This document discusses several cardiovascular drugs used to treat conditions like congestive heart failure, arrhythmias, angina, hypertension, and hyperlipidemia. It provides information on the mechanisms and side effects of common drugs in each class, including digoxin, antiarrhythmics, nitroglycerin, ACE inhibitors, statins, warfarin, and Plavix. It emphasizes the importance of dental practitioners understanding a patient's cardiovascular medications due to potential drug interactions and bleeding risks during procedures.

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Cardiovascular Drugs
Maghan Das
Generic BscN Sem IV
Pharmacology
Ma’m: ShabanaMaghan Das

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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.
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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.
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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).
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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
 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.
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Antiarrhythmic Agents
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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
 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.
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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.
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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.
 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 side-
effect profiles.
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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.
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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.
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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.
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Anticoagulant Drugs
 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.
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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.
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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.
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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.
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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.
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References
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Sue Ruhoy Ilene; Daughton Christian G (2008). "Beyond
the medicine cabinet: An analysis of where and why
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1169. doi:10.1016/j.envint.2008.05.002.
Maghan Das

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Maghan Das

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Maghan Das