cvd fin nish

8/8/2019 cvd fin nish

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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


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CARDIOVASCULAR

DISEASES


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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


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A)SYMPTOMS AND HISTORY OF PERSENT ILLNESS1. DYSPNOEA

2. CHEST PAIN

3. PALPITATION4. SYNCOPE

5. COUGH WITH EXPECTORATION AND HAEMOPTYSIS

6. CYANOSIS

7. RIGHT HYPOCONDRIAL PAIN, SWELLING OF FEET AND DECREASE IN THE URINEOUTPUT

8. GASTROINTESTINAL SYMPTOMS LIKE ANOREXIA, FULLNESS OF ABDOMEN ANDVOMITING

9. FATIGABILITY10. FEVER

11. DIABETES MELLITUS AND HYPERTENSION

B)PAST HISTORY

1. RHEUMATIC FEVER

2. CYANOTIC SPELLS

3. RECURRENT RESPIRATORY INFECTIONS SINCE CHILDHOOD

4. DETEC

TION OF MU

RMU

R/CARDIA

CLESION AT S

CHOOL5. RECENT DENTAL EXTRACTION, GENITOURINARY INSTRUMENTATIONS

6. HYPERTENSION, DIABETES MELLITUS, ISCHAEMICHEART DISEASE OR ANY OTHERSIGNIFICANT MEDICAL ILLNESS


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C)FAMILY HISTORY

1. HYPERTENSION

2. ISCHAEMICHEART DISEASE

3. CONGENTAL HEART DISEASE4. RHEUMATICHEART DISEASE

5. SUDDEN DEATH

D)PERSONAL HISTORY

1. APPETITE

2. WEIGHT LOSS

3. DISTURBED SLEEP

4. BOWEL AND BLADDER DISTURBANCES5. HABITS- SMOKING AND ALCOHOLISM

6. EXPOSURE TO SYPHILIS

E)TREATMENT HISTORY

NIFEDIPINE- GINGIVAL HYPERPLASIA


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APPROACH TO A PATIENT OF CARDIAC DISEAASEANALYSIS OF PRESENTING SYMPTOMS

1)DYSPNOEA

DEFINITION:-ABNORMAL AWARENESS OF BREATHING WITH DISCOMFORT.

DYSPNOEA IS A SIGNIFICANT MANIFESTATION OF CARDIAC FAILURE.

DYSPNOEA IS MORE COMMONLY DUE TO LEFT-SIDED CARDIAC FAILURETHAN DUE TO RIGHT HEART FAILURE.

SEVERITY (GRADING)FUNCTIONAL GRADING OF DYSPNOEA

GRADE I : NO LIMITATN OF ANY PHYSIAL ACTIVITY BUT DYSPNOEA OCCURSON 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)ORTHOPNOEA

DEFINITION: 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 (PULMONARYOEDEMA).

MANIFESTS LATER THAN PND. (IN SLOWLY PROGRESSIVE LEFT HEART

DISEASE).


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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 LATERALPOSITION.

MAY BE DUE TO VENTILATION PERFUSION RELATIONSHIP

ALTERATION IN CERTAIN BODY POSITION.

5)PROXIMAL NOCTURNAL DYSPNOEA

ATTACK OF BREATHLESSNESS AT NIGHT.SIGN OF SEVERE

DEGREE OF LEFT HEART FAILURE.

6)CHEYNES-STROKE BREATHING

THERE IS SEVERE PERIODS OF HYPERVENTILATION FOLLWEDBY PERIODS OFAPNOEA.SIGN OF SEVERE HEART FAILURE.

7)CYANOSIS

A)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 OUTFLOWOBSTRUCTION.

C)HISTORY OF CYANOSIS IN A SUSPECTED PATIENT OF CONGENITAL HEART DISEASEBETWEEN THE AGE OF 5-20 YEARS INDICATES REVERSAL OF LEFT TO RIGHTSHUNT(EISENMEGER)


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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 PAIN

THIS IS DUE TO ENLARGED AND CONGESTED LIVER AND STREACHING OF ITSCAPSULE.

10) DECREASED URINE OUTPUT

IN THE PRESENCE OF CARDIAC FAILURE DUE TO DECREASED CARDIACOUTPUT, RENAL BLOOD FLOW DECREASES WITH DECREASE IN THEGLOMERULAR FITRATION RATE, THIS CAUSES DECREASE OF URNEOUTPUT IN PATIENTS WITHCARDIAC FAILURE.

11)SYNCOPE

TRANSIENT LOSS OF CONSCIOUSNESS WITH POSTURAL COLLAPSE.

12)COUGH AND EXPECTORATION

13)PALPITATION

SUGGESTS AWARENESS OF HEARTBEAT,WHCH MAY BE UNPLEASANT.


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EXAMINATION OF CARDIOVASCUAR SYSTEM

SCHEME OF EXAMINATION

GENERAL EXAMINATION

1. BUILD

2. NOURISHMENT

3.PALLOR

4.CYANOSIS

5. CLUBBING

6. JAUNDICE

7. PEDAL ODEMA

8. LYMPHADENOPATHY


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EXTERNAL MARKERSOF CARDIAC

DISEASE

EXAMINATION OF :-FACE

EYES

EARS

SKIN AND MUCOSA

EXTREMITIES

VITAL SIGNS:-

PULSE

BLOOD PRESSURE

RESPIRATORY RATE

TEMPERATURE

EXAMINATION OF PERIPHERALCARDIOVAS

CUAR SYSTEM

RADIAL PULSE:-

RATE

RTHYM

VOLUME

CHARACTER

CONDITION OF VESSEL WALL

EXAMINATION OF:-

THE CAROTIDS

THEIR PERIPHERAL PULSES

JUGULAR VENOUS PULSE AND PRESSURE

PERIPHERAL SIGNS OF WIDE PULSE

PRESSU

RE(IN RELEVANT SITUATION)PERIPHERAL SIGNS OF INFECTIVE

ENDOCARDITIS

PERIPHERAL SIGNS OF RHEUMATIC FEVER


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EXAMINATION OF THE PRECORDIUM

INSPECTION

1. PREC

ORDIAL BU

LGEPOSITION OF APICAL IMPULSE

PULSATIONS IN THE:-

A. LEFT PARASTERNAL REGION

B. 2ND LEFT INTERCOSTAL SPACE

C. 2ND RIGHT INTERCOSTAL SPACE

D. EPIGASTRIC PULSATIONE. SUPRASTERNAL PULSATION

F. ENGORGED VEINS OVER THE CHEST

G. SPINE(KYPHOSCOLIOSIS)

PALPATION1)APICAL IMPULSE- POSITION AND

CHARACTER

2)LEFT PARASTERNALHEAVE

3) OF EPIGASTRIC PULSATION

TH

RILLS4)PALPABLE SOUNDS

PERCUSSION1)RIGHT CARDIAC BORDER

2)LEFT CARDIAC BORDER

3)LEFT AND RIGHT 2ND INTERCOST

SPACE.


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AUSCULTATION

MITRAL, TRICUSPID, AORTIC, PULMONARY AND OTHER ADDITIONAL

AREAS FOR:-

A. 1STAND 2ND HEART SOUNDS

B. ADDITOINAL SOUNDS C. MURMURS


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EXAMINATION ALSO INCLUDES THEFOLOWING SIGNS

A)PALLOR

SEVERE ANEMIA MAY BE ASSOCIATED WITH:

1.CH

RONIC

CC

F2. INFECTIVE ENDOCARDITIS

SEVERE ANEMIA CAN ITSELF CAUSE- CARDIAC FAILURE ORAGGRAVATE THE UNDERLYING HEART DISEASE.

PATIENTS WITHCYANOTICCONGENITAL HEART DISEASE MAYHAVE POLYCYTHEMIA WITH SUFFUSED CONJUNCTIVA.


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B)CYANOSIS:

CENTRAL CYANOSIS OCCURS IN:

1. CYANOTICCONGENITAL 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

DIFFERENTIALCYANOSIS:

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

REVERSE DIFFERENTALCYANOSIS:

1. FINGERS ARE MORE CYANOSED THAN TOES.

E.G. TRANSPSITION OF GREAT VESSELS WITH PULMONARY HYPERTENSIONWITH PREDUCTAL COARCTATION WITH REVERSED FLOW THROUGH PDA.


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C))CLUBBING

CARDIACCAUSES:

1. CYANOTICCONGENTAL HEART DISEASE

2. REVERSAL OF LEFT TO RIGHT SHUNT

3. INFECTIVE ENDOCARDITIS

CYANOTICCONGENITAL HEART DISEASE MAY BE ASSOCIATED WITHHYPERTROPHIC PULMONARY OSTEOARTHROPATHY.

D)JAUNDICE

FOLLOWING CARDIACCONDITIONS MAY BE ASSOCIATED WITHJAUNDICE:

1.C

ONGESTIVECARDIA

CFAIL

URE WIT

HC

ONGESTIVEH

EPATOMEGALY2. CARDIACCIRRHOSIS

3. PULMONARY INFARCTION


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E)PEDAL EDEMAPITTING EDEMA OF FEET CAN OCCUR IN:

1. CONGESTIVE CARDIAC FAILURE

2. CONSTRICTIVE PERICARDITIS

3. TRICUSPID VALVE DISEASE

F)LYMPHADENPATHY:CONDITION ASSOCIATED WITH GENERALIZED

LYMPHADENOPATHY MAY INVOLVE THE CARDIOVASCULARSYSTEM. E.G. LYMPHOMA, SLE ETC.


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EXAMINATION OF FACE

FOLLOWING FEATURES MAY BE INDICATIVE OF UNDERLYINGCAARDIAC ABNORMALITY WHILE EXAMINATION OF FACE.

ABNORMALITIES CONDITION

ASSOCIATED

ELFIN FACIES RECEDING JAWS,

FLARED NOSTRILS,

POINTED EARS

SUPRAVENTRICULARAORTIC STENOSIS

HIGH ARCHED PALATE MARFAN SYNDROME

MITRAL FACIES MALAR FLUSH ANDPINKISH PURPLE

PATCHES OVER THE

CHEEK

MITRAL STENOSISWITH DECREASED

CARDIAC OUTPUT AND

SYSTEMIC

VASOCNSTRICTION


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MALAR FLUSH

MARFAN SYNDROME

TERATOLGY OF FALLOT


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Acute macroglossia:

the tongue is diffusely

enlarged and bright red along its lateral

portion. The patient had bleeding into the

tongue while on anticoagulants.

Acute macroglossia due to Enalapril: this

75-year-old Black female developed acute swelling of

tongue 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


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GUM HYPERPLASIA

DUE TO DILANTIN. SIMILAR FINDINGS

MAY BE SEEN IN PATIENTS ON

NIFEDIPINE

TANGIER DISEASE OF THE TONSILS:

THE TONSILS ARE ENLARGED WITH

BRIGHT

ORANGE YELLOW STREAKS (TIGER

STRIPES)(PREMATURE CAD).


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EXAMINATION OF EAR:EXAMINATION OF EAR:

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

ASSOCIATED WITH INCREASED INCIDENCE OF CORONARY ARTERYASSOCIATED WITH INCREASED INCIDENCE OF CORONARY ARTERY

DISEASE.DISEASE.


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EXAMINATION OF EYES:

EXOPTHALMUS: ASSOCIATED WITH THYROID ARTERY

DISEASE.

BLUE SCLERA: OSTEOGENESIS IMPERFECTA WITH AORTICREGULTATION.

OPTHALMIC FUNDUS: LOOK FOR

A. ARTERIOSCLEROTICCHANGES

B. HYPERTENSIVE RETINOPATHY C. ROTHS SPOTS( OF INFECTIVE ENDOCARDITIS)

D. ARTERIAL PULSATION IN AR

E. CORK SCREW ARTERIES- COARCTATION OF AORTA.

BLUE SCLERAROTHS SPOT


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EXAMINATION OF FINGER

CLUBBING

CLUBING NEGATIVE


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OSLERS NODE IN ENDOCARDITIS

SUBUNGAL HAEMORRHAGES

JANEWAY LESIONS


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CAUSES OF CARDIOVASCLAR DISEASE

ORGANIC DISEASE OF HEART

1. MYOCARDIAL

A. OVERLOAD SECONDARY TO HYPERTENSON OR VALVE DISEASEB. CORONARY( ISCHAEMIC) HEART DISEASE

C. CARDIOMYOPATHIES

2. ENDOCARDIAL

A. RHEUMATIC HEART DISEASE

B. CONGENITAL ANOMALIES

C. INFECTIVE ENDOCARDITIS

3. PERICARDIAL

A. PERICARDITIS

B. PERICARDIAL EFFUSION

C. FUNCTIONAL DISORDERS

DUE TO HYPERTENSION

DUE TO ABNORMALITIES IN HEART RATEA. TACHYCARDIA

B. BRADICARDIA

C. OTHER DYSRTHYMIAS

CHANGES IN CIRCULATORY VOLUME

A. HYPOVOLOEMIA (SHOCH SYNDROME)

B. HYPERVOLAEMIA ( CIRCULATORY OVERLOAD)

C. OTHERS


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FUNCTIONAL CAPACITY OBJECTIVE ASSESSMENT

CLASS I. PATIENTS WITHCARDIAC DISEASE BUT WITHOUT RESULTINGLIMITATION OF PHYSICAL ACTIVITY. ORDINARY PHYSICAL ACTIVITY

DOES NOT CAUSE UNDUE FATIGUE, PALPITATION, DYSPNEA, ORANGINAL PAIN.

A. NO OBJECTIVEEVIDENCE OFCARDIOVASCULARDISEASE.

CLASS II. PATIENTS WITHCARDIAC DISEASE RESULTING IN SLIGHTLIMITATION OF PHYSICAL ACTIVITY. THEY ARE COMFORTABLE ATREST. ORDINARY PHYSICAL ACTIVITY RESULTS IN FATIGUE,PALPITATION, DYSPNEA, OR ANGINAL PAIN.

B. OBJECTIVE EVIDENCEOF MINIMALCARDIOVASCULARDISEASE.

CLASS III. PATIENTS WITHCARDIAC DISEASE RESULTING IN MARKEDLIMITATION OF PHYSICAL ACTIVITY. THEY ARE COMFORTABLE ATREST. LESS THAN ORDINARY ACTIVITYCAUSES FATIGUE,

PALPITATION, DYSPNEA, OR ANGINAL PAIN.

C. OBJECTIVE EVIDENCEOF MODERATELYSEVERE

CARDIOVASCULARDISEASE.

CLASS IV. PATIENTS WITHCARDIAC DISEASE RESULTING IN INABILITY TOCARRY ON ANY PHYSICAL ACTIVITY WITHOUT DISCOMFORT.SYMPTOMS OF HEART FAILURE OR THE ANGINAL SYNDROME MAYBE PRESENT EVEN AT REST. IF ANY PHYSICAL ACTIVITY ISUNDERTAKEN, DISCOMFORT IS INCREASED.

D. OBJECTIVE EVIDENCEOF SEVERECARDIOVASCULARDISEASE.

NYHACLASSIFIACTION


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HYPERTENSION

Hypertension 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 billion27


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Definition

Hypertension is defined

as having systolic blood

pressure (SBP) >/=

140mm ofHg or

diastolic blood pressure

(DBP) >/= 90mm ofHgor

as having to use antihypertensive

medications.28


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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


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Types

PRIMARY (orESSENTIAL)

HYPERTENSION

Which developsgradually over many

years & has nounderlying cause.

90% of people have thistype of hypertension.

SECONDARYHYPERTENSION

Which has anunderlying cause such

as renal disorders,endocrinal disturbances,

neurologic causes etc.

10% of people have thistype of hypertension.

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Other Risk Factor of

HypertensionLack of exercise

Increased salt intake

Family historyToo little potassium

Alcohol

SmokingStress &

Age31


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Effect of hypertension

The common target organs damaged by

long standing hypertension are:

Brain

H

eartKidneys

Eyes &

Peripheral arteries.32


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Complications of hypertension

Left ventricular hypertrophy

Heart failure

Cerebral hemorrhage

Renal insufficiency

Aortic dissection

Atherosclerotic disease

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Symptoms

Symptoms due to hypertension:1. Headache - usually in morning hours.

2. Dizziness

3. Epistaxis

Symptoms due to affection oftarget organs:

1. CVS:a. Dyspnea on exertion

b. Anginal chest pain

c. Palpitations34


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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.

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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 testing36


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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 presentwith non-elevated BP in an

ambulatory setting.

20% of mild hypertensive

individuals may present with white

coat hypertension. 37


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Dental Management

Measure and record BP at initial visit

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Recheck :-Every 2 yrs for patient with BP 140-90 mm

Hg.

Every visit for patient with establishedcoronary artery disease, diabetes mellitus

or chronic renal disease with BP >135-85

mm Hg.

Every visit for patient with established

hypertension.Beforeinitiating dental care:

Assess presence of hypertension

Determine presence of target organ disease

Determine dental treatment modifications


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1. Asymptomatic BP 180/110 mm Hg, no history of target organ disease

No elective dental care

3. Presence of target organ disease or poorlycontrolled diabetes mellitus

No elective dental care until BP is controlled , preferable below140-90 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 ofCholesterol

& Saturated fat.

Adequate intake ofCalcium &

Magnesium.

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5. Limit of alcohol intake

6. Relaxation such as yoga, psychotherapyetc.

7. Regular exercise.


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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

Inhibitors43


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ORAL MANIFESTATION OF

HYPERTENSION

There are no recognized manifestations ofhypertension but anti-hypertensive drugs canoften cause side affects , such as:

Xerostomia,Gingival overgrowth,

Salivary glandswelling orpain,

Lichenoid drug reactions,

Erythema multiforme,

Tastesense alteration,

Paresthesia.44


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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.45


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CORONARY

(ISHAEMIC)ARTERY DISEASE


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Atherosclerosis is the most common

cause ofCAD

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


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8. vitamins & homocystiene

9. plasma fibrinogen

10. endothelial dysfunction

11. antioxidants

12. estrogen deficiency


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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


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DIAGNOSIS

1) Based onclinical 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)


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MANAGEMENT

Management ofCAD 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 exercisetolerance, and normal LV function may be safelytreated with pharmacologic therapy.

Selected use of aspirin, -blockers, ACEIs, and HMG CoAreductase inhibitors.

Nitrates and calcium channel blockers may be added toprimary agents to relieve symptoms of ischemia inselected patients.


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Percutaneous coronary

intervention (PCI) with

percutaneous

transluminal coronary

angioplasty (PTCA) andintra coronary stenting

relieves symptoms

chronic ishchemia.


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Patient with complexmultivessel CAD requirePCI with medical therapyof surgical

revascularization. Patients with reduced LV

function and severeischemia, oftenassociated with left main

or multivessel CAD, arebest served by coronaryartery bypass graft(CABG) surgery.


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DENTAL ASPECTS

STRESS, ANXIETY, EXERTION or PAINcan provoke angina

Short, minimally stressful dental

appointments Late morning appointments

Excessive dose of LA containing

adrenaline to be avoided in patients takingbeta blockers

More severe dental caries and periodontaldisease in pts of IHD


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Acute Coronary Syndromes

Represent a continuous spectrum of

disease ranging from unstable angina to

MI


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Angina pectoris

Name given to paroxysms of severe chest pain

CLINICAL FEATURES1) 40 TO 60 years , M > F

2) pain often described as sense of Strangling, choking , Tightness,

Heaviness ,Compression, orConstriction of chest3) PAIN MAY RADIATE TO JAW or left arm

4) 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


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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)


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PTS with vascular stents no antibiotic

cover

except during 1st 6 week postop foremergency dental care

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

-lichenoid reaction Ca channel

- gingival swelling blockers

- ulcers (nicorandil)


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Gingival hyperplasia

in patient consumingCa channel blockers


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Myocardial infarction

Synonyms coronary thrombosis or heart attack

CLINICAL FEATURES1. Clinical picture is variable

2. More than 50% patients are symptomless

3. MI may be preceded by angina often felt as indigestion likepain

4. any anginal attack lasting longer than 30 minutes isconsidered MI

5. Tachycardia &irregular pulse

6. nausea, vomitting, sweating ,restlessness, facialpallor

7. breathlessness, cough

8. Loss of conciousness, shock & even death

9. Many pts die within 1st hour to few days after attack

THUS, MI is a MEDICAL EMERGENCY


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DIAGNOSIS

I. Based on clinical features

II. Elevated TLC & ESR during 1st wk

III. EC

G changesIV. Rise in serum cardiac enzymes ( CPK)

V. Rise in troponin T within 4-8 hours

VI. echocardiography


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General Precautions during Dental

Procedures

Dental clinic should have advancedcardiac life supportor at least basic cardiac life support.

Use ofpulse oximeter to determine the leveloxygenation.

Automatic external defibrillator. Determination ofvital signs prior to dental care.

BP & pulse rate & rhythm should be recorded & anyabnormal findings should be addressed.

Premedication with antianxiety drugs and inhalationnitrous oxide in anxious patients.

Elective procedures esp those requiring GA should beavoidedforatleast 4 wks aftrMI. consult pts physicianprior to dental therapy


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Management on dental chair

1. Terminate all dental treatment

2. Position pt in semirecline position

3. Give nitroglycerin(TNG) (abt 0.4 mg) tablet or spray

4. Administer oxygen

5. 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 over5 mins

8. Modify t/t to prevent recurrence discomfort discomfortcontinues

relieved 3 mins afterTNG


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8. give 3rd TNG dose

9. Monitor vitals

10. Call for medical assistance

Discomfort relieved discomfort continues 3 mins after 3rd TNG

dose

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

evaluation before 13. start i.v. linewith drip of a crystalloid

solution

further dental care at 30 mL/ hr

14. If discomfort severe titrate morfinesulphate2mg s/c or i/v every 3

mins until relief is obtained

15. Transport to emergency care. AdministerBasic Life Support ,if

necessary.


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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 stentimplantation

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

surgical procedures Associated conditions which predispose patient to

uncontrolled hemostasis : uraemia or liverdiseases or use of NSAIDS If emergency surgery needs to be done,DDAVP(1-

desamino-8-D-arginine vasopressin) isadministered{0.3 micro kg/body wt parenterally}within 1 hr of surgery


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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.


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3 different protocols used to treat patients withelevated INR :

Ist protocol warfarin not discontinued(minimizes thromboembolic events & increasesrisk of bleeding after surgery).

IIndprotocol warfarin discontinued (drug

should be discontinued 2-3 days prior tosurgery, during this period patient is at risk ofdeveloping thromboembolic event but notbleeding).

IIIrdprotocol warfarin discontinued & patientplaced on alternative anticoagulant therapy(thromboembolic event minimized).


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We always plan a t/t by comparing

potential risk for excessive bleeding

after procedures if anticoagulationtherapy is not reduced or stopped v/s

risk of pt experiencing a

thromboembolic event ifanticoagulation therapy is altered.


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Rheumaticfeveris an inflammatory disease

that may develop two to three weeks after a

Group A streptococcal infection (such as

strep throat orscarlet fever). It is believed to

be caused by antibody cross-reactivity andcan involve the heart,joints, skin, and

Brain

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

first time attacks occurring in adults


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Rheumatic fever


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What are thesymptoms ofstrep throat?

sudden onset of sore throat

(streptococcal oropharyngitis)

pain on swallowing

fever, usually 101104F

Headache

Red and edematous soft palateand oropharynx.

Areas of tonsillar ulceration andexudation.

abdominal pain, nausea andvomiting may also occur,especially in children


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What are thesymptoms/clinical features ofrheumaticfever?

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


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Diagnosis

Two majorcriteria, or

onemajor and twominorcriteria,

Majorcriteria(jones)

Joints (Migratory

polyarthritis): O [imagine heart-shaped

O] (carditis):

Nodules (subcutaneous

nodules - a form of

Aschoff bodies):

Erythema marginatum:

Sydenham's chorea


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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


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Minor criteria

Fever: Arthralgia

Laboratory abnormalities: increased

Erythrocyte sedimentation rate Electrocardiogram abnormalities

Evidence ofGroup A Strepinfection:

elevated or risingAntistreptolysin O titre,


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LAB INVESTIGATIONS-

raised ESR

culture studies of throatswabs is always negativein RF

High anti sterptolysino(ASO)titre-!300 todd

units

Chest radiograph-enlargement of heart

ECG-prolonged PR

interval Echocardiogram-confirms

ventricular dilatation npericardial effusion

TREATMENT


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TREATMENT-

Oral phenoxymthylpenicillin 500 mguntil

age of 20 yrs. Allergic to penicillin,sulfadimidine by

mouth.

Aspirin for fever and pain 50mg/kg bwt in 4hrly doses

Corticosteroids 60-80mg prednisolone

Digoxin and diuretics for heart failure

Ballon valvuloplasty,using inoue balloon,ifmitral valves damage.


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DENTALCONSIDERATION-

Dental extractions and localanesthesia in consent withphysician.

The prophylactic use of antibioticsprior to a dental procedure is nowrecommended ONLY for those

patients with the highest risk ofadverse outcome resulting fromendocarditis

No2 used with approval ofphysician.

GA shd be avoided if essentialmust be given in hospital.

Rhe matic heart disease


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Rheumatic heart disease-

History of rheumatic fever during

childhood or adollescence can act as apredisposing factor for RHD after several

years.

Common signs-murmur due to valvulardamage n later enlargement of heart.


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ORAL

MANIFESTATIONS

Most prominent duringacute phase,

Pharyngitis

Inc oral temperature Distended neck veins

and a bluish color of the

skin.

DENTAL CONSIDERATIONS


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DENTAL CONSIDERATIONS-

To prevent complication of infective

endocarditis ,all dental procedures shouldbe carried under antibiotic cover.

Amoxicillin prophylaxis-1 hour before and6 hours after the initial dose.

Good oral hygiene measures ,fluoride

treatment, chlorhexidine rinses and routinecleanings to reduce harmful bacteremias.


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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 physicianconsultation.

HEART FAILURE


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HEARTFAILURE-

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'sneeds .

Common causes of heart

failure

ischemic heart diseases Hypertension

Valvular diseases

L ft id d f il (MORE COMMON)


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Left-sidedfailure(MORE COMMON)

Backward failure of the left ventricle causes congestionof the pulmonary vasculature, and so the symptoms are

predominantly respiratory in nature. The patient willhave dyspnea (shortness of breath) on exertion and insevere cases, dyspnea at rest. Increasingbreathlessness on lying flat, called orthopnea.

Another symptom of heart failure is paroxysmal

nocturnal dyspnea also known as "cardiac asthma", asudden nighttime attack of severe breathlessness,usually several hours after going to sleep

Inadequate cerebral oxygenation leads to loss ofconcentration,restlessness and irritability.

Ri ht id d f il


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Right-sidedfailure

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 peripheraledema oranasarca)

IF occurs with MS is called congestive

heart failure.


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Biventricular failure

,faiure of one side of

heart leads to failure of

other.

CLINICAL FEATURES

pedal edema

Dyspnea

Congestion of neck veins

Cynosis

Fatigue


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DIAGNOSIS

ImagingEchocardiography

Electrophysiology

electrocardiogram

(ECG/EKG) Blood tests

Angiography

Monitoring

TREATMENT MODALITIES-


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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 waterload

stress reduction,rest

Stop smoking

Ph l i l t


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Pharmacological management

diuretic

Loop diuretics (e.g. furosemide, bumetanide)

ACE inhibitor/Angiotensin II receptor antagonist

Positiveinotropes Digoxin

Beta blockers

Alternativevasodilators

The combination ofisosorbide

dinitrate/hydralazine


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ORAL MANIFESTATIONS

Distention of the externaljugular viens.

Compensatory polycythemia ruddy complexion and

bleeding tendencies.

Abnormal production of clottingfactors

Bleeding can be spontaneousor extravasational.

DENTAL ASPECTS-


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The dental chair should be kept in partiallyreclining 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 morningbecause of epinephrine levels peak in earlymorning.


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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


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Supplemental o2 shd be available

Rubber dam is contraindicated when itcontributes to breathing difficulty.

NSAIDS other than aspirin shd be avoidedin pts taking ACE inhibitors(renaldamage).

Erythromycin and tetracycline to be

avoided as they may induce digitalistoxicity

GA is contraindicated in cardiac


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GA is contraindicated in cardiac

failure.until under control(venous

thrombosis and pulmonary embolism)

ACE inhibitors can sometimes cause

erythema multiforme,angioedema orburning mouth.

Antibiotic prophylaxis req for dental care

History of recent MI ,req delay of elective

dental care for 6 months


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Ortho static hypotension

CARDIAC


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CARDIACARRHYTHMIA -Cardiacarrhythmia (also

dysrhythmia) is a termfor any of a large andheterogeneous group ofconditions in which thereis abnormal electricalactivity in the heart. The

heart beat may be toofast or too slow, and maybe regular or irregular

Accordingly there r 2types-

Atrial arrhythmia Ventricular arrhythmia

More fatal than AA

TACHYCARDIA-


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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.


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TREATMENT


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TREATMENT

AA-

Digoxin

Propanolol

qUinidine sulphate

Anticoagulant such as

warfarin

VA-

Procainamide

Phenytoin

Dispyramide

Propanolol


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Physical maneuvers

Antiarrhythmic drugs Electricity

Electrical cautery

ORAL MANIFESTATIONS


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ORAL MANIFESTATIONS

Procainamide can causeagranulocytosis,oralulcerations

Quinidine-infrequent oral

ulcerations

Disopyramide is anticholinergicagent capable of producingxerostomia.

verapamil,enalapril can causegingival hyperplasia.

DENTAL


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CONSIDERATIONS-

A proper history to be

taken Stress and anxiety

be minimized

Short appointments

U

se of epinephrine to beminimized

Proper chair position isimportant, SUPINE

At end of appointment

chair should be raisedslowly to minimizeorthostatic hypotension.

Use of vasoconstrictors should be


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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 aftertreatment in recently placed pacemaker

patients.

Pts who report palpitations or skippedbeats must be evaluated by physician

Sustained sinus tachycardia above 100


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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


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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 Americanheart 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


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PROPHYLAXIS TO MINIMISE RISK OF

BACTERIAL ENDOCARDITIS

Extractions.

Periodontal procedures includingsurgery,subgingival,placement of antibiotic fibers orStrips,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


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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.

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