Has anyone heard of this??

[Dee]

Hi everybody,

Just got back from my one year post op echo and appt. with cardio. The good news, the valve looks great as does the rest of the heart. Yea!!!! The bad news, is I need to see a plastic surgeon (preferably a burn specialist) to fix the bottom part of my scar that has never healed right.

Okay, here's the real reason for this post....My cardio told me that there is now a new set of "rules" as far as pre-treatment before dental procedures. He said this changed a couple of months ago and should be followed by everyone with a heart valve. Instead of taking oral antibiotics, you must now have IV antibiotics, one to two hours before. What????? I haven't heard anyone on here talking about this. Has anyone else heard of this??? I just called my dentist and they don't have the capability to do IV injections in their office, so then what do you do??? I have a call into my cardio to ask him this same question, but it sounds like he's out of the office until Friday. What a pain in the *** this will be if I have to go somewhere else to get started on the IV before I can even go to the dentist and I'm one of those that has to go every 4-6 months.

I'm very curious to see if anyone else has been told this yet???

 

[Ross]

Someone is blowing smoke up your tail pipe!

 

[tommy]

Dee,

It's news to me.

 

[tobagotwo]

Endocarditis

Endocarditis

Sounds like your cardio has been sippin' the IVs.

Here is some endocarditis info gleaned from http://www.emedicine.com/emerg/topic164.htm :

- Throughout the developed world, the infection rate ranges to 4.2 cases per 100,000 people per year (about .0042%, if I didn't bobble my zeroes). Considering the number of folks on the site who have had it, I suspect our group has a generally higher risk than that, though.

- "More than 50% of these infections occur within 2 months after surgery."

- "Sex: The male-to-female ratio is approximately 2:1."

In other words, more than a couple months past your ARV or MVR or PVR or TVR, your chances of getting endocarditis go back to being highly minute. The predental antibiotics are also only supposed to be used for invasive work, such as scalings, root canals, and extractions, not for "everyday" dental work. An IV would be ludicrous, especially since there is no study and no evidence that shows that predental antibiotics are effective at preventing endocarditis at all!


YES, ROSS, I DID VOTE. DID EVERYONE ELSE?

 

[Karlynn]

Interesting. It wasn't too long ago we had a discussion on whether pre-medicating really did what it was supposed to do. Sounds like they're assuming that IV medication is in your system much faster. But even taking an oral medication, I would have to believe that it is running through your system by the time work is begun and any germs are working their way in.

 

[geebee]

Dee,
News to me too. I have been going to the dentist every 3 months for a number of years and still take oral antibiotics. I have never had any problems even with numerous root canals and crowns.
I also had surgery (in 1995, about a year after my last OHS) to remove infected tissue from my scar area. I had a plastic surgeon do the procedure and he found a lot more infection than he expected (even wrapped around my abdominal muscles) and I ended up with a more extensive operation than anticipated. Not trying to scare you but letting you know what COULD happen in case you want to make any "time off" preparations.
I did receive IV antibiotics for this procedure because he had an IV hooked up for the happy juice and it was just easier to do IV than to have anything in my stomach. I am sure it depends on the procedure you are having. I did take oral Keflex for a week following the surgery.
The plastic surgeon also ordered a compression vest for me to wear after surgery (like the kind used for burn victims). It helped keep the scar less "puffy".
Good luck and smiles,
Gina

 

[tobagotwo]

OK. More on Endocarditis Recommendations...

OK. More on Endocarditis Recommendations...

The amount of antibiotics and guidelines for requiring it have lessened, not increased. Here are some of the reasons why, taken from the American Heart Association: http://www.americanheart.org/presenter.jhtml?identifier=1729

"Conclusions Major changes in the updated recommendations include the following: (1) emphasis that most cases of endocarditis are not attributable to an invasive procedure; (2) cardiac conditions are stratified into high-, moderate-, and negligible-risk categories based on potential outcome if endocarditis develops; (3) procedures that may cause bacteremia and for which prophylaxis is recommended are more clearly specified; (4) an algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse; (5) for oral or dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended, erythromycin is no longer recommended for penicillin-allergic individuals, but clindamycin and other alternatives are offered; and (6) for gastrointestinal or genitourinary procedures, the prophylactic regimens have been simplified. These changes were instituted to more clearly define when prophylaxis is or is not recommended, improve practitioner and patient compliance, reduce cost and potential gastrointestinal adverse effects, and approach more uniform worldwide recommendations.

"Endocarditis is a life-threatening disease, although it is relatively uncommon. Substantial morbidity and mortality result from this infection, despite improvements in outcome due to advances in antimicrobial therapy and enhanced ability to diagnose and treat complications. Primary prevention of endocarditis whenever possible is therefore very important."

Bolding of the print for emphasis is mine. The link above will get you to the entire article.

Here's a very similar article from the American Academy of Family Physicians: http://www.aafp.org/afp/980201ap/taubert.html

More specifically, in relation to which dental procedures, here is an excerpt from the American Heart Association that has the seal of approval from the American Dental Association. This one is a good one to read and print for yourself: http://www.americanheart.org/presenter.jhtml?identifier=11086

"Dental procedures for which endocarditis prophylaxis is recommended
· Dental extractions
· Periodontal procedures including surgery, scaling, and root planing, probing, and recall maintenance
· Endodontic (root canal) instrumentation or surgery only beyond the apex
· Subgingival placement of antibiotic fibers or strips
· Initial placement of orthodontic bands but not brackets
· Intraligamentary local anesthetic injections
· Prophylactic cleaning of teeth or implants where bleeding is anticipated"

As you can see, most dentists insist that we take prophylactic antibiotics for a much wider range of dental services than either the ADA or the AHA recommends.

Moreover, if you want to know what scientists found when they attempted to do a real study of dental work in relation to endocarditis, look over this eye-opener: http://www.personalmd.com/news/a1998111607.shtml

You will probably want to continue to follow the AHA/ADA guidelines regardless, just for the common sense of it, but it does give you something to think about.

I am thinking that on this particular topic, yer cardio is full of donkey dust...

Best wishes,

 

[Dee]

I'm soooooo confused!!! I was thinking the same thing, that they were lessening it instead of increasing it. The cardio said that this just gives them more assurance that we're protected. He had a pamphlet explaining the dosses and everything.

Thanks Bob, for all of the info!! I'm at the office right now and haven't had much time to really look at what you sent, but I really appreciate your time looking into it, so when I get home I'm going to read more. I just don't know what to think. How do I argue with my cardio about something like this?? I'm not a very aggressive person and tend to sit back and let them tell me how it is and I listen and very rarely question it. I guess one way would be to print off these facts that you've gathered and show him. Any other ideas??

When I get home, I'll scan the paper he gave me that explains what I need to do to pre-medicate. Thanks again for the info!!!

AND YES, I DID VOTE (ACTUALLY LAST WEEK)!!!!!!!

 

[tobagotwo]

Oh yeah? Well, I VOTED TWICE!

er...uh...I mean...um...never mind...

Dee,

My best, non-expert advice would be to print the current AHA/ADA recommendations from the page I indicated and give that to him. There are no "newer" guidelines extant in any of the cardiological literature that I could locate, nor new suggestions, nor articles proposing them. And the recommendation certainly has not been changed, as these links are fresh from the AHA site.

Regardless, unless I had some obscure reason to be at tremendous personal risk, I would simply have my GP or dentist prescribe the normal, recommended antibiotics.

If your cardio is okay about other things, I guess he can be a kook about this. However, he would have to come up with a much better reason for his very unusual recommendation than he has so far, before it would make sense to follow it blindly.

Best wishes,

 

[Harpoon]

You know, for some people it would be EXTREMELY impractical for such a requirement to be in place UNLESS there was a capability of doing it at the dentist office.


Ok, my dentist office is at point A, the nearest hospital that I could get an IV line set up at would be at point B

Point A and point B are 90 minutes away from each other.


What do I do?

Oh yeah, and it takes anywhere from 15 minutes to well over 3 hours for IV medications to be fully delivered into your system. Sure, you get a faster result, but not until after everything's been given.

I used to get IV Lasix while in the hospital after my valve replacement. It took 20 minutes for the dose to be administered. Almost as soon as I was disconnected from the IV I had to PEE and there wasn't anything getting in my way. Now it takes me less than a minute to take my lasix (two pills) but it's usually about an hour before I feel the urge come on....



MAYBE if you needed urgent dental work just after surgery, like within the first few weeks or so, but beyond that I seriously doubt such a recommendation has been made, or could be floowed by most patients who use prophylaxis before seeing their dentist.

 

[Ross]

Another great disinformation campaigne by some crackhead cardio.

 

[Dee]

Okay, so I called the Cardio's office and talked to the nurse about how I'm supposed to go about getting an IV if my dentist doesn't do them. She informed me that I would have to go to CCU at our hospital a couple of hours before my appt.!! You've got to be kidding me!!! This is insane!!! (The Cardio was gone for the day and won't be back until Friday).

I was so blown away by all of this I decided to really look over the pre-med instructions that he had given me. (I tried to scan it so I could post it on here, but it wouldn't scan well enough to read it.) So, I'll type it out and notice the Title at the top.......I think my Cardio might be taken something in an IV himself, like Bob said.
______________________________________________
Prophylactic Regimens for Genitourinary/Gastrointestinal Procedures (Hint Hint......notice it says nothing about Dental procedures)

High-risk patients:
(because I'm allergic to Amoxicillin, I would have to do the following drugs)
Vancomycin 1.0g; IV over a 1-2 hours plus gentamicin 1.5 mg IV. Complete injection within 30 minutes before starting procedure.
___________________________________________________

My other pre-med instruction sheet says Dental Procedures right on it. I think he got this update and assumed it was about dental work and didn't even bother to see that it said Gastrointestinal procedures, which I can understand needing an IV antibiotic for.

I feel funny about questioning him about this, but I am definitely going too. I think he's a little confused which worries me a bit He's the only cardio within 100 miles and has only been here for one year exact (I was his first patient here). He's been at some big hospitals before he came here and is an associate with a group of Cardio's in Grand Jct. (100 mi). I really like him as a person, but I'm a little uneasy about some of the decisions he's made. He's also the one that put me in the hospital for 3 days for a sinus infection when I was 3 mths post op. I thought that was a little odd too.

I'm going to print out the info that Bob got for me on the American Heart Assoc. web site and show him that if he thinks I'm just blowing smoke. What is up with these Dr.'s anyway???

Thank you guys for all of the info and I'll keep you up to date with what happens from here.

 

[tobagotwo]

You shouldn't feel funny about questioning this. You have the "smoking gun," and can easily see where he misinterpreted things.

Remember, when you question a doctor about an issue such as this, you are not just doing it for yourself, but for all of the other patients who are dealing with the same issues.

It's only a matter of time before the CCU people at the hospital and the insurance investigators tell him to cut it out anyway. Help people noy have to go through this, especially those who will now avoid dental work because of this bacl call on his part.

Best wishes,

 

[Dee]

Since my cardio is out of town until Friday, I called the group that he's with, which is in a different town, to ask them what they thought. The girl I talked to had never heard of such a thing and thinks too, that he is confused about it being only for Gastrointestinal procedures and not dental.

So, I called and left a message on my cardio's voice mail and explained my concern and what I thought might be some confusion. We'll see on Friday what he says. I'm sure he'll be embarassed once he realizes that he was wrong (or I'm assuming he's wrong). We're all human and we all make mistakes....it's just a little harder to take from your cardiologist who is the one responsible for your heart!!

I'll let you know when I finally hear back from him.

 

[Ross]

I do not see how there can be any confusion if his a learned professional. That is scary!

 

[karenm]

Dee,
Thanks for taking the bravery and time to follow-up on this. If it had been me, I would have just started to cry and never ever gone to the dentist again as I am so very terrifed of getting an IV. Yes everyone, I KNOW that I need regular dental care, and in one week when I have my PVR I will get an IV and then some ... but I would NEVER get an IV at the dentist. EVER.
~Karen

 

[John & Joann]

Sorry that we must take a different position. Cleveland Clinic has required IV prior to dental procedures for Joann. She is HIGH risk and they do not want any chances of infection.

Now the interesting part! The IV was covered by our insurance. Medicare entered the picture in 03. IV was administered in hospital, denied by Medicare since it was dental related. Appeal to Medicare. Denied again.

Cardiologist said that we should go to the drug store and get injection. Medication was not covered by insurance (Prescription plan does not cover injection). Paid for the injection and delivered to cardiologist office. Injection caused HUGE swelling on the hips.

After further investigation, if the physican pays for the drug and it is delivered to his office, medicare will cover the injection.

Joann has dental appointment next month. No idea what she will do but Cleveland Clinic still recommends IV for High Risk. $425 still outstanding since hospital feels that they are partly responsible. Had a pacemaker check the same day that was also denied. Won the appeal for that small portion of the bill.

Medical issue, insurance issues, and bureaucrats!!!!!

 

[Bryan B]

I believe Paul Nourie said his cardio was requiring he get IM antibiotic injections in the rear end before his dental work as well. I hope this doesn't become the standard. I think it would cause more "at risk" patients to put off regular dental work due to the hassle of going to the cardio before going to the dentist as well as the added cost, which may lead to more people at risk of infection.

 

[Dee]

FALSE ALARM EVERYBODY!!!

Guess who I got a call from first thing this morning???? You got it, my cardio!! He was soooo embarassed to say the least!!! He said thank goodness I read the headline at the top and figured out that the IV pre med was not for dental work, but for more invasive procedures, somewhere along the way he got confused. Oooooops!!!

Whew.....I was really glad to hear that too, because getting an IV before dental work would be a royal pain in the rear!!!! He said to just keep doing the oral antibiotics before dental work.

He was good hearted about it and really felt bad that he misinformed me and was able to laugh about it a little too.

Sorry if I had you all worried.....but I think we all knew it must have been a mistake. I sure feel better now!!!

 

[Les]

Getting an IV before dental work would be a royal pain in the rear!!!!

Dental schools must not teach where IV's are normally administered!