Chapter 15
Cardiovascular Drugs
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Cardiac Glycosides
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Dental Implications of Cardiovascular Disease
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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
• Uncontrolled congestive heart failure
• Uncontrolled arrhythmias
• Significant, uncontrolled hypertension
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Cardiac Glycosides
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Congestive Heart Failure (CHF)
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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.
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Cardiac Glycosides

Congestive Heart Failure
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Digoxin in combination with epinephrine can
cause increased sympathetic activity.
Local anesthetics with a vasoconstrictor should
be used with caution in people with CHF.
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Cardiac Glycosides
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Managing Dental Patients Taking Digoxin
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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).
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Cardiac Glycosides

Congestive Heart Failure

Other Drugs used to Treat CHF
• Angiotensin-converting enzyme inhibitors
• Angiotensin receptor blockers
• Β-adrenergic blockers
• Vasodilators
• Diuretics
• Aldosterone antagonists
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Antiarrhythmic Agents
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Antiarrhythmic Agents
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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.
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Antiarrhythmic Agents
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Antianginal Drugs
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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.
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Antianginal Drugs
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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.
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Antianginal Drugs
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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.
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Antianginal Drugs
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Calcium channel blockers, β-adrenergic
blockers, and ranolazine are used for longterm 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.
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Antianginal Drugs
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Dental Implications of an Acute Angina
Attack
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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.
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Antihypertensive Agents
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Hypertension
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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.
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Antihypertensive Agents

Antihypertensive Agents
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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.
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Antihypertensive Agents
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Antihypertensive Agents
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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.
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Antihypertensive Agents
• Diuretics
Most diuretics can cause hyperglycemia,
hyperlipidemia, hypercalcemia, anorexia, and
hyperuricemia, hypokalemia, and
hyponatremia.
Potassium-sparing diuretics can cause
hyperkalemia.
• β-Adrenergic Blockers
Adverse effects include bronchospasm,
sedation, reflex tachycardia, depression,
masking the symptoms of hypoglycemia, and
increased serum triglycerides.
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Antihypertensive Agents
• 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.
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Antihypertensive Agents
• 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.
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Antihypertensive Agents
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Angiotensin Receptor Blockers
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Adverse effects are similar to ACE inhibitors.
α-Adrenergic Blockers
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This drugs can cause significant “first-dose”
orthostatic hypotension.
Other adverse effects include drowsiness,
excitation, headache, tachycardia, and
dizziness.
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Antihypertensive Agents
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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.
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Managing Adverse Effects that
Impact on Oral Health Care
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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.
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Managing Adverse Effects that
Impact on Oral Health Care
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Raise the dental treatment chair slowly and keep
the patient seated for a few minutes before
allowing the patient to stand up.
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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.
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Managing Adverse Effects that
Impact on Oral Health Care
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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.
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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.
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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.
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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 sideeffect profiles.
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Antihyperlipidemic Drugs
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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.
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Antihyperlipidemic Drugs
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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 bileacid binding drugs.
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Anticoagulants
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Anticoagulant drugs interfere with
coagulation and effect bleeding times.
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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.
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Anticoagulant Drugs
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The risk for bleeding is increased
depending on the dental procedure.
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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.
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Anticoagulants
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Patients taking warfarin require special
attention.
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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.
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Anticoagulants
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Check with physician regarding resuming
dose.
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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.
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Anticoagulants
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Clopidogrel and Ticlopidine are two newer
agents used for their anticoagulant effects.
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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.
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Anticoagulants
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NSAIDs should not be given to people
taking clopidogrel or ticlopidine.
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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.
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