6.1 Cardiovascular Disease

Hypertension

Hypertension is persistently raised arterial blood pressure. NICE defines stage 1 hypertension as clinic BP >= 140/90 mmHg and stage 2 as >= 160/100 mmHg. Most patients are asymptomatic and diagnosed opportunistically, but severe hypertension (>= 180/120 mmHg) warrants urgent medical review.

Dental relevance

• Uncontrolled hypertension increases the risk of intraoperative bleeding, syncope, and cardiovascular events.
• Check BP at the assessment visit for known hypertensives; if BP is >= 180/110 mmHg, defer non-urgent treatment and refer back to the GP.
• Postural hypotension is a common side effect of antihypertensives (especially ACE inhibitors, alpha-blockers, and diuretics). Raise the chair back slowly at the end of the appointment and allow the patient to sit upright for a minute before standing.
• Epinephrine in dental local anaesthetic can transiently raise BP; keep doses low (e.g. up to 2 cartridges of 2% lidocaine with 1:80,000 epinephrine in a stable adult) and always aspirate.

Ischaemic Heart Disease, Angina and Myocardial Infarction

Ischaemic heart disease (IHD) results from reduced coronary perfusion, most often atherosclerosis. Angina is exertional chest discomfort relieved by rest or glyceryl trinitrate (GTN); myocardial infarction (MI) is prolonged ischaemia causing myocardial necrosis.

Dental treatment timing after MI

• For urgent care within the delay window, contact the cardiologist. Treatment in hospital may be appropriate.
• Patients may carry GTN spray; ensure it is to hand at every appointment. If angina occurs during treatment, stop, allow the patient to use GTN sublingually, give oxygen, and reassess.
• Persistent chest pain, pain at rest, or pain not relieved by GTN within 5 minutes is a medical emergency: call 999.

Heart Failure and Arrhythmias

Heart failure is impaired ventricular filling or ejection. Look for breathlessness, orthopnoea, ankle oedema, and basal crackles. Patients with severe heart failure tolerate the supine chair position poorly; treat semi-upright and keep appointments short.

Arrhythmias include atrial fibrillation (AF), the most common sustained arrhythmia. AF is relevant dentally because it is frequently managed with anticoagulants (see Section 5.4). A regular narrow-complex tachycardia in the chair is usually anxiety-driven; settle the patient first.

Valvular and Congenital Heart Disease

Valvular disease (e.g. rheumatic mitral valve disease, bicuspid aortic valve, prosthetic valves) and congenital lesions (e.g. unrepaired cyanotic heart disease, previous infective endocarditis) place patients in the group historically considered 'at risk' of infective endocarditis (IE).

UK infective endocarditis prophylaxis guidance

NICE Clinical Guideline 64 (CG64), published in March 2008, amended in 2016 and amended again in October 2024, states:

'Antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures.'

Key points for the MFDS candidate:

• The guidance applies to all patients at risk of IE, including those with prosthetic valves and previous IE.
• Chlorhexidine mouthwash is not recommended as IE prophylaxis (recommendation 1.1.4).
• Antibiotic prophylaxis is indicated if there is a local infection at the surgical site (e.g. drainage of an abscess) — treat the infection on its own merits.
• In October 2024 NICE amended recommendation 1.1.3 to link directly to the SDCEP implementation advice Antibiotic Prophylaxis Against Infective Endocarditis (2nd edition). NICE did not change its recommendation, but the SDCEP advice identifies a small group of 'special consideration' patients with high-risk cardiac conditions — including a prosthetic valve or prosthetic material used for valve repair, previous infective endocarditis, and specified congenital heart disease — for whom antibiotic prophylaxis before invasive dental procedures should be discussed and considered through shared decision-making, ideally with the cardiology team. Prophylaxis is not recommended for moderate-risk cardiac conditions, and no prophylaxis is indicated for non-invasive treatment such as a routine scale and polish.
• If a patient at risk of IE develops a fever or systemic symptoms after dental treatment, advise urgent medical review — IE presents non-specifically and early diagnosis matters.

Pacemakers and Implanted Defibrillators

Pacemakers and implantable cardioverter defibrillators (ICDs) are not a contraindication to conventional dental local anaesthesia. Modern pacemakers are shielded from the small electrical signals used in dentistry. Avoid:

• Surgical diathermy near the device (can cause reprogramming or inhibition); if needed, use bipolar and consult the cardiologist.
• Ultrasonic scalers directly over the generator box — use manual scaling or position the scaler away from the device.

Stress Reduction and General Measures

Cardiac symptoms are often precipitated by anxiety. Use a calm environment, short morning appointments, effective pain control, and stress reduction protocol:

1. Confirm medication taken and BP on the day.
2. Use adequate local anaesthesia; consider sedation for very anxious patients (after medical assessment).
3. Break long procedures into shorter visits.
4. Have GTN, oxygen, and a protocol for chest pain ready.
5. Position semi-upright for heart failure; supine is acceptable for most stable patients.