Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 15 Cardiovascular Drugs

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Cardiac Glycosides  Dental Implications of Cardiovascular Disease  Cardiovascular Contraindications to Dental Treatment  Acute or recent myocardial infarction (within the preceding 3 to 6 months) Unstable or the recent onset of angina pectoris Unstable or the recent onset of angina pectoris Uncontrolled congestive heart failure Uncontrolled congestive heart failure Uncontrolled arrhythmias Uncontrolled arrhythmias Significant, uncontrolled hypertension Significant, uncontrolled hypertension 2

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Cardiac Glycosides  Congestive Heart Failure (CHF)  Several different drugs are available to treat CHF.  The most common drug used to treat CHF is digoxin.  Digoxin increases the force and strength of contraction of the failing heart.  Adverse reactions are many and include GI, arrhythmias, neurologic, and increased salivation. 3

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Cardiac Glycosides  Congestive Heart Failure  Digoxin in combination with epinephrine can cause increased sympathetic activity.  Local anesthetics with a vasoconstrictor should be used with caution in people with CHF. 4

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Cardiac Glycosides  Managing Dental Patients Taking Digoxin  Watch for overdose side effects such as nausea, vision changes, and copious salivation.  Use epinephrine with caution to minimize arrhythmias.  Monitor pulse to check for bradycardia.  Tetracycline and erythromycin can increase digoxin levels (in ~10% of patients). 5

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Cardiac Glycosides  Congestive Heart Failure  Other Drugs used to Treat CHF Angiotensin-converting enzyme inhibitors Angiotensin-converting enzyme inhibitors Angiotensin receptor blockers Angiotensin receptor blockers Β-adrenergic blockers Β-adrenergic blockers Vasodilators Vasodilators Diuretics Diuretics Aldosterone antagonists Aldosterone antagonists 6

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antiarrhythmic Agents  Antiarrhythmic Agents  Arrhythmias are loosely defined as abnormal heart beats.  Antiarrhythmic agents are placed into one of four groups (I-IV).  The specific actions of these drugs are complicated.  Antiarrhythmics can change the slope of depolarization, raise the threshold for depolarization, and alter the velocity in different parts of the heart.  Antiarrhythmics have narrow therapeutic indexes and are difficult to manage. 7

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antiarrhythmic Agents 8

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antianginal Drugs  Angina pain can be caused by stress.  Some patients find dental appointments to be stressful and these appointments can precipitate an angina attack.  Angina occurs when the coronary arteries cannot meet the oxygen demand placed on the heart.  The basic pharmacology of antianginal drugs is to reduce the workload of the heart by decreasing cardiac output, peripheral vascular resistance or both. 9

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antianginal Drugs  Nitroglycerin is a vasodilator drug that is used to prevent and treat acute attacks and as long-term therapy.  Sublingual nitroglycerin is used to treat or prevent acute attacks.  Adverse reactions include severe headache, flushing, hypotension, lightheadedness, and syncope.  Sublingual nitroglycerin can produce a localized burning or tingling in the mouth. 10

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antianginal Drugs  Nitroglycerin should not be administered if the patient has taken a phosphodiesterase 5 inhibitor drug such as Viagra.  The combination can cause dangerously low blood pressure.  Nitroglycerin needs to be stored in its original, amber-colored container away from light and moisture. 11

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antianginal Drugs  Calcium channel blockers, β-adrenergic blockers, and ranolazine are used for long- term treatment of angina.  These drugs cannot treat an acute attack.  They cannot be used as prophylaxis.  These drugs have a longer onset of action and duration of action than sublingual nitroglycerin. 12

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antianginal Drugs  Dental Implications of an Acute Angina Attack  Make sure that the patient has his or her sublingual nitroglycerin prior to starting dental treatment.  Place the sublingual nitroglycerin on the treatment tray.  If nitroglycerin must be administered make sure that the patient has not used a PDE5 inhibitor within the past 24 hours.  If the patient has taken a PDE5 inhibitor call 911.  If the patient has not taken a PDE5 inhibitor then have the patient place a sublingual nitroglycerin under the tongue.  A second tablet can be given in 5 minutes, followed by a third tablet in another 5 minutes if necessary.  If the patient does not respond call 911. The patient should be taken to an emergency room. 13

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antihypertensive Agents  Hypertension  Almost 50 million Americans have hypertension.  Most all of these people see a dental health practitioner on a regular basis.  It is important to check their blood pressure and pulse at each visit.  Uncontrolled hypertension is a contraindication to vasoconstrictor therapy. 14

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antihypertensive Agents  Antihypertensive Agents  There are many different hypertensive drugs available.  The 5 most commonly used groups are the diuretics, β-blockers, calcium channel blockers, angiotensin converting enzyme inhibitors, and angiotensin receptor blockers.  The choice of antihypertensive is dependent upon the patient’s blood pressure and any compelling indications.  The different groups of antihypertensive drugs have very distinct mechanisms of action. 15

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antihypertensive Agents  Antihypertensive Agents  These agents can work in the kidneys, on alpha or beta receptors, calcium receptors and within the angiotensin system.  Most antihypertensive drugs share adverse effects.  Each group has an adverse effect profile unique to them. 16

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antihypertensive Agents Diuretics Diuretics  Most diuretics can cause hyperglycemia, hyperlipidemia, hypercalcemia, anorexia, and hyperuricemia, hypokalemia, and hyponatremia.  Potassium-sparing diuretics can cause hyperkalemia. β-Adrenergic Blockers β-Adrenergic Blockers  Adverse effects include bronchospasm, sedation, reflex tachycardia, depression, masking the symptoms of hypoglycemia, and increased serum triglycerides. 17

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antihypertensive Agents Calcium Channel Blockers Calcium Channel Blockers  Calcium channel blockers can cause hypotension, dizziness, and lightheadedness.  They can also cause nausea, vomiting, and constipation.  Several calcium channel blockers can cause a reflex tachycardia.  Diltiazem and verapamil can cause bradycardia.  Calcium channel blockers can cause gingival enlargement as well as an altered sense of taste. 18

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antihypertensive Agents Angiotensin Converting Enzyme (ACE) Inhibitors Angiotensin Converting Enzyme (ACE) Inhibitors  ACE inhibitors can cause hyperkalemia, dry hacking cough, angioedema, rash, and hypotension.  Same people complain of GI upset.  ACE Inhibitors can cause an altered sense of taste. 19

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antihypertensive Agents  Angiotensin Receptor Blockers  Adverse effects are similar to ACE inhibitors.  α-Adrenergic Blockers  This drugs can cause significant “first-dose” orthostatic hypotension.  Other adverse effects include drowsiness, excitation, headache, tachycardia, and dizziness. 20

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antihypertensive Agents  Several older antihypertensive drugs are used in patients whose blood pressure cannot be controlled with the other drugs.  These drugs include clonidine, guanethidine, reserpine, methyldopa, guanabenz and hydralazine.  These drugs cause significant dry mouth, sedation, depression, orthostatic hypotension, and tachycardia. 21

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Managing Adverse Effects that Impact on Oral Health Care  Xerostomia can be minimized by having the patient suck on tart sugarless gum or candy and by drinking plenty of water.  Meticulous home oral hygiene and frequent recall appointments can help minimize or prevent the gingival enlargement associated with calcium channel blockers. 22

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Managing Adverse Effects that Impact on Oral Health Care  Raise the dental treatment chair slowly and keep the patient seated for a few minutes before allowing the patient to stand up.  This well help prevent orthostatic hypotension.  If the patient complains of GI adverse effects avoid analgesics or other drugs that have similar GI adverse effects.  Avoid sedating drugs, such as opioids and antianxiety drugs, if the patient experiences sedation with his or her antihypertensive drugs. 23

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Managing Adverse Effects that Impact on Oral Health Care  Check the patient’s blood pressure and pulse before each appointment.  Elevated blood pressure or pulse rate may prevent the use of vasoconstrictors.  Opioid analgesics can exacerbate constipation. Check to see if the patient complains of constipation as a result of the antihypertensive drugs. 24

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antihyperlipidemic Drugs It is not necessarily the drugs that are used to treat elevated cholesterol levels that are of particular concern to a dental health practitioner. It is not necessarily the drugs that are used to treat elevated cholesterol levels that are of particular concern to a dental health practitioner.  Elevated cholesterol levels are as much of a concern as the drugs used to treat them.  More often than not, people with elevated cholesterol levels have comorbid hypertension and diabetes.  All three of these disease states have a significant impact on heart health. 25

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antihyperlipidemic Drugs  If a patient is taking a drug to lower cholesterol levels, the dental health practitioner should immediately check the person’s blood pressure and pulse rate.  Antihyperlipidemic drugs affect cholesterol, triglycerides, VLDL, LDL, and HDL levels to varying degrees.  Antihyperlipidemic drugs work by several different mechanisms of action.  HMG Co-A reductase inhibitors inhibit HMG Co-A reductase, which is the rate-limiting enzyme in cholesterol synthesis.  HMG Co-A reductase inhibitors have very tolerable side- effect profiles. 26

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antihyperlipidemic Drugs  Ezetimibe is the newest drug available to lower cholesterol.  It works by inhibiting the intestinal absorption of cholesterol.  It is used alone or in combination with an HMG Co-A reductase inhibitor.  Niacin is a B vitamin that lowers cholesterol.  It can cause vasodilation and hypotension. 27

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Antihyperlipidemic Drugs  Bile-acid binding drugs prevent the absorption of cholesterol from the GI tract.  Adverse reactions include a bad taste, abdominal bloating, gas, and constipation.  Gemfibrozil is another agent used to lower cholesterol.  It causes fewer GI complaints than bile- acid binding drugs. 28

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Anticoagulants  Anticoagulant drugs interfere with coagulation and effect bleeding times.  This is of particular concern to the dental health practitioner.  Persons taking anticoagulant drugs can bleed for longer periods of time even as a result from planing and scaling during a simple oral hygiene visit. 29

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Anticoagulant Drugs  The risk for bleeding is increased depending on the dental procedure  The risk for bleeding is increased depending on the dental procedure.  NSAIDs and aspirin can cause bleeding, and their use should be avoided in patients taking anticoagulant drugs.  Warfarin is the oldest oral anticoagulant drug.  It is a narrow therapeutic index drug whose blood levels must be carefully monitored.  Dose is dependent upon PT and INR times. 30

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Anticoagulants  Patients taking warfarin require special attention.  Always assess for any signs of bleeding.  Obtain prothrombin time (PT) or international normalized ratio (INR) and history to establish bleeding potential.  For PT or INR greater than 2 times normal, request reduction in dose.  Latent time to onset and recovery allows several days for a change in effect if the dose of warfarin changed. 31

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Anticoagulants  Check with physician regarding resuming dose.  Avoid aspirin and aspirin-containing compounds.  Acetaminophen and opioids are OK.  Oral hygiene with subgingival calculus removal can produce bleeding (oozing); use local pressure.  Determine underlying disease of patient.  May have atrial fibrillation.  Patient should be free of infection before scaling/root planning. 32

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Anticoagulants  Clopidogrel and Ticlopidine are two newer agents used for their anticoagulant effects.  They are used to prevent additional heart attacks or strokes.  Both can cause significant bleeding.  Clopidogrel can cause thrombotic thrombocytopenia purpura (TTP). This can occur within 2 weeks of beginning therapy.  Ticlopidine increases bleeding after trauma or surgery. 33

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Anticoagulants  NSAIDs should not be given to people taking clopidogrel or ticlopidine.  Aspirin is often given in combination with clopidogrel to treat acute coronary syndrome.  Patients taking either one of these drugs should be carefully managed by their dental health practitioner. 34