely single organism to cause the infection The antibiotic effect should be continued as long as the contamination occurs Allow 10 days to elapse before starting new coverage period Plan treatment to minimize the number of antibiotic administrations Invective endocaraditis prophylaxis – Carry as much treatment as possible during the 34 hrs after taking prophylaxis – If multiple coverage periods are needed use antibiotics in alternate, penicillin, clindamycin – Advise the patient to recall if he notes any abnormal fatigue, weight loss night sweatiness, fever or arthralgia. etc. – Consult the physician whenever possible Low risk patients no longer need prophylaxis For dental procedure Dental procedure associated with bleeding is no longer exclusively indicated for prohylaxis Only procedures associated with high degree of baxcteremia can ve covered dental procedures are proven cause of few cases of IE Adverse reactions to antimicrobials including In 2006 British Society for antimicrobial Chemotherapy (BSAC) recommend antibiotic prophylaxis in only three (high risk) circumstance: – Previous IE – Prosthetic valves – Surgically repaired defects with residual patches National Institution for clinical excellence (NICE) NICE (2008) issued recommendations removing the need for antibiotic prophylaxis in relation to dentistry (antibiotic prophylaxis is not recommended for patients at risk of endocarditis undergoing dental procedures) and advise that such patient should receive high standard of oral health Infective endocaraditis prophylaxis regime LA Not allergic to penicillin 3 gm amoxycillin, orally start 1 hr PO GA allergic to penicillin 600 mg* clindamycin orally start 1 hr PO No special risk Special risk Not allergic to penicillin Not allergic to penicillin allergic to penicillin 1 gm IM Amoxicillin + .5 gm orally 6 hrs later 1 gm amoxycillin IM + 120 mg Gentamycin 0.5gm amoxycillin orally 6 hrs later 1 gm Gentamycin + 120 mg vancomycin IV The use of azithromycin syrup for children who refuse tablets or capsules or for patients who have dysphagia is advocated by British national formulary Ischemic heart disease Ischemic heart disease A long term decrease in oxygen delivery to the heart leads eventually to the a condition known as ischemic heart disease (IHD) or coronary artery disease (CAA) Atherosclerosis is the most common cause of IHD Clinically IHD may be manifested as: Angina pectoris Myocardial infarction Acute coronary artery syndrome is a term used to refer to clinical features attributed to coronary artery obstruction. It may take the form of: – Unstable angina – Myocardial infarction ANGINA PECTORIS Ischemia is temporary and reversible, Constant short acting chest pain or discomfort due to Coronary Insufficiency Lactic acid and other metabolites accumulate in the anoxic myocardium Pain is retrosternal, lasts for few minutes and relieved by rest and anti-anginal drug No enzymatic elevation in all types of angina Pt with H/O angina should be carefully assessed: stable or unstable type of angina Dental management and implications of angina – Consult the physician about unstable or untreated angina – Reduce the anxiety and reassure the patient e.g. show concern and worm approach, use of sedation – You may need to ask the patient to take glyceryl nitrate before treatment – Have the antianginal drug readily available in the clinic to be used if required ( 0.2 mg nitroglycerin sublingually) – ?? Use LA with no adrenaline but make sure that the anesthesia is profound and effective – Adrenaline containing LA can be used with certain precautions like using aspirating technique – Adequate oxygen supply should be available for use ( 100 % O2 with face mask and nasal cannula) Direction of blood through the heart with normal pressure in each chamber coronary artery angiogram with stenosis coronary artery bypass Dental management and implications of angina Pts with unstable angina ( present at rest, becomes worse recently, increase in frequency, poor response to treatment) are best referred to a specialist for management Short appointment and terminate appointment if patient got fatigued If the patient develop angina stop the procedure and give glyceryl nitrate sublingually Anginal pain may be referred to the mandible Drugs like nefidipine may be used in such patients and may cause gingival enlargement Anginal patients are susceptible to develop MI, so be ready to deal with !!! by keeping up to date with practical skills to manage severe angina and skills for cardiopulmonary resuscitation Myocardial infarction (MI) Attack of severe chest pain is characterized by: – – – – – 1. lasting more than half an hour,up to hours or days 2. Not relieved by vasodilators 3. Relieved only by morphine sulphate injection 4. Rapid and week pulse, pale face and cold (shock) 5. Acute myocardial infarction could be diagnosed by ECG changes& elevation of serum enzymes : – – – – – creatine phosphokinase C P K serum glutamic oxaloacetic transaminase SGOT aspartate transaminase AST lactic dehydrogenase LD serum level of Tropinin T (myocardial fibrillar protein ) is specific and rapid aid in diagnosis Management of MI: Primary care – Aim to get patient to hospital! – Analgesia, Aspirin & reassurance – Basic life support if required Hospital – thrombolysis if indicated – aspirin – streptokinase (SK) and tissue plasminogen activator (Altepase) – drug treatment to reduce tissue damage – prevent recurrence/complications Complications of MI Death Arrhythmias Heart Failure Ventricular hypofunction & thrombosis Papillary muscle rupture - valve disease! DVT & pulmonary embolism Complications of thrombolysis Dental implications of MI – No routine dental treatment before six months after attack – Same measures applied as for angina – Bleeding tendencies due to the use of anticoagulants – Note that patient might be hypertensive HYPERTENSION Persistently raised blood pressure above the normal range for age and sex The prevalence of hypertension is about 20% May be classified into: Essential hypertension: 80-90% of cases Secondery hypertension: Renal, endocrine, drugs, pregnancy etc. Most of essential hypertension cases are insidious & asymptomatic and to be discovered during routine clinical checkups or later as a result of complications Systems affected by hypertension: – Cardiac: Lt. Ventricular hypertrophy and accelerated coronary artery diseases, heart failure, dysrrhythmias – Eyes: retinopathy, hemorrhages, exudates, papilloedema and blindness – Neurogenic: occipital headache on walking, dizziness, blurred vision, vertigo, tinnitus, syncope and stroke – Renal: arteriosclerotic changes, hematuria and proteinuria The hypertensive patient may or may not be under medical treatment Whenever the patient gave a H/o hypertension or you suspect it: Make the pt sit and relax Check the BP. If raised recheck after some time (15 minutes) The diagnosis of hypertension is the responsibility of the physician Diastolic BP is better indication of hypertension, so: 85 mm Hg diastolic is normal BP 85-89 mm Hg may be considered to be high normal (borderline cases) 90-100 is mildly hypertensive 101-110 is moderately hypertensive 110 is severely hypertensive (only emergency dental care can be carried out) (malignant hypertension) is an emergency and need immediate referral Systolic BP: – – – – – – – 130 normal 130-139 high normal 140-159 mild hypertensive 160-179 moderate 180-209 severe > 209 very severe (need immediate referral) < Clinical features of hypertension: Most patients are asymptomatic Occipital throbbing headache Insomnia Disturbed vision Dizziness Palpitation Spontaneous epistaxis Ringing ear Weakness Dental management of hypertensive patient When systolic and diastolic pressures fall into different categories, the higher of the categories is determined as the patient classification status With severe hypertension delay all surgical procedure and consult the physician immediately Limit care to pain control and antibiotic therapy Start the dental treatment only after the BP is under control Short appointments, sedative therapy and good pain control may be necessary Management of mild to moderate hypertensive patients: LA is preferable whenever possible and aspirating syringes must be used Reduce anxiety (5 mg diazepam the night before and one hour preop.) and reassure the patient Use LA with no adrenaline (prilocaine + felypressin) or with 1:100.000 adrenaline + minimum dose ( 3-4 cartridges) + aspiration and slow injection Extraction can be done under LA with one or two teeth and avoid multiple extraction & trauma Minimize the waiting time Reduce pain & anxiety to reduce the sequels of increased hypertension Do not change the Patient position abruptly to avoid postural hypotension Take into account the management of the problems caused by underlying disease or complications caused by hypertension e.g. renal failure Systemic steroids may rise the BP GA potentiate the effect of antihypertensive drugs Be aware of the hypertensive drugs side effects such as: – xerostomia, – lichenoid reactions – postural hypotension – swelling and pain of the salivary glands Oral complications of antihypertensive drugs Xerostomia as in diuretics Lichenoid reactions: thiazide, methyldopa, propranolol Lupus- like reactions: hydralazine bleeding after surgical procedures if the patient is taking anticoagulant or aspirin Swelling and pain of salivary gland THERE IS NO EVIDENCE THAT ADRENALINE IN LA IS A HAZARD TO CARDIAC PATIENTS, IN FACT THIS VASOCONSTRICTOR MAY ENHANCE THE DURATION AND DEPTH OF LA, PROVIDE GOOD PAIN CONTROL AND REDUCE THE RELEASE OF ENDOGENOUS Dysrrythemia Usually it is due to ischemic heart disease so manage as angina case should be suspected in: thyroid disease open heart surgery significant heart disease hypertensive patient Dysrrhythmias may include: Tachycardia Bradycardia Atrial fibrillation: – Is the commonest chronic dysrrythemias as it occurs in 4% of people above the 65 years – Increase the risk of intracardiac clot formation and systemic embolism – These patients usually kept under aspirin and warfarin Ventricular fibrillation Cardiac arrest These patients are at high risk of developing cardiac arrest Patients with H/O palpitations, dizziness, angina, dyspnea and syncope should be referred for medical consultations Those with abnormal physical signs like irregular pulse, tachycardia, bradycardia should be referred before dental treatment to determine the need for a cover and confirm the medication/s being taken If they are on anticoagulants manage accordingly If they have a cardiac pacemaker: it is not contraindication to LA or GA no need for antibiotic cover avoid the use of electrocautery or diathermy, electric pulp tester or ultrasonic scalar as the leakage of current may affect the pacemaker function Pace makers Are devices use to supply an electrical stimulus to the heart to make it contract at desired level (as there is problem with the conducting system of the heart) Inserted subcutaneously under left clavicle and connected to the heart through subclavian vein Used commonly to treat Bradyarrhythmias or less commonly to suppress resistant tachycardia Keep heart rate at a minimum level Theoretical risk of electrical interference: – electrical fields - MRI, electro-surgery/diathermy – dental equipment THEORETICAL risk only – avoid electrical scalers Cardiac pacemaker Implanted pace maker Cardiomyopathy Is heart muscle disorder that is not secondary to IHD, Hypertension, congenital, valvular or pericardial diseases Classified into: – Hypertrophic: – Dilated: – Constrictive: Classified into: – Hypertrophic: Hypertrophic cardiomyopathy (HCM) is a disease in which the heart muscle (myocardium) becomes abnormally thick (hypertrophied). The thickened heart muscle can make it harder for the heart to pump blood Commonly hereditary but may occur sporadically cause dyspnea, angina, palpitation and syncope It may be complicated by atrial fibrillation, emboli, heart failure and sudden death in extraneous exercise – Dilated: The ventricles are dilated and contract only poorly Causes: – Viral & bacterial infection – Alcohol – Infiltrations like Sarcoidosis, amyloidosis and hemochromatosis – May present with signs and symptoms of heart failure , cardiomegally, fibrillation and emboli – Constrictive: Due to endomyocardial stiffness Amyloidosis is the most common cause Heart failure The heart is no longer act as a pump to maintain sufficient cardiac output to meet the demands of the body despite the normal filling pressures Classification: 1.Lt ventricular heart failure: – Causes: IHD HYPERTENSION AORTIC & mitral valve disease Anemia Thyrotoxicosis Cardiomyopathy Excretional dyspnea Orthopenea Paroxysmal nocturnal dyspnea Fatigue Wheezing and cough Hemoptysis – Signs and symptoms 2. Rt. ventricular heart failure: Occur secondary to chronic lung disease (cor pulmonale) e.g. COPD Signs and symptoms – Pitting oedema – Ascites – Increased JVP 3.Congestive heart failure: Occur secondary to Lt Vent. Failure Cyanosis Fatigue Nausea swollen ankles Abdominal discomfort Treatment of heart failure Diuretics ACE inhibitors Nitrates Digoxin Dental implications heart failure: – In Poorly controlled or uncontrolled patients only emegency treatment to treat pain and infection can be carried out and elective treatment should be deferred until the medical condition is stabilized – Appointment must be in late morning and of short duration – Pain and anxiety might precipitate angina, dysrhythmia so good analgesia must be given – Take care of the underlying disease and drugs including anticoagulants Dental implications heart failure: – Lidocaine and preilocaine can be used with caution but bupivicaine should be avoided as it is cardiotoxic – Adrenaline should not be given in large doses for patients taking B-blockers as it might increase BP – Gingival retraction containing adrenaline should be avoided. – Manage patient in upright position specially for patients wit Lt. sided heart failure General Principles Of Dental Management Of Patients With Heart Disease 1. The chief hazards are likely to be: a. Anxiety and pain which cause increased sympathetic activity and leads to increased load on the heart and the possibility of inducing arrhythmia b. GA is particularly hazard and in general it is contraindicated in dental surgery for such patients c. Infective endocaraditis is hazardous for some cardiac patients 2. Routine dentistry is safe for most patients with heart disease unless they are overanxious 3. Sedation using midazolam by SLAW INJECTION may be helpful to reduce anxiety. Alternatively, nitrous oxide sedation may be more pleasant and acceptable. Neither of these two agents have significant adverse effects if competently given 4. Extraction under LA should be carried out with one or two at a time and the blood loss of multiple extractions should be avoided 5. LA is generally safe and should always be used in preference of GA. The hazard of adrenaline in LA used in sensible dose ( up to four cartridges) is little more than theoretical 6. LA containing nor adrenaline are totally contraindicated, as even in normal persons they have caused fatal hypertensive attacks 7. GA is generally contraindicated in dental surgery and it is particularly hazard in the following conditions: After MI specially recent one Angina specially recent and unstable Severe hypertension Intractable arrhythmia Some congenital heart diseases 8. GA is a hazard because it may: depress cardiac activity, aggravate or possibly precipitate heart failure, cause dysrhythmias, dilate vascular bed causing a full in BP, depress respiration and oxygenation.