Cardiovascular Diseases & Treatments Chapter 14

Cardiovascular disease includes:

-Hypertension

-Angina

-Coronary artery disease

-Cerebrovascular accident

-Arrhythmias

-Congestive Heart Failure

Vasoconstrictor Limit

Limiting the dose to the cardiac dose (0.04 mg) may be warranted.

Use slow rate of injection.

Heart Failure

Incidence of heart failure rises with age.

Inefficient pumping mechanism results in an inadequate cardiac output & unsatisfactory circulation. One or both sides of the heart can fail; usually the left side fails 1st.

Diuretics

Reduce edema/fluid retention

**Angiotensin

Converting enzyme inhibitors(ACE inhibitors) ...considered 1st line therapy

Angiotensin Receptor Blockers (ARBs)

Given to patients who can NOT tolerate ACE inhibitors

***Digitalis Glycosides

Most common is digoxin(Lanoxin)

Digoxin (Lanoxin)

***KNOW THIS DRUG

Increases the force & strength of heart contractions. Reduces edema; better pumping, better circulation thru the kidneys. Treatment of arrhythmias or more specifically atrial fibrillation. Signs of toxicity: GI effect, anorexia, nausea, vomiting, increased salivation & gagging.

Combing digoxin w/ sympathomimetics can lead to cardiac arrhythmias; use caution when using vasoconstrictors added to local anesthetics.

Digoxin drug interactions

-Digoxin + sympathomimetic > increase chance of arrhythmias

-Digoxin + erythromycin > increase digoxin toxicity

-Digoxin + tetracycline > increase digoxin toxicity

-both in 10% of patients

Arrhythmia & Dysrhythmia

Terms arrhythmia & dysrhythmia are used interchangeably to mean abnormal rhythm.

Automaticity

The cells of the cardiac muscle's own rhythm

Anti arrhythmic Agents

1A- quinidine, procainamide, disopyramide

1B- lidocaine, phenytoin

1C- flecainide, encainide

ALL BLOCK CONDUCTION RATE

Amiodarone

Anti arrhythmic agent used to treat atrial fibrillation or ventricular tachycardia- photosensitivity to dental light

Calcium channel blocker or CCB

Gingival enlargement (verapamil most important)

Phenytoin

Gingival enlargement

B-blocker, nonspecific

Drug interaction w/ epinephrine; limit to cardiac dose

Angina Pectoris

-Is a cardiovascular disease characterized by pain/discomfort in the chest radiating to the left arm & shoulder.

-Pain can also radiate to the neck, back, & lower jaw...can be confused w/ toothache

-Angina occurs when arteries do NOT supply enough O2 to the myocardium

-Precipitated by physical exercise, stress, anxiety, apprehension generated by a dental appointment

Nitroglycerin-Like compound (NTG)

-Nitroglycerin is the drug of choice for management of acute anginal episode

-Vasodilator that produces relaxation of vascular smooth muscle throughout the body, reducing the heart workload

-Sublingual nitroglycerin used to treat acute anginal attacks

-Sublingual isosorbide denigrate is also effective for an acute anginal attack

NTG: Adverse Reactions

-Severe headaches because of its effects on the vascular smooth muscle... dilates the blood vessels in the brain.

Mixing alcohol with nitroglycerin will cause extremely low blood pressure

Calcium Channel Blockers (CCB)

CCBs are used as initial therapy for angina pectoris when beta blockers are contraindicated or side effects intolerable.

Nifedipine

Associated w/ gingival enlargement & dysgeusia

Ranolazine

Used for the treatment of chronic angina alone or in combination w/ nitrates, beta blockers, CCBs, anti platelet therapy, lipid-lowering therapy, ACE inhibitors or ARBs.

Angina

Patients w/ symptoms of angina attack that are not relieved by 3 doses of SL NTG, may be experiencing a myocardial infarction

Treatment of Hypertension

-The choice of anti-hypertensive therapy depends on the stage of hypertension

-Diuretics

-Beta Blockers

-CCBs

-ACE inhibitors

-ARBs

Diuretics

-Are considered the 1st line of therapy for hypertension

-Work in general by promoting excretion of sodium & H2O which turn decreases the blood volume & blood pressure.

Hydrochlorothiazide (HCTZ)

-Works by preventing sodium from being absorbed in the kidneys

-Increases the excretion of potassium which can result in electrolyte imbalance referred to as hypokalemia.

Thiazide Diuretics: Adverse Reactions

-Hypokalemia

-Xerostomia

-Orthostatic hypotension could result after patient has been lying in a supine position

-NSAIDs can reduce effectiveness of thiazide diuretics

-Hypokalemia...can sensitize the myocardium to develop arrhythmias

-Epinephrine.. limit epinephrine in local anesthetics

Furosemide (Lasix)

-Most common loop diuretic

-Used for rapid diuresis

-Much more potent than thiazide diuretics

-Side Effects: NSAIDs interfere w/ furosemide action & used in management of hypertensive patients w/ congestive heart failure

ACE inhibitors

ACE inhibitors work by preventing the conversion of angiotensin I to angiotensin II...causing vasodilation & reducing peripheral resistance

ACEIs

-Oral adverse reactions: Dysgeusia (altered taste sensation) fairly common

-Hypotension

-allergic reactions

-Dry cough

-Effectiveness of ACEIs is reduced by administration of the NSAIDs

CCBs

Treatment of arrhythmias/angina pectoris/hypertension

Adverse Reactions: Xerostomia & gingival enlargement (nifedipine)

B-Adrenergic Blocking Agents for Hypertension

-Beta adrenergic blockers lower blood pressure by decreasing cardiac output

-Usually 2nd line of therapy

-olol

Common suffix for Beta adrenergic blocking agents

HMG-CoA: Adverse Effects

-Myositis results in complaints of muscle pain

-Increase anticoagulant effect of warfarin

Warfarin (Coumadin)

-Most common anticoagulant

-Aspirin is the most serious drug interaction; increases bleeding tendencies

-Monitored by means of the international normalized ration (INR)

Heparin

-one of the most commonly used anticoagulant agents for hospitalized patients

-Injection only