Exam 7 CV Diseases of Concern; Blood pressure/pulse; Pathology
Exam 7 CV Diseases of Concern; Blood pressure/pulse; Pathology
Terms in this set (65)
What are the 7 congential heart defects?
2. Patent Ductus Arteriousus ("PDA")
3. Tetralogy of Fallot (VSD< PULmonary stenosis, overiding aorta, R Ventricular Hypertrophy)
4. Pulmonary or aortic stenosis
5. Coarctation of aorta
6. Transposition of Great vessels
7. Mitral Valve prolapse
What is the anatomic defect of ASD/VSD?
1. ASD - Foramen ovale fails to close - skips pulmonary
2. VSD - failure of interventricular septum to completely fuse. Goes through pulmonary but not systemic
What is the anatomic defect of Patent ductus arteriosus (PDA)?
Connection between aorta and pulmonary artery. Allows bypassing of lungs during fetal development
What is the anatomic defect of tetralogy of fallot?
Right ventricle enlarges Stenosis of artery of pulmonary aorta Ventricular septal defect Over riding aorta
What is the anatomic defect of coarctation of the aorta?
Aorta is crinkled Causes blood pressure before the coarctation to be high and blood pressure to be low after
What is the anatomic defect of transposition of great vessels?
Ex: It starts on the left side, goes to the lungs, goes back to left side = Not getting any oxygen
What is the anatomic defect of Mitral valve prolapse?
The mitral valve (bicuspid) on the left side prolapses up into left atrium.
What is the mechanism and type of bacteria associated with development of rheumatic fever?
1. Streptococcal infection (Group A-Beta-hemolytic Streptococcus) 2. Antibodies to bacterial antigens cross react with host tissue antigens
3. MAY result in valve scarring and damage especially mitral valve
What is the difference between functional Functional (non-patholgic) heart murmer andan Organic (pathologic) murmer?
Nonorganic (functional) Murmer: BENIGN (pregnancy, anemia, childhood) Organic (pathologic): Valvular heart disease a) VALVE DOES NOT OPEN OR CLOSE PROPERLY Valvular stenosis: improper opening Valvular insufficiency: improper closing
Valvular stenois -
Improper (incomplete) opening
Improper closing of heart valve
Improper opening of valvular opening
Of Grade I and Grade VI murmurs which is most severe (loud)?
Grade VI is the most severe while Grade I is the least severe
In mitral Valve prolaps, which valve is prolapsing (bulging) and into which chamber of the heart?
The Bicuspid valve is prolapsing into the left atrium
Name the two types of prosthetic heart valves and there: a) Material used b) Need anticoagulants? c) Need antibiotic for premedication? d) What type of suture?
1. Tissue - Bioprosthetic
a) Tissue - porcine(pig)
d) Non-resorbable sutures
2. Artificial -
a) Plastic or plastic/metal
b) Always require life-long anticoagulant
d) non-resorbable sutures
What are the indications for an artificial heart valve?
1. Replacement of dysfunctional heart valve
2. Treatment of valvular heart disease
3. Reduce chance of emboli formation (improper valve function can lead to heart largement and failure!)
What is the mechanism for the development of endocarditis and what organisms are involved with the development?
1. Pre-existing valvular disease (usually)
2. Bacterial, viral, fungal "seeding" of the valve
What are the locations/origin of dysrhythmias?
1. Ventricular - Dangerous
2. Supraventricular (Sinus/Atrial)
What are the types of dysrhythmias (arrhythmias)?
What is the mechanism for development of angina pain?
1. Stress, excitement, exercise
2. Coronary artery disease
3. Intermmittent hypoxia of myocardium
4. INCOMPLETE blockage of coronary artery(ies)
5. ATHEROSCLEROSIS in coronary arteries
How should angina be treated if an attack occurs in the dental office?
What are medications that can be given to a person with angina?
What treatments are used to control symptoms and preserve cardiac muscle tissue for patient with atherosclerotic heart disease?
1. CABG -Coronary artery bypass graft
3. EECP - Enhanced External Counterpulsation
What is a CABG and how does it work?
Coronary artery bypass graft Take saphenous vein from leg and graft between aorta and blockage or Take thoracic (internal mammary) artery and position to divert blood past blockage.
What is angioplasty and how does it work?
If angina NOT responsive to meds
1. Catheter inserted into coronary artery via femoral artery 2. "Balloon" covering catheter is inflated to open artery
3. Stent is left in place to keep artery open
What is EECP and how does it work?
Non-Invasive - Enhanced External Counterpulsations Pressure cuffs applied to lower body 1. INFLATION of cuffs synchronised with distole (I.D.) 2. Deflation with systole (D.S)
What should be done if the patient has a history of angina? What should be done if there is not history of angina
What is Atherosclerosis?
Atherosclerosis is a condition in which fatty material collects along the walls of arteries. This fatty material thickens, hardens (forms calcium deposits), and may eventually block the arteries.
Describe the pathology involved with myocardial infarction.
1. TOTAL blockage of coronary artery by thrombus
2. Arterial plaque fissures/ulcerates initiating platelet clot (aspirin treatment)
3. No blood reaches part of myocardium supplied by blocked artery = Death
Myocardial infarction induces death on what tissues? How is the death repaired?
1. Myocardial Muscle
2. Myocardial muscle does NOT regenerate but replaced by scar tissue (6 months to mature for physician to determin recovery)
What is recommended precautions for treating patients with Myocardial infarction?
1. Must have the following in the dental office:
a) Aspirin (ASA) (antiplatelet meds) b) Oxygen
c) Vasodilators (nitroglycerin)
What is the pathology associated with Congestive Heart Failure (CHF)?
1. Ischemic heart disease: myocardial infarcts (insufficient blood supply)
2. Vulvular heart disease (heart is being overworked)
3. Hypertensive heart disease
4. Congential heart disease
What are the symptoms of a patient with congestive heart failure?
2. Recumbent SOB
3. Nocturnal dyspnea
4. coughing 4*Abdominal organomegaly
What are the pathological findings associated with brain, kidney, liver, and lungs?
1. Reduced pump function
2. Organ congestion (liver/lungs)
3. Reduced organ perfusion (brain/kidneys)
List 2 dental precautions for congestive heart failure.
1. Watch epinephrine given
2. Patient need to be sat up at 45 degrees in the chair.
What is endartectomy?
Endarterectomy is a surgical procedure to remove the atheromatous plaque material, or blockage, in the lining of an artery constricted by the buildup of soft/hardening deposits. It is carried out by separating the plaque from the arterial wall.
What is embolus/embolism?
Embolus: Anything floating in blood is an embolus (including a blood clot)
What is a thrombus?
A blood clot
Where will clots from the venous side of circulation end up?
Damages Lungs Thrombus formation --> blood stream (embolus) --> Inferior vena cava --> R atrium --> R Ventricle -- Lung --> Pulmonary Embolism
Where will clots from the arterial side of circulation end up?
Can damage: Brain Kidney Legs Feet
What is the blood pressure reading which indicate hypertension?
Systolic (contracting) 140-159 Diastolic (relaxing) 90-99 mm Hg
STAGE 2 Hypertension
What is a Cerbrovascular Accident (CVA) Stroke?
Compression/ischemia of tissue Blockage (thrombus of cerebral vessel (80%) Rupture of cerebral vessel (brain tissue compression (20%)
What is a Transient Ischemic Attack (TIA)?
Mini Stroke Same as CVA but clot dissolves on its own (blockage or rupture)
What is the INR and how is it determined? What is the correct therapeutic level for patient taking medication for prosthetic heart valves and other indications (stroke prevention, post-myocardial infarction, deep venous thrombosis)?
1. INR (INternational Normalized Ratio. It is a measure of prothrombin time. Patients prothrombin time is just a measure of coagulation over laboratory normal (1)
2. For artificial heart valves the range should be 2.5-2.5x normal For all other conditions 2.0-3.0 **For most dental procedures NO modifications in anticoagulant dosage (INR 2-3) is indicated
What are the high-risk conditions for development of bacterial endocarditis?
High Risk for Endocardits (Unrepaired Cyanotic Congenital Defects) > Unrepaired or incompletely repaired cyanotic heart disease (Transposition of Great Vessels, TOF, Coarctation of the Aorta; > A completely repaired defect with prosthetic material or device > A repaired defect with residual defect at the site or adjacent to the site of a prosthetic patch or prosthetic device. *
Anything that is unrepaired or has been repaired
What is the "safe" amount of epinephrine that can be given to patients with heart disease?
Limit epinephrine to
What do you do for patient who starts to have chest pain in the office (without history of angina)?
If an attack occurs use:
c) Stop treatment
d) Call ambulance
Dr. Schaaf: "...you call for the EMS right away." (This is all he says about angina in office with NO history of angina in the verbatim, slide #55 in the Cardiovascular Conditions verbatim) i. (Mike and Greg assume that you would also go ahead and give them oxygen, aspirin, and nitroglycerine in addition to immediately calling the EMS... but again, that is just our interpretation).
Describe the consequences of abruptly stopping an antiplatelet medication (e.g Plavix + aspirin) in a dental patient who has had a drug eluting stent placed in a coronary artery. What should you do before performing any dental work that will cause bleeding?
1. Stent thrombosis and possible Myocardial infarction = 50% chance of death
2. Advise patient to take meds as usual prior to appointment (these include their anticoagulants) Consult with physician concerning patient's PT/INR
Which dental treatments will induce bacteremia?
Ones that manipulate the gingival or apical areas of the teeth
What is the oral premedication protocols (antibiotic and its dosing schedule)?
a) Single dose 30-60 minutes before procedure
b) Adults: 2 grams
2. Ampicillin (if can't take oral meds)
a)30-60 min prior
b) Adult 2 g IM or IV
3. Cephalexin (if allergic to penicillins)
a) 30-60 minutes prior
b) Adult: 2g
how do you prescribe an antibiotic for endocarditis prevention for a patient who has been taking penicillin for several days for a dental or other type of infection
Another class (clindamycin if taking penicillin) of antibiotic should be selected as premedication.
Who do you take pule in the wrist and what artery is palpated to obtain pulse?
1. Taking pulse
a)Use INDEX or MIDDLE finger to palpate
b) BEST result if taken for full 60 seconds
c) Patient should be resting for 10 minutes
d) normal is 60-100 beats per minute
2. RADIAL artery (pulse)
How do you take blood pressure in the arm? What is implication of 1st and 2nd sound? What artery do you use?
1. Blood pressure determination a) Identify location of BRACHIAL artery b) Put cuff on arm above elbow c) Bladder of cuff against skin and overlying location of brachial artery d) Don't restrict blood flow by pulling sweater or shirt to high on arem e)Palpate medial aspect of antecubital fossa to determine location of BRACHIAL artery f) place stethoscope over brachial artery and inflate cuff to 200mm (or 20-33 mmHg above their last reading) g) SLOWELY deflate cuff at rate of 2-4mm HG per second h) First sound is systolic (contracting) i) second sound is diastolic (relaxing)
During which phase (systole or Diastole) does the heart receive its blood supply?
During diastole or the relaxation phase
What are the complications and causes of ischemic heart disease?
a) Angina Pectoris
b) Myocardial infarction
d) Congestive heart failure
a) Atherosclerois (plaque)
b) Hypertrophy - heart too large for blood supply
c) Drugs (e.g. cocaine)
What are the complications of hypertension?
1. Cardiac enlargement
2. Ischemic heart disease
3. Valvular heart disease - aortic root dilation => valvular insufficiency
5. Myocardial infarct
6. Conduction abnormalities
7. Heart failure
8. Other organ and vessel disease / failure (brain, kidneys, peripheral arteries)
Which organs become congested and which are affected by a reduced perfusion as result of congestive heart disease?
1. Congestion (backward deficiency) a) Lungs b) Liver
2. Perfusion deficiency (forward failure) a) Brain b) kidneys
Wha tis the major cause of Myocarditis?
Viral infection (MOST Common)
What are the 3 types of non-ischemic Cardiomyopathy?
1. Dilated cardiomyopathy
2. Hypertrophic cardiomyopathy
3. Restrictive Cardiomyopathy
What is the most common cause of non-traumatic death in young athletes?
Hypertrophic Cardiomyopathy *
Hypertrophic Idiopathic Subaortic Stenosis (IHSAS)
Risk of sudden death due to dysrhythmia
What is Aortic dissection? Where is its most common location? What are the associated complications?
1. Disease of the media; blood dissects into the media and a false channel is formed
2. Most common location = Ascending aorta
3.Complications a) Rupture b) Obstruction of artery arising from aorta c) Aortic regurgitation
What is an aneurysm and the common causes?
1. Dilation of aorta due to weakening or degenerative process in the wall of the vessel; degeneration of elastin in vessel wall; degeneration of media; contains all layers of normal vessel wall.
Dilation 1.5-2 x normal vessel diameter
a) Atherosclerosis i.most extensive in abdominal aorta ii. most common is below renal arteries
f) Genetic (15-25%)
What is the etiology and manifestations of TIAS and CVAS?
CVA: 1.Etiology a)Ischemia - 80% b)Compression/Hemorrhage - 20% 2. Manifestations (Symptoms) a)Unilateral paralysis, weakness, and numbness b)Speech and visual disturbances
1. Etiology a) Same as CVA but clot dissolves on own
2. Manifestation a) Same as CVA but will clear < 24 hours
What's wrong with this sentence that might be written in a medical consultation? "This patient gives a history of having a CABG (Xs 2) Please advise if he will need antibiotic premedication for the prevention of endocarditis?"
a.CABGs are placed outside of the heart, whereas endocarditis affects the heart valves... which, for those of you who weren't paying attention to the anatomy of the heart lecture, reside inside the heart. Only having CABG does not put you at risk for endocarditis, and you do not need premedication.