Cardiovascular & Renal Disease

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Cardiovascular andRenal DiseaseFebia KaruniaGroup A 20101006658663

CARDIOVASCULAR DISEASECardiovascular disease (CVD) is the leading cause of mortality in the world, representing over 29% of all global death.The largest proportion of this high mortality is attributed to coronary artery disease (CAD) or coronary heart disease (CHD).

3HYPERTENSIONClassification of Blood Pressure for AdultsClassificationSystolic BP (mmHg)Diastolic BP (mmHg)Normal< 120And< 90Prehypertension120 139Or80 89Stage 1 Hypertension140 159Or90 99Stage 2 Hypertension 160Or 100Hypertension is defined as having systolic blood pressure (SBP) 140 mm Hg or diastolic blood pressure (DBP) 90 mm Hg or as having to use antihypertensive medications.HypertensionSecondaryPrimary95% is unknown causeRenal DisordersEndocrinologic DisturbancesRemaining CausesRenal parenchymal diseaseRenovascular diseaseRenin-producing tumorsPrimary sodium retentionThyroid diseaseAdrenal disordersCarcinoidExogenous hormonesAortic coarctationComplication of pregnancyNeurologic causesAcute stressAlcohol ingestionNicotine useIncreased intravascular volumeUse of drugs (cyclosporine or tacrolimusHypertension usually has a long asymptomatic course the diagnosis is made only after an elevated BP has been recorded on multiple occasionsSymptoms :Early : Elevated blood pressure readings, narrowing and sclerosis of retinal arterioles, headache, dizziness, tinitusAdvanced : Rupture & hemorrhage of retinal arterioles, papillaedema, congestive heart failure, angina pectoris, renal failure, dementia3 main goals of the medical evaluation of patients with hypertension :To identify treatable (secondary) or curable causesTo assess the impact of persistently elevated BP on target organs To estimate the patients overall risk profile for the development of premature CVDEXAMINATIONPhysical ExaminationsLaboratory TestsAdditional TestsPalpation of the peripheral pulsesAuscultation of the abdomenFunduscopic assessmentHemoglobinUrinalysisRoutine blood chemistriesA fasting lipid profile(Total and high-density lipoporotein cholesterol and trigyceridesElectrocardiographyEchocardiographyAmbulatory BP monitoringPlasma renin activity testingRadiographic testingMANAGEMENTLifestyle ModificationsAntihypertensive AgentsWeight reductionAdopt DASH eating planReduction intake of sodium, fats, cholesterol foodsRegular physical activityLimited alcohol intakeDiuretics (thiazide diuretics)-blockersCalcium channel blockersAngiotensin-converting enzyme inhibitors (ACEIs)Angiotensin II receptor blockers (ARBs)Direct vasodilators

ORAL HEALTH CONSIDERATIONSOral health care providers also need to be aware of medications that:May have sistemic side effects that are of importance to the provision of careInteract with medications used during dental careCause intraoral changes

No oral complications are due to hypertension itself. Adverse effects such as dry mouth, taste changes, and oral lesions may be drug-related

Blood Pressure MeasurementIn The Dental SettingCORONARY ARTERY DISEASEAtherosclerosis is the most common cause of CAD. The result is plaque formation, with compromise of effective arterial luminal area.The process:

A chronic reduction incoronary blood flow and oxygen supply

Risk factors:Lipids, hypertension, Glucose Intolerance and Diabetes Mellitus, Cigarette Smoking, Lifestyle and Dietary Factors, Exercise, Obesity, Vitamins and Homocysteine, Plasma Fibrinogen, Antioxidants, Endothelial DysfunctionFatty streak Plaques ThromboticChest tightness, jaw discomfort, left arm pain, dyspnea, epigastric diseaseECG, Coronary angiography, Myocardial perfusion imaging, Stress echocardiographySymptomsDiagnostic TestingPatient with a small ishcemic burden, normal exercise tolerance, and normal LV function : pharmacologic therapy (Aspirin, b-blockers, ACEIs, HMG CoA reductase inhibitors)Patient with angina : addition of nitrates and calcium channel blockersPatient with symptoms of chronic ischemia : Percutaneous coronary intervention (PCI) with percutaneous transluminal coronary angioplasty (PTCA) and Intracoronary stentingManagementThe primary concern : prevention ischemia or infarctionIn rare situations, impaired hemostasis due to one or more medications may also require dental modifications.In addition, side effects from cardiac drugs may cause oral changes, and drug interactions with medications used for dental care may occur. The current cardiac status and medications should be discussed with the patients physicians prior to stressful or invasive procedures.Oral Health Considerations

ACUTE CORONARY SYNDROMEThe sudden rupture of an atherosclerotic plaque, with ensuing intracoronary thrombus formation that acutely reduces coronary blood flowDiagnosis : clinical data, ECG, level of serum cardiac enzymesTherapy : the relief of myocardial ischemia and the institution of pharmocologic therapy targetting the underlying thrombotic mechanism(Aspirin, -blockers, nitroglycerin, antithrombotic therapy)

HEART FAILUREThe inability of cardiovascular system to meet the demands (blood supply) of the end-organs (body)ETIOLOGY OF HEART DISEASECoronary artery diseaseInfiltrative disordersHypertensionToxins (chemotheurapetic agents)Idiopathic dilated cardiomyopathyMetabolic disorders (hypothyroidism)Hyperthropic cardiomyopathyValvular heart diseaseAlcoholPericardial diseaseDiabetesIncessant tachyarrythmiaViruses (CV, HIV)High-output statesSymptomsClassic symptoms : dyspnea, orthopnea, paroxysmal nocturnal dyspneaNonspecific complaints : chest discomfort, fatigue, palpitations, , dizziness, syncopePhysical examinationCardiac percussion and palpation, auscultation, chest radiography, ECG, transthoracic echocardiography (TTE), nuclear imaging techniques, cardiac catheterizationSignsRapid, & shallow breathing, inspiratory rales, heart murmur, distended neck veins, large & tender liver, peripheral edema, jaundice

ARRYTHMIAThe most common type : atrial fibrilationEtiology : primary cardiovascular disorders, pulmonary disorders, systemic disorders, drug-related adverse effectsArrhythmiaDisturbance in rhythm, rate, or the conduction pattern of the heartTachyarrhythmiasHeart rate > 100 bpmBradyarrhythmiasHeart rate < 60 bpmSigns:Slow heart rate (< 60 bpm)Fast heart rate (>100 bpm)Irregular rhythmSymptoms:Palpitations, fatigueDizziness, syncope, anginaCongestive heart failure (shortness of breath, orthopnea, peripheral edema)The ECG is the primary tool used in the identification and diagnosis of cardiac arrhythmias.Management:Patients with asymptomatic arrhythmias : no therapyPatient with symptomatic arrhythmias : treated first with medicationsPatients who do not respond to medications : treated by cardioversion, ablation, or implanted pacemaker or ICDPatients with certain arrhythmias : surgery Any tachyarrhythmias that compromise hemodynamics or are life-threatening : Emergency cardioversion

RENAL DISEASEKidney functions:Maintaining a stable internal environment (homeostasis)Regulating the acid-base and fluid-electrolyte balances of the body by filtering bloodSelectively reabsorbing water and electrolytesExcreting urineExcrete metabolic waste products (urea, creatinine, and uric acid)Secreting renin, the active form of vitamin D, and erythropoietin

Nephron is the kidneys functional unit

Nephron destroyedDo not regenerateHypertrophy of the remaining functional unitsDiagnostic procedures:Serum chemistryUrinalysisCreatinin clearance testIntravenous pyelographyRenal ultrasonographyCT-MRIBiopsyThe kidneys lose their normal ability to maintain the normal composition and volume of bodily fluidsACUTE RENAL FAILUREA rapid decline in kidney function over a period of days to weeks, leading to severe azotemia (the building up of nitrogenous waste products in the blood)Most common causes: medications, surgery, pregnancy-related complications, and traumaPatients with ARF usually have normal baseline renal functionThe clinical course of ARF most often progresses through three stages:Oliguria (urine volume 400 mLper day)RecoveryPrerenal FailureCompromises renal function without permanent physical injury to the kidneyResults from reversible changes in renal blood flowThe most common cause of ARFPostrenal FailureCauses of failure are less common (3 months, as defined by structural or functional abnormalities of the kidney with or without a decrease in GFR manifest either by pathologic abnormalities or other markers of kidney damage, including abnormalities in the composition of blood or urine, or abnormalities in imaging testsThe presence of GFR 3 months, with or without other signs of kidney damage.

MEDICAL MANAGEMENTAim : to minimalize uremia complication, monitoring growth disease, maintaining the quality life of patient, decided whether dialysis or transplantation is needed or notAccomplished by dietary modifications including instituting a low-protein diet and limiting fluid, sodium, and potassium intakeA medical procedure that artificially filters bloodInitiate dialysis when the GFR is