CARDIOVASCULAR

Cardiovascular system

Hypertension
Coronary Heart Disease
Acute Coronary Syndromes
Valvular Heart Disease
Heart Failures

Arrhythmia
Endocarditis

HYERTENSION
DEFINITION
Hypertension is defined as having systolic blood pressure (SBP) >140 mmHg or
diastolic blood pressure (DBP) > 90 mmHg
As having to use antihypertensive medications
CLASSIFICATION
(According to etiology)
Primary (Essential)
Secondary
(According to SBP and DBP score)
Normal
Prehypertension
Stage 1 hypertension
Stage 2 hypertension

RISK FACTORS
HTN is well recognized risk factors for CAD
With improved control of BP, there has been a
steady decrease in mortality from CHD an
even greater decrease in mortality from stroke
Treatment focuses on prevention to reduce
complications -> brain, heart, kidney, eyes,
peripheral arteries
Complications -> Cerebral hemorrage, left
ventricular hypertrophy, CHF, renal
insufficiency, etc

DIAGNOSIS
Hypertention usually has a long and asymtomatic course -> undiagnosed
Diagnosis is made only after an elevated BP has been recorded on multiple occasions
Stage 1 : SBP 140 to 150 mmHg or DBP 90 to 99 mmHg
Stage 2 : SBP >160 mmHg or DBP > 100mmHg
The BP level determines severity of HTN
3 main goals of medical evaluation :
- Identify tretable of curable cause
- Assess the impact of persistently elevated BP on target organs
- Estimate the patient overall risk profile for the development of the CVD
- Routine history and physical examintaion should be performed

EXAMINATION:

Routine History
Duration of the hypertention and any prior treatment

Physical Examination -> Sign of end-organ damage and a cause of secondary

hypertention and a cause of secondary hypertention, Peripheral pulses, abdomen
auscultated, funduscopic assessment

Laboratory Routine blood chemistries, fasting lipid (total, HDL, cholesterol and
triglycerides), twelve-lead electrocardiography (ECG).

Additional Testing Electrocardiograhy, Ambulatory BP Monitoring, Plasma Renin

activity testing, radiologic testing

MANAGEMENT
Lifestyle modification

Medication
Diuretics : Reduce blood volume oral dryness, lichenoid reaction
b-blockers : reduce stimulation by sympathetic nervous system oral
dryness, oral ulceration, taste changes
Calcium channel blockers : reduce calcium flow into heart muscle and
therefore heart rate relax smooth muscle lining coronary arteries
gingival overgrowth
Angiotensin-converting enzyme
Inhibitors (ACEIs) : interfere with renin-angiotensin pathway
angiotensin II receptor blockers lichenoid reaction
Direct vasodilators : open up blood vessels (reduce resistance)
lupuslike oral and skin lesion, lymphadenophaty
Centrally acting agents.

ORAL HEALTH CONSIDERATIONS

1.
2.
3.

Effect of HTN on Oral Health

More sensitive to adrenaline in dental anesthetics
Medications lead to dry mouth
Increased bleeding after dental surgery

1.
2.
3.

Dentist should be aware of medications that

May have systemic side effects that are of importance to provision of care
Interact with medications used during dental care
Cause intraoral changes -> oral dryness, gingival overgrowth, ulceratotions

Concentrations of epinephrine greater than 1:100.000 aren unnecessary and carry a higher
risk

CORONARY ARTERY DISEASE (CAD)

DEFINITION
Condition when coronary arteries become narrowed by a gradual build-up of
fatty material within their walls. The condition is called Atherosclerosis and the
fatty material is called atheroma
30-50% of all CVD

Disrupt of vascular
nedothelium

Plaque formation

Chronic reduction in
coronary blood flow and
ensuing myocardial
ischemia/ acute plaque
rupture

 Atherosclerosis may affect any vascular bed -> coronary, cerebral. Renal,
mesenteric, and peripheral vascular system
When end-organ blood flow is compromised, the resulting ischemia can cause
subsequent organ dysfunction
ETIOLOGY
- Artherosclerosis
- Fatty streak -> progress into plaque -> thrombotic occlusions and coronary
events
- Lipid metabolism abnormalities, systemic hypertension, diabetes mellitus,
cigarette smoking -> total atherosclerosis plaque burden

RISK FACTORS
- Risk factors assessment is useful as a guide to therapy for dyslipidemia,
hypertension, and diabetes

Hypertension

Exercise

DM

Obesity

Plasma
Fibrinogen

Cigarette
Smoking

Lifestyle and
Diatery factors

Lipids

Vitamins and
Homocysteine

Antioxidants

Endothelial
Dysfunction

RISK FACTORS MODIFICATION

- When artherosclerosis is identified -> relieve symptoms and improve organ
perfusion
- Risk factor modification -> prevent ongoing atherosclerosis
- Smoking cessation, meticulous control of hypertension and DM, weight
management, agressive lipid-lowering therapy -> should be all advised
- Lipid-lowering therapy with HMG CoA reductase inhibitor -> reduce mortality
- Low-fat, low-calorie diet -> also effective
DIAGNOSIS
- Clinical presentation -> taking history or resting symptoms including chest
tightness, jaw discomfort, left arm pain, dyspnea, or epigastric distress
- Test : Blood test, doppler ultrasound, ankle-brachial index, electrocardiogram
(ECG). Stress test

MANAGEMENT
- High blood pressure -> Angiotensin-converting enzyme (ACE) inhibitors, calcium channel
blockers, thiazide diuretics
- High colesterol level -> Statins
- Preventing blood clots -> Antiplatelets
- Surgery -> Coronary artery bypass graft (CABG), Carotid arteries, Carotid
endarterectomy, carotid angioplasty Extracranial to intracranial bypass
DENTAL CONSIDERATION
- Prevent ischemia and infarction
- Impaired hemostatis due to one or more medications may also require dental
modifications
- Side effects from cardiac drugs -> cause oral change
- Current cardiac status and medications should be discussed with the patients physicians

Acute coronary syndrome

Sudden rupture of an atherosclerotic plaque with ensuing intracoronary

thrombus formation that acutely reduces coronary blood flow -> ACUTE
CORONARY SYNDROMES (ACSs)

Acute coronary syndrome (ACS) refers to a spectrum of clinical presentations

ranging from those for ST-segment elevation myocardial infarction (STEMI) to
presentations found in nonST-segment elevation myocardial infarction
(NSTEMI) or in unstable angina

Atherosclerosis is the primary cause of ACS

SIGN AND SYMPTOMS

Atherosclerosis is the primary cause of ACS

Palpitations
Pain, which is usually described as pressure, squeezing, or a burning sensation
across the precordium and may radiate to the neck, shoulder, jaw, back, upper
abdomen, or either arm
Exertional dyspnea that resolves with pain or rest
Diaphoresis from sympathetic discharge
Nausea from vagal stimulation
Decreased exercise tolerance

DIAGNOSIS
Patients history, electrocardiography (ECG) is the most important diagnostic test
MANAGEMENT

Initial therapy -> stabilizing patients condition, relieving ichemic pain, providing
antothrombotic therapy
Pharmacologic anti-ischemic -> Nitrates, beta blockers
Pharmacologic antithrombotic -> Aspirin, clopidogrel, prasugrel, ticagrelor,
glycoprotein
Pharmacologic anticoagulant -> UFH, LMWH, Factor Xa inhibitors

Valvular heat disease

A. MITRAL VALVE DISEASE

Condition mitral valve does not work properly, patient can
experience symptoms such as fatigue and shortness of breath
because the defective valve is allowing blood to flow backwards
into the left atrium. When this happens, your heart will not pump
enough blood out of the left ventricular chamber to supply your
body with oxygen-filled blood

Typically caused by rheumatic fever. Usually a childhood disease,

rheumatic fever results from the bodys immune response to a
streptococcal bacterial infection. Rheumatic fever is a serious
complication of strep throat or scarlet fever.

SYMPTOMS

Mitral valve disease symptoms vary depending on the exact problem with your valve.
A problem with your mitral valve may cause no symptoms at all. When symptoms do
occur, the can include:
Cough
Shortness of breath (especially when you are lying down on your back or exercising)
Fatigue and tiredness
Lightheadedness

DIAGNOSIS

Imaging test -> endocardiogram, x-ray, cardiac catheterization, etc

Test of monitor heart activity -> electrocardiogram
Stress test

MANAGEMENT

Drugs and medications

Valvuloplasty
Surgery

B. AORTIC VALVE DISEASE

DEFINITION
Aortic valve disease is a condition in which the valve between the main pumping
chamber of your heart (left ventricle) and the main artery to your body (aorta) doesn't
work properly.
ETIOLOGY:
Congenital, rheumatic and senile calcific valve disease
Aortic Regurgitation (AR) imposes an acute or chronic volume load to the LV, with
subsequent eccentric hypertrophy, LV enlargement, and eventual LV contractile failure.

DIAGNOSIS:
Hystory heart murmur, exertional or resting dyspnea, or symptoms of heart failure,
such as orthopnea, paroxysmal nocturnal dyspnea, or peripheral edema.
Auscultatory findings harsh systolic crescendo-decrescendo murmur and a
diminished or absent aortic component of the second heart sound.
TREATMENT:
Surgery

C. PROSTHETIC HEART VALVES

DEFINITION
Bioprosthetic valves used in heart valve replacement generally offer functional properties (eg,
hemodynamics, resistance to thrombosis) that are more similar to those of native valves.
Implantation of prosthetic cardiac valves to treat hemodynamically significant aortic or mitral
valve disease has become increasingly common.
CLASSIFICATION:
Mechanical caged-ball (Starr-Edwards) valve, the single tilting-disk (BjorkShiley) valve, and bileaflet tilting-disk valves.
Bioprosthetic Heterografts, Homografts.
THERAPY:

Anticoagulant (tipically with warfarin) to prevent thromboembolism

ORAL HEALTH CONSIDERATION

Heart failures

Inability of the cardiovascular

system to meet the demands
of the end-programs
May be due to pericardial
disease, valvular heart
disease, most commonly ->
myocardial disease ->
Systolic and Diastolic
dysfunction

SIGN AND SYMPTOMS

Exertional dyspnea and/or dyspnea at rest

Orthopnea
Acute pulmonary edema
Chest pain/pressure and palpitations
Tachycardia
Fatigue and weakness
Nocturia and oliguria
Anorexia, weight loss, nausea, etc

DIAGNOSIS

The following tests may be useful in the initial evaluation for suspected heart failure :
Electrocardiography
Complete blood count (CBC)
Urinalysis
Electrolyte levels
Renal and liver function studies
Fasting blood glucose levels
Lipid profile

MANAGEMENT
Nonpharmacologic therapy: Oxygen and noninvasive positive pressure
ventilation, dietary sodium and fluid restriction, physical activity as
appropriate, and attention to weight gain
Pharmacotherapy: Diuretics, vasodilators, inotropic agents,
anticoagulants, beta blockers, and digoxin
Surgical options
ORAL HEALTH CONSIDERATIONS
No special dental modifications for this patient
But, when patient suffer from uncompensated CHF, it is prudent to inquire about patients ability
to be placed in a suspine positions

arrythmia

Is abnormalities of the heartbeat or cardiac rythms

Caused by Primary cardiovascular disease, Pulmonary disorders, Autonomic
disorders, Systemic diseases, Drug-related adverse effects, Electrolyte
imbalances.
Symptoms :
Fatigue
Dizziness
Lightheadedness
Fainting or near-fainting spells
Rapid heartbeat or pounding
Shortness of breath
Chest pain
In extreme cases, collapse and sudden cardiac arrest

TREATMENT
Bracycardias -> Pacemaker
Tachycardias -> Vagal maneuvers, Medications, Cardioversions, Catether
Ablations
Implantable devices : Pacemaker, ICD
Surgery
ORAL HEALTH CONSIDERATIONS
Patients with supraventicular tachycardia -> Should be only treated by
consultation by cardiologist
Patients with defibrilations and pacemaker -> no oral prophylaxys unless the
patients presents with an acute odontogenic infections

ENDOCARDITIS

Infection of the endocardial surface of

the heart (see the image below), which
may include one or more heart valves,
the mural endocardium, or a septal
defect. Its intracardiac effects include
severe valvular insufficiency, which may
lead to intractable congestive heart
failure and myocardial abscesses. If left
untreated, IE is generally fatal.

ETIOLOGY
Approximately 70% of infections in Endocarditis are caused
by Streptococcus species, including S viridans, Streptococcus bovis, and
enterococci. Staphylococcusspecies cause 25% of cases and generally
demonstrate a more aggressive acute course (see the images below).
PREDISPOSING CONDITION:
Mitral valve prolapse
Aortic valve disease
Congenital heart disease
Prosthetic valve
Intravenous drug use
No identifiable cause in 25-47%

MANAGEMENT
- Antibiotic -> Penicillin G, Gentamicin

DENTAL CONSIDERATION:
Antibiotic prophylaxis a very high risk of developing endocarditis:
Prosthetic heart valves.
Previous infectious endocarditis.
Congenital heart disease, only in the following
Heart transplant patients who develop cardiac valve disease.