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ACQUIRED HEART DISEASE CONGENITAL HEART DISEASES VALVULAR HEART DISEASE INFECTIVE ENDOCARDITIS RHEUMATIC FEVER
ATHEROSCLEROSIS
ANGINA PECTORIS
It is a severe paroxysmal chest pain caused due to higher myocardial oxygen demand. Cause: ruptured coronary atherosclerotic plaques.
ANGINA PECTORIS
Clinical features: Strangling, or tightness, heaviness, compression of the chest sometimes radiating to the left arm or jaw. Precipitated by physical exertion especially in cold weather and emotional stress. Pain is relieved by rest. (unlike AMI)
ANGINA PECTORIS
ANGINA PECTORIS
Dental considerations: Pre-operative glyceryl trinitrate & oral sedation with timazepam are adviced. Dental care should carried out with minimal anxiety & monitor oxygen saturation, BP & pulse. Effective local anesthesia is essential. Ready access to medical help, oxygen & nitroglycerin is essential
ANGINA PECTORIS
Management of acute attack during Dental treatment : 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. Patient should then rest & be accompanied home
ANGINA PECTORIS
Management of acute attack during Dental treatment : Pain that persists after 3 doses of nitroglycerin given every 5 minutes & that lasts for more than 15-20 minutes or that is associated with nausea, vomiting, syncope or hypertension is highly suggestive of MI Continue oxygen & chew 300 mg aspirin & insert IV cannula. Nitrous oxide/oxygen or 5-10mg of morphine sulphate IV to relieve pain & anxiety
Clinical features: Sometimes it is preceded by angina. Strangling, or tightness, heaviness, compression of the chest sometimes radiating to the left arm or jaw. Precipitated by physical exertion and emotional stress. Pain is NOT relieved by rest. Persist for a few hours if death does not supervene.
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 consciousness may also occur.
Dental considerations: Dental intervention can precipitate dysrhythmias or aggravate cardiac ischaemia especially patients within 6 months of an MI attack (ASA IV). Simple emergency dental treatment under LA can be given but opinion of the physician should be sought first. In asymptomatic patients with previous older MI ( >6months & <12 months), pain & anxiety should be minimized. In symptomatic patients but older MI (>12 months), elective dental care can be carried out safely, but pain & anxiety should be minimized.
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
HYPERTENSION
When either or both systolic or diastolic pressure are persistently raised, & on remeasurement , with systolic pressure >140 & diastolic >90 mm Hg, it is generally regarded as hypertension.
I II III
1 2
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. quiet rest. Only emergency care until BP controlled. Medical advice before routine dental care. Avoid vasoconstrictor.
>180,>110
IV
HYPERTENSION
Dental considerations: BP should be controlled before elective dental treatment. Appointments should be short & minimally stressful. Avoid anxiety & pain. Pre-operative assurance is important. sedation with 10mg temazipam 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 position as it may cause postural hypotension & loss of consciousness. Some NSAIDS can reduce the efficacy of anti hypertensive agents.
HYPERTENSION
Dental considerations.: Adequate analgesia must be provided. confirm negative aspiration Vasoconstrictor containing LA should not be given in large doses to patients taking beta blockers. Epinephrine effect may be reversed in patients taking beta blockers causing vasodilatation.
CLUBBING
RHEUMATIC FEVER
It is a disease which sometimes follows a sore throat caused by certain strains of beta-haemolytic streptoccoci (strep.pyogenes) Clinical features A sore throat maybe followed after 3 weeks by an acute febrile 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), lung involvement, subcutaneous nodules usually around the elbows. Essential features of c/c rheumatic heart disease are fibrotic stiffening & distortion of heart valves often causing mitral stenosis.
ERYTHEMA MARGINATUM
RHEUMATIC FEVER
Dental considerations: Acute rheumatic fever patients are exceedingly unlikely to be seen during an attack, but emergency dental treatment maybe necessary. No special precautions should be necessary as there appears to be little risk of infective endocarditis at this stage. Treatment can be done under LA in consultation with the physician.
INFECTIVE ENDOCARDITIS
It is a rare but dangerous, potentially lethal infection predominantly affecting the heart valves. Causative organisms: viridans streptococci such as strep.mutans & S.sanguis It results from two main predisposing factors-bacteraemia and a cardiac lesion where there is turbulent blood flow.
INFECTIVE ENDOCARDITIS
Clinical features: In a previously healthy patient who acquires endocarditis,3-4 weeks after dental operation there is insidious onset of low fever & malaise. palor, caf-au-lait pigmentation of the skin, joint pains, hepatosplenomegaly are typical. Main effects include progressive heart damage, infection or embolic damage of many organs especially kidneys.
Allergic to pencillin
Adult-600mg, children-20mg/kg IV with 30min before procedure Adult-1gm, children-25mg/kg IM/IV with 30min before procedure
HEART FAILURE
Heart failure is when the pumping action of the heart is insufficient to meet the bodys demand. Lack of tissue & organ perfusion results. Most common cause :IHD
HEART FAILURE
Clinical features Left sided heart failure: lying down worsens pulmonary congestion,oedema, dyspnoea, makes respiration less effective ,cyanosis, coughing, pink frothy sputum Right sided heart failure: congestion of systemic & portal venous system causing peripheral oedema ,fatigue, hepatomegaly&ascites.
HEART FAILURE
Dental considerations: It is dangerous to lay any person with left sided heart failure supine. dental chair should be kept in a partially reclining or erect position. Dental treatment may precipitate dysrhythmias, angina & heart failure. Mild controlled cardiac failure: routine dental care can usually 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 the condition has been stabilized medically. Emergency dental care with analgesics & antibiotics.
HEART FAILURE
Dental 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)
CARDIMYOPATHIES
It is a disease of the heart muscle commonly caused by alcoholism Clinical features Frequently there are no symptoms until complications develop. Alcoholic effects on the heart: precordial pain, palpitations, dysrhythmias, pulmonary hypertension, right ventricular failure.
CARDIMYOPATHIES
Dental considerations Heart muscle enlargement may restrict the movement of the mitral valve leaflets leading to valvular insufficiency & regurgitation. Hence patient is susceptible to Infective endocarditis.Antibiotic prophylaxis must be given. Use epinephrine only in limited amounts Nitroglycerines or similar drugs are contraindicated If angina pectoris, MI or fibrillation occurs, oxygen should be administered & CPR must be given. Activate the medical emergency response system
DYSRHYTHMIAS
Clinical features They are disturbances of the heart rhythm or gross disturbances of heart rate resulting from disturbed cardiac impulse generation or conduction. Dysrhythmias may arise from cardiac, respiratory autonomic or endocrine disease, fever, hypoxia or electrolyte disturbances. May be symptomless. Reduce cardiac efficiency & cardiac output. Causes dyspnoea, palpitations & syncope
DYSRHYTHMIAS
Dental considerations Appointments must be made for late mornings or early afternoon. Confirm negative aspiration before injection. Vasoconstrictor-containing local anesthetics should not be given to patients taking B-blockers. Effective analgesia must be provided. Epinephrine & other vasoconstrictors should be used with caution (lower dose & careful monitoring) in patients with pacemakers & implanted cardioverter,defibrillators.