Cardiology PDF

Cardiology Dr. Muhammad Reihan, MBBS, MD Associate Professor Internal Medicine Department  Overview Hypertension Coronary artery disease Valvular heart disease Congenital heart disease Heart failure Arrhythmia Heart transplant  Learning Objectives Knowledge & Un...

Cardiology Dr. Muhammad Reihan, MBBS, MD Associate Professor Internal Medicine Department  Overview Hypertension Coronary artery disease Valvular heart disease Congenital heart disease Heart failure Arrhythmia Heart transplant  Learning Objectives Knowledge & Understanding Describe common heart diseases including signs and symptoms, clinical manifestation, pathogenesis, management, and their significance to dental practice.  Overview Cardiovascular disease is a leading cause of mortality globally It includes hypertension, coronary artery disease, heart failure, congenital defects and strokes  Hypertension (HTN) Hypertension is when your blood pressure, the force of your blood pushing against the walls of your blood vessels, is consistently too high 2017 ACC/AHA: persistent syst olic blood pressure ≥ 130 mm Hg and/or diastolic blood pressure ≥ 80 mm Hg  Hypertension (HTN) Types of HTN: Primary hypertension Secondary hypertension  Hypertension (HTN) Symptoms: Usually patients are asymptomatic Complications: Cardiac o CAD o HF o Aortic dissection Central nervous system o Strokes o intracranial hemorrhage o encephalopathy Kidneys (renal failure) Eyes (retinal changes)  Hypertension (HTN) Diagnosis: Clinical diagnosis oNeed two  readings, oideally 2 weeks apart  Hypertension (HTN) Management: Lifestyle modification Pharmacological treatments If HTN is secondary, treat the underlying cause  Hypertension (HTN) Management: Medications are relatively well tolerated Most commonly used medications are beta blockers, diuretics, ACEi, ARB, & CCB  Hypertension (HTN) Patients with HTN have increased risk for adverse events Primary concern is precipitating hypertensive crisis, stroke or MI American Dental Association recommends the following: If Blood pressure < 160/100 mmHg  No modification needed If Blood pressure > 160/100 mmHg  Modification might be needed  Hypertension (HTN) If remains elevated, no elective dental treatment and the patient should be Elective Repeat referred to a medical doctor procedure measurement If blood pressure is reduced, can proceed with procedure Blood Pressure > 160/100 Blood pressure>180 mmHg and/or diastolic pressure >110 mmHg, seek consultation with a physician Not changed, initiate emergency care with Emergency Repeat blood pressure monitoring every 10 to 15 procedure measurement minutes If blood pressure is reduced, can proceed with procedure  Coronary Artery Disease (CAD) A condition where the major blood vessels supplying the heart are narrowed from atherosclerosis  Coronary Artery Disease (CAD) Stable angina: oxygen demand,  supply Unstable angina: oxygen demand is unchanged,  supply CAD Myocardial infarction (MI): Necrosis of myocardium due to  supply Acute coronary Stable Angina syndrome (ACS) Unstable STEMI NSTEMI Angina  Coronary Artery Disease (CAD) Symptoms: Typically, retrosternal chest pain or pressure Dyspnea Dizziness, palpitations Restlessness, anxiety Autonomic symptoms (e.g., diaphoresis, nausea, vomiting) Cough CPR as the treatment for cardiac arrest: Myth or fact? - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Indicators-and-symptoms-of-chest-pain-at-the-heart-attack_fig1_348649074 [accessed 20 Jan, 2022]  Coronary Artery Disease (CAD) Diagnostics: Electrocardiogram (ECG) Cardiac enzymes (Troponin, CK-MB) Cardiac stress test Cardiac catheterization  Coronary Artery Disease (CAD) Management: Risk factor modification Medical therapy includes Aspirin, lipid lowering agents, β-blockers, CCB, & Nitrates Revascularization by percutaneous coronary intervention (PCI) or Coronary artery bypass graft (CABG) Many of these patients might be on dual antiplatelet therapy (Aspirin + P2Y12 inhibitor such as colpidogrel)  Coronary Artery Disease (CAD) Dental care modification: The primary concern is to prevent ischemia or infarction Anxiety can increase heart rate & blood pressure & provoke ischemia Multiple short appointments Minimize discomfort during procedure Excellent post-operative analgesics After MI, Patient may be safely treated in dental setting 30 days after the event Ideally you should be BLS certified  Coronary Artery Disease (CAD) Patients on blood thinners: Average patient: No need to Drug Class Drug Names discontinue medication; use local measures to control Anticoagulant warfarin bleeding Clopidogrel, ticlopidine, High bleeding risk patient: Any Antiplatelet agents prasugrel, ticagrelor, suggested modification to the aspirin medication regimen prior to dental surgery should be done in consultation with and on Dabigatran, rivaroxaban, advice of the patient’s Direct-acting oral physician anticoagulants apixaban,edoxaban  Valvular Disease The heart has four valves Damage to the valve can lead to heart disease Stenosis Vs. regurge Vs. mixed  Valvular Disease Signs & Symptoms may vary but include: Heart murmur Shortness of breath Swelling in the legs Chest pain Fatigue Dizziness Syncope or pre-syncope  Valvular Disease Diagnostics: History & physical examination Echocardiograph (Echo) Cardiac MRI Cardiac cauterization  Valvular Disease Management: Medical management Vs. Valve replacement Valves are either bioprosthetic Vs. Mechanical Mechanical valves require life-long anticoagulation Replaced valves are at an increased risk of infection  Congenital Heart Disease Congenital heart disease (CHD) occurs when there is a problem with the heart that is present at birth It can affect the heart’s shape, how it works or both  Valvular Disease Dental management considerations: Infective endocarditis is a serious disease with a high overall mortality rate (20-30%) 30-45% of cases are caused by oral bacteria Antibiotic prophylaxis may be indicated in certain at risk patients Historically antibiotic prophylaxis was over-utilized American Heart Association amended the guidelines in 2007  Valvular Disease Indications for Bacterial endocarditis prophylaxis: 1. Prosthetic heart valve 2. Previous infective endocarditis 3. Structural valve abnormality in transplanted heart 4. Certain CHD subtypes Unrepaired cyanotic CHD Repaired CHD with residual defect Repaied CHD with use of prosthetic material in the preceding 6 months  Valvular Disease Indicated dental procedures: Manipulation of gingival tissue Or the periapical region of teeth Or perforation of the oral mucosa Appropriate coverage: Viridans group Streptococcus coverage (Amoxicillin) If allergic to penicillin  use azithromycin One dose, given 30-60 minutes before the procedure  Heart Failure Heart Failure (HF): a clinical syndrome in which the heart can’t supply enough blood to meet the body’s demands  Heart Failure Causes of heart failure: Coronary artery disease Hypertension Diabetes mellitus Valvular heart disease Infiltrative diseases Cardiac arrhythmias Obesity Smoking Lung disease Drugs & Alcohol abuse  Heart Failure Signs & Symptoms Dyspnea Orthopnea Paroxysmal nocturnal dyspnea Lower limb edema Fatigue Physical examination findings S3 heart sound Lung crackles Laterally displaced apical heart beat Coolness and pallor of lower extremities Jugular venous distention Liver enlargment  Heart Failure Diagnostics: History & physical Chest radiographs Echocardiogram (Echo) B-type natriuretic peptide (BNP)  Heart Failure Management: Lifestyle modification Medications include β-Blockers & ACE inhibitors, ARBs, aldosterone antagonists, Hydralazine/nitrates, & diuretics Occasionally, patients might require Invasive therapies (Defibrillators & pacemakers) Advanced HF requires heart transplant  Heart Failure Dental management considerations Patients with well-compensated HF, no special modifications required Patients with decompensated HF, important to inquire about patients' ability to be placed in the supine position Stressful prolonged dental procedures may put an increased demand on the heart Patients may have iatrogenic orthostatic hypotension, bring to a sitting position in several stages, then have them sit their feet on the floor for few minutes If they use diuretics, they might need to use the bathroom before the procedure  Arrhythmias Cardiac arrhythmias are o accelerated, o slowed, or o irregular heart rates caused by abnormalities in the electrical impulses of the myocardium Normal heart rate 60 - 100 beat/min Bradyarrhythmias: heart rates of < 60/min Tachyarrhythmias: heart rate of > 100/min  Arrhythmias Tachyarrhythmia Bradyarrhythmia Supraventricular Ventricular arrhythmias arrhythmias AV node Premature Atrial Origin origin Atrial Origin AV node origin ventricular contraction (PVC) Paroxysmal Sinus supraventricul tachycardia Ventricular ar tachycardia tachycardia Atrioventricular Sick sinus syndrome block (1st, 2nd, 3rd Atrial Junctional degree) fibrillation tachycardia Torsade de pointes Atrial flutter Ventricular fibrillation Sinus bradycardia Multifocal atrial tachycardia (MAT)  Arrhythmias Most Arrhythmias will present with: Fatigue Dyspnea Palpitations Dizziness/syncope Angina Most Arrhythmias will be diagnosed with a simple ECG  Arrhythmias Tachyarrhythmias: Medications such as beta blockers or calcium channel blockers (rate control) Medications such as antiarrhythmic (rhythm control) Some arrhythmias will require anticoagulation Some a arrhythmias will require radiofrequency catheter ablation Bradyarrhythmias: Some will require intraventricular pacer  Arrhythmias Atrial Fibrillation Most common sustained arrhythmia Incidence increases with age Multiple foci in the atria fire continuously in a chaotic pattern, causing a totally irregular, rapid ventricular rate  Arrhythmias Atrial Fibrillation An irregularly irregular pulse Blood stasis leads to formation of intramural thrombi, which can embolize to the brain, causing ischemic stroke Most patients will require lifelong anticoagulation  Arrhythmias Patients on blood thinners: Average patient: No need to discontinue medication; use local Drug Class Drug Names measures to control bleeding Anticoagulant warfarin Dabigatran, High bleeding risk patient: Any Direct-acting oral rivaroxaban, suggested modification to the anticoagulants apixaban,edoxab medication regimen prior to dental an surgery should be done in consultation with and on advice of the patient’s physician  Arrhythmias Patients with ICDs or Pacemakers: Some electronic dental devices may cause interference with implanted cardiac devices Newer cardiac devices are better shielded and may be less susceptible to interference Piezoelectric dental scalers may be safer than magnetostrictive models Electrosurgery devices have the highest potential of electromagnetic interference Proper use and distance are two important factors affecting risk of interference it may help reduce the risk to avoid waving the device or its cords over the patient’s pectoral region and turn off this equipment when not in use  Heart Transplant Major concern for this patient population is the lifelong use of immunosuppressants Patients with a heart transplant may be anticoagulated Watch for oral complications or side effects from medications such as oral candidiasis (Secondary to steroids) & Cyclosporine-induced gingival hyperplasia  Case Scenario 1 A 42-year-old patient comes to your dental clinic for routine checkup. The nurse tells you that he has known high blood pressure controlled on medication and that his blood pressure reading today is 130/90 mm Hg and the patient is feeling fine. Which of the following is the recommended course of action? A. No modification needed, can proceed with elective dental care B. You should send the patient to the emergency department C. You should obtain a medical physician’s consent to treat D. You should play the patient music to calm him down  Case Scenario 2 A 34-year-old woman presents to your clinic for a toothache. When asked about her past medical history, she tells you that she underwent an aortic valve replacement surgery when she was young after being born with a congenital anomalous valve. You anticipate gingival tissue manipulation during her procedure today. What is the best step of managing this patient? A. Be gentle with gingival manipulation B. Ask the patient to provide more information about her valve surgery C. Give the patient an oral dose of amoxicillin for prophylaxis D. Reassure the patient and tell her she doesn’t need any antibiotics today Questions?  Step-Up to medicine 5th edition Burket’s oral medicine 12th edition References & AHA scientific statement - Prevention of Viridans Group Streptococcal Infective further reading Endocarditis ADA - Antibiotic Prophylaxis Prior to Dental Procedures Thank You