Heart

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Heart
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Congestive heart failure

• or heart failure
• condition heart is unable to adequately
  pump blood throughout the body

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• Characterized
• shortness of breath (dyspnea)
• abnormal fluid retention, which usually results
  in swelling (edema) in the feet and legs.

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Heart failure

• Left-sided heart failure
• Right-sided heart failure

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• Left-sided heart failure.
• When LV cannot adequately pump blood out
  of the left atrium, or when one or more of the
  heart valves becomes leaky or narrowed
  (stenotic), blood can "back up" into the lungs

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• left-sided heart failure
• lungs become congested with fluid (called
  pulmonary edema),
• causing difficulty breathing and
• interfering with the movement of oxygen from the
  lungs into the bloodstream, causing fatigue.

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• Right-sided heart failure
• abnormality or condition affects the flow of
  blood through the right ventricle, pressure in
  the blood vessels increases and fluid is forced
  from the blood vessels into body tissues.
• causes swelling (edema), usually in the feet and
  legs, and sometimes, in the abdomen.

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• The NYHA functional class
• (the New York Heart Association)
• determine how much CHF limits their lifestyle
• Useful in following the course of disease and
  assessing the effects of therapy
• Aid in the dental management

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• Class I No symptoms at any level of exertion,
• no limitation of physical activity
• Class II Slight limitation of physical activity.
• Fatigue, palpitations and dyspnea
  with
• ordinary physical activity but
• 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 at rest, and any
• physical exertion exacerbates
  the symptoms

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Congestive heart failure

• Potential problem related to dental care
• 1. sudden death from cardiac arrest or
• arrhythmia
• 2. Myocardial infarction
• 3. CVA
• 4. Infective endocarditis if CHF is caused
• by rheumatic heart dis., congenital
• heart dis.

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CHF

• Potential problem related to dental care
• 5. Shortness of breath
• 6. Drug side effects
• orthostatic hypotension (diuretics,vasodila
  tors)
• arrhythmia (digoxin overdose)
• nausea, vomiting (digoxin, vasodilators)
• palpitations (vasodilators)
• 7. Infection

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• Prevention of complication
• 1. Detection and referral to physician
• 2. No routine dental care until under good
  medical management (class I or II and possibly
  III)
• 3. Good medical management cause of heart
  failure
• - hypertension
• - valvular dis. (rheumatic heart dis.)
• - congenital heart dis., MI
• - Renal failure
• - Thyrotoxicosis
• - chronic obstructive lung disease

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• 4. Class I or II, use max. 0.036 mg epinephrine
• avoid vasoconstrictors in class III or IV
• 5. Semisupine or upright position
• (decrease collection of fluid in lung)
• 6. Terminate appointment if patient becomes
  fatigue
• 7. Drug considerations
• digitalis N/V
• anticoagulants - PT 2times or less,
• - INR 3.0 or
  less
• antidysrhythmic agents, antihypertensive
• avoidance of outpatient general
  anesthesia

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CHF

• Emergency care
• 1. Conservative in acute congestive failure
• drug for pain control and
• antibiotics for infection
• 2. Under good medical management
• deal with underlying cause and presence of
• any complications in dental management

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Endocarditis

• Inflammation of endocardium
• most common structures involved are the heart
  valves.
• Endocarditis can be classified by etiology as
  either infective or non-infective

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Infective endocarditis

• valves of the heart do not actually receive any
  blood supply of their own, defense mechanisms
  (such as white blood cells) cannot enter.
• If an organism (such as bacteria) hold on the
  valves, the body cannot get rid of them.

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• If valve damaged (for instance in rheumatic
  fever) bacteria have a chance to hold.
• clinically divided into
• acute and subacute endocarditis.
• This classifies both the tempo of progression
  and severity of disease.

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• Subacute bacterial endocarditis (SBE) often due
  to streptococci of low virulence and mild to
  moderate illness which progresses slowly over
  weeks and months
• Acute bacterial endocarditis (ABE)
• fulminant illness over days to weeks, more
  likely due to Staphylococcus aureus (greater
  virulence, or disease-producing capacity)

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• Aetiology and pathogenesis
• altered blood flow around the valves is a risk
  factor in obtaining endocarditis.
• The valves may be damaged congenitally, from
  surgery, by auto-immune mechanisms, or simply as
  a consequence of old age.
• The damaged part of a heart valve becomes covered
  with a blood clot, a condition known as
  non-bacterial thrombotic endocarditis (NBTE).

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• In healthy individual, a bacteraemia would
  normally be cleared quickly with no adverse
  consequences.
• If a heart valve is damaged and covered with a
  piece of a blood clot, the valve provides a place
  for the bacteria to attach themselves and an
  infection can be established.

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• The bacteraemia is often caused by minor dental
  procedures, such as a tooth removal.
• Another causes result from a high number of
  bacteria getting into the bloodstream.
  (Colorectal cancer, serious urinary tract
  infections and IV drug use)
• With a large number of bacteria, even a normal
  heart valve may be infected.
• A more virulent organism (Staphylococcus aureus)
  is usually responsible for infecting a normal
  valve.

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• Intravenous drug users right heart valves
  infected (veins that are injected enter the right
  side of the heart)
• The injured valve is most commonly affected when
  there is a pre-existing disease. (rheumatic heart
  disease this is the aortic and the mitral valves)
  left heart valves

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• Clinical and pathological features
• Fever (often spiking)
• Continuous presence of micro-organisms in the
  bloodstream determined by serial collection of
  blood cultures
• Vegetations on valves on echocardiography
• Septic emboli, causing circulatory problems
  (stroke, gangrene of fingers)
• Chronic renal failure

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• Clinical and pathological features
• Osler's nodes (painful subcutaneous lesions in
  the distal fingers)
• Janeway lesions (painless hemorrhagic cutaneous
  lesions on the palms and soles)
• Roth spots on the retina
• Conjunctival petechiae
• A new or changing heart murmur, particularly
  murmurs suggestive of valvular incompetence
• Splinter haemorrhages

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• Micro-organisms responsible
• Many types of organism
• isolated by blood culture
• Alpha-haemolytic streptococci, that are present
  in the mouth will often be the organism isolated
  if a dental procedure caused the bacteraemia.

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• If bacteraemia was introduced through the skin,
  such as contamination in surgery, during
  catheterisation, or in an IV drug user
• Staphylococcus aureus

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• A third important cause of endocarditis is
  Enterococci (abnormalities in the
  gastrointestinal or urinary tracts)
• Enterococci causes of nosocomial or
  hospital-acquired endocarditis.
• alpha-haemolytic streptococci and Staphylococcus
  aureus causes of community-acquired
  endocarditis.

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• Treatment
• High dose antibiotics ( by intravenous route)
• Antibiotics are continued for a long time,
  typically two to six weeks.
• Surgical removal of the valve is necessary in
  patients who fail to clear micro-organisms from
  their blood in response to antibiotic therapy, or
  in patients who develop cardiac failure resulting
  from destruction of a valve

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• A removed valve is usually replaced with an
  artificial valve which may either be mechanical
  (metallic) or obtained from an animal such as a
  pig (bioprosthetic valves)
• Infective endocarditis is associated with a 25
  mortality.

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ENDOCARDITIS RISK STRATIFICATION

• Endocarditis prophylaxis recommended
• High risk
• Prosthetic heart valves
• Prior bacterial endocarditis
• Complex cyanotic congenital heart disease
• Surgically constructed systemic pulmonary shunts
  or conduct

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ENDOCARDITIS RISK STRATIFICATION

• Endocarditis prophylaxis recommended
• Moderate risk
• Most other congenital cardiac malformations
• Acquired valvular dysfunction
• Hypertrophic cardiomyopathy
• Mitral valve prolapse with regurgitations and/or
  thickened leaflets

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ENDOCARDITIS RISK STRATIFICATION

• Endocarditis prophylaxis not recommended
• Negligible risk
• Isolated secundum atrial septal defect
• Surgical repair of ASD, VSD, or PDA (without
  residua beyond 6 mo.)
• Prior coronary artery bypass graft
• Mitral valve prolapse without regurgitation
• Physiologic, functional, or innocent heart
  murmurs

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ENDOCARDITIS RISK STRATIFICATION

• Endocarditis prophylaxis not recommended
• Negligible risk
• Previous Kawasaki dis. without valvular
  dysfunction
• Previous rheumatic fever without valvular
  dysfunction
• Cardiac pacemakers and implanted defibrillators

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DENTAL AND ORAL SURGERY PROCEDURES AND
ENDOCARDITIS PROPHYLAXIS

• Endocarditis prophylaxis recommended in
• high- and moderate-risk cardiac conditions
• Exodontia
• Periodontal procedures
• Incision and drainage of abscesses
• Dental implant placement and uncovering
• Reimplantation of avulsed teeth
• Endodontic therapy or apical surgery
• Placement of intermaxillary fixation

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DENTAL AND ORAL SURGERY PROCEDURES AND
ENDOCARDITIS PROPHYLAXIS

• Endocarditis prophylaxis recommended in
• high- and moderate-risk cardiac conditions
• Reduction of contaminated maxillofacial fractures
• Osteotomies
• Subgingival placement of antibiotic fibers or
  strips
• Intraligamentary LA injections
• Prophylactic dental or implant cleaning
• Intraoral biopsies

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DENTAL AND ORAL SURGERY PROCEDURES AND
ENDOCARDITIS PROPHYLAXIS

• Endocarditis prophylaxis not recommended
• Restorative dentistry
• Nonintraligamentary LA injections
• Postoperative suture removal
• Placement of removable orthodontic or
  prosthodontic appliances
• Taking oral impressions
• Shedding (naturally) of primary teeth

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ANTIBIOTIC PROPHYLACTIC REGIMENS FOR DENTAL AND
ORAL SURGICAL PROCEDURES
circumstance drug regimen
Standard prophylaxis amoxicillin Adults 2 g po Children 50 mg/kg po 1 hr before procedure
Unable to take oral medications ampicillin Adults 2g IM or IV Children 50 mg/kg IM or IV Within 30 min of procedure
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circumstance drug regimen
Penicillin allergy Clindamycin or Cephalexin or cefadroxil or Azithromycin or clarithromycin Adults 600 mg po 1hr before Children 20 mg/kg po Adults 2g po 1hr before Children 50 mg/kg po Adults 500 mg po Children 15 mg/kg po 1 hr before procedure
Penicillin allergy and unable to take oral medications Clindamycin or cefazolin Adults 600 mg IM or IV Children 20 mg/kg IM or IV within 30 min of procedure Adults 1 g IM or IV Children 25 mg/kg IM or IV within 30 min of procedure
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Congenital heart disease

• defect of heart that exists primarily at birth
• environmental, such as chemicals, drugs, or
  infection (i.e. rubella)
• genetic
• mother's excessive intake of alcohol and drugs
  while pregnant

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Classifications

• Acyanotic
• Cyanotic

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• Cyanotic
• Disorders that cause profusion or an
  insufficient amount of oxygen in the blood pumped
  throughout the body (bluish-grey discoloration of
  the skin)
• truncus arteriosus, total anomalous pulmonary
  venous return, tetralogy of Fallot, transpositon
  of the great arteries, and tricuspid atresia.

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Types of congenital heart disease

• Patent ductus arteriosus
• Obstruction defects
• pulmonary valve stenosis
• aortic valve stenosis
• coarctation of the aorta
• Septal defects

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Signs and Symptoms

• related to the type and severity of defects.
• no signs
• exhibit shortness of breath,
• cyanosis, chest pain, syncope, sweating, heart
  murmur, respiratory infections, underdeveloping
  of limbs and muscles, poor feeding, or poor
  growth

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Patent ductus arteriosus

• In developing fetus, ductus arteriosus (DA) is a
  shunt connecting the pulmonary artery to the
  aortic arch
• allows blood from the right ventricle to bypass
  the fetus' fluid-filled lungs.
• During fetal development, shunt protects the
  lungs from being overworked and allows the right
  ventricle to strengthen.

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• first breath, the lungs open and pulmonary
  pressure decreases below that of the left heart.
• At the same time, the lungs release bradykinin to
  constrict the smooth muscle wall of the DA and
  reduce blood flow.
• reduced pulmonary resistance, more blood flows
  from the pulmonary arteries to the lungs and
  lungs deliver more oxygenated blood to the left
  heart. This further increases aortic pressure so
  that blood no longer flows from the pulmonary
  artery to the aorta via the DA.

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PDA

• normal newborns, DA is closed within 15 hours
  after birth, and is completely sealed after three
  weeks.
• A nonfunctional vestige of the DA, called
  ligamentum arteriosum, remains in the adult
  heart.
• not close in the newborn, the blood that is
  suppose to flow through the aorta goes to the
  lungs PDA
• common in premature infants

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Signs and symptoms

• oxygenated blood flow from aorta to pulmonary
  arteries
• some of infant's oxygenated blood does not reach
  the body, and the infant becomes short of breath
  and cyanotic.
• Tachycardia increasing the speed with which
  blood is oxygenated and delivered to the body
• Untreated suffer from congestive heart failure

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Atrial septal defects (ASD)

• communication between atria of the heart and may
  involve the interatrial septum.
• possible for blood from left side of heart to
  right side,
• or resulting in mixing of arterial and venous
  blood

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• foramen ovale remains open during fetal
  development (allow blood from the venous system
  to bypass the lungs and go to the systemic
  circulation)
• prior to birth, the oxygenation of the blood is
  via the placenta and not the lungs.
• A layer of tissue begins to cover the foramen
  ovale during fetal development, and will close
  completely soon after birth
• After birth, pressure in the pulmonary
  circulation drops, and foramen ovale closes

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• approximately 30 of adults the foramen ovale
  does not seal over.
• In this case, elevation of pressure in the
  pulmonary circulation (ie pulmonary
  hypertension) can cause opening of the foramen
  ovale. This is known as a patent foramen ovale
  (PFO).

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• right ventricle have to push out more blood than
  the left ventricle due to the left-to-right
  shunt.
• Eventually the pulmonary vasculature will develop
  pulmonary hypertension to try to divert the extra
  blood volume away from the lungs.

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• lead to right ventricular failure (dilatation and
  decreased systolic function of the right
  ventricle) or elevations of the right sided
  pressures to levels greater than the left sided
  pressures.
• uncorrected, pressure in right side gt left side
• cause pressure in right atrium gt left atrium This
  will reverse the pressure gradient across the
  ASD, and the shunt will reverse a right-to-left
  shunt will exist.

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• Once right-to-left shunting occurs, a portion of
  oxygen-poor blood will get shunted to the left
  side of the heart and ejected to the peripheral
  vascular system. This will cause signs of
  cyanosis
• types of atrial septal defects.
• They are differentiated
• involve other structures of the heart and
• how they are formed during the developmental
  process during early fetal development

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1. Ostium secundum atrial septal defect

• most common type of ASD
• 6-10 of all congenital heart diseases
• usually from
• enlarged foramen ovale,
• inadequate growth of the septum secundum,
• or excessive absorption of the septum primum.
• 10 to 20 percent of individuals with ostium
  secundum ASDs also have mitral valve prolapse

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• Complications of an uncorrected secundum
• ASD
• pulmonary hypertension,
• right-sided heart failure,
• atrial fibrillation or flutter,
• stroke
• Eisenmenger's syndrome.

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2. Ostium primum atrial septal defect

• endocardial cushion defect
• defect in the atrial septum at the level of the
  tricuspid and mitral valves
• often involves the endocardial cushion
• most common congenital heart defect that is
• associated with Down's syndrome

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3. Sinus venosus atrial septal defect

• defect in the septum involves the venous inflow
  (superior vena cava or the inferior vena cava)

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4. Common or single atrium

• failure of development of the embyologic
  components that contribute to the atrial septal
  complex

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Treatment

• Closure of an ASD in individuals under age 25 has
  been shown to have a low risk of complications
• have a normal lifespan

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Ventricular septal defect

• defect in the ventricular septum
• Congenital VSDs the most common congenital
  heart defect
• associated with other congenital conditions, such
  as Down syndrome
• ventricular septum
• muscular (inferior)
• membranous portion (superior) - is close to the
  AV node is most commonly affected

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Pathophysiology

• Large VSDs result in a significant left-to-right
  shunt and increase load on the right ventricle.
  If untreated, they result in hypertrophy of the
  right ventricle, which ultimately leads to right
  heart failure and death.

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Treatment

• Treatment
• surgical
• conservative
• Smaller congenital VSDs often close on their own
  (as the heart grows) and are treated
  conservatively

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Tetralogy of Fallot

• significant and complex congenital heart defect.

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• involves four different heart malformations
• ventricular septal defect (VSD)
• Pulmonic stenosis Right ventricular outflow
  tract obstruction, a narrowing at or just below
  the pulmonary valve.
• Overriding aorta The aorta is positioned over
  the VSD instead of in the left ventricle.
• Right ventricular hypertrophy (RVH) The right
  ventricle is more muscular than normal.

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• Sometimes pulmonary valve is completely
  obstructed (pulmonary atresia).
• Infants and young children with unrepaired TOF
  are often cyanotic (some oxygen-poor blood is
  pumped to the body)

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• The development of right ventricular hypertrophy
  is a result of a longstanding, untreated disease.
• right-to-left shunt

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• Squatting
• simple procedures such as knee-chest
  position which reduces systemic venous return (to
  reduce the right-to-left shunting), increases
  systemic vascular resistance
• Surgical TreatmentA temporary operation may be
  done at first if the baby is small
• Complete repair later

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Pulmonary valve stenosis

• reduction of flow of blood to the lungs
• The most common cause is congenital
• cyanosis
• secondary to other conditions such as
  endocarditis
• valve may become narrowed (stenotic) or leaky
  (insufficient). The stenosis, insufficiency or
  both can be mild to severe.

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• Surgical Treatment
• If stenosis is severe, the pulmonary valve must
  be opened to increase blood flow to the lungs. A
  balloon-tipped catheter is used
• If the insufficiency is severe, an operation is
  required to repair or replace the pulmonary
  valve.

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Coarctation of the aorta

• ???????????? aorta

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• Symptoms decreased exercise performance, cold
  feet or legs, and shortness of breath.
• Other symptoms include
• dizziness or fainting
• headache
• nosebleed
• leg cramps with exercise
• hypertension with exercise

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• Note There may be no symptoms.
• Signs and tests
• examination high BP in the arms and
• low BP in the legs,
• significant BP difference between the arms
  and legs.
• The femoral pulse is weaker than the carotid
  pulse, or the femoral pulse may be totally
  absent.

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Congenital heart disease

• Potential problem
• 1. Infective endocarditis, infective
  endarteritis
• 2. Prolonged bleeding
• Thrombocytopenia
• Lack of coagulation factor (thrombosis in small
  vessels)
• Anticoagulation medication

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• 3. Infection leukopenia
• 4. Congestive heart failure
• Infection
• Cardiac arrest
• Cardiac dysrhythmia
• Breathing difficulties (pulmonary edema)

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• Prevention of complications
• 1. Detection
• 2. Referral for medical Dx. and treatment
• 3. Consult before dental Treatment
• 4. Prophylactic antibiotic before dental
• procedure

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• 5. Avoidance of dehydration in oral infection
• 6. Bleeding time and prothrombin time before
  surgery, consult if prolonged
• 7. White blood cell count
• Low antibiotic
• 8. Effective local anesthetic maximum
  epinephrine 0.036 mg, aspirate, injection slowly

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Valvular heart disease
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Mitral stenosis

• the valve does not open completely,
• so the left atrium has to have a higher pressure
  than normal to have the blood overcome the
  increased gradient caused by the mitral valve
  stenosis

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Symptoms and signs

• Pulmonary hypertension
• Exertional dyspnea
• Orthopnea
• congestive heart failure
• Treatment requires replacement of the
• diseased valve with a porcine valve, or an
• prosthetic valve.

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Aortic insufficiency

• aortic regurgitation (AR),
• leaking of the aortic valve that causes blood to
  flow in the reverse direction during ventricular
  diastole, from the aorta into the left ventricle.
• some of the blood that was already ejected from
  the heart is regurgitating back into the heart

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Etiology

• Most cases secondary to rheumatic fever and the
  consequent rheumatic heart disease
• Less common causes calcification of the mitral
  valve leaflets, and as a form of congenital heart
  disease

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Aortic valve stenosis

• The more constricted the valve, the higher the
  gradient between the LV and the aorta.
• LV has to generate an increased pressure in order
  to overcome the increased afterload caused by the
  stenotic aortic valve and eject blood out of the
  LV
• Due to the increased pressures generated by the
  left ventricle, the myocardium of the LV
  undergoes hypertrophy

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• thickening of the walls of the LV. The type of
  hypertrophy most commonly seen in AS is
  concentric hypertrophy, meaning that all the
  walls of the LV are (approximately) equally
  thickened

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Etiology

• include acute rheumatic fever, bicuspid aortic
  valve and congenital anomalies.
• As individuals age, calcification of the aortic
  valves may occur and result in stenosis.

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Symptoms and signs of aortic stenosis

• Symptomatic
• syncope, angina and congestive heart failure
• Treatment requires replacement of the diseased
  valve with a porcine aortic valve or a cadaveric
  aortic valve, or an prosthetic aortic valve.

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Aortic insufficiency

• aortic regurgitation (AR),
• leaking of the aortic valve that causes blood to
  flow in the reverse direction during ventricular
  diastole, from the aorta into the left ventricle.
• some of the blood that was already ejected from
  the heart is regurgitating back into the heart

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Etiology

• half of the cases of aortic insufficiency are due
  to the aortic root dilatation idiopathic in
  over 80 of cases
• aging and hypertension, Marfan syndrome, aortic
  dissection, and syphilis
• 15 the cause is bicuspidal aortic valve
• 15 due to retraction of the cusps
  (postinflammatory processes of endocarditis in
  rheumatic fever and collagen vascular diseases)

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• regurgitant flow causes
• decrease in the diastolic blood pressure,
• increase in the pulse pressure and hypertension
• pressure overload causes left ventricular
  hypertrophy (LVH).

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• Acute aortic insufficiency
• acute perforation of aortic valve due to
  endocarditis
• sudden increase in the volume of blood in the
  left ventricle
• pressure of the left ventricle will increase
• causes pressure in the left atrium to rise, and
  the individual will develop congestive heart
  failure

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• Severe acute aortic insufficiency
• is considered a medical emergency
• immediate surgery for aortic valve replacement

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• Chronic aortic insufficiency
• left ventricle adapts by hypertrophy and
  dilatation of the left ventricle, and the volume
  overload is compensated
• Eventually the left ventricle will become
  decompensated, and filling pressures will
  increase symptoms of congestive heart failure

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Valvular heart disease

• Potential problem
• 1. Infective endocarditis
• 2. Prolonged bleeding
• - Anticoagulation medication
• 3. Congestive heart failure

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• Prevention of complications
• 1. Detection
• 2. Referral for medical Dx. and treatment or
• consult before dental Tx.
• 3. Prophylactic antibiotic before dental
• procedure
• 4. Bleeding time and prothrombin time
• before surgery, consult if prolonged
• 5. Effective local anesthetic maximum
• epinephrine 0.036 mg, aspirate, injection
• slowly

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Ischemic heart disease

• Definition   
• weakened heart pumps (due to previous heart
  attacks or due to current blockages of the
  coronary arteries)
• Cardiomyopathy - ischemic

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• Causes, incidence, and risk factors   
• coronary arteries are blocked.
• Ischemic cardiomyopathy is a common cause of
  congestive heart failure.
• heart attack, angina or unstable angina.
• A few patients may not have noticed any previous
  symptoms.

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• Risks include
• personal or family history of heart attack,
  angina, unstable angina, atherosclerosis,or other
  coronary artery diseases.
• High blood pressure, smoking, diabetes, high fat
  diet, high blood cholesterol, obesity
• (rarely) stress can precipitate

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• Symptoms   
• chest pain
• under the sternum may radiate to the neck, jaw,
  back, shoulder, arm
• may feel tight, pressure, crushing, squeezing
• may or may not be relieved by rest or
  nitroglycerin
• sensation of feeling the heart beat
  (palpitations)
• irregular or rapid pulse
• shortness of breath, especially with activity

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• shortness of breath that occurs after lying down
• cough
• fatigue, weakness, faintness
• decreased alertness or concentration
• decreased urine output
• excessive urination at night
• overall swelling
• breathing difficulty when lying down

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• Physical examination
• may be normal
• may reveal signs of fluid buildup
• (leg swelling, enlarged liver, "crackles" in
  the lungs, extra heart sounds, or an elevated
  pressure in the neck vein)
• may be other signs of heart failure.

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MI

• Potential problem related to dental care
• Cardiac arrest
• MI
• Angina pectoris
• Congestive heart failure
• Bleeding tendency secondary to anticoagulant
• Electrical interference with pacemaker

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• Prevention of complication
• 1. No routine dental care until at least 6 mo
  after MI
• (increase risk of new infarction and
  arrhythmia)
• 2. Consultation before starting routine dental
  care
• 3. Morning appointments
• 4. Short appointments
• 5. Terminate appointment if fatigue , short of
• breath, change in pulse rate or rhythm
• Inform physician
• Chest pain manage as unstable angina

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• 6. LA with max. epinephrine 0.036 mg,
• aspiration, inject slowly
• avoid use of vasopressor to control loss of
  blood, in gingival packing material
• do not use epinephrine In LA in severe
  arrhythmia
• 7. Premedication with diazepam 5-10 mg before
• appointment and/or the night before
• 8. Anticoagulant medication
• surgery or scaling for patient taking
  coumadin
• consult physician, PT 2 times normal or
  less,
• INRlt 3.0, ASA or other antiplatelet
  aggregation may have increased bleeding

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• 9. Digitalis prone to N/V, avoid stimulating
  gag reflex
• 10. Antisialagogues atropine and scopolamine
  may cause tachycardia check physician before use
• 11. Antiarrhythmic agents (quinidine,
  procainamide) nausea,vomit, hypotension
• oral ulceration may indicate
  agranulocytosis
• 12. Avoid use of electrocautery in patients with
  pacemaker

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• Treatment plan modifications
• 1. 6 mo. or more after infarction with no
  complications, any routine dental care can be
  performed
• 2. complications such as CHF are present, dental
  Tx. should be limited to immediate needs only

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• Emergency care
• During first 6 mo. After infarction, emergency
• dental care only after consultation
• - Conservative as possible
• - Drug for pain control
• - Antibiotics for infection
• - Pulpotomy rather than extraction
• 2. More than 6 mo. after infarction
• a. no complications can receive any
  treatment indicated
• b. complications medical consultation