AHA Guidelines on dental prophylaxis

[sgv]

First off, sorry about posting this in allopathic.

I just need some help understanding the AHA guideline on dental prophylaxis for infective endocarditis. It says prophy is indicated for unrepaired cyanotic congenital heart disease. What exactly is unrepaired cyanotic heart disease? I thought cyanosis was pretty serious and would present in infants. Can infants with this survive onto adulthood and have unrepaired cyanotic heart disease? Also, I read online that heart murmurs can be caused by cyanotic congential heart disease. When I mention that my patient has a heart murmur to my attending, he says prophy is not indicated but my patient says his "grandmother had a hole in her heart" which makes me concerned about what exactly caused his murmur. But right now, I'm assuming he's alright considering he is asymptomatic and does not take any med's.

Any help would be nice so that when I call the physician, he/she won't figure out I'm an idiot.

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[pd1112]

Cyanotic CHD that presents in infants as a congenital R->L shunt usually is repaired surgically at a young age. Unprepared CHD that becomes cyanotic later in life is Eisenmenger syndrome, when a L->R shunt causes higher pulmonary pressures which eventually reverses the shunt. Many of these patients are managed medically instead of surgically, so there's your unrepaired cyanotic CHD.

The murmurs that don't require Abx prophylaxis are bicuspid aortic valve, HCM & acquired aortic/mitral valve defects with murmurs. Just having a murmur doesn't = prophylaxis.

 

[BigRedBeta]

First off, sorry about posting this in allopathic.

I just need some help understanding the AHA guideline on dental prophylaxis for infective endocarditis. It says prophy is indicated for unrepaired cyanotic congenital heart disease. What exactly is unrepaired cyanotic heart disease? I thought cyanosis was pretty serious and would present in infants. Can infants with this survive onto adulthood and have unrepaired cyanotic heart disease? Also, I read online that heart murmurs can be caused by cyanotic congential heart disease. When I mention that my patient has a heart murmur to my attending, he says prophy is not indicated but my patient says his "grandmother had a hole in her heart" which makes me concerned about what exactly caused his murmur. But right now, I'm assuming he's alright considering he is asymptomatic and does not take any med's.

Any help would be nice so that when I call the physician, he/she won't figure out I'm an idiot.

1) yes, you'd notice cyanosis. That's a pretty serious finding in an adult.

2) You'd be amazed how well kids do that have cyanotic lesions with sats in the low 70's. It's exceedingly rare that they survive into adulthood without some sort of intervention, but there could be the rare case where, for various reasons they can't have a complete repair and have a relative degree of hypoxia (sats in the low to mid 80's). You would know that these patients needed prophylaxis by the time they reached the adult clinics. Congenital lesions that go through a single ventricle repair (tricuspid atresia, hypoplastic left heart, double inlet left ventricle, some very specific types of Double Outlet Right Ventricle), would be the most likely forms as they go through a staged palliation (Norwood procedure -> Glenn -> Fontan). Along the way there may be reasons why they weren't candidates to get a Fontan procedure and "only" have a Glenn, but again, you'd have that history well in hand.

I suppose that a mild Tetralogy of Fallot could possibly escape detection in the right set of circumstances as the cyanosis would only manifest itself during Tet spells, but that'd be quite the surprise.

I did see an extremely dark skinned infant present with Transposition of the Great Arteries at 8 months of age. Everyone was extremely shocked but despite sats in the 50's you really couldn't tell she was cyanotic. She was actually surprisingly large for an 8 month old too, and a very happy baby. But because of her advanced age, her post surgical course was much more complicated than is typical for patients that get that repair done as neonates.

3) Important fact to know, cyanosis is only visible when there is about 4.5-5g/dl of deoxygenated hemoglobin in the blood. If your patient has a Hgb of 7, even with an O2 sat of 50%, they'll not be cyanotic. If their Hgb is 4, they'll be pink even with a sat of 5%. So the lesson is that you shouldn't put too much stock in absence of cyanosis as a clinical finding.

 

[Psai]

1) yes, you'd notice cyanosis. That's a pretty serious finding in an adult.

2) You'd be amazed how well kids do that have cyanotic lesions with sats in the low 70's. It's exceedingly rare that they survive into adulthood without some sort of intervention, but there could be the rare case where, for various reasons they can't have a complete repair and have a relative degree of hypoxia (sats in the low to mid 80's). You would know that these patients needed prophylaxis by the time they reached the adult clinics. Congenital lesions that go through a single ventricle repair (tricuspid atresia, hypoplastic left heart, double inlet left ventricle, some very specific types of Double Outlet Right Ventricle), would be the most likely forms as they go through a staged palliation (Norwood procedure -> Glenn -> Fontan). Along the way there may be reasons why they weren't candidates to get a Fontan procedure and "only" have a Glenn, but again, you'd have that history well in hand.

I suppose that a mild Tetralogy of Fallot could possibly escape detection in the right set of circumstances as the cyanosis would only manifest itself during Tet spells, but that'd be quite the surprise.

I did see an extremely dark skinned infant present with Transposition of the Great Arteries at 8 months of age. Everyone was extremely shocked but despite sats in the 50's you really couldn't tell she was cyanotic. She was actually surprisingly large for an 8 month old too, and a very happy baby. But because of her advanced age, her post surgical course was much more complicated than is typical for patients that get that repair done as neonates.

3) Important fact to know, cyanosis is only visible when there is about 4.5-5g/dl of deoxygenated hemoglobin in the blood. If your patient has a Hgb of 7, even with an O2 sat of 50%, they'll not be cyanotic. If their Hgb is 4, they'll be pink even with a sat of 5%. So the lesson is that you shouldn't put too much stock in absence of cyanosis as a clinical finding.

I dunno man, I'm not a doc but 5% sounds low

 

[genericpremedstudent]

Cyanotic CHD that presents in infants as a congenital R->L shunt usually is repaired surgically at a young age. Unprepared CHD that becomes cyanotic later in life is Eisenmenger syndrome, when a L->R shunt causes higher pulmonary pressures which eventually reverses the shunt. Many of these patients are managed medically instead of surgically, so there's your unrepaired cyanotic CHD.

The murmurs that don't require Abx prophylaxis are bicuspid aortic valve, HCM & acquired aortic/mitral valve defects with murmurs. Just having a murmur doesn't = prophylaxis.

a little out of my league seeing as i am pre-med, but i just thought i'd mention i have a bicuspid aortic valve and every doctor i've seen has required abx prophylaxis.

 

[pd1112]

a little out of my league seeing as i am pre-med, but i just thought i'd mention i have a bicuspid aortic valve and every doctor i've seen has required abx prophylaxis.

Guidelines are just that - guidelines. Particularly with updated ones (IE prophylaxis updates were in 2007), you will see many physicians don't follow them, I would assume mostly because they don't stay current with the literature and/or haven't fully committed to EBM.

 

[CubsFan314]

A lot more people used to be recommended to get prophylaxis, but then it turned out that for most underlying reasons, prophylaxis was not effective or ended up causing too many adverse events.

 

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