Heart Disease

Congestive
Ischemic
Myocardial Infarction
Brittany Ryder
Victoria Sisco

Introduction

Cardiovascular includes diseases of the heart and blood vessels

Patients with cardiovascular diseases are frequently encountered in a dental

office and may be any age, although more frequently seen in older adults

A heart disease may be present for many years before symptoms occur; we
may see patients who have no obvious symptoms or those nearly disabled

Studies have shown there is a link between periodontal inflammation and

cardiovascular disease point to the need for maintenance of healthy oral
tissues and to prevent periodontal infections

https://www.youtube.com/watch?v=I8WgVGy05FA

Healthy Heart

Blood flows in one direction as each chamber contracts, the valves acts as a
trap door that close after each contraction to prevent backflow of blood

Right side contains deoxygenated blood from the body to the lungs

Left side contains oxygenated blood from the lungs being pumped out of the
aorta on the way to the body

Septal wall divides the left and right side of the heart

Congestive Heart Failure

Congestive heart failure and heart failure are

the same thing and those terms are actually
used interchangeably

A condition in which the heart is unable to

perform the work necessary to keep up with
the bodys needs and could be the result of
different types of heart disease such as
coronary heart disease, heart valve disease
like aortic stenosis, cardiomyopathy, and
cardiac arrhymias

Etiology: the most common causes in the

United States is coronary artery disease, high
blood pressure, longstanding alcohol abuse,
and disorders of the heart valves

Occurrence: 4.8 million people in the US

have congestive heart failure with poor 50%
that will only have a 5 year survival rate

Congestive Heart Failure

Signs and Symptoms: Can produce many symptoms including

dyspnea, edema, weakness, fatigue, and lightheadedness
depending on which side of the heart is effected. The most common
are dyspnea and edema. These cause the generalized fluid
accumulation or congestion and usually occurs in the lungs and
lower extremities

They call it congestive heart failure because it acknowledges that

lung congestion and dyspnea result from it and are typically the
most common and prominent symptoms but diagnosis is based on
the individuals medical history, a careful physical examination, and
selected laboratory tests

Congestive Heart Failure

Treatment: The goal is to have the heart beat more efficiently so that it can
meet the energy needs of the body. This could be fluid restriction and
decrease in salt intake, lifestyle modifications, addressing potentially
reversible factors, medications, and heart transplant or mechanical therapies

Medications:

ACE inhibitors (angiotensin converting enzyme inhibitors) and ARBs

(angiotensin receptor blockers) both of these decrease systemic
resistance and reduce blood pressure

Beta blockers lowers the heart rate and increase cardiac output

Digoxin helps increase cardiac output and control symptoms

Congestive Heart Failure

Indications: Recent research has linked periodontal disease with the risk of
coronary artery disease and stroke but there is not enough evidence to show
whether periodontal disease causes these other conditions. The treatment of
periodontal disease can reduce overall inflammation in the body but there is
no evidence that is prevents heart disease, heart attack or stroke

Contraindications: ultrasonic use on a patient is not advised if the patient

has a pace maker due to their condition. It can interfere with the pacemaker
causing it to alter in function and stop completely. In the dental setting we
should also be cautious with electric toothbrushes, electro surgery machines,
and certain casting equipment's because these can all cause interference as
well. Also for class I or II patients the maximum of 0.036 mg epinephrine or
0.20 mg levonordefrin is to be used and vasoconstrictors are to be avoided in
class III or IV patients.

Congestive Heart Failure

Impaction on the oral health:

Xerostomia

Gingival hyperplasia

Syncope

Dysgeusia or altered sense of taste

Impaction on oral health due to medical treatment and or medications:

Diuretics can cause dry mouth and orthostatic hypotension

Anticoagulants cause issues by not clotting open wounds and could make dental
treatment difficult and or impossible because the patient would just continue to
bleed

Digoxin can cause nausea and vomiting and arrhythmias

Vasodilators can cause nausea, vomiting, and palpitations

Congestive Heart Failure

Periodontal management:

A patient that has congestive heart failure and also has

periodontitis needs to get their teeth cleaned and oral cavity back
to health. Studies have shown that people with periodontal
disease may be more likely to have coronary artery disease. When
cleaning the patients teeth with CHF it is important to be up to
date with all of their medications and to also know if the patient
needs pre medication. This is important because depending on the
severity of CHF there are usually no special changes unless made
by the dentist depending on the types of medication they are on
or if they have a more severe heart failure.

Congestive Heart Failure

Some people with severe CHF may need their teeth cleaned in a hospital
setting. These would include the patients that fall under the New York Heart
Association Functional classification of III or IV

New york Heart Association Classifications of heart failure:

Class I- patients without limitation of physical activity

Class II- patients with slight limitation of physical capacity in which marked
increase in physical activity leads to fatigue

Class III- patients with marked limitation of physical activity in which minimal
ordinary activity results in fatigue, palpitation, dyspnea, or angina pain; they are
comfortable at rest

Class IV- patients who are not only unable to carry on any physical activity without
discomfort but who also have symptoms of heart failure or angina syndrome even
at rest; the patients discomfort increases if any physical activity is undertaken

Congestive Heart Failure

Pre-med:
this would all depend on the severity of the CHF which the
dentist could confirm by speaking to the patients physician or cardiologist but
almost all patients with a heart disease or a pacemaker need a premed. This
patient is at a high risk for endocarditis which is when bacteria in the
bloodstream attach to damages valves or other damaged heart tissue

Patient Positioning: if the patient has a severe heart failure they should not
lie down too far due to the fluid build up in their lungs that could affect their
breathing. You should also not sit your patient up or down too quickly for this
could make them dizzy and light-headed.

Appointment Length: Short appointments

Recall intervals: the patient should have a regular oral hygiene visit every 6
months

Ischemic Heart Disease

Ischemic heart disease aka Coronary heart

disease, caused by a decrease in blood flow
through one or more of the blood vessels that
carry oxygen to your heart.

Etiology- accumulation of lipid plaque inside

blood vessels impairs blood flow and blocks the
oxygen supply to the heart

Occurrence- Affects 4 million people in the

United States. Leading cause of death after the
age of 40 or 50. About 610,000 people die of
heart disease in the US every yearthats 1 in
every 4 deaths. Mostly in African Americans,
Hispanics, and Whites

Ischemic Heart Disease

Signs and Symptoms:
- Angina or chest pain

- Shortness of breath

- Shoulder or arm pain

- Pain in the neck or jaw

- Fast heart beat

- Palpitations

- Nausea

- Sweating

- Weakness or dizziness

- Clammy skin

Risk Factors:
- Hypertension

- Hyperlipidemia

- Tobacco use

- Lack of exercise

- Diabetes

- Genetics

- Obesity

- Age (45-men & 55-women)

Ischemic Heart Disease

Prevention/Management:
- Healthy diet - Exercise
- Tobacco cessation

- Manage diabetes

- Reducing cholesterol

- Maintain blood pressure

Treatment:
- Surgical procedures

Angioplasty and stent placement- procedure to remove plaque and

restore blood flow in clogged arteries

Coronary artery bypass graft- procedure that helps restore blood

flow to the heart by routing the flow through transplanted arteries

- Medications

Ischemic Heart Disease

Medications used in treatment:

Angiotensin-converting enzyme (ACE) inhibitorsrelaxes the blood vessels and lower blood
pressure

Angiotensin receptor blockers (ARBs)- lowers

blood pressure

Anti-ischemic agents such as ranolazine (Ranexa)

Antiplatelet drug- prevents the formation of

blood clots

Beta-blockers- lowers the heart rate

Calcium channel blockers- reduces workload on

the heart muscle

Nitrates- dilates the blood vessels

Statins- lowers cholesterol

Ischemic Heart Disease

Dental Concerns
Indications
- There is a link between periodontal
pathogens and cardiovascular
diseases that clearly point to the
need for regular cleanings and
maintenance.

Contraindications
- Acute or recent myocardial infarction
within the preceding 3 to 6 months

- RDH need to educate patients about

the significant relationship between
oral health and systemic health

- Uncontrolled heart failure

- Unstable or the recent onset of angina

pectoris

- Uncontrolled arrhythmias
- Significant, uncontrolled hypertensionblood pressure reading higher than 180/110

Ischemic Heart Disease

How will the oral health be impacted?

Periodontal disease may increase the risk for heart disease and stroke.

Studies have shown that people with periodontal disease may be more likely to
have coronary artery disease than people with healthy mouths.
Will medications impact oral health?

Angiotensin-converting enzyme (ACE) inhibitors- burning mouth, taste loss, dry

cough

Angiotensin receptor blockers (ARBs)- taste loss

Anti-ischemic agents- xerostomia

Antiplatelet drug- prolonged bleeding

Beta-blockers- xerostomia

Calcium channel blockers- drug induced gingival enlargement

Nitrates- xerostomia, hypotension

Statins- xerostomia

Ischemic Heart Disease

Periodontal Management

Update MDX at every appointment; assess of vital signs- blood pressure reading of
below 180/110

Patients who have had an MI in the past 30 days or unstable angina should not be seen
for routine preventive dental care

Emergency treatment should only occur after a consult with the patient's cardiologist to
assess cardiac status prior to treatment

Scaling and root debridement are low-risk procedures but, maxillofacial surgery with
general anesthesia is a high-risk dental procedure.

Use of anti-anxiety medications taken 1 hour before the appointment. Some patients
may be best served by taking a nitroglycerin tablet prior to certain stress-provoking
dental procedures.

Nitrous oxide/oxygen sedation is an effective method for controlling anxiety and stress
during the appointment.

During the appointment, the patient's nitroglycerin spray or tablets should be easily
available so it can be reached.

Ischemic Heart Disease

Expected and Accepted Treatment Options

Pre-med- consult with cardiologist

Patient Positioning- semi Supine

Appointment length- short, stress-free, mid-morning/afternoon

appointments

Ultrasonic use- avoid in implantable cardioverter defillators (ICD) and

pacemakers

Recall Intervals- 3 months

Anesthesia-epinephrine (0.04 mg) can provide safe, long-lasting pain control

during scaling and root debridement for most patient

Myocardial Infarction

Also known as a heart attack, occurs when blood flow stops to a part
of the heart causing damage to the heart muscle

Etiology: Most occur because of coronary heart disease but can also be
cause from thrombosis, atherosclerosis, and necrosis

Signs and symptoms:

pain around the sternum that could also extend to the arm and neck

Cold sweat

Cyanosis

Anxiety

Weakness

Difficulty breathing

Los of consciousness

Low blood pressure

Myocardial Infarction

Risk factors: high blood pressure, smoking, diabetes, lack of exercise,

obesity, high blood cholesterol, poor diet, and excessive alcohol intake

Occurrence: 30% of people have symptoms, women more likely than men.
Happens to those over 75 years of age and about 5% have had a MI with little
or no symptoms. About 1 million people have a MI each year in the United
States

Myocardial Infarction

Treatment: use of a clot busting medicine or emergency procedure to restore

blood flow to through the blocked blood vessel as soon as possible.

Emergency angioplasty- best treatment if available and can be done within a few
hours of symptoms starting. It is the use of a tiny wire with an attached balloon out
into a large artery in the groin or arm to be passed up to the heart into the blocked
section of a coronary artery and blown up to open the artery back up wide

Clot busting medicine- alternative to emergency angioplasty. Can be given quickly

and easily and some ambulance crews are trained to give it.

Medications:

aspirin- reduces the stickiness of the platelets

injections of heparin- helps prevent further blood clots from forming

morphine- just as a pain relief

beta blocker- blocks the action of adrenaline to help prevent abnormal heart beats
and can also help prevent another heart attack

Myocardial Infarction

Indications: to prevent systemic diseases, bacteremia, and periodontal

disease

Contraindications: the patient should wait at least 6 months before getting

dental treatment after a heart attack.

Oral Health: some medications the patient is taking could cause xerostomia,
altered sense of taste, gingival overgrowth, and more likely to faint when
being raised in a dental chair too fast.

Medications that impact oral health: anticoagulants (blood thinners) make

your blood less likely to clot and the patient would need to stop taking the
medication before treatment but only with the permission of their physician

Myocardial Infarction

Periodontal management: if the patient has an attack while in the

chair it is important you recognize the signs and symptoms and stop
treatment. Sit the patient up for them to breath comfortably and
administer nitroglycerin. If the pain in their chest has not reduced
within 3 minutes, prepare for basic life support and call 911. You can
also administer 162-325mg of chewable aspirin. You would want to
monitor their vitals and administer oxygen. Keep the patient calm by
reassuring them and never leave their side. Call for help and get
someone to get you the things your need that way you do not leave
your patients side.

Myocardial Infarction

Pre med: prophylactic antibiotic, pravastatin, aspirin

Patient positioning: semi supine position

Appointment length: short morning appointments for stress and anxiety

management

Ultrasonic use: should not be used with a patient who has active angina or
within 6 months of MI

Recall intervals: these would depend on medical release from their physician
and last documented heart attack

Question 1
Congestive heart failure is a condition in which the heart is unable to
perform the work necessary to keep up with the bodys needs, but is not
the same as heart failure.
A.

Both statements are false

B.

Both statements are true

C.

The first statement is false and the second statement is true

D.

The first statement is true and the second statement is false

Question 2
Ischemic heart disease is the accumulation of lipid plaques inside
the blood vessels it is an asymptomatic disease.
A.

Both statements are true

B.

Both statements are false

C.

The first statement is true and the second statement is false

D.

The first statement is false and the second statement is true

Question 3
All of the following are signs and symptoms of Myocardial Infarction EXCEPT:
A.

Cold sweat

B.

High blood pressure

C.

Anxiety

D.

Cyanosis

References
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