Pharmacotherapy in Patients With Heart Disease
Heart disease is the leading killer of both men and women, so assessment of current cardiac status and risk factors for heart disease are essential during the health history review.
QUESTION: I will be starting a new position in a private practice composed mostly of older adults. Many of my patients are taking angiotensin-converting enzyme (ACE) inhibitors, diuretics, beta blockers, calcium channel blockers, and vasodilators. How will this affect my provision of care?
ANSWER: Heart disease is the leading killer of both men and women, so assessment of current cardiac status and risk factors for heart disease are essential during the health history review. You should assess the patient’s American Society of Anesthesiologists (ASA) status, as patients with an ASA of III or IV have frequent co-morbidities and higher risks associated with treatment.1For example, the safe cardiac dose of epinephrine (0.04 mg) should be used as the limit for patients with heart disease who are ASA III or higher.2
Approximately 75 million American adults (one in every three adults) have hypertension, and of those affected, only half have their hypertension under control. Another one out of three adults has prehypertension.3 Be sure to ask your patients about how their blood pressure readings have trended over the past 3 months. Blood pressure is often elevated at the start of the dental appointment due to anxiety and possibly pain. If it is elevated, take a repeat blood pressure reading after waiting 5 minutes and reassess the patient’s status. Many patients self-monitor their blood pressure on a regular basis and can provide insights as to where your reading is in relation to their own history. Additional information may be requested from the cardiologist prior to initiating treatment.
Compliance is frequently poor with antihypertensive medications due to their side effects, which may include postural hypotension, increasing the risk of fall, fatigue, and sexual dysfunction. Some calcium channel blockers are associated with gingival hyperplasia, which may worsen in the presence of poor oral hygiene. Lisinopril, a popular ACE inhibitor, is among the top 10 most commonly prescribed drugs in the US and may cause a persistent dry cough. Affected patients may present with demineralization from excessive use of cough drops or syrups, which do not resolve the cough. ACE inhibitors are associated with risk for angioedema. Clinicians should remember that angioedema may be a side effect of medication use, and patients who present for evaluation of sudden onset of swollen lips, face, tongue, or airway should be managed with an antihistamine (diphenhydramine) and then referred for immediate medical attention. Diuretics, such as hydrochlorothiazide (HCTZ) or furosemide (a loop diuretic), will cause chronic dry mouth, increasing risk for bacterial (caries, gingivitis/periodontitis), fungal and viral infections. Salivary replacement agents increase comfort and function, and risk reduction agents—such as therapeutic mouthrinses and dentifrices, xylitol, and fluoride—are especially helpful for this population.
Patients with hypertension are at risk for chronic kidney damage, myocardial infarction, and stroke. Use of nonsteroidal anti-inflammatory analgesics, such as ibuprofen, have recently received a “black box warning” from the US Food and Drug Administration regarding risk for promoting new or worsening hypertension, myocardial infarction, stroke, and exacerbation of congestive heart failure and thus, these analgesics should be avoided in at-risk patients.4
Dental hygienists play an important role in helping patients to reduce their risk factors, by promoting healthy behaviors through nutritional counseling, smoking cessation education, and encouraging patients to lose weight and increase exercise habits. Patients should be encouraged to have good oral hygiene to reduce both oral and systemic inflammation.
References
- American Society of Anesthesiologists. ASA Physical Status Classification System. Available at: asahq.org/resources/clinical-information/asa-physicalstatus-classification-system. Accessed September 26, 2017.
- Malamed SF. Handbook of Local Anesthesia. 6th ed. St. Louis: Elsevier;2013:44.
- Merai R, Siegel C, Rakotz M, et al. CDC Grand rounds: a public health approach to detect and control hypertension. MMWR Morb Mortal Wkly Rep. 2016;65:1261–1264.
- United States Food and Drug Administration (FDA). FDA Strengthens Warning That Non-Aspirin Nonsteroidal nti-Inflammatory Drugs (Nsaids) Can Cause Heart Attacks or Strokes. Available at: fda.gov/ Drugs/ DrugSafety/ ucm451800.htm. Accessed September 26, 2017.
From Dimensions of Dental Hygiene. October 2017;15(10):68.
