CARDIOVASCULAR
SYSTEM REVIEW
Anatomy
Anatomy
The Vascular System
Cardiovascular Diseas
Class of disease that involves the heart and
blood vessels
Cardiovascular Diseas
Valvular disease
Coronary heart disease
• Aortic and mitral valve disorders
Ischemic heart disease
•Pulmonary and Tricuspid valve
Angina disorders
Heart Attack Displasia
•Tetralogy of Fallot
Hypertension •Ebstein’s anomally
Cardiomyopathy Rheumatic Disorders
Heart failure •Artificial heart valve
Arrhythmias
Inflamatory heart disease
Stroke
Endocardidtis
•Hemorrhagic
Myocarditis •Ischemic
Cardiovascular Diseas
84.7
90
73.6 73.1 78.8
80
70
Percent of Population
60
50 39.6 39.6
40
30
20 14.9
8.7
10
0
20-39 40-59 60-79 80+
Men Women
Prevalence of CVD in adults age 20 and older by age and sex
(NHANES 2003-2006). Source: NCHS and NHLBI.
These data include coronary heart disease, heart failure, stroke and hypertension.
Cardiovascular Diseas
450,000
400,000
350,000
300,000 CLRD
Deaths Accidents
250,000
Cancer
200,000 All Other CVD
Stroke
150,000
Heart Disease
100,000
50,000
0
All Ages <85 85+
CVD and other major causes of death: males
(United States: 2006). Source: NCHS and NHLBI.
Cardiovascular Diseas
500,000
400,000 Alzheimer
CLRD
Deaths 300,000
Cancer
200,000 All Other CVD
Stroke
100,000 Heart Disease
0
All Ages <85 85+
CVD and other major causes of death: females
(United States: 2006). Source: NCHS and NHLBI.
Cardiovascular Diseas
Risk Factors
A. Nonmodifiable
Increasing age, 83 percent of people who die of coronary heart disease
are 65 or older
Male sex (gender), Men have a greater risk of heart attack than
women do, and they have attacks earlier in life
Heredity (including Race), African Americans, Mexican
Americans, American Indians, native Hawaiians and some Asian Americans
Cardiovascular Diseas
Risk Factors
B. Modifiable
Tobacco smoke, 2–4 times that of nonsmokers
High blood cholesterol
High blood pressure
Physical inactivity
Obesity and overweight
Diabetes mellitus, three-quarters of people with diabetes die of
some form of heart or blood vessel disease
Cardiovascular Diseas
Coronary Heart Disease (CHD)
Due to accumulation of artheromatous plaques within
the walls of the coronary arteries that supply the heat
with oxygen and nutrients.
As the degree of CHD progresses there may be
complete obstruction of the lumen leading to:
1. Angina
2. Heart attack
Cardiovascular Diseas
Formation of Artheromatous plaques
There is participation of inflammation in all stages of
artherosclorosis.
normal homeostatic functions of the endothelium are
altered, promoting an inflammatory response
molecules expressed by inflamed endothelium (vascular
cell adhesion molecule-1 VCAM-1) recruit leukocytes,
including monocytes
Once adherent to the endothelium, the leukocytes
penetrate into the intima
Cardiovascular Diseas
Formation of Artheromatous plaques
Once resident in the arterial wall, the blood-derived
inflammatory cells participate in and perpetuate a local
inflammatory response
Macrophages express scavenger receptors for modified
lipoproteins, permitting them to ingest lipid and become
foam cell
T cells likewise encounter signals that cause them to
elaborate inflammatory cytokines such as -interferon and
lymphotoxin (tumor necrosis factor [TNF]–ß) that in turn
can stimulate macrophages as well as vascular endothelial
cells.
Cardiovascular Diseas
Formation of Artheromatous
plaques
Angina
Severe chest pain due to ischemia (a lack of
blood, hence a lack of oxygen supply) of the
heart muscles
Classifications:
A. Stable
B. Unstable angina
Angina
Stable
Typical presentations of stable angina is that of
chest discomfort and associated symptoms
precipitated by some activity (running,
walking, etc.) with minimal or non-existent
symptoms at rest.
Angina
Unstable
It has at least one of these three features:
it occurs at rest (or with minimal exertion),
usually lasting >10 min;
it is severe and of new onset (i.e., within the
prior 4–6 weeks); and/or
it occurs with a crescendo pattern (i.e.,
distinctly more severe, prolonged, or frequent
than previously).
Angina
Treatment Planing Modificaitons
A. Stable: Any dental treatment may be
provided.
Prevention of problems:
[Link] reduction meassures
a. Morning apt
2. Limit quantity of vasoconstrictor
3. Have nitroglycerin available
Angina
Treatment Planing Modificaitons
A. Unstable: Dental treatment should be limited
to that which is absolutely necessary (infection,
Pain)
Prevention of problems:
1. Obtain consultation with physician
2. IV sedation
3. Pulse oximeter
4. Prophylactic nitroglycerin
Angina
Incidence of Angina Pectoris* by Age and Sex.
P er 1,000 P erso n Y ears
12
10.1 10.5
10
7.6
8
5.6 5.3
6 5.0
4.0 4.2
4 3.1
2 0.9
0
45-54 55-64 65-74 75-84 85-94
Age
Men Women
(FHS: 1980-2002/2003). Source: NHLBI. *
AP uncomplicated based on physicians interview of patient.
Note: Rate for women age 45-54 considered unreliable
Heart Attack/MI
The interruption of blood supply to part of the
heart, causing heart cells to die
symptoms :chest pain (typically radiating to
the left arm or left side of the lower jaw
neck),shortness of breath, nausea, vomiting,
palpitations, sweating and anxiety (often
described as a sense of impending doom)
Classification:
A. Transmural
B. Subencocardial
Heart Attack/MI
Transmural
associated with atherosclerosis involving major
coronary artery
subclassified into anterior, posterior, or
inferior.
extend through the whole thickness of the
heart muscle and are usually a result of
complete occlusion of the area's blood supply
Heart Attack/MI
Subencocardial
small area in the subendocardial wall of the left
ventricle, ventricular septum, or papillary
muscles
result of locally decreased blood supply,
possibly from a narrowing of the coronary
arteries.
Heart Attack/MI
Treatment Planing Modificaitons
A. Recent MI < 1 month dental treatment should
be limited to that which is absolutely necessary
(infection, Pain)
Prevention of problems:
1. Obtain consultation with physician
2. IV sedation
3. Pulse oximeter
4. Prophylactic nitroglycerin
Heart Attack/MI
Incidence of Myocardial Infarction* by
Age, Race and Sex.
Per 1,000 Perso n Years
12
10.3
10 9.2
8 5.1 7.2
6.1 6.2
6
2.4 4.3
3.5
4 3.0
1.8
2 0.9 1.2 1.0
0.3 0.7
0
35-44 45-54 55-64 65-74
White Men Black Men White Women Black Women
(ARIC Surveillance: 1987-2004). Source: NHLBI.
* MI diagnosed by expert committee based on review of hospital records.
Hypertension
Chronic medical condition in which the
systemic arterial blood pressure is elevated
Classifications:
A. Primary (essential), high blood pressure for
which no medical cause can be found 90–95%
of cases
B. Secondary, caused by other conditions that
affect the kidneys, arteries, heart, or endocrine
system 5–10% of cases
Hypertension
Classifications:
BP Classification SBP mm Hg DBP mm Hg
Normal <120 and <80
Prehypertension 120–139 or 80–89
Stage 1 140–159 or 90–99
hypertension
Stage 2 160 or 100
hypertension
Hypertension
Treatment Planning
Modifications
A. For BP ≥180/110 delay dental care and refer
to physician
Prevention of problems:
1. Reduced stress and anxiety
2. Judicious use of vasopressor
Prevalence of high blood pressure in
Adults age 20 and older, by age and sex
90
77.3
80 70.8
65.4 64.6
Percent of Population
70
60 53.2 54.1
50 38.8 38.4
40
30 24.4
16.2
20 12.2
6.6
10
0
20-34 35-44 45-54 55-64 65-74 75+
Men Women
(NHANES: 2003-2006). Source: NCHS and NHLBI.
Cardiomyopathy
a weakening of the heart muscle or a change in
heart muscle structure. It is often associated
with inadequate heart pumping or other heart
function problems
Two most common types:
A. Dilated
B. Hypertrophic
Cardiomyopathy
Dilated, the heart becomes weakened and
enlarged. It cannot pump blood efficiently.
Cardiomyopathy
Hypertrophic the heart muscle becomes thick, its
harder for blood to leave the heart, forcing the
heart to work harder to pump blood. Hereditary
Congestive Heart Failure
A condition in which the heart can no longer
pump enough blood to the rest of the body
Classifications:
A. Systolic heart failure, heart muscle cannot
pump, or eject, the blood out of the heart very
well
B. Diastolic heart failure, heart's pumping
chamber does not fill up with blood
Congestive Heart Failure
Stages
First stage, ventricular dysfunction with the
development of a gallop rhythm
Second stage, congestive failure with dyspnea,
pulmonary congestion, and peripheral edema
Third stage, (compensated heart failure)
control of the clinical symptoms of CHF by
medical therapy.
Congestive Heart Failure
Functional classification that grades the severity
of CHF
Class 1, No limitation of physical activity
Class 2, Slight limitations (fatigue, palpitations,
dyspnea) with ordinary physical activity but
are comfortable at rest
Congestive Heart Failure
Functional classification that grades the severity
of CHF
Class 3, Mark limitations but comfortable at
rest
Class 4, Symptoms present at rest and physical
exertion exacerbates the symptoms
Congestive Heart Failure
Treatment Planning
Modifications
Class 1 & 2 can receive routine outpatient
dental care
Some Class 3 can receive routine outpatient
dental care with consultation with PCP
Class 3 and 4 are best treated in special care
facility such as a hospital
Prevalence of heart failure by age
and sex
16
14.7
14 12.8
Percent of Population
12
10 9.1
8
6 4.9
4 1.9 1.4
2 0.3 0.2
0
20-39 40-59 60-79 80+
Men Women
(NHANES: 2003-2006). Source: NCHS and NHLBI.
Inflammatory Heart Disease
Inflammation of the heart muscles because of an
infection from a bacteria or virus or from an internal
peculiarity.
Classifications:
A. Myocarditis, inflammation that occurs within the heart
muscle
B. Pericarditis, inflammation that occurs within fluid sac
that envelopes the heart
C. Endocarditis, inflammation that occurs within inner
lining of the heart mostly in the heart valves
Inflammatory Heart Disease
Inflammation of the heart muscles because of an
infection from a bacteria or virus or from an internal
peculiarity.
Classifications:
A. Myocarditis, inflammation that occurs within the heart
muscle
B. Pericarditis, inflammation that occurs within fluid sac
that envelopes the heart
C. Endocarditis, inflammation that occurs within inner
lining of the heart mostly in the heart valves
Inflammatory Heart Disease
Patients at risk of infective
endocarditis
Prosthetic cardiac valve or prosthetic material
used for cardiac valve repair
Previous endocarditis
Congenital heart disease for these conditions:
– Unrepaired cyanotic congenital heart
disease, including palliative shunts and conduits
Inflammatory Heart Disease
Patients at risk of infective
endocarditis
Completely repaired congenital heart defect with prosthetic
material or device, whether placed by surgery or by catheter
intervention, during the first six months after the procedure
Repaired congenital heart disease with residual defects
(persisting leaks or abnormal flow) at the site or adjacent to
the site of a prosthetic patch or prosthetic device (which
inhibit endothelialization)
Cardiac transplantation recipients who develop cardiac
valve abnormalities
Inflammatory Heart Disease
Dental procedures which
require prophylaxis
All dental procedures that involve manipulation of
gingival tissue or the periapical region of teeth, or
perforation of the oral mucosa
Inflammatory Heart Disease
Antibiotic prophylaxis is NOT
recommended for the following
dental procedures or events:
routine anesthetic injections through noninfected tissue
Taking dental radiographs
Placement of removable prosthodontic or orthodontic
appliances
Adjustment of orthodontic appliances
Shedding of deciduous teeth
Bleeding from trauma to the lips or oral mucosa.
Inflammatory Heart Disease
Antibiotic Prophylactic Regimens
