Hypertension and Coronary Diseases PDF

Lecture IV: Cardiovascular Diseases 1. Hypertension Hypertension is persistently elevated systolic blood pressure (SBP) above 140 mmHg or diastolic blood pressure (DBP) above 90 mmHg. According to the 2020 American Heart Association (AHA) guidelines:  High-no...

Lecture IV: Cardiovascular Diseases 1. Hypertension Hypertension is persistently elevated systolic blood pressure (SBP) above 140 mmHg or diastolic blood pressure (DBP) above 90 mmHg. According to the 2020 American Heart Association (AHA) guidelines:  High-normal BP: Individuals who could benefit from lifestyle interventions and who would receive pharmacological treatment if compelling indications are present.  Grade 1 and grade 2 Hypertension: Individuals should receive pharmacological treatment. General Manifestations of Hypertension: A. May remain asymptomatic for years. B. Early symptoms: 1. Headache 2. Blurred vision 3. Tinnitus 4. Dizziness 5. Fatigue 1  C. Complications: 1. Ventricular hypertrophy 2. Stroke 3. Arteriosclerosis 4. Retinal damage 5. Renal failure D. Hypertensive emergency:  Blood pressure exceeding 180/120 + evidence of organ dysfunction as: o intracerebral hemorrhage, o unstable angina pectoris o acute Myocardial Infarction, or o Heart failure.  Clinical picture: can be associated with: o chest pain, o dyspnea, o change in mental status, o visual disturbance, or o neurologic deficit. Management of Hypertension: 1. Lifestyle changes: losing weight, low-salt diet, stopping smoking and alcohol. 2. Antihypertensive medications: including Diuretics, Beta-blockers, Calcium channels blockers, Angiotensin converting enzyme (ACE) inhibitors and Vasodilators. Oral manifestations of Hypertension: 1. Facial palsy 2. Side effects of antihypertensives: 1) Xerostomia 2) Salivary gland swelling 2  3) Lichenoid reaction 4) Erythema multiforme 5) Angioedema 6) Gingival hyperplasia (2ry to Calcium channel blockers: Nifidipine) Dental Management of Hypertension patient: 1. The dentist should spot an undiagnosed hypertensive patient through detailed history of symptoms, medications of hypertensive complications and routine BP measurement at the first dental visit. 2. Delaying dental treatment and referral in cases of: a. Undiagnosed patient b. BP above the patient's baseline (uncontrolled) c. BP above180 mm Hg systolic or 100 mm Hg diastolic If emergency dental condition, it should be managed pharmacologically until the patient is controlled. 3. Stress-reduction protocol to avoid endogenous release of adrenaline and higher rise in BP. 4. Drug-induced orthostatic hypotension. So, rapid changes in chair position are avoided. 5. Bleeding is not commonly caused by hypertension; but by anticoagulants used by hypertension patients. 6. Use of epinephrine-containing local anaesthesia: Benefits Risks Delays systemic absorption, Elevation in plasma Increases the duration of anesthesia, and epinephrine, provides local hemostasis Rise in BP and heart rate So, Profound local anesthesia: critical for pain and anxiety control 3  Thus, the existing evidence indicates that the benefits of use of epinephrine outweigh the increased risks, so long as modest doses (one or two cartridges of 2% lidocaine with 1: 100,000 epinephrine) is used. BUT AVOID: o Intravascular injection (aspirating syringe is used) o Levonordefrin due to excessive vasoconstriction o Topical vasoconstrictor use for local hemostasis. o Epinephrine-impregnated gingival retraction cords. 7. Drug interactions: a. Prolonged used of NSAIDs reduce the efficacy of antihypertensives. b. Erythromycin and Clarithromycin increase the hypotensive action of calcium channel blockers. 4  2. Ischemic heart disease Ischemic (coronary) heart disease occurs due to persistent reduction in the blood supply and oxygen supply to the heart through the coronaries. This reduction may be due to a thrombus obstructing the arteries, or thickening of the arterial walls and so narrowing of its lumens (atherosclerosis). Depending on the duration and extent of the ischemia, the heart will suffer from: a. Angina Pectoris: pain due to temporary low blood and oxygen supply to a certain part of the heart muscle: oxygen demands exceeding the supply. b. Myocardial infarction (MI): necrosis of the affected part of the heart muscle due to permanent loss of blood and oxygen supply. General manifestations of ischemic heart disease: 1. CHEST PAIN: Angina Myocardial infarction Stable Unstable  Retro-sternal chest pain  aching, heavy, squeezing pressure or tightness  may radiate into the shoulder, left or right arm, neck, or lower jaw  recurring,  Worsening pain with unchanging pattern increasing severity,  precipitated by frequency, or 5  exertion but also may duration. occur with eating or  or occurring at rest stress. or during sleep. Relieved by cessation of Not relieved by rest, or the precipitating activity, Not relieved by with the use of by rest, or with the use nitroglycerin. nitroglycerin. of Nitroglycerin. lasts longer than 15 min. Lasts 5 to 15 minutes. (>20 min) 2. palpitations (disagreeable awareness of the heartbeats) 3. Syncope (transient loss of consciousness) due to inadequate cerebral blood flow 4. Complications: - Heart failure - Retinal changes 2ry to hypertension (the risk factor). MEDICAL MANAGEMENT 1. Treatment of risk factors for cardiovascular disease (hypertension). 2. Lifestyle modification (weight loss, exercise, smoking cessation). 3. Pharmacologic management: Nitrates (Nitroglycerin), Beta- blockers, Calcium channel blockers, and antiplatelet agents. 4. Surgical management: stenting, coronary artery bypass grafting (CABG). ORAL MANIFESTATIONS 1. Coronary heart disease does not directly induce oral lesions. 2. In rare cases, cardiac pain is referred to the lower jaw, or teeth. The pattern of onset and relief of pain serves as a diagnostic clue. 3. Side effects of drugs include:  Xerostomia,  Lichenoid reactions  Angioedema 6   Stomatitis (ulcers)  Gingival hyperplasia  Increased bleeding due to antiplatelet drugs (Aspirin). DENTAL MANAGEMENT 1. Identification and referral of undiagnosed patient  Distinguish the 3 types of coronary heart diseases.  If the patient has a pacemaker or defibrillator. The primary concern is to prevent ischemia or infarction. 2. Risk assessment: Intermediate CV risk Major CV risk 1. Stable angina or 1. unstable angina or 2. A past history of MI without 2. those who have had an MI within the ischemic symptoms (especially past 30 days one month or more after the 3. a history of MI in association with MI.) other clinical risk factors (e.g., heart failure) General management elective care should be postponed modifications medical consultation Best cared for in a hospital environment. General management modification: 1. Chair position: comfortable non-supine position, and o avoid rapid position changes due to orthostatic hypotension. 2. Timing: short early afternoon appointments to avoid the time of peak of endogenous epinephrine levels. 3. Stress-reduction protocol: o Sedation o Profound local anesthesia:  LA without vasoconstrictors may be used as needed. 7   If a vasoconstrictor is necessary, patients with intermediate clinical risk factors can safely be given, up to 2 cartridges containing 1:100,000 epinephrine at one appointment  Intravascular injections are to be avoided.  Gingival retraction cord impregnated with epinephrine should be avoided. o Effective postoperative pain control:  NSAIDs (except for aspirin) should be avoided: Increase the risk for a subsequent MI. 4. Prophylaxis: o Patients with ischemic heart disease, coronary artery stents, or CABG surgery do not require ANTIBIOTIC prophylaxis. o Prophylactic administration of NITROGLYCERIN sublingually or by inhalation may be indicated if the patient has angina more than once a week. 5. Drugs: o Precipitation of an angina attack, MI, arrhythmia, or cardiac arrest is possible. So, nitroglycerin should be readily available as well as oxygen. o Azole antifungals and erythromycin or clarithromycin should be avoided as they interact with antihypertensive drugs. 6. In patients having pace-maker, apex locators and ultrasound scalers should be avoided. 8 WHEN TO TREAT? 1. MI: safely treated in an outpatient dental setting 30 days after an MI unless the patient has heart failure. 2. CABG procedures or coronary stenting: no data to support waiting as long as 6 months before resuming dental treatment. BUT, Elective dental care should be postponed until the patient can sit comfortably for the required time period. 3. Antiplatelet drugs after coronary artery stenting: dental procedures can be undertaken after 4 weeks provided the patient is able to continue on their current antithrombotic therapy uninterrupted. Discontinuation of these agents before dental treatment generally is unnecessary and can increase the risk of thrombosis, MI, or death. 4. If the procedure cannot be performed safely on antiplatelet therapy, consultation with the patient’s cardiologist is recommended. 5. Purely elective procedures requiring interruption of antiplatelet therapy will be delayed by 6–12 months, though more urgent procedures can be considered after 3 months. EMERGENCY If a patient experiences chest pain in the dental clinic: 1. Dental treatment must be stopped 2. Place the patient upright 3. A: Airway: Ensure open airway. 4. B: Breathing: Ensure that breathing is adequate. 5. C: Circulation: Check pulse. 6. Give NITROGLYCERIN 0.5mg sublingually 7. Give oxygen 8. Monitor vital signs. 9 9. The pain should be relieved within 5 minutes; the patient should then rest and be accompanied home. 10.If chest pain is not relieved, a further dose should be given. 11. Pain that persists after three doses of nitroglycerine given every 5 minutes; that lasts more than 15–20 minutes; or that is associated with nausea, vomiting, syncope, or hypertension is highly suggestive of MI. 12.If MI: a. call ambulance b. oxygen c. 300mg of aspirin should be chewed, d. 5–10mg of morphine sulphate IV 13. If signs of cardiac arrest (i.e. no pulse); commence basic life support (Cardiopulmonary resuscitation CPR) and attach the automated external defibrillator (AED). 10