Cardiovascular Diseases By Dr Haider Al Shamaa

1. Cardiovascular Diseases By Dr Haider Al Shamaa

2. Cardiovasculardiseases Infective endocarditis and endarteritis: Infective endocarditis is a disease caused by microbial infection of the heart valves and endocardium, most proximity to congenital or acquired cardiac defects. Infective endarteritis is a disease caused by microbial infection of patent ductus arteriorus (PDA), coaretation of the aorta, suegical grafts of major vessels, and surgical arteriovenous shunts. These diseases have a very high mortality rate even with intensive care that’s why the dentist's management to a patient with cardiovascular disease is of prime importance to the patient.

3. Etiology: 1-Bacterial: Caused by streptococci, staphylococci, and cloxiella bunatte (from sheep). 2-Fungal: Is very serious and difficult to treat. Pathophysiology and complications: The lesions of endocarditis are divided into three groups: 1-Carditis: The cardiac lesions are usually valvular. 2-Embolic: Embolic lesions are commons since the lesions are friable and easily detached causing thrombosis. 3-General: As cardiac failure, liver disease, and anemia because of the toxemia. The patients who recover are still faced with many complications including reinfection, congestive heart failure, renal disease, and cerbrovascular accident.

4. Dental management: The dentist's goal is to prevent endocarditis from occurring in susceptible dental patients; even a mild injury may cause a transient bacteremia causing endocarditis so these medical complications are prevented by giving prophylactic antibiotic coverage: Regimen A: For low and moderate risk adult patients. Regimen B: For high risk adult patients.

5. Rheumatic fever It is an acute inflammatory condition that develops in some individuals as a complication following group A streptococcal infections as a result of autoimmune reaction between normal tissues of the heart, joints, and skin that have been altered by the products (Exotoxins and endotoxins) of the bacteria and antibobodies that have been produced by the host in response to these altered tissues. Rheumatic heart disease It is the cardiac damage that results from an acute attack of rheumatic fever. The basic lesions consist of: 1-Valvular changes. 2-Myocardial changes. 3-Pericardial changes.

6. Dental management:If the patient has a history of rheumatic fever but with no cardiac involvement the patient should treated as a normal patient but if the patient is not sure we should refer the patient to the physician to determine the presence or absence of rheumatic heart disease. If rheumatic heart disease is present the requires prophylactic antibiotic coverage of regimen A but if the patient taken a low daily oral dose of penicillin or monthly injection of penicillin to prevent recurrent attacks of rheumatic fever then: 1-Instruct patient to continue medication. 2-Then add 1g erythromycin orally for at least 1/2 hours before dental procedures followed by 500mg erythromycin orally every 6 hours for eight doses.

7. Surgically Corrected Cardiac And Vascular Diseases 1-Clssure of an atrial or ventricular septal defect . 2-Ligation or resection of ductus arteriorus . 3-Commissurotomy for diseased cardiac valve . 4-Prosthetic replacement of diseased cardiac valve . 5-Coronary artery bypass graft . 6-Arterial graft . 7-Implantation of tranvenous pacemaker . 8-Transplntation of heart .

8. Dental management : The degree of susceptibility to endocarditis and endarteritis differs and depending on the location of surgery , materials used for the correction or replacement , and the length of the time since surgery . 1-Consult's with patient physician for medical evaluation and fitness for dental treatment . 2-Prophylactic antibiotic coverage using regimen B for all dental procedures up to 6 months postoperative correction or replacement . 3-Regimin A or no coverage after 6 months of operation ,decided by consultation .

9. 4-Patient with commissurotomy or prosthetic replacement of diseased cardiac valves remain very susceptible for infection(need regimen B). 5-Patients with coronary bypass grafts usually require no antibiotic cover. 6-Anticaogulants if taken must be reduced by the physician if surgery is planned. 7-Electrical equipments should not be used on patient with cardiac pacemaker.

10. Regimen A : Patient not allergic to penicillin : Amoxicillin 2g orally 1hour before dental procedure followed by 500mg amoxicillin every 8 hours for seven days . Patient allergic to penicillin : Clindamycin 600mg orally 1hour before dental procedure followed by 500mg erythromycin every 6hours for seven days . Or Azithromycin or Clarythromycin 500mg orally 1hour before dental procedure followed by erythromycin 500mg every 6 hours for seven days.

11. Regimen B : Patient not allergic to penicillin : Amoxicillin 2g I.V or I.M with 80mg gentamycin I.v or I .M 30 min before dental procedure followed by 500mg amoxicillin orally every 8hours for seven days. Patient allergic to penicillin : Clindamycin 600mg I.V with 80mg gentamycin I.V or I.M 30min before dental procedure followed by 500mg erythromycin every 6hours for seven days .

12. Liver diseases: The functions of the liver include: 1-Metabolism of amino acids, protein, carbohydrates, and lipid. 2-Coagulation mechanism. 3-Drugs metabolism. Therefore liver disorders will impair these functions. Alcoholic liver disease: 10-20% of heavy alcohol uses develop liver cirrhosis.

13. Dental management: 1-Deteection by history and clinical examination and information from family and friends. 2-if clinical examination is suggestive or patient admits heavy use of alcohol and is not managed or has not visited the physician for several months, we send him for laboratory test: complete blood count with differential, SGOT, bleeding time, thromboplastin and prothrombin time. 3-If lab reading are abnormal referral to physician for diagnosis and treatment and management of bleeding tendency by fresh frozen plasma, vitamin K,platelets,and antifibrinolytic agents if surgical procedures are planned. 4-minimize drugs metabolized by the liver and give: Ester type local anesthetics as procaine and not amide types. No analgesic as aspirin, paracetamol.codein and mepiridine. No sedatives as diazepam or barbiturates. Penicillin antibiotics and not ampicillin or tetracycline.

14. Notes: jaundice is clearer in sclera and is only apparent when the plasma level of biliruben exceeds 3mg/100ml (normal is less than 1mg/100ml).

15. Viral hepatitis: The dental management: 1-Patients with active hepatitis (presence signs and symptoms): a) Consult with the patient physician about infectiousness. b) Give emergency dental care only. 2-Patients with past history of hepatitis (may be carrier): a) Consult with the physician regaurding type carrier status. b) Ask about age at time of infection and source of infection. c) If type is vague order for HBSAg so patient know if carrier and the dentist can take precautions.

16. 3-Carrier (HBSAg positive): a) Consult with the physician to discuss status and planned treatment. b) Employ strict aseptic technique (isolation). c) Use rubber gloves, gown and masks. d) Use rubber dam when possible to minimize contact with saliva or blood. e) Minimize aerosol production by using slow speed handpiece and avoid air syringe. f) Scrub and sterilize all instruments including the handpiece after use. c) Minimize drugs metabolized by the liver. 4-High risks patient, haemodialysispatient, health care worker and recipient of blood transfusion we order for HBSAg.

17. 5-Since more than 50% of carriers of hepatitis B are undetectable by history because the case was probably mild, subclinical and non-icteric, all patients should be treated with strict aseptic approach and hepatitis B vaccine can be used. The dentist may be actively infected or a carrier and may transmit hepatitis to his patients.