59861570 Cardiovascular Diseases Ppt

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    CARDIOVASCULAR DISEASES

    ACQUIRED HEART DISEASE

    CONGENITAL HEART DISEASES

    VALVULAR HEART DISEASE INFECTIVE ENDOCARDITIS

    RHEUMATIC FEVER

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    AQUIRED HEART DISEASE

    ISCHAEMIC HEART DISEASE(CORONARY ARTERY DISEASE)

    ANGINA PECTORIS

    MYOCARDIAL INFARCTION

    HYPERTENSION

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    CORONARY (ISCHAEMIC)

    HEART DISEASECAUSE

    Atherosclerosis: it is the accumulation of

    lipids in the arterial walls due to variety offactors.

    It can lead to vascular thrombosis (clots)and result in embolism

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    ATHEROSCLEROSIS

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    CORONARY (ISCHAEMIC)

    HEART DISEASEClinical features:

    Cardiac ischaemia in itself is symptomless.

    Its presence is manifested only by itsdramatic complications namely:-

    ANGINA PECTORIS

    MYOCARDIAL INFARCTION IHD often comes without warning or

    history of heart disease.

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    CORONARY (ISCHAEMIC)

    HEART DISEASEDental considerations: Stress, anxiety, exertion or pain can

    provoke angina.

    Patient should receive dental care in short,minimally stressful appointments.

    Patients are best treated in the late

    mornings. Effective painless local anesthesia is

    essential.

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    CORONARY (ISCHAEMIC)

    HEART DISEASEDental considerations..:

    Confirm negative aspiration before

    injection. Vasoconstrictor-containing local

    anesthetics should not be given to patientstaking B-blockers.

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    ANGINA PECTORIS

    It is a severe paroxysmal chest pain caused

    due to higher myocardial oxygen demand.Cause: ruptured coronary atherosclerotic

    plaques.

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    ANGINA PECTORIS

    Clinical features:

    Strangling, or tightness, heaviness,

    compression of the chest sometimesradiating to the left arm or jaw.

    Precipitated by physical exertion especiallyin cold weather and emotional stress.

    Pain is relieved by rest. (unlike AMI)

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    ANGINA PECTORIS

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    SIGNS & SYMPTOMS

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    ANGINA PECTORIS

    Dental considerations:

    Pre-operative glyceryl trinitrate & oralsedation with timazepam are adviced.

    Dental care should carried out withminimal anxiety & monitor oxygensaturation, BP & pulse.

    Effective local anesthesia is essential. Ready access to medical help, oxygen &

    nitroglycerin is essential

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    ANGINA PECTORIS

    Management of acute attack during Dentaltreatment :

    Stop the treatment immediately.

    Give 0.3-0.6mg sublingual glyceryl trinitrate.

    Give oxygen & seat the patient upright.

    Monitor vital signs.

    Pain should be relieved in 2-3 minutes. Patientshould then rest & be accompanied home

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    ANGINA PECTORIS

    Management of acute attack during Dentaltreatment :

    Pain that persists after 3 doses of nitroglyceringiven every 5 minutes & that lasts for more than15-20 minutes or that is associated with nausea,

    vomiting, syncope or hypertension is highlysuggestive of MI

    Continue oxygen & chew 300 mg aspirin & insert

    IV cannula. Nitrous oxide/oxygen or 5-10mg of morphinesulphate IV to relieve pain & anxiety

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    MYOCARDIAL INFARCTION(CORONARY THROMBOSIS OR

    HEART ATTACK)Clinical features: Sometimes it is preceded by angina.

    Strangling, or tightness, heaviness, compression

    of the chest sometimes radiating to the left armor jaw.

    Precipitated by physical exertion and emotionalstress.

    Pain is NOT relieved by rest. Persist for a few hours if death does not

    supervene.

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    MYOCARDIAL INFARCTION(CORONARY THROMBOSIS OR

    HEART ATTACK)Clinical features:

    The pain of MI may sometimes start at

    rest and is not relieved by nitrates. Vomiting, facial pallor, sweating,

    restlessness, apprehension are common.

    Restlessness, cough , loss of consciousnessmay also occur.

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    MYOCARDIAL INFARCTION(CORONARY THROMBOSIS OR

    HEART ATTACK)Dental considerations: Dental intervention can precipitate dysrhythmias or

    aggravate cardiac ischaemia especially patientswithin 6 months of an MI attack (ASA IV).

    Simple emergency dental treatment under LA canbe given but opinion of the physician should besought first.

    In asymptomatic patients with previous older MI

    ( >6months & 12

    months), elective dental care can be carried outsafely, but pain & anxiety should be minimized.

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    MYOCARDIAL INFARCTION(CORONARY THROMBOSIS OR

    HEART ATTACK)Dental considerations..: Monitor BP, ECG, pulse & oxygen saturation.

    Dental care should be stopped if there is /are:

    - chest pain- dyspnoea

    - rise in HR>40beats/minute

    - rise in ST segment displacement > 0.2mv on ECG- dysrhythmias

    - rise in systolic BP >20mmHg

    There should be ready access to oxygen & medical

    help

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    MANAGEMENT OF MI AS ANEMERGENCY IN DENTAL

    SURGERY

    Assess the situation : shake the person &

    ask in a loud voice Are you OK? If thereis no response-

    Call for medical help

    Begin basic life support & CPR& continueuntil help arrives.

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    CARDIO PULMONARYRESUSCITATION

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    EXTERNAL CARDIAC MASSAGE

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    HYPERTENSION

    When either or both systolic or diastolicpressure are persistently raised, & onremeasurement ,

    with systolic pressure >140 &

    diastolic >90 mm Hg,

    it is generally regarded as hypertension.

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    Features of advanced hypertension

    SYMPTOMS

    Headaches

    Visual disorders Tinnitus

    Dizziness

    Angina

    SIGNS

    Hypertension on

    testing Retinal changes

    Left ventricular

    hypertrophy Proteinuria

    hematuria

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    ASA grading & dental management considerations for hypertension

    BP (mmHg)

    systolic,diastolic

    ASA

    grade

    Hypertension

    stage

    Key considerations

    110

    I

    II

    III

    IV

    -

    1

    2

    3

    Routine dental care

    Recheck BP before starting.

    Routine dental care

    Recheck BP before starting

    .Medical advice before routine

    dental care. Restrict use of

    epinephrine

    Recheck BP after 5 mins. quietrest. Only emergency care until

    BP controlled. Medical advice

    before routine dental care. Avoid

    vasoconstrictor.

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    HYPERTENSIONDental considerations:

    BP should be controlledbefore elective dental treatment.

    Appointments should be short & minimally stressful.

    Avoid anxiety & pain.

    Pre-operative assurance is important. sedation with 10mgtemazipam may be helpful.

    Patients are best treated in the late morning.

    Continuous BP monitoring is indicated.

    Do not raise the patient suddenly from the supine positionas it may cause postural hypotension & loss ofconsciousness.

    Some NSAIDS can reduce the efficacy of anti hypertensiveagents.

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    HYPERTENSION

    Dental considerations.:

    Adequate analgesia must be provided.

    confirm negative aspiration Vasoconstrictor containing LA should notbe given in large doses to patients takingbeta blockers.

    Epinephrine effect may be reversed inpatients taking beta blockers causingvasodilatation.

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    CONGENITAL HEART DISEASE

    Clinical features

    Most striking feature: CYANOSIS

    Shunting of deoxygenated blood from the right

    ventricle directly into the left side of the heart &systemic circulation leads to chronic hypoxemia.

    Chronic hypoxemia causes severely impaireddevelopment & often gross clubbing of fingers &

    toes. Hemorrhagic or thrombotic tendencies may

    develop.

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    CLUBBING

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    CONGENITAL HEART DISEASE

    Dental considerations:

    Confirm negative aspiration before injection of LA.

    Adequate analgesia must be provided.

    Oral abnormalities associated are: Delayed eruption of both dentitions, greater

    frequency of positional anomalies, enamelhypoplasia, greater caries & periodontal disease

    activity.

    Patient with congenital cardiac defects are oftenliable to infective endocarditis & other

    complications.

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    RHEUMATIC FEVER

    It is a disease which sometimes follows a sore throat causedby certain strains ofbeta-haemolytic streptoccoci(strep.pyogenes)

    Clinical features

    A sore throat maybe followed after 3 weeks by an acutefebrile illness with pain flitting from one joint to another. Usually resolves within 6-12 weeks Other effects: cerebral involvement causing spasmodic

    involuntary movements (sydenhams chorea), a

    characteristic rash (erythema marginatum), lunginvolvement, subcutaneous nodules usually around theelbows.

    Essential features of c/c rheumatic heart disease are fibroticstiffening & distortion of heart valves often causing mitralstenosis.

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    ERYTHEMA MARGINATUM

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    RHEUMATIC FEVER

    Dental considerations:

    Acute rheumatic fever patients are exceedinglyunlikely to be seen during an attack, but

    emergency dental treatment maybe necessary.

    No special precautions should be necessary asthere appears to be little risk of infectiveendocarditis at this stage.

    Treatment can be done under LA in consultationwith the physician.

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    INFECTIVE ENDOCARDITIS

    It is a rare but dangerous, potentiallylethal infection predominantly affectingthe heart valves.

    Causative organisms:viridans streptococcisuch as strep.mutans &S.sanguis

    It results from two main predisposingfactors-bacteraemia and a cardiac lesionwhere there is turbulent blood flow.

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    INFECTIVE ENDOCARDITIS

    Clinical features:

    In a previously healthy patient who acquiresendocarditis,3-4 weeks after dental operation

    there is insidious onset of low fever & malaise.palor, caf-au-lait pigmentation of the skin, jointpains, hepatosplenomegalyare typical.

    Main effects include progressive heart damage,infection or embolic damage of many organsespecially kidneys.

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    PROPHYLAXIS OF INFECTIVE ENDOCARDITIS

    Situation Medication Dosage

    Standard prophylaxis Amoxicillin

    Adult-2 gm

    Children-50 mg/kg orally 1 hr before

    procedure

    Unable to take oral

    medicationAmpicillin

    Adult-2gm IM/IV

    Children-30 mg/kgIM/V

    30min before procedure

    Allergic to pencillin

    Clindamycin

    OR

    Cephalexin orcefadroxil

    OR

    Azithromycin orclarithromycin

    Adult-600mg, children-20 mg/kg orally 1

    hour before procedure

    Adult-2 gm children-50mg/kg orally 1

    hrbefore procedure

    Adult -500mg, children-15mg/kg Orally

    1 hr before procedure

    Allergic to pencilin &unable

    to take oral medication

    Clindamycin

    OR

    cefazolin

    Adult-600mg, children-20mg/kg IV with

    30min before procedure

    Adult-1gm, children-25mg/kg IM/IV

    with 30min before procedure

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    HEART FAILURE

    Heart failure is when the pumping actionof the heart is insufficient to meet thebodys demand.

    Lack of tissue & organ perfusion results.

    Most common cause :IHD

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    HEART FAILURE

    Clinical features

    Left sided heart failure: lying down worsenspulmonary congestion,oedema, dyspnoea,

    makes respiration less effective ,cyanosis,coughing, pink frothy sputum

    Right sided heart failure: congestion ofsystemic & portal venous system causingperipheral oedema ,fatigue,hepatomegaly&ascites.

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    HEART FAILURE

    Dental considerations: It is dangerous to lay any person with left sided heart

    failure supine. dental chair should be kept in apartially reclining or erect position.

    Dental treatment may precipitate dysrhythmias,angina & heart failure.

    Mild controlled cardiac failure: routine dental care canusually be provided

    Anxiety & pain must be minimised

    Poorly controlled or uncontrolled cardiac failure:attain medical attention before dental treatment.

    Elective dental treatment should be delayed until thecondition has been stabilized medically.

    Emergency dental care with analgesics & antibiotics.

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    HEART FAILURED

    ental considerations: Late morning appointments are recommended. Confirm negative aspiration before injection. Vasoconstrictor-containing local anesthetics should not be

    given to patients taking B-blockers.

    Effective analgesia must be provided. Diuretic drugs may cause orthostatic hypotension.thus

    patient should be raised slowly to upright position. NSAIDs other than aspirin should be avoided in those

    patients taking ACE inhibitors as they increase risk of renal

    damage. Monitor BP & ECG especially in patients taking digoxin. Drugs that can complicate dental treatment:

    Digitalis - (vomiting)ACE inhibitors - (coughing)

    itraconazole - (cardiac failure)

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    CARDIMYOPATHIES

    It is a disease of the heart musclecommonly caused by alcoholism

    Clinical features

    Frequently there are no symptoms untilcomplications develop.

    Alcoholic effects on the heart: precordial

    pain, palpitations, dysrhythmias,pulmonary hypertension, right ventricularfailure.

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    CARDIMYOPATHIESDental considerations

    Heart muscle enlargement may restrict themovement of the mitral valve leaflets leading to

    valvular insufficiency & regurgitation. Hence patient

    is susceptible to Infective endocarditis.Antibioticprophylaxis must be given.

    Use epinephrine only in limited amounts

    Nitroglycerines or similar drugs are contraindicated

    If angina pectoris, MI or fibrillation occurs, oxygenshould be administered & CPRmust be given.

    Activate the medical emergency response system

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    DYSRHYTHMIAS

    Clinical features

    They are disturbances of the heart rhythm or grossdisturbances of heart rate resulting from disturbed

    cardiac impulse generation or conduction. Dysrhythmias may arise from cardiac, respiratory

    autonomic or endocrine disease, fever, hypoxia orelectrolyte disturbances.

    May be symptomless.

    Reduce cardiac efficiency & cardiac output.

    Causes dyspnoea, palpitations & syncope

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    DYSRHYTHMIAS

    Dental considerations

    Appointments must be made for late mornings orearly afternoon.

    Confirm negative aspiration before injection.

    Vasoconstrictor-containing local anesthetics shouldnot be given to patients taking B-blockers.

    Effective analgesia must be provided. Epinephrine & other vasoconstrictors should be

    used with caution (lower dose & carefulmonitoring) in patients with pacemakers &

    implanted cardioverter,defibrillators.

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    THYROID-RELATED HEARTDISEASE

    Clinical features

    Untreated thyrotoxicosis: tachycardia,

    dysrhythmias leading to cardiac failure &MI especially in elderly.

    Hypothyroidism: slows heart rate

    Myxoedema: hypercholestremiaassociated with atherosclerosis.

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    THYROID-RELATED HEARTDISEASE

    Dental considerations

    Sedation is desirable as they have heightenedanxiety, hyperexcitabilty & excessive sympathetic

    activity. Hypothyroidism patients with IHD are at increased

    riskin the dental surgery

    In severe myxoedema diazepam & other CNS

    depressants can precipitate coma. Confirm negative aspiration before injection.

    Vasoconstrictor-containing local anesthetics shouldnot be given to patients taking B-blockers.

    Effective analgesia must be provided.

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    PULMONARY HEART DISEASE

    Clinical features

    Right ventricular hypertrophy leads to

    right sided failure with systemic venouscongestion & persistent hypoxia.

    In early stages: dyspnoea, chronic cough,wheezing, often cyanosis

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    PULMONARY HEART DISEASE

    Dental considerations

    Ipratropium bromide can cause dry mouth

    Contraindicated drugs: Diazepam or midazolam

    IV barbituarates

    -due to their respiratory depressant effects

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