CARDIOVASCULAR DISEASES

Infective endocarditis

A microbial infection of the endothelial surface of the heart or heart valves that most often occurs in proximity to congenital or acquired cardiac defects

Infective endarteritis

a clinically and pathologically similar infection that may may occur in the endothelial lining of an artery, usually adjacent to a vascular defect (coarctation of the aorta) or a prosthetic device (arteriovenous shunt)

Bacteria endocarditis

is in common use, reflecting the fact that most cases of IE are caused by bacteria;

Infective endocarditis

preferred nomeclature

Complications of Infective Endocarditis

• Heart failure

• embolization

• stroke

• myocardial infarction (MI)

• peripheral abscesses

• organ failure: septic shock, invasive infection, prosthetic valve dehiscence, heart block, and mycotic aneurysm, and death

Infective endocarditis

A disease of significant morbidity and mortality that is difficult to treat; therefore, emphasis has long been directed toward prevention

Staphylococci

most common pathogen identified in IE associated with IV drug abuse or secondary to health care contact

Viridans streptococci (a-hemolytic streptococci)

constituents of the normal flora and gastrointestinal (GI) tract

Viridans streptococci (a-hemolytic streptococci)

remain the most common cause of community-acquired NVE w/o regard for IV drug abuse

Viridans streptococci (a-hemolytic streptococci)

they cause 30% to 65% of cases of IE

Species that most commonly cause endocarditis

• Streptococcus sanguis

• Streptococcus oralis (mitis)

• Streptococcus salivarius

• Streptococcus mutans

• Gemella morbillorum

Streptococcus morbillorum

Gemella morbillorum is formerly called as ________

Other microbial agents that less commonly cause IE

• HACEK group

• Pseudomonas aeruginosa

• Corynebacterium pseudodiphtheriticum

• Listeria monocytogenes

• Bacteroides fragilis

• Fungi

HACEK group

• Haemophilus

• Actinobacillus

• Cardiobacterium

• Eikenella

• Kingella

Endothelial damage can result from any of a variety of events, including:

• Directed flow from a high-velocity jet onto the endothelium

• Show from a high- to a low-pressure chamber

• Flow across a narrowed orifice at high velocity

NONBACTERIAL THROMBOTIC ENDOCARDITIS (NBTE)

A condition where fibrin and platelets then adhere to the roughened endothelial surface, where they form small clusters or masses

Libman-Sacks verrucous endocarditis

a similar and frequently indistinguishable condition is found in some patients with systemic lupus erythematosus

• Local destructive effects of intracardiac (valvular) lesions

• Embolization of vegetative fragments to distant sites, resulting in infarction or infection

• Hematogenous seeding of remote sites during continuous bacteremia

• Antibody response to the infecting organism, with subsequent tissue injury caused by deposition of preformed immune complexes or antibody–complement interaction with antigens deposited in tissues

clinical outcome of IE depends on several factors, including:

Heart Failure

the most common complication of IE and the leading cause of death, which results from severe valvular dysfunction

Fever, heart murmur, positive blood culture

S/S of infective endocarditis

less than 2 weeks in more than 80% of patients with IE

Interval between the presumed initiating bacteria and the onset of symptoms of IE

Osler nodes

small, tender, subcutaneous nodules that develop in the pulp of the digits

Janeway lesions

small, erythematous or hemorrhagic, macular nontender lesions on the palms and soles

Roth spots

oval retinal hemorrhages with pale centers

• Petechiae of the palpebral conjunctiva

• Buccal and palatal mucosa

• Extremities

• Osler nodes

• Janeway lesions

• Splinter hemorrhages in the nail beds

• Roth spots

• Splenomegaly

• Clubbing of the digits

Peripheral manifestations of IE caused by emboli or immunologic responses

• a predisposing cardiac lesion or behavior pattern

• Bacteremia

• Embolic phenomena

• Evidence of an active endocardial process

Cardinal elements of IE

Duke criteria

Developed and later modified to facilitate the definitive diagnosis of IE

Major criteria

• positive blood cultures

• Evidence of endocardial involvement

Minor criteria

• Predisposing heart condition or IV drug use

• Fever

• Vascular phenomena, including embolic events

• Immunologic phenomena

• Microbiologic evidence other than positive blood culture

Definitive diagnosis of IE requires the presence of:

• two major criteria

• One major and three minor criteria

• Five minor criteria

Urinalysis

reveals microscopic hematuria and proteinuria

Electrocardiography

may show evidence of conduction block with myocardial involvement or infarction

Echocardiography, transthoracic or transesophageal

is used to confirm the presence of vegetation in patients suspected of having IE

Echocardiography, transthoracic or transesophageal

has become the cornerstone in the diagnostic process

Laboratory and Diagnostic Findings

• blood culturing

• Complete blood count with differential, electrolyte panel, renal function tests, urinalysis, plain chest radiography, electrocardiography (ECG)

Antibiotic therapy or surgical treatment (or both)

Medical management of IE

Antibiotic prophylaxis

Dental management for patients at risk for acquiring IE

Bacteremia

can result from many normal daily activities such as toothbrushing, flossing, manipulation of toothpicks, use of oral water irrigation devices, and chewing

HYPERTENSION

An abnormal elevation in arterial pressure that can be fatal if sustained and untreated

Pts with hypertension

may not display clinical signs or symptoms for many years but eventually can experience symptomatic damage to several target organs, including the kidneys, heart, brain, and eyes.

>140mmHg/>90mmHg

BP of adults with hypertension

Primary (essential) hypertension

90% of patients have no readily identifiable cause for their disease

Secondary hypertension

In the remaining 10% of patients, an underlying cause or condition may be identified

In primary hypertension,

the basic underlying defect is a failure in the regulation of vascular resistance

Pulsating force

modified by the degree of elasticity of the walls of larger arteries and the resistance of the arteriolar bed

Control of vascular resistance

multifactorial, and abnormalities may exist in one or more areas

In Isolated systolic hypertension

commonly is seen in older adults, the underlying problem is one of central arterial stiffness and loss of elasticity

Hypertension

Asymptomatic (only sign is elevated BP)

Circadian variation

BP demonstrates a ______ with a highest levels seen in early to mid-morning, lower levels as the day progresses, lowest BP at night

systolic pressure

pressure at the peak of ventricular contraction

Diastolic pressure

represents the total resting resistance in the arterial system after passage of the pulsating force produced by contraction of the left ventricle

Pulse pressure

Difference between systolic and diastolic is equal to ______

Mean arterial pressure

sum of the diastolic pressure plus one third the pulse pressure

White Coat Hypertension

consistently elevated BP only in the presence of a health care worker but not elsewhere

White coat hypertension

About 20% of patients with untreated stage 1 hypertension have _______

Patients with WCH

Accurate BP readings may require self-measurement at home or 24-hour ambulatory monitoring

ISOLATED DIASTOLIC HYPERTENSION

systolic BP of 140 or less and a diastolic BP of 90 or greater, is uncommon and most often is found in younger adults

ISOLATED SYSTOLIC HYPERTENSION

systolic pressure of 140 mm Hg or higher and a diastolic BP of 90 mm Hg or less; found in older patients

Blurred vision caused by retinal vessel hemorrhage, exudate, and papilledema

indicative of accelerated malignant hypertension, a medical emergency that requires immediate intervention.

Hypertensive encephalopathy

is characterized by headache, irritability, alterations in consciousness, and other signs of central nervous system (CNS) dysfunction

HYPETENSIVE EMERGENCY

characterized by a BP ≥180/120 mm Hg with evidence of impending or progressive target organ dysfunction

HYPERTENSIVE EMERGENCY

Can be associated with chest pain, dyspnea, change in mental status, visual disturbance, or a neurologic deficit

Renal involvement

can result in hematuria, proteinuria, and renal failure

Late S/S of hypertension are related to the involvement of various target organs including:

Kidneys, brain, heart, or eyes

Persons with hypertension

may report fatigue and coldness in the legs or claudication resulting from the peripheral arterial changes that may occur in advanced hypertension

LABORATORY AND DIAGNOSTIC FINDINGS OF HYPERTENSION

• 12-lead electrocardiography (ECG)

• Urinalysis

• blood glucose

• hematocrit

• electrolytes

• creatinine

• calcium

• lipid profile

Patients with a diagnosis of prehypertension

not usually candidates for drug therapy but rather are encouraged to adopt lifestyle modifications to decrease their risk of developing the disease

Referral to a nephrologist or endocrinologist

Patients found to have an identifiable cause for their hypertension should be treated for that disorder

First task of the dentist

identify patients with hypertension, both diagnosed and undiagnosed

Primary concern in dental management of a patient with hypertension

during the course of treatment, a sudden, acute elevation in BP might occur, potentially leading to a serious outcome such as stroke or MI

Acute elevations in BP may result from the

• release of endogenous catecholamines in response to stress and anxiety

• from injection of exogenous catecholamines in the form of vasoconstrictors in the local anesthetic

• from absorption of a vasoconstrictor from the

  gingival retraction cord

Oral manifestations of hypertension

• facial palsy

• Excessive bleeding after surgical procedures or trauma (pts w/ severe hypertension)

• Dry mouth (antihypertensive drugs)

• Lichenoid reactions (thiazides, methyldopa, propranolol, labetalol

• Delayed healing or gingival bleeding (ACE inhibitors

  may cause neutropenia)

• Gingival overgrowth (CCBs)

LIFESTYLE MODIFICATIONS

• reduce BP

• prevent or delay the incidence of heart hypertension

• enhance antihypertensive drug therapy

• decrease cardiovascular risk

Atherosclerosis

thickening of the intimal layer of the arterial wall caused by the accumulation of lipid plaques

Atherosclerosis

narrowed arterial lumen with diminished blood flow and oxygen supply

Atherosclerosis

is the most common underlying cause of coronary heart disease (angina and myocardial infarction [MI]), cerebrovascular disease (stroke), and peripheral arterial disease (intermittent claudication)

Symptomatic coronary atherosclerotic heart disease

often is referred to as ischemic heart disease

Ischemic symptoms

the result of oxygen deprivation secondary to reduced blood flow to a portion of the myocardium

Other conditions that cause ischemic heart disease

• embolism

• coronary ostial stenosis

• coronary artery spasm

• congenital abnormalities

Risk factors of ischemic heart disease

• male gender

• older age

• a family history of cardiovascular disease

• hyperlipidemia

• hypertension

• cigarette smoking

• physical inactivity

• obesity

• insulin resistance and diabetes mellitus

• mental stress

• depression

increased levels of LDL

Greater risk for coronary atherosclerosis

Increased levels of HDL

Reduce risk of coronary atherosclerosis

Low-density lipoprotein

Bad cholesterol

High-density lipoprotein (HDL)

Good cholesterol

Complication of MI

• weakened heart muscle, resulting in acute congestive heart failure,

• postinfarction angina

• infarct extension

• cardiogenic shock

• pericarditis

• arrhythmias.

Causes of death in patients who have had an acute MI:

• ventricular fibrillation

• cardiac standstill

• congestive heart failure

• embolism

• rupture of the heart wall or septum

CHEST PAIN

most important symptom of coronary atherosclerotic heart disease

Angina Pectoris

described as a sensation of aching, heavy, squeezing pressure or tightness in the midchest region

Stable Angina

is pain that is predictably reproducible, unchanging, and consistent over time

Stable Angina

Pain typically is precipitated by exertion such as walking or climbing stairs but also may occur with eating or stress

Stable Angina

Pain is relieved by cessation of the precipitating activity, by rest, or with the use of nitroglycerin

Unstable Angina

defined as new-onset pain, pain that is increasing in frequency, increasing in intensity, precipitated by less effort than before, or occurring at rest

Unstable angina

This pain is not readily relieved by nitroglycerin

Acute Coronary Syndrome

Describes a continuum of myocardial ischemia that ranges from unstable angina at one end to non–ST segment MI at the other

Prinzmetal variant angina

occurs at rest and is caused by focal spasm of a coronary artery, usually with varied amounts of atherosclerosis

Predominant symptoms and signs that most often precede sudden death include:

• chest pain

• cough

• shortness of breath

• diaphoresis

• dizziness

• fainting

• fatigue

• palpitations (tachycardia)

Ventricular fibrillation

most common cause of sudden death

Ventricular defibrillation

a form of abnormal electrical activity resulting from interruption of the heart’s electrical conduction system

Palpitations of the heart

disagreeable awareness of the heartbeat