2.1.1. Location

• Coronary arteries
• Cerebral arteries
• Peripheral arteries

2.1.2. Ischemia vs. Infarcation

• Ischemia = transient, from partial occlusion
• Infarction = permanent, from total occlusion

2.1.3. Symptoms of Ischemia

• Angina
• Transient Ischemic Attack (TIA)
• Associated symptoms of Angina (breathlessness, nausea and vomiting, diaphoresis, palpitations)

2.1.4. Unstable Angina - avoid elective procedures!!!

• New onset
• Crescendo
• Rest
• Treatment:
  • I.V. Medicines
  • Angioplasty (PTCA)
  • Coronary Artery Bypass Grafting (CABG)

2.1.5. Myocardial Infarction (MI) - avoid elective procedures for 3-6 months after MI

• Common medications:
  • Anti-anginals (including Nitroglycerine)
  • Anti-Hypertensives
  • Cholesterol lowering medicines
  • Anti-Coagulants
• Use of medicines in CAD patients Peri-Procedure
  • Except for anticoagulants, patients with CAD should continue their meds prior to Dental visit
  • Patients should be specifically told to continue their medicines
• Care of Patients with CAD
  • Assess history of recent symptoms
  • Contact Primary Care Doctor for questions
  • Minimize stress during procedures
  • Patients with CAD alone, or CABG, do not need antibiotic prophylaxis
• Management of Chest Pain during Procedures
  • Discontinue procedure
  • Give patient Nitroglycerine
  • To emergency Room if no relief after 3 NTG
  • Notify patient's primary doctor

2.2.1. Considerations with Valvular Patients

• Antibiotic SBE prophylaxis
• Anticoagulants
• Associated Cardiac Abnormalities

2.2.2. Valvular Abnormalities

• Stenosis - failure to open, "narrowing"
• Regurgitation or insufficiency - failure to close, "leaking"
• Combined

2.2.3. Mitral Valve Disease

• Mitral Stenosis
  • Rheumatic Fever
  • Fibrocalcific Deposits
  • Congenital
  • Autoimmune Diseases (Lupus, etc.)
• Mitral Regurgitation
  • Rheumatic Fever
  • Cardiac Enlargement
  • Infarction
  • Endocarditis
  • Mitral Valve Prolapse (MVP)
• Mitral Valve Prolapse
  • Abnormal bowing of valve leaflets (floppy)
  • Common finding on Echocardiography
  • Importance of +/- Regurgitation
• SBE Prophylaxis
  • MS & MR require prophylaxis
  • MVP without MR - no prophylaxis (unless valve apparatus abnormal)
• Atrial fibrillation commonly associated with MV disease
  • Often with anticoagulants +/- antiarrythmics

2.2.4. Aortic Valve Disease

• Aortic Stenosis
  • Rheumatic Fever
  • Senile or Degenerative (Calcific)
  • Congenital (Bicuspid)
• Aortic Regurgitation
  • Rheumatic Fever
  • Endocarditis
  • Congenital (Bicuspid)
  • Traumatic
  • Aortic Root Disease

SBE prophylaxis is required for both Aortic Stenosis and Aortic Regurgitation.

2.2.5. Prosthetic Heart Valves

• bioprosthetic
  • Combination of animal (or human) tissues and synthetics
  • No need for anticoagulation
• Mechanical Prosthetic
  • Synthetic materials alone (usually metal)
  • Always require anticoagulation

All artificial heart valves require SBE prophylaxis.

2.3.1. Nomenclature

• Normal sinus rhythms
• Tachycardia - rapid heart rate (>100 bpm)
• Bradycardia - slow heart rate (<60 bpm)
• Supraventricular - originates above the ventricles (atria)
• Ventricular - originates within the ventricles, usually life-threatening

2.3.2. Treatment options

• Medications
  • Antiarrhythmic -- must be discontinued
  • Anticoagulants -- should be discontinued
• Devices
  • Pacemakers
  • Defibrillators
  • Devices do not require SBW prophylaxis

2.4.1. Definition

2.4.2. Demographics

• 50 million Americans have HTN
• 1 in 4 adults
• Only 27% are on adequate therapy
• 31% of American with HTN don't know they have it
• HTN kills 42,500 Americans per year, and contributes to 210,000 deaths annually

2.4.3. Modifiable Risk Factor

• People with uncontrolled HTN are:
  • Three times more likely to develop Coronary Artery Disease
  • Six times more likely to develop Congestive Heart Failure
  • Seven times more likely to suffer a Stroke

2.4.4. Etiology

• 92-94% is Essential HTN (Ideopathic)
• 6-8% is Secondary HTN (secondary to another disease)
  • 3-5% due to Renal disease
  • 1% due to Endocrine causes

2.4.5. Treatment

• Diuretics
• Beta Blockers
• Calcium Channel Blockers
• Angiotension Converting Enzyme Inhibitors
• Vasodilators
• Nitrates
• Sodium Restriction

2.5.1. Etiologies

• Cardiomyopathy - intrinsic muscular defect
• Ischemia
• Infarction

2.5.2. Cardiomyopathies

• Hypertrophic - thickened cardiac wall
  • Primary - IHSS or ASH
  • Secondary - Hypertension
• Dilated - enlarged cardiac chamber volume
  • Primary - Ideopathic
  • Secondary - Infarct, Hypertension, Valvular Dz
• Medical Considerations
  • Can be very ill, congestive heart failure
  • ? +/- anticoagulants

2.6.1. Common Disorders

• Pulmonic and Aortic Stenosis
• Patent Ductus Areteriosis (PDA)
• Aortic Coarctation
• Ventricular Septal Defect (VSD)
• Atrial Septal Defect (ASD)
• Transposition of the Great Vessels
• Tetralogy of Fallot

2.6.2. Associated Illnesses

• SBE
• Heart Failure
• Thrombosis
• Cyanosis
• Pulmonary Hypertension

2.6.3. SBE Prophylaxis

• NOT required for:
  • ASD of the secundum type
  • > 6 months after complete surgical repair
• Required for:
  • Everyone else