Heart Failure Handout PDF

Lecture V: Cardiovascular Diseases 3. Infective Endocarditis (IE) Infective endocarditis (IE) is a microbial infection of the endothelial surface of the heart or heart valves. It can be caused by bacteria (Streptococcus Viridans, Staphylococcus) or fung...

Lecture V: Cardiovascular Diseases 3. Infective Endocarditis (IE) Infective endocarditis (IE) is a microbial infection of the endothelial surface of the heart or heart valves. It can be caused by bacteria (Streptococcus Viridans, Staphylococcus) or fungus. Pathogenesis of IE The following sequence of events results in IE: 1. Deposition of platelets and fibrin (forming vegetations) on the surface of a cardiac valve or on a pre-existing endocardial damage, 2. Bacteremia. Strept. Viridans are commensals of the normal skin, oral, respiratory, and GI tract flora; that may enter to the blood stream causing: a. low grade but repeated bacteremia: from repeated activities such as chewing, tooth brushing or flossing, or b. high grade bacteremia caused by invasive dental procedures. 3. Adherence of the bacteria from the bloodstream to the vegetations, 4. Proliferation of bacteria within a vegetation: Microorganisms adherent to the vegetation stimulate further deposition of fibrin and platelets on their surface. 5. When the infection is established, vegetations composed of organisms, fibrin and platelets grow and may become large enough to cause obstruction or embolism. 6. Complications include: a. Cardiac: Myocardial infarction, heart failure and death. b. Extracardiac: due to embolism: - Organ infarctions: renal failure, spleen infarction, stroke. - Skin lesions and vasculitis 1 Clinical features: Symptoms arise after 3-4 weeks of the procedure that caused IE (previously called Subacute) in the form of: 1. Low grade, intermittent fever and chills. 2. Persistent malaise 3. Petechiae in the skin and mucosae 4. Splinter hemorrhage: bleeding under the nail beds. 5. Osler nodes: tender subcutaneous nodules on the distal pads of the digits. 6. Finger clubbing at a late stage: enlargement of the terminal phalanx of fingers with loss of angle between the nail and nail fold. 7. Symptoms of the complications. Diagnosis: A patient should be suspected and further investigated for IE in case of: Fever+ one or more of: 1. Predisposing cardiac condition 2. Bacteremia 3. Embolic phenomena 4. Evidence of an active endocardial process (+ve blood culture). Treatment of IE: Professional medical care 1. Medical: long course of high doses of antibiotics. 2. Surgical intervention. 2 Dental management: Antibiotic prophylaxis prevents bacterial colonization on the vegetations during the transient high grade bacteremia and so, prevents IE. But, prophylaxis is indicated only in specific cases because: i. Bacteremia can be caused by normal daily activities rather than dental procedures; so oral health maintenance & biannual dental examination would be more effective. ii. The risks of adverse events of antibiotics (Allergy, GIT upset & emergence of resistant strains) exceed the benefits of therapy. Therefore, Antibiotics are prescribed under certain conditions: High risk patients High risk dental procedure 1. Prosthetic heart valve All dental procedures involving 2. Prior incidence of IE (previous, mucosal perforation or manipulation relapse or recurrence) of gingival tissues or the periapical 3. Heart transplant patients with region. valvulopathy Procedures that DO NOT require 4. Congenital heart disease prophylaxis: (CHD): 1. Anesthetic injection in non- a. Unrepaired cyanotic CHD infected tissue b. CHD repaired by prosthetic 2. Taking radiographs material (for 6 months after 3. Prosthetic or orthodontic procedure) appliance placement c. Residual defects after 4. Shedding of deciduous teeth repair. 5. Bleeding due to trauma 3 According to the 2021 modification of the American Heart Association guidelines, Antibiotic protocol for IE prevention: Situation Drug Single Dosage 30-60 minutes before procedure Adult Children Oral Amoxicillin 2g 50 mg/kg Unable to take oral Ampicillin 2 g IM or IV 50 mg/kg IM or IV medication Cefazolin 1 g IM or IV 50 mg/kg IM or IV Or Ceftriaxone Allergic to penicillins Cephalexin 2g 50 mg/kg or ampicillin (oral) Azithromycin 500 mg 15 mg/kg Or Clarithromycin Doxycyline 100 mg If 45 kg: 100 mg Allergic to penicillins Cefazolin 1 g IM or IV 50 mg/kg IM or IV or ampicillin + Unable Or to take oral Ceftriaxone medication Scenarios for antibiotic prophylaxis: 1. If the patient does not meet the criteria of high-risk group, but the physician recommends antibiotic prophylaxis, an agreement should be reached between the dentist and the physician on the protocol to be used with the patient, based on established medical reasoning. 2. If the patient's risk group can not be clearly determined, medical consultation is indicated. If immediate dental treatment is indicated, prophylaxis should be used as that of high-risk patients until consultation is possible. 3. If the patient did not take the prophylaxis before the procedure, it may be administered up to 2 hours after the procedure. 4. In case of series of dental procedures, procedures should have 10 days interval in-between to minimize the risk of developing resistant strains. 4  5. If multiple procedures are planned on a course of a single day, a second dose should be judged (standard amoxicillin dose may be adequate for 6 hours). 6. If the patient is taking antibiotic for another condition and prophylaxis is indicated, an antibiotic of another class should be used for prophylaxis. It is preferable to delay an elective dental procedure for at least 10 days after completion of a short course of antibiotic therapy. 7. Preoperative dental evaluation should be performed and necessary dental treatment should be provided before cardiac valve surgery or replacement or repair of congenital heart disease to decrease the incidence of late IE Cardiac devices that DO NOT indicate antibiotic prophylaxis: Implantable electronic devices coronary and other vascular stents Non-cardiac indications of prophylactic antibiotics prescription: 1. Organ transplants 2. Prosthetic joints 3. Cerebrospinal fluid shunts 4. HIV infection/AIDS 5. Immunosuppressive drugs (e.g., steroids, chemotherapy) 6. Autoimmune disease (e.g. SLE) 7. Undiagnosed or uncontrolled diabetes mellitus 8. Splenectomy 9. Severe neutropenia 10.Sickle cell anemia 11.Renal failure 5  4. Heart Failure Heart failure (also called cardiac failure or congestive heart failure) occurs when the heart is unable to efficiently pump blood to meet the body's needs. General Manifestations: 1. Fatigue and weakness 2. Dyspnea: shortness of breath 3. Orthopnea: shortness of breath while laying supine 4. Jugular vein distention 5. Peripheral edema 6. Hepatomegaly and ascites 7. Cyanosis 8. Finger clubbing. Classification of HF: Class I: No limitation of ordinary physical activity. Class II: Slight limitation of ordinary physical activity+ comfortable at rest. Class III: Marked limitation of activity. Less than ordinary physical activity results in symptoms, but patients are comfortable at rest. Class IV: Symptoms are present with the patient at rest. Medical management: 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. 3. Digitalis or nitrates. 4. Anticoagulants (Warfarin). 5. Implantable devices: Pacemaker, implantable defibrillator. 6. Heart transplant. 6 Oral Manifestations of heart failure: 1. Distended sublingual veins. 2. Cyanosis of the lips and tongue. 3. Side effects of the medications: 1) Xerostomia 2) Lichenoid reaction 3) Erythema Multiforme 4) Angioedma 5) Digitalis may exaggerate gag reflex. Dental Management: 1. Identification and referral of undiagnosed patient: Medical history of signs and symptoms of HF. Identify the class of HF. If the patient has a pacemaker or defibrillator. 2. Consultation before dental treatment of: o Undiagnosed patient. o Uncontrolled patient: are at high risk during dental treatment for complications such as cardiac arrest, cerebrovascular accident & MI. o Patient having classes II, III and IV HF. 3. Dental treatment setting: a. Class I HF: receive routine outpatient dental care. b. Class II and most Class III: receive routine outpatient dental care AFTER approval of the physician. c. The rest of Class III and Class IV: best treated in a hospital dental clinic for emergency dental care only. Postpone elective dental treatment until the condition is stabilized. 4. Chair position: o comfortable non-supine position, and 7  o Avoid rapid position changes due to orthostatic hypotension 2ry to drugs. 5. Timing: short early afternoon appointments to avoid the time of peak of endogenous epinephrine levels. 6. Stress-reduction protocol: a. Sedation b. Profound local anesthesia: i. LA without vasoconstrictors may be used as needed. ii. If a vasoconstrictor is necessary, up to 2 cartridges containing 1 : 100,000 epinephrine can safely be given at one appointment even in advanced HF; iii. Intravascular injections are to be avoided (Aspirating syringe used). iv. Gingival retraction cord impregnated with epinephrine should be avoided. v. Epinephrine is avoided in patients on Digitalis, because the combination precipitates arrhythmia. c. Effective postoperative pain control: NSAIDs (except for aspirin) should be avoided: o exacerbate HF. o when administered with ACE inhibitors, increase the risk of renal failure. d. General Anasthesia (GA) is contraindicated in uncontrolled patients. 7. Prophylaxis: o Patients with HF do not require ANTIBIOTIC prophylaxis; unless having a prosthetic valve. 8. Drugs: o Itraconazole antifungal may precipitate HF. 8  o Erythromycin & Tetracyclin interfere with the metabolism of Digitalis causing Digitalis toxicity. 9. In patients having pace-maker, apex locators and ultrasound scalers should be avoided. Emergency: Acute pulmonary edema: 1. Anxiety 2. Dyspnea 3. Productive cough 4. Cyanosis Management of acute pulmonary edema: 1. Stop the dental procedure. 2. Place the dental chair in an upright position. 3. Oxygen. 4. If no improvement, Call for medical help (ambulance). 5. If cardiac arrest occurred: start CPR. 9