Does a patient with a history of Hypertension (HTN), Hyperlipidemia (HLD), poorly controlled Type 2 Diabetes Mellitus (DM), Coronary Artery Disease (CAD) with Coronary Artery Bypass Grafting (CABG) and a Permanent Pacemaker (PPM) require antibiotic prophylaxis for dental procedures?

Antibiotic Prophylaxis Not Required for This Patient

This patient with CABG and a pacemaker does NOT require antibiotic prophylaxis for dental procedures including cleaning, filling, crown, bridge, extraction, root canal, or local anesthetic administration. 1

Why Prophylaxis Is Not Indicated

This patient lacks the specific high-risk cardiac conditions that warrant antibiotic prophylaxis according to the 2021 ACC/AHA guidelines and 2007 AHA guidelines (reaffirmed 2015). 1

High-Risk Conditions Requiring Prophylaxis (Patient Does NOT Have These):

• Prosthetic cardiac valves (including transcatheter-implanted prostheses like TAVR) 1, 2
• Prosthetic material used for cardiac valve repair (annuloplasty rings, chords, clips) 1
• Previous infective endocarditis 1
• Unrepaired cyanotic congenital heart disease or repaired CHD with residual shunts/regurgitation 1
• Cardiac transplant with valve regurgitation 1

What This Patient Has (NOT Indications for Prophylaxis):

• Coronary artery bypass grafting (CABG) - NOT an indication 1
• Permanent pacemaker - NOT an indication 1
• Hypertension, hyperlipidemia, diabetes - NOT indications 1
• Peripheral arterial disease - NOT an indication 1

Evidence Supporting This Recommendation

The 2021 ACC/AHA guidelines provide a Class 2a recommendation (reasonable) for antibiotic prophylaxis ONLY in the five specific high-risk conditions listed above. 1 The guidelines explicitly state that prophylaxis is reasonable for "the subset of patients at highest risk of developing IE and at high risk of experiencing adverse outcomes from IE." 1

Critical distinction: CABG involves coronary arteries and does not create prosthetic valvular material or alter cardiac valve structure. 1 The saphenous vein grafts (SVG) and left internal mammary artery (LIMA) used in this patient's bypass surgery are not cardiac valves or valve repair materials. 1

The 2007 AHA guidelines (endorsed by IDSA in 2015) emphasize that "IE is more likely to result from daily activities" and that "maintaining optimal oral health for daily activities is more important than antibiotic prophylaxis for a dental procedure to reduce IE risk." 1

The Pacemaker Question

Pacemakers and implantable cardiac devices are NOT indications for endocarditis prophylaxis. 1 The concern about device infection relates to the generator pocket and leads, not to endocarditis risk from transient bacteremia during dental procedures. 1

Strength of Evidence and Guideline Evolution

A 2022 Cochrane systematic review concluded there is "no clear evidence about whether antibiotic prophylaxis is effective or ineffective against bacterial endocarditis" in at-risk patients undergoing dental procedures. 3 However, a 2022 case-crossover study in JACC found that in truly high-risk patients (those meeting AHA criteria), antibiotic prophylaxis was associated with reduced IE incidence (OR: 0.49). 4

The key is that this benefit only applies to the specific high-risk cardiac conditions defined in guidelines, which this patient does not have. 1, 4

Practical Implications

For dental procedures involving manipulation of gingival tissue, periapical region, or oral mucosa perforation (which includes extractions, root canals, and deep cleanings), prophylaxis would be: 1

• Amoxicillin 2g orally, 30-60 minutes before procedure (if prophylaxis were indicated, which it is NOT for this patient) 1, 2
• Alternatives for penicillin allergy: Cephalexin 2g orally, OR clindamycin 600mg orally, OR azithromycin 500mg orally 1, 2

Common Pitfall to Avoid

Do not confuse coronary artery disease/CABG with valvular heart disease. 1 Many practitioners incorrectly assume that any cardiac surgery history warrants prophylaxis. The guidelines are explicit that only prosthetic valves, valve repair materials, and the other four specific high-risk conditions require prophylaxis. 1

Emphasis on Oral Hygiene

Instead of antibiotics, this patient should focus on maintaining excellent oral hygiene and regular dental care to minimize daily bacteremia from routine activities like brushing and flossing, which pose greater cumulative IE risk than isolated dental procedures. 1