Cardiovascular Disease Lecture Notes with Prof. Sura Ali Ahmed

MCP L3-Cardiovascular Disease

  • Instructor: Prof. Sura Ali Ahmed Fuoad B D S, M Sc, MFDS RCPS, MHPE, Ph D in Oral Medicine.

  • Affiliations: Head of Diagnostic and Surgical Dental Sciences Department, Specialist in Oral Medicine-MOH, College of Dentistry/GMU (Website: www.gmu.ac.ae)

  • Date: August 23, 2025

CONTENTS

  • Infective Endocarditis (IE)

    • Definition

    • Causative Factors

    • Infective Endarteritis

    • Age

    • Gender

    • Predisposing Factors

    • Classification of IE

    • Oral Manifestations

    • Potential Problems Related to Dental Care

    • Prevention of Problems

    • Treatment Planning Modifications

  • Hypertension (HBP)

    • Definition and Types

    • Signs and Symptoms of Hypertensive Disease

    • Clinical Predictors of Increased Perioperative Cardiovascular Risk

    • Potential Problems Related to Dental Care

    • Prevention of Problems

    • Treatment Planning Modifications

LEARNING OBJECTIVES

By the end of the lecture, students should be able to:

  • Define Infective Endocarditis (IE) and distinguish it from Infective Endarteritis

  • Identify the causative, predisposing factors, along with age and gender predisposition.

  • List classifications of Infective Endocarditis.

  • Understand oral manifestations of Infective Endocarditis.

  • Assess potential problems related to dental care.

  • Implement preventive measures for problems during dental care.

  • Modify treatment planning for Hypertension.

INFECTIVE ENDOCARDITIS (IE)

Definition

  • Infective Endocarditis: A microbial infection affecting the endothelial surface of the heart or heart valves, often associated with congenital or acquired cardiac defects.

Causative Factors

  • Bacteria (e.g., the group typically identified as Bacteroides) or fungi.

Infective Endarteritis

  • Refers to an infection within the endothelial lining of an artery, generally adjacent to a vascular defect (e.g., aorta coarctation) or a prosthetic device (e.g., arterio-venous [AV] shunt).

Age and Gender

  • Age: Commonly observed in middle-aged to elderly individuals.

  • Gender: More prevalent in men than in women.

Predisposing Factors

  • Underlying conditions such as:

    • Rheumatic heart disease

    • Mitral valve prolapse

    • Prosthetic heart valves

    • Intravenous (IV) drug use

Common Manifestations

  • A. Splinter Hemorrhage

  • B. Conjunctival Petechiae

  • C. Osler’s Nodes: Tender subcutaneous nodules found in digits.

  • D. Janeway Lesions: Erythema, hemorrhage, or pustule forming in the palm or sole.

  • Nail Clubbing

CLASSIFICATION OF INFECTIVE ENDOCARDITIS

  • Acute and Sub-Acute

  • Based on causative microorganisms (e.g., Streptococcal or Candidal Endocarditis).

  • Based on the infected valve type (e.g., Native valve endocarditis [NVE], Prosthetic valve endocarditis [PVE]).

  • Based on the source of infection:

    • Community acquired

    • Hospital acquired

    • IV drug user

Oral Manifestations

  • Oral petechiae may manifest in patients suffering from IE.

Dental Concerns

  • Bacteremia Risk: Dental procedures that manipulate gingival tissues, the periapical region, or perforation of oral mucosa may produce bacteremia.

  • Bacteremia can also occur daily by brushing, flossing, chewing, etc.

  • While one procedure is unlikely to result in IE, there remains a remote possibility.

  • Patients with prosthetic heart valves may experience excessive bleeding from invasive dental procedures due to anticoagulant therapy.

PREVENTION OF PROBLEMS

  • Identify patients at highest risk for adverse IE outcomes including:

    • Prosthetic cardiac valves

    • History of previous IE

    • Certain congenital heart diseases (e.g., unrepaired cyanotic congenital heart disease)

    • Cardiac transplant recipients developing valvulopathy.

  • Antibiotic Prophylaxis: Prescribe for the aforementioned patients undergoing relevant dental procedures.

  • Timing: Administer a single dose of antibiotics 30 minutes to 1 hour prior to procedures.

High-Risk Cardiac Conditions for IE Outcomes

  • Patients eligible for antibiotic prophylaxis with dental procedures include those diagnosed with:

    • Prosthetic cardiac valves

    • Previous infective endocarditis history

    • Unrepaired congenital heart disease

    • Cardiac transplant recipients with valvulopathy.

Moderate-Risk Categories (NOT Recommended for Antibiotic Prophylaxis)

  • Rheumatic fever

  • Nonrheumatic valve disease

  • Congenital valve anomalies

Not Recommended

  • Prophylaxis for implantable devices, hemodialysis grafts, and other vascular grafts, among others.

DENTAL PROCEDURES RECOMMENDED FOR IE PROPHYLAXIS

  • Procedures involving gingival tissue, periapical region, or mucosal perforation:

    • Excluded Procedures:

    • Routine anesthetic injections

    • Dental radiographs

    • Removable prosthodontic/orthodontic appliance placements

    • Orthodontic appliance adjustment

    • Shedding of deciduous teeth

AMERICAN HEART ASSOCIATION GUIDELINES ON ANTIBIOTIC REGIMENS FOR DENTAL PROCEDURES


  • Antibiotic Administration:

    • Administration recommended 30-60 minutes before procedure.


  • Standard Agents for Adults and Children:

    Situation

    Adults

    Children


    Oral

    Amoxicillin 2g

    50mg/kg


    Unable to take oral medication

    Ampicillin or Cefazolin or Ceftriaxone 2g IM

    50mg/kg IM or IV


    Allergic to PCNs

    Cephalexin 2g

    50mg/kg


    Allergic to PCNs and unable to take oral

    Cefazolin or Ceftriaxone 1g IM or IV

    4.4mg/<45kg IM or IV


    Clindamycin

    Not recommended anymore.

    TREATMENT PLANNING MODIFICATIONS

    • Promote optimal oral hygiene in patients at risk for IE.

    • Prescribe prophylaxis only to high-risk patients.

    • Allow durations of at least 9 days between treatment appointments if prophylaxis is given.

    • If multiple appointments are needed, allow antibiotic modification if performed before the 9-day period.

    • Adjust dosages for those on anticoagulants based on INR levels and procedure invasiveness.

    HYPERTENSION (HBP)

    Definition & Types

    • Hypertension: An abnormal elevation in arterial pressure, potentially fatal if untreated.

      • Normal Blood Pressure: <120 systolic and <80 diastolic

      • Hypertensive Adults: Defined as sustained systolic BP ≥140 mm Hg or sustained diastolic BP ≥90 mm Hg.

    • Stages

      • Prehypertension: 120-129/<80

      • Stage 1: 130–139 or 80–89

      • Stage 2: ≥140 or ≥90

    • White Coat Hypertension: Persistently elevated BP when health care workers are present,

    • Prevalence: Increases with aging due to central arterial stiffness; 90% of hypertension cases are primary.

    Signs and Symptoms of Hypertensive Disease

    Early Signs

    • Elevated BP readings

    • Narrowing and sclerosis of retinal arterioles

    • Headache

    • Dizziness

    • Tinnitus

    Advanced Signs

    • Eye: Ruptured retinal arterioles, papilledema

    • Heart: Angina pectoris, left ventricular hypertrophy, congestive heart failure

    • Kidney: Proteinuria, renal failure

    • Brain: Dementia, encephalopathy, stroke

    • Note: Before age 50, both systolic and diastolic pressures elevate, while isolated diastolic hypertension is rare and mostly found in younger adults.

    ORAL MANIFESTATIONS

    • No direct oral complications due to hypertension; potential adverse effects include dry mouth, taste changes, gingival hyperplasia, and oral lesions linked to medications.

    CLINICAL PREDICTORS OF INCREASED PERIOPERATIVE CARDIOVASCULAR RISK

    • Major Predictors:

      • Unstable coronary syndromes

      • Acute myocardial infarction with ischemic signs

      • Decompensated heart failure

    • Intermediate Predictors:

      • History of ischemic heart disease

      • History of compensated heart failure

      • History of cerebrovascular disease

      • Diabetes mellitus

      • Renal insufficiency

    • Minor Predictors:

      • Older age (>70 years)

      • ECG abnormalities (left ventricular hypertrophy)

      • Uncontrolled hypertension (≥180/110 mm Hg)

    DENTAL MANAGEMENT OF PATIENTS WITH HYPERTENSION

    A. Preoperative Risk Assessment

    • Review medical history, details on medications, and BP measurements accurately.

    • Determine adherence to antihypertensive protocols.

    • Seek medical advice for patients harbored with undiagnosed or poorly controlled hypertension.

    • Proceed with treatment if BP is controlled (<180/110 mmHg).

    B. Antibiotics

    • Avoid erythromycin and clarithromycin in those receiving calcium channel blockers due to hypotension risk.

    C. Anesthesia

    • Affecting anesthesia should ensure profound effects; avoid large doses of epinephrine in uncontrolled hypertensive patients.

    D. Follow-up Protocol

    • Ensure patients are dismissed seated to avoid dizziness and encourage regular physician follow-ups, especially for severe cases.

    • Avoid long-term use of NSAIDs to prevent interference with blood pressure medications.

    E. Capacity to Tolerate Care

    • Patients with controlled BP can tolerate routine care;

    • BP >180/120 mm Hg necessitates emergent care.