DR.ABDULELAH MOBEIREK FRCP(C)

History  History of CAD, CHF, RHD, VHD, Hypertension  Symptoms: chest pain, dyspnea, edema,syncope  Any change in symptoms  Medications : warfarin, aspirin  Treating Physician, last visit  Allergy: Penicillin

Infective Endocarditis  Infection of the endothelial lining of the heart  May involve : valves,arteries,ventricles,chordae, annulus

Pathogenesis Hemodynamic Factors  A high velocity jet  Flow from high to a low pressure chamber  A narrow orifice separating two chambers creating a pressure gradient

 Jet lesion  Sterile vegetation's (NBTE)  Transient bacteremia  Infected vegetation's Pathogenesis

Predisposing conditions  Acquired valvular disease:  Rheumatic  Degenerative  MVP  Prosthetic Valves / Shunts  Hypertrophic Cardiomyopathy

Predisposing conditions  Congenital  Bicuspid aortic valve  VSD, PDA, primum and venosus ASD  Coarctation of aorta  Tetralogy of Fallot  Isolated secundum ASD ;not associated with IE

Dental Procedures & IE  Oral cavity is One of the portals of entry of organisms in IE  Chewing, brushing teeth or oral irrigation produces positive cultures in up to 50%  Dental procedures : %  The frequency of bacteremia is related to degree of gingivitis and degree of trauma

Dental Procedures & IE  Most cases of IE of oral origin are not caused by dental procedures, but rather by poor oral health and hygiene  PT with cardiac lesions should be encouraged to maintain a high level of oral health

Prevention  No RCT have established the efficacy of prophylaxis  Most episodes of IE occur unrelated to a prior procedure  Prophylaxis likely prevents only a small fraction of IE

Clinical Studies of IE Prophylaxis For Dental Procedures Why is it difficult to do large randomized placebo controlled trials? 1)the low incidence of IE, which requires a large number of patients (2) the wide variation in the types and severity of underlying cardiac conditions (3) the large variety of invasive dental procedures and dental disease states, which would be difficult to standardize for control groups. dental disease states, which would be difficult to standardize for control groups.

Risk of IE resulting from a dental Procedure  The number of cases of IE that results from a dental procedure is exceedingly small.  Therefore, the number of cases that could be prevented by antibiotic prophylaxis, even if 100 percent effective, is similarly small.

Determining Risk  Identification of PTS at risk (cardiac condition)  knowing which procedure require prophylaxis

AHA Guidelines Circulation published online Apr 19, 2007;

Conclusions —The major changes in the updated recommendations include the following: (1) The Committee concluded that only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100% effective. (2) Infective endocarditis prophylaxis for dental procedures should be recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. (3) For patients with these underlying cardiac conditions, prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.

Conclusions-2 (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis. (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are These changes are intended to define more clearly when infective endocarditis prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations. (Circulation. 2007;115:&NA;-.) intended to define more clearly when infective endocarditis prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations. (Circulation. 2007;115:&NA;-.)

Recent Advances  Transesophageal Echocardiography  Improvement in diagnostic criteria  Improvement in surgical techniques  Use of outpatient antibiotic regimens in uncomplicated penicillin-sensitive streptococcal endocarditis

Conclusion  IE has considerable mortality and morbidity  Recognize patient at risk  Know what type of procedure require prophylaxis  Educate patient on the importance of prophylaxis