2.1 Clinical Cardiology Flashcards by Narmeen Abunijmeh

what blood vessel supplies the anterior wall and septum of the heart?

left anterior descending artery

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what blood vessel supplies the lateral wall of the heart?

left circumflex artery

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what blood vessel supplies the inferior wall and right ventricle?

right coronary artery

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Atherosclerosis–>Coronary artery disease

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coronary artery disease doesn’t clinically become obvious until a patients presents with:

angina

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what is the cause of an acute myocardial infarction?

rupture of arterial plaque resulting in thrombosis

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myocardial infarction caused chest pain:

angina

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where in the oral cavity can a myocardial infarction present with pain?

jaw

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patients that only experience exertional/stable angina most likely have what issue?

fixed coronary lesion

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patients that experience acute coronary syndromes most likely have what issue?

rupture of arterial plaque resulting in thrombosis

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what are 5 risk factors for coronary artery disease?

Age (M>45, F>55)
Hypertension
Hyperlipidemia
Tobacco abuse
Family History (M<55, F<65)
Diabetes

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4 step Management of patient with acute chest pain:

1.Stop the procedure

2.Give sublingual nitroglycerin

3.Give aspirin

4.Transfer to Emergency Department/Call EMS

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two types of cardiac stents:

bare metal stent
drug eluting stent

(DAPT=Dual antiplatelet therapy)

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Your 50 year old patient returns to your clinic to have tooth extracted. He received a drug eluting stent for his myocardial infarction two months ago. He is now taking aspirin and clopidogrel. You, the dentist, assess and realize that he still needs a tooth extraction. Which of the following options are appropriate and safe for the patient?
A.Stop aspirin
B.Stop clopidogrel (Plavix)
C.Stop both aspirin and clopidogrel
D.Postpone tooth extraction
E.Extract the tooth without interruption of anti-platelet therapy and use local measures to control bleeding

Postpone tooth extraction
Extract the tooth without interruption of anti-platelet therapy and use local measures to control bleeding

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for a typical patient taking anti-coagulant drugs, what should you do about their medications vs your need to control bleeding?

No need to discontinue medication; use local measures to control bleeding

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for patients taking anti-coagulant drugs that have a high risk of bleeding, what should you do about their medications vs your need to control bleeding?

Any suggested modification to the medication regimen prior to dental surgery should be done in consultation with and on advice of the patient’s physician

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How many uninterrupted months should patients go on dual antiplatelet therapy (aspirin AND clopidogrel)** that have Bare-metal stents?**

1 month

Talk to cardiologist of the patient before stopping any drugs related to the stents, if you stop it then could result in heart attack

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How many uninterrupted months should patients go on dual antiplatelet therapy (aspirin AND clopidogrel) that have Drug-Eluting stents?

12 months

Talk to cardiologist of the patient before stopping any drugsrelatedto the stents, if you stop it then could result in heart attack

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patients with vascular stents may also be taking:

dual antiplatelet therapy

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*Abnormality of heart muscle function
*can result in abnormal contraction, abnormal relaxation, or both

this is called:

cardiopathies

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cardiomyopathies clinically manifests as :

congestive heart failure

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two types of cardiomyopathies:

Ischemic cardiomyopathy
Non-ischemic cardiomyopathy

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what causes ischemic cardiomyopathy?

coronary disease

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what causes non-ischemic cardiomyopathy?

-HTN
-Valve disease
-Genetics
-Viral infection
-Arrythmia
-Alcohol
-Infiltrative disease
-Chemotherapy

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should patients in decompensated heart failure undergo (nonemergent) procedures?

no, quickly evaluated and treated

this occurs when there are problems with the conduction system of the heart:

arrythmias

HR > 100 beats per minute: HR < 60 beats per minute: | how do we read an EKG? (see image)

**tachycardia bradycardia**

if you count the large boxed in between the R-R intervals to estimate heart rate, what is the value of each large box (in order)?

300, 150, 100, 75, 60, 50, 40

P wave denotes: QRS complex denotes: T wave denotes:

P wave denotes:**atrial depolarization** QRS complex denotes: **ventricular depolarization and atrial repolarization** T wave denotes: **ventricular repolarization

What is a normal sinus ryhythm?

- The features of normal sinus rhythm is that each** P is followed by one QRS** -The** atrium contracts and then the ventricle contracts** This is the simplest rhythm which happens to be normal.

Name the conduction pathology on an ECG: *** Lack of P waves** (due to no organized electrical signal originating from the sinus node causing many random depolarizations occurring in the atria) * **Irregularity of R waves** (irregularly irregular) | what is the biggest concern with this pathology?

atrial fibrillation | Biggest concern is **stroke** – causes a quarter of all strokes

this conduction pathology presents on the ECG with: -saw-tooth shaped P-waves - electrical signal spins around atria

Atrial Flutter

this conduction pathology presents on the ECG with: - p wave occurs after QRS complex - space between QRS complete is narrow - causes rapid heart beating | what is it caused by?

narrow complex tachycardia | Caused by re-entry of a wave around the AV node

how wide should the QRS complex be?

3 small boxes

1. when there is a** narrow QRS complex,** where is the arrhythmia coming from? 2. when there is a wide QRS complex, where is the arrhythmia coming from?

- narrow: atria - wide: ventricles

-Wide QRS -Each QRS complex occurs over a long span of time -Could represent an arrythmia called ventricular tachycardia (fatal) - Wide QRS is a fatal problem

Wide Complex Tachycardia = suspect Ventricular Tachycardia (Vtach)

what type of arrhythmias can cause sudden death?

wide complex tachycardia

56 year old female with a mechanical mitral valve presents with "bad gingivitis." She has a procedure with you scheduled for next week that will involve tissue removal. She also wants you to do a "thorough cleaning".* She is on Coumadin and her INR today is 3.5 Her peri-procedure management includes....

- Call her medical providers - Review her INR target - & collaborate on a peri-procedural plan

74 year old gentleman sees you for a dental procedure that requires electrocautery. He had a ventricular tachycardia cardiac arrest 5 years ago during a heart attack, for which he has an ICD (implantable cardioverter defibrillator). Does he need endocarditis prophylaxis prior to dental work?

what disables an Implantable Cardioverter Defibrillator? (IDC)

magnets

do magnets deactivate pacemakers?

Can electrocautery alter the ICD programing?

yes

What are cardiovascular defibrillators? | does a pt still need antibiotics prior to dental work within a 6 months

-*Monitors heart rhythm and shocks the heart back into a normal rhythm if it detects an irregular arrhythmia - Within 6 months of implantation the need for antibiotics goes away –*** no need for endocarditis prophylaxis prior to dental work*** - Some dental chairs have magnets on them that can affect the function of a pacemaker or defibrillator** – these patients can't sit in these chairs **

the first heart sound indicates: the 2nd heart sound indicates:

Systole Diastole

**turbulent blood flow usually from a stenotic or regurgitant valve**

cardiac murmur

what can be used as a helpful in evaluation, as distinguishing between an innocent murmur and a pathological murmur

echocardiogram (ECG)

what are the different types of prosthetic valves? | are there medications to fix valve problems?

mechanical & bioprothestic it's a mechanical problem

Valve disease is, by and large, a __________ problem

it's a mechanical problem

What are the pros and cons of a mechanical valve?

**Pro**: Last longer (15 years+) **Con**: Requires lifelong anticoagulation

What are the pros and cons of a bioprosthetic valve?

**Pro**: Do not need lifelong anticoagulation. **Con**: Does not last as long

what is the INR goal is for all mechanical valves: | INR: international normalised ratio (INR) blood test

2.5 to 3.5

INR goal of (__________ )is allowed in patients with a bi-leaflet or Medtronic Hall mechanical aortic valve if the patient has no history of stroke, atrial fibrillation, left ventricular dysfunction or hypercoagulable state.

2.0-3.0

**what categorizes a patients as low-risk?**

Low: bi-leaflet aortic valve AND no history of stroke, atrial fibrillation, left ventricular dysfunction or hypercoagulable state

what categorizes a patients as high-risk?

***Mitral or tricuspid valve *Multiple valves** *Older valves *Previous clot event *Left ventricular dysfunction *Atrial fibrillation *Hypercoagulable state

warfarin considerations for low risk patients:

Warfarin should be withheld 48 to 72 hours before the procedure to allow the INR to fall below 1.5. - Warfrin restarted 24 hours after procedure - heprin is NOT necessary

what is the highest risk factor for infective endocarditis?

have preexisting structural abnormalities

what bacteria is the most common cause of infective endocarditis?

Strep viridans

clinical manifestations of infective endocarditis?

*Fever (most common) *Anorexia, malaise, weight loss, night sweats (in subacute cases) *Murmur *Heart failure Conduction abnormalities

what are the major criteria for diagnosing infective endocarditis?

- Persistently positive blood cultures with a typical micro-organism - Evidence of endocardial involvement - Echocardiographic evidence of vegetation - New murmur consistent with valvular regurgitation

what are the minor criteria for diagnosing infective endocarditis?

*Fever *Single positive blood culture *Predisposing condition (IV drug use, cardiac abnormality) *Embolic event (embolic stroke, pulmonary infarcts, renal infacts, conjuctival hemorrhages, Janeway lesions) *Immunologic phenomenon

Indications for Antibiotic prophylaxis (AP): reasons to give patients antibiotic prophylaxis

*Prosthetic valve or material *Previous endocarditis *Congenital HD -Some types; cyanotic *Cardiac transplant with valvulopathy

What to do with Warfrin/Coumadin before procedure for high & low risk patients

see image

ADA: Anti-Coagulant and –Platelet Management and Dental Procedures for typical patients and patients with high risk of bleeding?

Concluding points

Take home points questions: 1. what is a symptoms of myocardial infarction? 2. for patients who recently received coronary stents, should you interrupt asprin & antiplatlets agents? 3. "Heart failure" is a complex spectrum of what? 4. Recognize & treat "wide complex tachycardia" and "sinus arrest" (not a question-just a statement) 5. if electrocautery will be used, what should you consider?

Take home points questions conti: 6. should you interrupt anticoagulation in patients with high risk mechanical valves? 7. even though most patients do not need endocarditis prophlaxis, what must you know/consider? 8. When in doubt, who should you ask?

**when in doubt, always ask cardiology aka husband <3**