Guided By:

Submitted By:
DR. NEELKAMAL
Nishtha Singhal (45)
DR. VERMA
Nidhi Nagar (46)
Neha Sachdeva (47)
Pallavi Singh (48)
BDS Final Year
Batch 2005-06
CARDIOVASCULAR
DISEASES
SCHEME OF HISTORY TAKING
A)SYMPTOMS AND HISTORY OF PERSENT ILLNESS

B)PAST HISTORY

C)FAMILY HISTORY

D)PERSONAL HISTORY

E)TREATMENT HISTORY
A)SYMPTOMS AND HISTORY OF PERSENT ILLNESS
1. DYSPNOEA
2. CHEST PAIN
3. PALPITATION
4. SYNCOPE
5. COUGH WITH EXPECTORATION AND HAEMOPTYSIS
6. CYANOSIS
7. RIGHT HYPOCONDRIAL PAIN, SWELLING OF FEET AND DECREASE IN THE URINE
OUTPUT
8. GASTROINTESTINAL SYMPTOMS LIKE ANOREXIA, FULLNESS OF ABDOMEN AND
VOMITING
9. FATIGABILITY
10. FEVER
11. DIABETES MELLITUS AND HYPERTENSION

B)PAST HISTORY
1. RHEUMATIC FEVER
2. CYANOTIC SPELLS
3. RECURRENT RESPIRATORY INFECTIONS SINCE CHILDHOOD
4. DETECTION OF MURMUR/CARDIAC LESION AT SCHOOL
5. RECENT DENTAL EXTRACTION, GENITOURINARY INSTRUMENTATIONS
6. HYPERTENSION, DIABETES MELLITUS, ISCHAEMIC HEART DISEASE OR ANY OTHER
SIGNIFICANT MEDICAL ILLNESS
C)FAMILY HISTORY
1. HYPERTENSION
2. ISCHAEMIC HEART DISEASE
3. CONGENTAL HEART DISEASE
4. RHEUMATIC HEART DISEASE
5. SUDDEN DEATH

D)PERSONAL HISTORY
1. APPETITE
2. WEIGHT LOSS
3. DISTURBED SLEEP
4. BOWEL AND BLADDER DISTURBANCES
5. HABITS- SMOKING AND ALCOHOLISM
6. EXPOSURE TO SYPHILIS

E)TREATMENT HISTORY
NIFEDIPINE- GINGIVAL HYPERPLASIA
APPROACH TO A PATIENT OF CARDIAC DISEAASE
ANALYSIS OF PRESENTING SYMPTOMS

1)DYSPNOEA
DEFINITION:- ABNORMAL AWARENESS OF BREATHING WITH DISCOMFORT.
DYSPNOEA IS A SIGNIFICANT MANIFESTATION OF CARDIAC FAILURE.
DYSPNOEA IS MORE COMMONLY DUE TO LEFT-SIDED CARDIAC FAILURE THAN
DUE TO RIGHT HEART FAILURE.
SEVERITY (GRADING)
FUNCTIONAL GRADING OF DYSPNOEA
GRADE I : NO LIMITATN OF ANY PHYSIAL ACTIVITY BUT DYSPNOEA OCCURS
ON MORE THAN ORDINARY (UNOCCUSTOMED) EXERTION.
GRADE II: DYSPNOEA ON ORDINARY DAILY ACTIVITY
GRADE III : DYSPNOEA ON LESS THAN ORDINARY DAILY ACTIVITIES.
GRADE IV : LIMITATIONS OF ALL ACTIVITIES( DYSPNOEA AT REST)

2)ORTHOPNOEA
DEFINITION: DYSPNOEA THAT OCCURS USUALLY ON LYING DOWN.
CHARACTERISTIC FEATURES: USALLY OCCURS WITHIN MINUTES OF
ASSUMPTION OF RECUMBENCY.
OCCURS WHEN A PATIENT IS AWAKE.
INDICATES THE PRESENCE OF SEVERE LEFT HEART FAILRE (PULMONARY
OEDEMA).
MANIFESTS LATER THAN PND. (IN SLOWLY PROGRESSIVE LEFT HEART
DISEASE).
3)PLATYPNEA: DYSPNOEA OCCURS ON SITTING (UPRIGHT) RATHER THAN ON
LYING DOWN POSITION.
EXAMPLE: LEFT ATRIAL MYXOMA,LEFT ATRIAL BALL VALVE THROMBUS

4)TREPOPNEA: OCCURS ON BREATHLESSNESS ONLY WHEN LYING DOWN IN LATERAL

POSITION.
MAY BE DUE TO VENTILATION PERFUSION RELATIONSHIP
ALTERATION IN CERTAIN BODY POSITION.

5)PROXIMAL NOCTURNAL DYSPNOEA

ATTACK OF BREATHLESSNESS AT NIGHT.SIGN OF SEVERE
DEGREE OF LEFT HEART FAILURE.

6)CHEYNES-STROKE BREATHING
THERE IS SEVERE PERIODS OF HYPERVENTILATION FOLLWEDBY PERIODS OF
APNOEA.SIGN OF SEVERE HEART FAILURE.

7)CYANOSIS
A)CYANOSIS APPEARING IN INFANCY INDICATES THE PRESENCE OF CONGENITAL
CARDIAC ANOMALIES WITH RIGHT TO LEFT SHUNT(TERATOLOGY OF FALLOT)
B)CYANOSIS BEGINNING TO APPEAR AFTER 6 WEEKS OF AGE MAY BE AN INDICATION OF
VSD WITH SLOWLY PROGRESSIVE RIGHT VENTRICUAR OUTFLOW OBSTRUCTION.
C)HISTORY OF CYANOSIS IN A SUSPECTED PATIENT OF CONGENITAL HEART DISEASE
BETWEEN THE AGE OF 5-20 YEARS INDICATES REVERSAL OF LEFT TO RIGHT
SHUNT(EISENMEGER)
8)SWELLING OF FEET (PEDAL ODEMA)
RIGHT HEART FAILURE CAUSES SYSTEMIC VENOUS CONGESTION
WITH INCREASED HYDROSTATIC PRESURE IN THE LOWER
LIMB VEINS. THIS RESULT IN THE TRANSUDATION OF FLUID
CAUSING EDEMA.
ANKLE EDEMA IS MORE COMMON IN AMBULATORY PATIENTS. BED-RIDDEN
PATIENT DEVELOP SACRAL EDEMA.

9) RIGHT HYPOCHODRAL PAIN

THIS IS DUE TO ENLARGED AND CONGESTED LIVER AND STREACHING OF ITS
CAPSULE.

10) DECREASED URINE OUTPUT

IN THE PRESENCE OF CARDIAC FAILURE DUE TO DECREASED CARDIAC OUTPUT,
RENAL BLOOD FLOW DECREASES WITH DECREASE IN THE GLOMERULAR
FITRATION RATE, THIS CAUSES DECREASE OF URNE OUTPUT IN PATIENTS
WITH CARDIAC FAILURE.

11)SYNCOPE
TRANSIENT LOSS OF CONSCIOUSNESS WITH POSTURAL COLLAPSE.

12)COUGH AND EXPECTORATION

13)PALPITATION
SUGGESTS AWARENESS OF HEARTBEAT,WHCH MAY BE UNPLEASANT.
EXAMINATION OF CARDIOVASCUAR SYSTEM

SCHEME OF EXAMINATION
GENERAL EXAMINATION
1. BUILD
2. NOURISHMENT
3.PALLOR
4.CYANOSIS
5. CLUBBING
6. JAUNDICE
7. PEDAL ODEMA
8. LYMPHADENOPATHY
EXTERNAL MARKERS
OF CARDIAC EXAMINATION OF PERIPHERAL
DISEASE CARDIOVASCUAR SYSTEM
RADIAL PULSE:-
EXAMINATION OF :- RATE
FACE
RTHYM
EYES
VOLUME
EARS
CHARACTER
SKIN AND MUCOSA
CONDITION OF VESSEL WALL
EXTREMITIES
EXAMINATION OF:-
VITAL SIGNS:-
THE CAROTIDS
PULSE
THEIR PERIPHERAL PULSES
BLOOD PRESSURE
JUGULAR VENOUS PULSE AND PRESSURE
RESPIRATORY RATE
PERIPHERAL SIGNS OF WIDE PULSE
TEMPERATURE PRESSURE(IN RELEVANT SITUATION)
PERIPHERAL SIGNS OF INFECTIVE
ENDOCARDITIS
PERIPHERAL SIGNS OF RHEUMATIC FEVER
EXAMINATION OF THE PRECORDIUM

INSPECTION
1. PRECORDIAL BULGE
POSITION OF APICAL IMPULSE
PULSATIONS IN THE:-
A. LEFT PARASTERNAL REGION
B. 2ND LEFT INTERCOSTAL SPACE
C. 2ND RIGHT INTERCOSTAL SPACE
D. EPIGASTRIC PULSATION
E. SUPRASTERNAL PULSATION
F. ENGORGED VEINS OVER THE CHEST
G. SPINE(KYPHOSCOLIOSIS)

• PALPATION PERCUSSION
1)APICAL IMPULSE- POSITION AND 1)RIGHT CARDIAC BORDER
CHARACTER 2)LEFT CARDIAC BORDER
2)LEFT PARASTERNAL HEAVE 3)LEFT AND RIGHT 2ND INTERCOSTAL
3) OF EPIGASTRIC PULSATION SPACE.
THRILLS
4)PALPABLE SOUNDS
• AUSCULTATION
• MITRAL, TRICUSPID, AORTIC, PULMONARY AND OTHER ADDITIONAL
AREAS FOR:-
• A. 1ST AND 2ND HEART SOUNDS
• B. ADDITOINAL SOUNDS
• C. MURMURS
EXAMINATION ALSO INCLUDES THE
FOLOWING SIGNS

A)PALLOR

SEVERE ANEMIA MAY BE ASSOCIATED WITH:

1. CHRONIC CCF
2. INFECTIVE ENDOCARDITIS
SEVERE ANEMIA CAN ITSELF CAUSE- CARDIAC FAILURE OR
AGGRAVATE THE UNDERLYING HEART DISEASE.
PATIENTS WITH CYANOTIC CONGENITAL HEART DISEASE MAY
HAVE POLYCYTHEMIA WITH SUFFUSED CONJUNCTIVA.
B)CYANOSIS:

CENTRAL CYANOSIS OCCURS IN:

• 1. CYANOTIC CONGENITAL HEART DISEASE
• 2. REVERSAL OF LEFT TO RIGHT SHUNT
• 3. INTRAPULMONARY RIGHT TO LEFT SHUNT
• 4. PULMONARY EDEMA (LEFT HEART FAILURE)

• PERIPHERAL CYANOSIS OCCURS IN:

• 1. CONGENITAL CARDIAC FAILURE
• 2. PERIPHERAL VASCULAR DISEASE

• DIFFERENTIAL CYANOSIS:
• 1. FEET AND TOES ARE BLUE BUT HANDS AND FINGERS ARE NOT CYNOSED.
• E.G. PDA WITH PULMONARY HYPERTENSION WITH REVERSAL OF SHUNT.

• REVERSE DIFFERENTAL CYANOSIS:

• 1. FINGERS ARE MORE CYANOSED THAN TOES.
• E.G. TRANSPSITION OF GREAT VESSELS WITH PULMONARY HYPERTENSION WITH
PREDUCTAL COARCTATION WITH REVERSED FLOW THROUGH PDA.
C))CLUBBING

CARDIAC CAUSES:
1. CYANOTIC CONGENTAL HEART DISEASE
2. REVERSAL OF LEFT TO RIGHT SHUNT
3. INFECTIVE ENDOCARDITIS

CYANOTIC CONGENITAL HEART DISEASE MAY BE ASSOCIATED WITH

HYPERTROPHIC PULMONARY OSTEOARTHROPATHY.

D)JAUNDICE

FOLLOWING CARDIAC CONDITIONS MAY BE ASSOCIATED WITH

JAUNDICE:
1. CONGESTIVE CARDIAC FAILURE WITH CONGESTIVE HEPATOMEGALY
2. CARDIAC CIRRHOSIS
3. PULMONARY INFARCTION
E)PEDAL EDEMA
PITTING EDEMA OF FEET CAN OCCUR IN:
1. CONGESTIVE CARDIAC FAILURE
2. CONSTRICTIVE PERICARDITIS
3. TRICUSPID VALVE DISEASE

F)LYMPHADENPATHY:
CONDITION ASSOCIATED WITH GENERALIZED
LYMPHADENOPATHY MAY INVOLVE THE CARDIOVASCULAR
SYSTEM. E.G. LYMPHOMA, SLE ETC.
EXAMINATION OF FACE

• FOLLOWING FEATURES MAY BE INDICATIVE OF UNDERLYING

CAARDIAC ABNORMALITY WHILE EXAMINATION OF FACE.

ABNORMALITIES CONDITION
ASSOCIATED
ELFIN FACIES RECEDING JAWS, SUPRAVENTRICULAR
FLARED NOSTRILS, AORTIC STENOSIS
POINTED EARS

HIGH ARCHED PALATE MARFAN SYNDROME

MITRAL FACIES MALAR FLUSH AND MITRAL STENOSIS

PINKISH PURPLE WITH DECREASED
PATCHES OVER THE CARDIAC OUTPUT
CHEEK AND SYSTEMIC
VASOCNSTRICTION
MALAR FLUSH

TERATOLGY OF FALLOT

MARFAN SYNDROME
EXAMINATION OF MOUTH
Acute macroglossia:
the tongue is diffusely
enlarged and bright red along its lateral portion.
The patient had bleeding into the tongue while
on anticoagulants.

Acute macroglossia due to Enalapril: this

75-year-old Black female developed acute swelling of
tongue and lips after being on enalapril for 2 days. She was
unable to talk or swallow (upper photo). In lower photo, 2
days after stopping enalapril, the tongue and lips have
returned to their normal size.
GUM HYPERPLASIA
DUE TO DILANTIN. SIMILAR FINDINGS
MAY BE SEEN IN PATIENTS ON
NIFEDIPINE

TANGIER DISEASE OF THE TONSILS:

THE TONSILS ARE ENLARGED WITH
BRIGHT
ORANGE YELLOW STREAKS (“TIGER
STRIPES”)
(PREMATURE CAD).
EXAMINATION OF EAR:
PRESENCE OF CREASE IN THE PINNA OF THE EAR-
ASSOCIATED WITH INCREASED INCIDENCE OF CORONARY ARTERY
DISEASE.
• EXAMINATION OF EYES:

• EXOPTHALMUS: ASSOCIATED WITH THYROID ARTERY

DISEASE.
• BLUE SCLERA: OSTEOGENESIS IMPERFECTA WITH AORTIC
REGULTATION.
• OPTHALMIC FUNDUS: LOOK FOR
• A. ARTERIOSCLEROTIC CHANGES
• B. HYPERTENSIVE RETINOPATHY
• C. ROTH’S SPOTS( OF INFECTIVE ENDOCARDITIS)
• D. ARTERIAL PULSATION IN AR
• E. CORK SCREW ARTERIES- COARCTATION OF AORTA.

BLUE SCLERA ROTHS SPOT

EXAMINATION OF FINGER

CLUBBING

CLUBING NEGATIVE
OSLERS NODE IN ENDOCARDITIS

SUBUNGAL HAEMORRHAGES

JANEWAY LESIONS
CAUSES OF CARDIOVASCLAR DISEASE

ORGANIC DISEASE OF HEART

1. MYOCARDIAL
A. OVERLOAD SECONDARY TO HYPERTENSON OR VALVE DISEASE
B. CORONARY( ISCHAEMIC) HEART DISEASE
C. CARDIOMYOPATHIES

2. ENDOCARDIAL
A. RHEUMATIC HEART DISEASE
B. CONGENITAL ANOMALIES
C. INFECTIVE ENDOCARDITIS

3. PERICARDIAL
A. PERICARDITIS
B. PERICARDIAL EFFUSION
C. FUNCTIONAL DISORDERS

DUE TO HYPERTENSION

DUE TO ABNORMALITIES IN HEART RATE

A. TACHYCARDIA
B. BRADICARDIA
C. OTHER DYSRTHYMIAS

CHANGES IN CIRCULATORY VOLUME

A. HYPOVOLOEMIA (SHOCH SYNDROME)
B. HYPERVOLAEMIA ( CIRCULATORY OVERLOAD)
C. OTHERS
NYHA CLASSIFIACTION

FUNCTIONAL CAPACITY OBJECTIVE ASSESSMENT

CLASS I. PATIENTS WITH CARDIAC DISEASE BUT WITHOUT RESULTING A. NO OBJECTIVE

LIMITATION OF PHYSICAL ACTIVITY. ORDINARY PHYSICAL ACTIVITY EVIDENCE OF
DOES NOT CAUSE UNDUE FATIGUE, PALPITATION, DYSPNEA, OR CARDIOVASCULAR
ANGINAL PAIN. DISEASE.

CLASS II. PATIENTS WITH CARDIAC DISEASE RESULTING IN SLIGHT B. OBJECTIVE EVIDENCE
LIMITATION OF PHYSICAL ACTIVITY. THEY ARE COMFORTABLE AT OF MINIMAL
REST. ORDINARY PHYSICAL ACTIVITY RESULTS IN FATIGUE, CARDIOVASCULAR
PALPITATION, DYSPNEA, OR ANGINAL PAIN. DISEASE.

CLASS III. PATIENTS WITH CARDIAC DISEASE RESULTING IN MARKED C. OBJECTIVE EVIDENCE
LIMITATION OF PHYSICAL ACTIVITY. THEY ARE COMFORTABLE AT OF MODERATELY
REST. LESS THAN ORDINARY ACTIVITY CAUSES FATIGUE, SEVERE
PALPITATION, DYSPNEA, OR ANGINAL PAIN. CARDIOVASCULAR
DISEASE.

CLASS IV. PATIENTS WITH CARDIAC DISEASE RESULTING IN INABILITY D. OBJECTIVE EVIDENCE
TO CARRY ON ANY PHYSICAL ACTIVITY WITHOUT DISCOMFORT. OF SEVERE
SYMPTOMS OF HEART FAILURE OR THE ANGINAL SYNDROME MAY CARDIOVASCULAR
BE PRESENT EVEN AT REST. IF ANY PHYSICAL ACTIVITY IS DISEASE.
UNDERTAKEN, DISCOMFORT IS INCREASED.
 HYPERTENSION
Hypertension is known as
Silent Killer of mankind.

Most of the sufferers (85 %)

are asymptomatic and hence
early diagnosis is a problem.

 More than 65 lakh

Americans and over 1 billion 27
 Definition
• Hypertension is defined as
having systolic blood
pressure (SBP) >/= 140mm
of Hg or

• diastolic blood pressure

(DBP) >/= 90mm of Hg or
• as having to use antihypertensive medications.

28
 Classification
The Seventh Joint National Committee Criteria
(JNC VII) classifies hypertension for adults aged
18 years and older into following stages:

Blood Pressure Classification SBP(mm Hg)

DBP(mmHg)
•Normal <120 & <90
•Pre hypertension 120-139 & 80-
89
•Stage I hypertension 140-159 & 90-
99 29
Types

30
Other Risk Factor of
Hypertension
•Lack of exercise
•Increased salt intake
•Family history
•Too little potassium
•Alcohol
•Smoking
•Stress &
•Age
31
 Effect of hypertension

The common target organs damaged by

long standing hypertension are:

•Brain
•Heart
•Kidneys
•Eyes &
•Peripheral arteries. 32
 Complications of hypertension
 Left ventricular hypertrophy
 Heart failure
 Cerebral hemorrhage
 Renal insufficiency
 Aortic dissection
 Atherosclerotic disease

33
 Symptoms
Symptoms due to hypertension:
1.Headache - usually in morning hours.
2.Dizziness
3.Epistaxis

Symptoms due to affection of target organs:

1.CVS:
a.Dyspnea on exertion
b.Anginal chest pain
34
c.Palpitations
 2. Kidneys: Hematuria , nocturia , polyuria .
3.CNS:
a.Transient ischemic attacks ( TIA or Stroke)
b.Hypertensive encephalopathy(headache ,
vomiting etc.)
c.Dizziness, Tinnitus & syncope.

4. Retina:
a.Blurred vision or
b.sudden blindness.
35
 Diagnosis
• Physical Examination
• Laboratory and Additional Testing – it includes
Routine laboratory procedures like
hemoglobin, urinalysis, routine blood
chemistries and fasting lipid profile.
• Electrocardiography
• Ambulatory BP Monitoring
• Plasma renin activity testing
• Radiologic testing
36
 WHITE COAT HYPERTENSION
‘’White coat hypertension’’ is a
phenomenon in which individuals
present with persistent elevated
BP in a clinical setting but present
with non-elevated BP in an
ambulatory setting.

•20% of mild hypertensive

individuals may present with white
coat hypertension. 37
 Dental Management
• Measure and record BP at initial visit

38
Recheck :-
•Every 2 yrs for patient with BP <120/80 mm
Hg.
•Every 1 yr for patient with BP 120-139/80-89
mm Hg.
•Every visit for patient with BP >140-90 mm
Hg.
•Every visit for patient with established
coronary artery disease, diabetes mellitus
or chronic renal disease with BP >135-85
mm Hg.
•Every visit for patient with established
hypertension.
Before initiating dental care:
•Assess presence of hypertension
•Determine presence of target organ disease
•Determine dental treatment modifications 39
1. Asymptomatic BP <159/99 mm Hg, no
history of target organ disease
• No modifications needed
• Can safely be treated in dental setting

2. Asymptomatic BP 160-179/100-109 mm Hg,

no history of target organ disease
• Assessment on an individual basis with regard to type of dental
procedure BP>180/110 mm Hg, no history of target organ disease
• No elective dental care

3. Presence of target organ disease or poorly

controlled diabetes mellitus
• No elective dental care until BP is controlled , preferable below
140-90 mm Hg.
40
 TREATMENT OF HYPERTENSION
NON PHARMACOLOGICAL
TREATMENT LIFESTYLE
MODIFICATIONS
1. Salt restriction
2. Weight reduction
3. Stop smoking
4. Diet modifications such as:
• Reduce intake of Cholesterol
& Saturated fat.
• Adequate intake of Calcium &
Magnesium.
41
5. Limit of alcohol intake

6. Relaxation such as yoga, psychotherapy

etc.

7. Regular exercise.

42
 ORAL MEDICATIONS USED FOR
TREATMENT OF HYPERTENSION

•Diuretics
•Beta-Adrenergic Blockers
•Central Acting Inhibitors
•Peripheral Acting Inhibitors
•Non-Selective alpha & beta Adrenergic
Inhibitors
•Vasodilators
•Angiotensin Converting Enzyme ACE 43
Inhibitors
 ORAL MANIFESTATION OF
HYPERTENSION
There are no recognized manifestations of
hypertension but anti-hypertensive drugs can
often cause side affects , such as:
•Xerostomia,
•Gingival overgrowth,
•Salivary gland swelling or pain,
•Lichenoid drug reactions,
•Erythema multiforme,
•Taste sense alteration,
•Paresthesia.
44
 CONCLUSION

• HYPERTENSION has no cure, but it can be

controlled with proper diet, lifestyle changes, and
if necessary medications.
• Get regular health check ups. Think about the
consequences of untreated high blood pressure.
• Do not take chances with the disease that can be
controlled.
• Lastly, Hypertension is a silent disease, but its
silence is not golden.

45
 CORONARY
(ISHAEMIC) ARTERY
DISEASE
• Atherosclerosis is the most common
cause of CAD
ETIOPATHOGENESIS
Various risk factors include:
1. lipids (especially HDL)
2. hypertension
3. diabetes mellitus & glucose intolerance
4. cigarette smoking
5. lifestyle & dietary factors
6. exercise
7. obesity
8. vitamins & homocystiene
9. plasma fibrinogen
10. endothelial dysfunction
11. antioxidants
12. estrogen deficiency
RISK FACTORS

Induce variety of pathological processes

Interaction & disruption of vascular endothelium

Plaque formation

Effective arterial luminal area compromised

Myocardial ischaemia acute plaque rupture

thrombus formation
angina
MI
 DIAGNOSIS
1) Based on clinical presentation :
 chest tightness
 Jaw discomfort
 Left arm pain
 Dyspnea
 Epigastric distress
2) E.C.G.
3) Exercise E.C.G.
4) Coronary Angiography
5) P.C.I.(Percutaneous Coronary Intervention)
 MANAGEMENT
Management of CAD depends on:
• Extent and severity of ischemia
• Exercise capacity
• Prognosis based on exercise testing
• Overall LV function
• Associated features such as diabetes mellitus
Patients with a small ischemic burden, normal exercise
tolerance, and normal LV function may be safely
treated with pharmacologic therapy.
Selected use of aspirin, β-blockers, ACEIs, and HMG CoA
reductase inhibitors.
Nitrates and calcium channel blockers may be added to
primary agents to relieve symptoms of ischemia in
selected patients.
• Percutaneous coronary
intervention (PCI) with
percutaneous
transluminal coronary
angioplasty (PTCA) and
intra coronary stenting
relieves symptoms
chronic ishchemia.
• Patient with complex
multivessel CAD require
PCI with medical therapy
of surgical
revascularization.
• Patients with reduced LV
function and severe
ischemia, often
associated with left main
or multivessel CAD, are
best served by coronary
artery bypass graft
(CABG) surgery.
 DENTAL ASPECTS
• STRESS, ANXIETY, EXERTION or PAIN can
provoke angina
• Short, minimally stressful dental
appointments
• Late morning appointments
• Excessive dose of LA containing adrenaline
to be avoided in patients taking beta blockers
• More severe dental caries and periodontal
disease in pts of IHD
 Acute Coronary Syndromes
• Represent a continuous spectrum of disease
ranging from unstable angina to MI
 Angina pectoris
• Name given to paroxysms of severe chest pain

CLINICAL FEATURES
1) 40 TO 60 years , M > F
2) pain often described as sense of Strangling, choking , Tightness,
Heaviness ,Compression, or Constriction of chest
3) PAIN MAY RADIATE TO JAW or left arm
4) rarely pain in mandible, teeth or other tissues

PRECIPITATING FACTORS
• Physical exertion(main) particularly in cold weather
• Emotion(anger or anxiety) & stress caused by fear or pain

TYPICALLY RELEIVED BY REST

 Dental aspects
 Preoprerative glyceryl trinitrate & oral sedation advised
sometimes
 dental care carried with minimal anxiety & oxygen
saturation
 Monitor pulse & B.P.
 POST ANGIOPLASTY elective dental care deffered for 6
months , emergency dental care in a hospital setting
 PTS with BYPASS GRAFTS – no anti biotic cover
against infective endocarditis
- LA containing adrenaline is
contraindicated (may ppt dysrhythmia)
 PTS with vascular stents – no antibiotic
cover
except during 1st 6 week postop for
emergency dental care

 DRUGS used in t/t of angina may cause

oral adverse effects like :
-lichenoid reaction Ca channel
- gingival swelling blockers
- ulcers (nicorandil)
Gingival hyperplasia
in patient consuming
Ca channel blockers
 Myocardial infarction
• Synonyms – coronary thrombosis or heart attack
CLINICAL FEATURES
1. Clinical picture is variable
2. More than 50% patients are symptomless
3. MI may be preceded by angina often felt as indigestion like pain
4. any anginal attack lasting longer than 30 minutes is considered
MI
5. Tachycardia &irregular pulse
6. nausea, vomitting, sweating ,restlessness, facial pallor
7. breathlessness, cough
8. Loss of conciousness, shock & even death
9. Many pts die within 1st hour to few days after attack
THUS, MI is a MEDICAL EMERGENCY
 DIAGNOSIS
I. Based on clinical features
II. Elevated TLC & ESR during 1st wk
III. ECG changes
IV. Rise in serum “cardiac” enzymes ( CPK)
V. Rise in troponin T within 4-8 hours
VI. echocardiography
 General Precautions during Dental
Procedures
• Dental clinic should have advanced cardiac life support or
at least basic cardiac life support.
• Use of pulse oximeter to determine the level oxygenation.
• Automatic external defibrillator.
• Determination of vital signs prior to dental care.
• BP & pulse rate & rhythm should be recorded & any
abnormal findings should be addressed.
• Premedication with antianxiety drugs and inhalation
nitrous oxide in anxious patients.
• Elective procedures esp those requiring GA should be
avoided for atleast 4 wks aftr MI. consult pt’s physician
prior to dental therapy
 Management on dental chair
1. Terminate all dental treatment
2. Position pt in semirecline position
3. Give nitroglycerin(TNG) (abt 0.4 mg) tablet or spray
4. Administer oxygen
5. Check pulse & B.P.

Discomfort relieved Discomfort continues 3 mins after 2nd TNG

6. Assume angina pectoris is 6. give 2nd TNG dose

present 7. monitor vital signs.
7. Slowly taper oxygen over
5 mins
8. Modify t/t to prevent recurrence discomfort discomfort continues
relieved 3 mins after TNG
8. give 3rd TNG dose
9. Monitor vitals
10. Call for medical assistance

Discomfort relieved discomfort continues 3 mins after 3 rd TNG dose

11. Refer pt for medical 12.assume MI is in progress

evaluation before 13. start i.v. line with drip of a crystalloid
solution
further dental care at 30 mL/ hr

14. If discomfort severe titrate morfine sulphate 2mg s/c or i/v every 3
mins until relief is obtained
15. Transport to emergency care. Administer Basic Life Support ,if
necessary.
 Anticoagulation Therapy & Dental
• Care
Anticoagulant therapy is used both to treat & to
prevent throboembolism.
• 2 major types : 1. antiplatlet medications
2. antithrombin medications
• Acetylsalicylic acid (ASA) + clopidogrel
( anticoagulant) given for 4 weeks after stent
implantation
• daily aspirin typically continued lifelong.
• May increase risk of oral bleeding following surgical
procedures
• Associated conditions which predispose patient to
uncontrolled hemostasis : uraemia or liver diseases
or use of NSAIDS
• If emergency surgery needs to be done,DDAVP(1-
desamino-8-D-arginine vasopressin) is
administered{0.3 micro kg/body wt parenterally}
within 1 hr of surgery
• Antithrombin medications are dicumarols ( eg.
Warfarin), it inhibits biosynthesis of vit. – K
dependent coagulations protein.

- Efficacy monitored by prothrombin time or the

international normalized ratio (INR), which is
calculated on the basis of international
sensitivity index (ISI).
- INR ranges from 2.0 – 3.5 & it should be
performed within 24 hrs of surgery.
- If INR is < 3.5, anticoagulation therapy should be
discontinued before minor surgical procedures.
3 different protocols used to treat patients with
elevated INR :
• Ist protocol – warfarin not discontinued
(minimizes thromboembolic events & increases
risk of bleeding after surgery).
• IInd protocol – warfarin discontinued (drug
should be discontinued 2-3 days prior to
surgery, during this period patient is at risk of
developing thromboembolic event but not
bleeding).
• IIIrd protocol – warfarin discontinued & patient
placed on alternative anticoagulant therapy
(thromboembolic event minimized).
• We always plan a t/t by comparing
potential risk for excessive bleeding
after procedures if anticoagulation
therapy is not reduced or stopped v/s
risk of pt experiencing a
thromboembolic event if
anticoagulation therapy is altered.
Rheumatic fever is an inflammatory disease
that may develop two to three weeks after a
Group A streptococcal infection (such as
strep throat or scarlet fever). It is believed to
be caused by antibody cross-reactivity and
can involve the heart, joints, skin, and
Brain
Acute rheumatic fever commonly appears in
children ages 5 through 15, with only 20% of
first time attacks occurring in adults
Rheumatic fever
• What are the symptoms of
strep throat?
• sudden onset of sore throat
(streptococcal oropharyngitis)

• pain on swallowing
• fever, usually 101–104°F
• Headache
• Red and edematous soft palate
and oropharynx.

• Areas of tonsillar ulceration and

exudation.

• abdominal pain, nausea and

vomiting may also occur,
especially in children
• What are the symptoms/clinical features of
rheumatic fever?
• Symptoms may include:
• fever
• painful, tender, red swollen joints
• pain in one joint that migrates to another one
• heart palpitations
• chest pain 
• shortness of breath
• skin rashes
• fatigue
• small, painless nodules under the skin 
• Diagnosis
• Two major criteria, or
one major and two
minor criteria,
• Major criteria(jones)
• Joints (Migratory
polyarthritis):
• O [imagine heart-shaped
O] (carditis):
• Nodules (subcutaneous
nodules - a form of
Aschoff bodies):
• Erythema marginatum:
• Sydenham's chorea
• mnemonic: C.A.N.C.ER
• C: Carditis
• A: Arthritis
• N: Nodules (sub cutaneous)
• C: Chorea
• ER: ERythema Marginatum
• Another way of remembering it is CASES
• Minor criteria
• Fever:
• Arthralgia
• Laboratory abnormalities: increased
Erythrocyte sedimentation rate
• Electrocardiogram abnormalities
• Evidence of Group A Strep infection:
elevated or rising Antistreptolysin O titre,
• LAB INVESTIGATIONS-
• raised ESR
• culture studies of throat
swabs is always negative
in RF
• High anti sterptolysin
o(ASO)titre-!300 todd
units
• Chest radiograph-
enlargement of heart
• ECG-prolonged PR
interval
• Echocardiogram-confirms
ventricular dilatation n
pericardial effusion
• TREATMENT-
• Oral phenoxymthylpenicillin 500 mguntil
age of 20 yrs.
• Allergic to penicillin,sulfadimidine by
mouth.
• Aspirin for fever and pain 50mg/kg bwt in 4
hrly doses
• Corticosteroids 60-80mg prednisolone
• Digoxin and diuretics for heart failure
• Ballon valvuloplasty,using inoue balloon,if
mitral valves damage.
• DENTAL
CONSIDERATION-
• Dental extractions and local
anesthesia in consent with
physician.
• The prophylactic use of antibiotics
prior to a dental procedure is now
recommended ONLY for those
patients with the highest risk of
adverse outcome resulting from
endocarditis
• No2 used with approval of
physician.
• GA shd be avoided if essential
must be given in hospital.
• Rheumatic heart disease-
• History of rheumatic fever during
childhood or adollescence can act as a
predisposing factor for RHD after several
years.
• Common signs-murmur due to valvular
damage n later enlargement of heart.
• ORAL
MANIFESTATIONS
• Most prominent during
acute phase,
• Pharyngitis
• Inc oral temperature
• Distended neck veins
and a bluish color of the
skin.
• DENTAL CONSIDERATIONS-
• To prevent complication of infective
endocarditis ,all dental procedures should
be carried under antibiotic cover.

• Amoxicillin prophylaxis-1 hour before and

6 hours after the initial dose.

• Good oral hygiene measures ,fluoride

treatment, chlorhexidine rinses and routine
cleanings to reduce harmful bacteremias.
• Proper history should be taken to identify
history of rheumatic fever during
childhood.
• Suspicious cases should be referred to
cardiologist for cardiac evaluation prior to
dental procedures.
• Clindamycin or erythromycin prophylaxis
during dental treatment.
• Elective dental treatment under physician
consultation.
• HEART FAILURE-
• Heart failure (HF) is a
condition in which a
problem with the structure
or function of the heart
impairs its ability to
supply sufficient
blood flow to meet the
body's needs .
• Common causes of heart
failure –
• ischemic heart diseases
• Hypertension
• Valvular diseases
• Left-sided failure(MORE COMMON)
• Backward failure of the left ventricle causes congestion
of the pulmonary vasculature, and so the symptoms are
predominantly respiratory in nature. The patient will
have dyspnea (shortness of breath) on exertion and in
severe cases, dyspnea at rest. Increasing
breathlessness on lying flat, called orthopnea.
• Another symptom of heart failure is paroxysmal
nocturnal dyspnea also known as "cardiac asthma", a
sudden nighttime attack of severe breathlessness,
usually several hours after going to sleep
• Inadequate cerebral oxygenation leads to loss of
concentration,restlessness and irritability.
• Right-sided failure
• Backward failure of the right ventricle
leads to congestion of systemic capillaries.
This helps to generate excess fluid
accumulation in the body. This causes
swelling under the skin (termed peripheral
edema or anasarca)
• IF occurs with MS is called congestive
heart failure.
• Biventricular failure
,faiure of one side of
heart leads to failure of
other.

• CLINICAL FEATURES
• pedal edema
• Dyspnea
• Congestion of neck veins
• Cynosis
• Fatigue
• DIAGNOSIS
• Imaging
Echocardiography
• Electrophysiology
electrocardiogram
(ECG/EKG)
• Blood tests
• Angiography
• Monitoring
• TREATMENT MODALITIES-
• Diet and lifestyle measures
• Weight reduction
• Monitor weight
• Sodium restriction -excessive sodium intake may
precipitate or exacerbate heart failure
• Fluid restriction – patients with CHF have a
diminished ability to excrete free water load
• stress reduction,rest
• Stop smoking
• Pharmacological management
• diuretic
• Loop diuretics (e.g. furosemide, bumetanide)

• ACE inhibitor/ Angiotensin II receptor antagonist

Positive inotropes
• Digoxin
• Beta blockers
• Alternative vasodilators
• The combination of isosorbide
dinitrate/hydralazine
 ORAL MANIFESTATIONS
• Distention of the external
jugular viens.

• Compensatory polycythemia –
ruddy complexion and
bleeding tendencies.

• Abnormal production of clotting

factors

• Bleeding can be spontaneous

or extravasational.
• DENTAL ASPECTS-
• The dental chair should be kept in partially
reclining or erect position and patient should be
raised slowly in upright position.

• Emergency dental care should be conservative

,principally with analgesics and antibiotics.

• Appointments should be short

• Non stressful appointments

• Patients are best treated in late morning because

of epinephrine levels peak in early morning.
• Bupivacaine should be avoided as it is
cardiotoxic.
• An aspirating syringe should be used to
give local anesthetic

• Epinephrine containing LA should be not

given in large doses to patients taking beta
blockers.

• Gingival retraction cords containing

epinephrine should be avoided
• Supplemental o2 shd be available

• Rubber dam is contraindicated when it

contributes to breathing difficulty.

• NSAIDS other than aspirin shd be avoided

in pts taking ACE inhibitors(renal
damage).
• Erythromycin and tetracycline to be
avoided as they may induce digitalis
toxicity
• GA is contraindicated in cardiac
failure.until under control(venous
thrombosis and pulmonary embolism)

• ACE inhibitors can sometimes cause

erythema multiforme,angioedema or
burning mouth.

• Antibiotic prophylaxis req for dental care

• History of recent MI ,req delay of elective

dental care for 6 months
Ortho static hypotension
• CARDIAC
ARRHYTHMIA -Cardiac
arrhythmia (also
dysrhythmia) is a term
for any of a large and
heterogeneous group of
conditions in which there
is abnormal electrical
activity in the heart. The
heart beat may be too
fast or too slow, and may
be regular or irregular
• Accordingly there r 2
types-
• Atrial arrhythmia
• Ventricular arrhythmia
• More fatal than AA
• TACHYCARDIA-
• Any heart rate faster than 100
beats/minute is labelled tachycardia.
BRADYCARDIAS
• A slow rhythm, (less than 60 beats/min),
can lead to syncope.
• HEART BLOCK-blockage of cardiac
impulse anywhere in the conduction
system.
 TREATMENT
• AA- • VA-
• Digoxin • Procainamide
• Propanolol • Phenytoin
• qUinidine sulphate • Dispyramide
• Anticoagulant such as • Propanolol
warfarin
• Physical maneuvers
• Antiarrhythmic drugs
• Electricity
• Electrical cautery
 ORAL MANIFESTATIONS
• Procainamide can cause
agranulocytosis,oral
ulcerations

• Quinidine-infrequent oral
ulcerations

• Disopyramide is anticholinergic
agent capable of producing
xerostomia.

• verapamil,enalapril can cause

gingival hyperplasia.
• DENTAL
CONSIDERATIONS-
• A proper history to be
taken
• Stress and anxiety
• be minimized
• Short appointments
• Use of epinephrine to be
minimized
• Proper chair position is
important, SUPINE
• At end of appointment
chair should be raised
slowly to minimize
orthostatic hypotension.
• Use of vasoconstrictors should be
minimized in pts taking digitalis glycosides.

• The equipments like pulp testers

,ultrasonic scalers ,electrosurgical units
,should not be in close proximity.

• Prophylactic antibiotics before and after

treatment in recently placed pacemaker
patients.

• Pts who report palpitations or skipped

beats must be evaluated by physician
• Sustained sinus tachycardia above 100
beats/min in resting position is indicative of
sinus tachycardia
• Dental treatment shd not be carried out in
patients with irregular pulse
• Long use of procainamide can cause a
lupus like syndrome
• Drug like quinidine can cause erythema
multiforme
• CA may be induced by general anesthesia
and vagal reflex
 ORAL HEALTH CONSIDERATION & ORAL
MANIFESTATION
• Valvular heart disease that compromises cardiac output produces
signs of hypoxemia.
• Cyanosis of lips and oral mucosa is the most prominent oral sign of
tissue hypoxia.
• According to American heart association guidelines: Antibiotic
prophylaxis should be administered to patitents who have
undergone mitral or aortic valve repair or replacement.
• Patients with a prior history of infective endocarditis.
• Patients with mitral or aortic regurgigation or stenosis.
• Patients with mitral valvular prolapse with valvular regurgigation.
• Prosthetic heart valves.
• Previous bacterial endocarditis.
• Acquired valvular dysfunction.
• Complex cyanotic congenital heart disease.
• Surgically constructed systemic pulmonary shunts.
ORAL PROCEDURES & NEED FOR ANTIBIOTIC
PROPHYLAXIS TO MINIMISE RISK OF
BACTERIAL ENDOCARDITIS
• Extractions.
• Periodontal procedures including
surgery,subgingival,placement of antibiotic fibers or
Strips,scaling &root planning.
• Implant placement.
• Tooth reimplantation.
• Placement of orthodontic bands(not brackets).
• Endodontic instrumentation.
• Intra ligamentary injection.
• Prophylatic cleaning of teeth where bleeding is anticipated.
• Other procedure in which significant bleeding is anticipated.
STANDARD REGIMENS FOR PROPHYLAXIS
TO MINIMISE RISK OF BACTERIAL
ENDOCARDITIS

• Oral medication.
• Adults & children not allergic to penicillin-amoxicillin.
• Adults & children allergic to penicillin-clindamycin.
• Non oral medication.
• Adults & Childrens not allergic to penicillin-iv or im ampicillin.
• Adults & children alergic to penicillin-iv clindamycin.