4. Medical Emergencies: Cardiovascular Flashcards by J L

Atherosclerosis “ a chronic ____

response in the walls of arteries caused by the formation of multiple ____ ”

inflammatory

plaques

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Clinical Manifestations of Atherosclerosis

NONCARDIAC

Diabetes mellitus
-diabetic ____ and
blindness
-increased ____ rate -poor healing of ____ limbs

Cerebral arteries

____ attack
cerebrovascular ____

retinopathy
infection
lower

transient ischemic
infarction

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Clinical Manifestations of Atherosclerosis

CARDIAC

Coronary artery disease

____ pectoris
____ angina
____ infarction
____ failure
____
____ death (cardiopulmonary arrest)

angina
unstable

myocardial
congestive heart

dysthrythmias

sudden

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Coronary Artery Disease “ the end result of the

accumulation of plaques ____ the walls of the arteries that supply the myocardium with oxygen and nutrients ”

within

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Again, coronary artery disease can manifest as ____ pectoris, or chest pain as we know it. This can be of a ____ variety which occurs only with exertion. So some kind of stressful event like after walking a couple blocks. This can be ____ when it happens at rest. Or if its happening at an increasing frequency – if the patient is having daily episodes of chest pain this would be unstable angina.

There’s also a variant called ____ disease and that’s also a form of angina, which will not be plaque formation in the coronary vessels but will result from ____ of the coronary vessels. So the lumen of those vessels will be diminished. We need those vessels to supply oxygen and nutrients to the heart so patients will manifest with the same kind of symptoms – chest pain – when they have this issue as well. And coronary artery disease can obviously lead to ____ and cardiopulmonary ____.

angina
stable
unstable

prinzmetal
spasm
MI
arrest

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Coronary Artery Disease: Incidence and Prevalence
● Affects approximately 14 million people
in the United States
● ____ cause of death
● Approximately 500,000-700,000 deaths
are caused by coronary artery disease annually in the United States

leading

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If you look at the various age groups – you look at these younger age groups (the 5-14, 15-24, 25-44 age groups) the most common cause of deaths in these patients are ____ deaths as well as ____ being the second most common in the younger age groups (5-14, 15-24).

We do start to see ____ disease creep up in the 25-44 age groups (as the second most common cause of death), more so in the patients over ____ or late 30’s that we see heart disease surpass cancer as the ____ most common cause of death.

accidental
cancer

heart
40
second

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Then we will see in the 45-64 year old group and the older elderly individuals, the 85+, that ____ disease predominates as the ____ killer in these two groups, followed by cancer, and then you see ____ accidents or strokes. So these problems are prevalent. Atherosclerosis manifesting in the brain in the form of CVA and in the heart in the form of coronary heart disease.

heart
leading
cerebrovascular

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Coronary Artery Disease: Risk Factors

Uncontrollable:
● ____
● ____
● ____ history

Controllable:
● Hypertension 
● Smoking 
● Hypercholesterolemia 
● Diabetes 
● Obesity 
● Stress 
● Type A personality 
● Sedentary lifestyle

male
age
family

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Sex
● ____ have a greater incidence of
CAD than females
● Women follow men by ____ years

males

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Age
● Increasing ____ = increasing CAD
● ____ risk factor
● ____ persons experience higher mortality and morbidity rates from CAD

age
strongest
elderly

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Hypertension

“ a consistent state of elevated blood pressure above ____ mm Hg ”

140/90

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Classification of Blood Pressure

HTN: Stage 3
Systolic (mmHg): \_\_\_\_
HTN: Stage 2
Systolic (mmHg): \_\_\_\_
HTN: Stage 1
Systolic (mmHg): \_\_\_\_

Borderline HTN: Systolic (mmHg): ____

Normal: Systolic (mmHg): ____

> 180
160-179
=140-159

135-139

<135

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Classification of Blood Pressure

HTN: Stage 3
Diastolic (mmHg): \_\_\_\_
HTN: Stage 2
Diastolic (mmHg): \_\_\_\_
HTN: Stage 1
Diastolic (mmHg): \_\_\_\_

Borderline HTN: Systolic (mmHg): ____

Normal: Systolic (mmHg): ____

> 110
100-109
90-99

85-89

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Hypertension: Etiology
● Essential (idiopathic) - accounts for
____%; obesity, salt sensitivity, renin homeostasis, insulin resistance, genetics, and age may be contributing factors

● Secondary - result of identifiable process
such as ____, primary aldosteronism, ____ syndrome, oral contraceptives, or renal disease

90-95
pheochromocytoma
cushing’s

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Hypertension: Incidence

● ____% of U.S. population has hypertension

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Hypertension: Clinical Presentation

1st stage:
no ____

2nd stage:
\_\_\_\_ (occipital) 
\_\_\_\_ 
\_\_\_\_ 
\_\_\_\_ 
\_\_\_\_ changes – arteriolar narrowing
\_\_\_\_ changes

3rd stage:
\_\_\_\_, MI 
Accelerated \_\_\_\_ 
CHF, \_\_\_\_ 
Blindness 
Proteinuria, \_\_\_\_ 
CVA

symptoms

headaches
vertigo
flushing
epistaxis
retinal
EKG

angina
atherosclerosis
LVH
ESRD

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Modified Stepped- Care Approach to Hypertension

Step 1. Begin with medically-supervised ____ changes and observation

Step 2. Begin pharmacologic therapy with one
of the following:
- a \_\_\_\_
- an  \_\_\_\_ blocker
- an \_\_\_\_ inhibitor
- an \_\_\_\_ antagonist
- a \_\_\_\_ channel blocker

Step 3. Continue ____ drugs of different pharmacologic class found in step 2.

lifestyle

diuretic
a or b
ACE
angiotensin II receptor
calcium

two

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Dental Management of the Hypertensive Patient: Reduction of Stress and Anxiety
● Establish honest, supportive relationship with
patient
● Discuss patient’s questions, concerns, fears
● Schedule ____ appointments
● Avoid ____ appointments
● Use pre-medication as needed - ____
● Use ____ as needed (avoid hypoxia)
● Provide gradual changes of position to avoid ____
● Avoid stimulating ____ reflex
● ____ patient if he or she appears to be overstressed

morning
long
diazepam
nitrous oxide
postural hypotension
gag
dismiss

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Smoking

● In males, 5 fold greater risk of ____ and a 3 fold greater risk of fatal ____ when compared to non-smokers

CVA

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Cholesterol
● Typical daily internal production is about ____ g and dietary intake is ____ mg
● Primarily synthesized from ____ through the HMG-CoA reductase pathway
● ____ in blood
● Transported in the circulatory system within lipoproteins
● Higher concentrations of ____ and lower concentrations of ____ are strongly associated with cardiovascular disease because these promote atherosclerosis

1
200-300
acetyl CoA
insoluble
LDL
HDL

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Cholesterol: Guidelines
● < ____ mg/dl = normal
● ____ mg/dl = borderline
● > ____ mg/dl = high risk; ____ X increase in
heart disease
● > ____ mg/dl = ____ X increase in heart disease

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Cholesterol: Guidelines
Total Cholesterol < ____ mg/dl
HDL >____ mg/dl
LDL

200
70
100

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Lipid-Lowering Drugs
Bile Acid Sequestrants
____
Colestipol

HMG CoA Reductase Inhibitors 
Atorva\_\_\_\_
Fluvastatin 
Lovastatin 
Simvastatin 
Pravastatin

Fibric Acid Derivatives
____

Miscellaneous drugs and natural compounds 
\_\_\_\_ 
\_\_\_\_ 
\_\_\_\_ (vitamin B3, niacin) 
\_\_\_\_

cholestyramine
statin
gemfibrozil
estrogens
probucol
nicotinic acid
vitamin E

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Diabetes | ● ____ X risk for CAD when ____ is present

2 | diabetes mellitus

``` Obesity Increased risk of: ____ disease Hypertension ____ Type II diabetes mellitus ____ Obstructive sleep apnea ```

coronary artery hypercholesterolemia osteoarthritis

Alcohol ● “Moderate” consumption increases serum levels of ____

HDL

``` Laboratory Tests for Coronary Heart Disease ● ____ blood tests ● ____ lipid profile ● Twelve-lead ____ ● ____ ECG stress test ● ____ ● ____ imaging studies using thallium, sestamibi, or teboroxime ● ____, adenosine or dobutamine nuclear stress test ● ____ angiography ● Increased ____ markers ```

``` routine fasting ECG treadmill echocardiography nuclear persantine MR serum ```

Management of CAD ● ____% reduction in mortality from CAD over the past 3 decades ● Prevention ◆ Control ____ factors ◆ ____ modification ◆ ____ ● Treatment ◆ Medical ◆ Surgical

30 risk lifestyle aspirin

CAD: Treatment ● Medical therapy: ◆ Drugs ◆ Alter risk factors ◆ ____ (PTCA)

percutaneous transluminal coronary angioplasty

``` Drugs Used in the Treatment of Coronary Artery Disease ● ____ ● ____ ● ____-blockers ● ____ channel blockers ● ____ inhibitors ● ____ ```

``` nitroglycerin aspirin B calcium ACE statins ```

Protective Effects of Aspirin Against Acute Myocardial Infarction and Death in Men with Unstable Angina: Results of a Veterans Administration Study Aspirin has a ____ effect against acute ____ in men with unstable angina and a similar effect on mortality ● Double Blind: 1266 men (625 aspirin/641 placebo) ● 324 mg of aspirin in a buffered solution ● 12 week duration ● MI and death 51% lower in aspirin group

protective | myocardial infarction

Percutaneous Transluminal Coronary Angioplasty (PTCA) PTCA. Again this is more considered ____ management. It isn’t actual surgery but basically a catheter is placed in the patient’s groin in the ____ artery and the catheter with wire is gone all the way to the coronary vessels, and you can see a blockage in the left main vessel by the arrow there. And what percutaneous transluminal coronary angioplasty is basically a ____ that is inserted into that vessel and that balloon is inflated, then you can see the reperfusion after that procedure has been done in the angiogram to the right. This is an angiogram you can see the vasculature of the entire heart with this and we can see if there’s any blockages. So if a patient comes into the hospital with chest pain they may perform this this is exactly where the clot is and they can bypass that and get flow of blood that you can see there.

medical femoral balloon

Percutaneous Transluminal Coronary Angioplasty (PTCA) ● 30-40% ____ after conventional angioplasty ● Currently 70-90% of patients have ____ inserted simultaneously

re-stenosis | stents

CAD: Treatment ● Surgical therapy: ◆ ____

coronary artery bypass grafts

Coronary Artery Bypass Graft (CABG) ● 600,000 a year in the U.S. ● ____, internal mammary artery, and radial artery ``` ● Recommended for: ◆ Disease of the ____ coronary artery ◆ Disease of ____ or more vessels ◆ Cases in which non-surgical management hasn't ____ ```

saphenous vein left main three worked

CABG ●  Mortality rate of 1% - 2% ●  ____ incidence at 0.4% - 13% ●  Risk of ____ damage (e.g. memory loss, confusion, dementia) ●  Saphenous vein does only about ____% of the work

stroke brain 10

The relation of risk factors to the development of atherosclerosis in … bypass grafts: 10 Year Study ●  132 grafts ◆  1st year all patent ◆  10 years 50% patent ●  Atherosclerosis is a progressive disease affecting grafts and native vessels ●  Progression may be related to elevated to elevated levels of plasma ____ (VLDL, LDL)

lipoprotein

Angina Pectoris a complex of symptoms highlighted by transient chest pain due to ____

ischemia

``` Angina Pectoris Etiology: ● Coronary ____ ● Coronary embolus ● Coronary artery spasm ● Coronary arteritis ● Reduction in ____ ● Reduction in ____ ``` ● Aortic ____ ● Aortic insufficiency

atherosclerosis BP CO stenosis

Angina Pectoris Chest Pain Characteristics: ____ intensity ____ localized retrosternal pain Radiation of the pain to the ____ arm and shoulder or neck and mandible ____ duration (2-10 minutes) relieved by ____ (noticeably within 2 minutes)

``` moderate poorly left brief nitroglycerin ```

``` Angina Pectoris Associated symptoms: ● ____ ● ____ ● weakness ● ____ ● diaphoresis ● increase in heart rate and ____ ```

nausea salivation pallor BP

``` Angina Pectoris Diagnosis: 1. ____ 2. ____ ● Rest ● Exercise –stress 3. ____ ```

history EKG coronary angiography

Medical Management of the Patient with Angina Pectoris ●  Explanation and reassurance ●  Reduction of risk factors ``` ●  Drug therapy ____ ____ ____ Blockers ____-channel blockers ____ ●  Percutaneous transluminal coronary angioplasty (PTCA) ●  Coronary artery bypass grafting (CABG) ```

``` nitrates aspirin B calcium statins ```

``` Differential Diagnosis of Chest Pain ____ disease Angina Myocardial infarction ____ hernia ____ ____ disease ```

musculoskeletal hiatil gastritis gallbladder

Angina Pectoris Stable Angina Pain on ____, relief with ____ Unstable Angina Pain at Up to 1/month or markedly changing ____ of attacks

exertion rest rest frequency

Mild Angina Frequency of attack Up to ____/month Stability ____ Changing frequency ____ Onset Following severse ____ or emotion Medications ____ (symptomatically)

``` 1 stable none exercise nitroglycerin ```

Moderate Angina Frequency of attack Up to ____/wk Stability ____ Changing frequency Slight ____ over previous year or more distant past Onset Following ____ or emotion or (infrequently) meals ``` Medications ____; long acting nitrates; ____ blockers; calcium channel blockers ```

``` 1 stable increase exertion nitroglycerin B ```

Severe Angina Frequency of attack ____ episodes Stability ____ Changing frequency Changes in last ____ months Onset Following ____, decreasing or mild emotion or exertion, and meals (frequently) ``` Medications ____; long acting nitrates; ____ blockers; calcium channel blockers ```

``` daily unstable 6 rest nitroglycerin beta ```

Treatment of angina in the dental office 1. ____ dental treatment 2. Recline patient to ____ degree angle; lower head position if systolic BP

stop 45 100 ``` nitroglycerin 3-5 5 therapeutic MI ```

reatment of angina in the dental office (cont.) 5. ____ administration 6. If pain persists after the above therapy a. Transport the patient to hospital by ambulance b. Monitor blood pressure and pulse every ____ min. c. Be prepared to administer cardiopulmonary resuscitation in the event of an arrest

O2 | 5

Myocardial Infarction irreversible damage to the myocardium due to prolonged ____ injury

ischemic

Myocardial Infarction: Clinical Presentation ● Severe chest pain is present in ____ or left precordial area, +/- left arm, ____ radiation ● Dyspnea, fatigue, palpitations, nausea, and vomiting

substernal | jaw

Myocardial Infarction: Etiology ● Most commonly the result of progressive coronary artery disease secondary to ____

atherosclerosis

Myocardial Infarction: Diagnosis ● ____ presentation ● ____ ● Cardiac ____ studies

clinical electrocardiogram enzyme

``` Myocardial Infarction: First -line treatment ●  ____ ●  ____ ●  ____ ●  ____ ```

morphine oxygen nitroglycerin aspirin

Myocardial Infarction: Secondary Treatment ●  ____-blockers ●  ____ agents ●  Reperfusion therapy ◆  ____ therapy ◆  PTCA ◆  CABG

B anticoagulant thrombolytic

Myocardial Infarction: Prognosis ●  Associated with a 30% mortality rate; half of the deaths occur ____ to arrival at the hospital ●  An additional 5-10% of survivors die within the ____ year after their MI ●  Risk of mortality and morbidity is 1.5-15 X greater than that of the rest of the population

prior | first

Myocardial Infarction: Complications ●  Extension of infarction or ____ ●  ____ ●  ____failure

reinfarction arrhythmias congestive heart

◦ If they need emergency surgery, will be done in hospital setting We do not treat these patients in the post-M.I. period - ____ months Especially if it's only elective treatment ◦

Risk stays the same after 12 months, they are at ____ risk for the rest of their lives

greater

Dental management of Patient with a history of myocardial infarction - consult ____ concerning management - no routine dental care until at least ____ mo post-infarct - patients on anticoagulation therapy needing deep scaling or surgical procedures - CHECK ____ - have emergency equipment and drugs available

physician 6 INR

●  With local anesthesia with 1:100,000 epinephrine; aspirate, inject slowly, and use no more than ____ cartridges ●  Avoid use of ____ to control local bleeding or in gingival packing material ●  If patient becomes fatigued or develops significant changes in heart rate or rhythm during appointment, ____ appointment at that time

three vasopressors terminate

Cardiac Arrest Cause: Sudden circulatory and respiratory collapse. May be secondary to M.I., anaphylaxis, etc. Signs and Symptoms 1. Pulse – absent (use ____) 2. B.P. – ____ 3. Resp. – ____ or agonal 4. Skin - ____ - ashen grey 5. Pupils - ____ and fixed

``` carotids unobtainable apnea cyanotic dilated ```

Congestive Heart Failure the inability of the heart to deliver an adequate supply of ____ to meet metabolic demands

blood

Precipitating Factors in Congestive Heart Failure ``` ●  ____ ●  Myocardial infarction ●  ____ and other forms of myocarditis ●  Arrhythmias ●  Infective endocarditis ``` ``` ●  ____ ●  Thyrotoxicosis ●  ____ infection ●  ____ embolism ●  ____ ●  Physical or emotional ____ ```

HTN rheumatic ``` anemia pulmonary pulmonary pregnancy stress ```

Symptoms of Congestive Heart Failure Left-sided heart failure (____): Fatigue ____ (shortness of breath), especially on exertion ____ ____ dyspnea Right-sided heart failure (PORTAL): ____ of the ankles and legs ____ ____ Pain

pulmonary dyspnea orthopnea paroxysmal nocturnal swelling nausea abdominal

Signs of Congestive Heart Failure Left-sided heart failure: ____ ``` Right-sided heart failure: Distended ____ veins Large tender ____ ____ ____ ____ gain, increase body girth ```

pulmonary edema ``` neck liver ascites peripehral edema weight ```

Management of the patient with congestive heart failure: ● ____ rest ● ____ modification ● Address potentially reversible factors ● Medications

bed | lifestyle

Chair Position Guidelines ●  The dental chair should be placed in a semi- reclined or upright position (____ degrees) ●  At the end of the appointment, the chair should be ____ raised to prevent orthostatic hypotension

45 | slowly

Patient at low risk ● History of ____ congestive heart failure ● ____ on therapy ● Usually on mild diuretics, with or without ____

mild asymptomatic cardiac glycosides

Patient at moderate risk ● History of ____ congestive heart failure ● Asymptomatic at rest, but may have symptoms with ____ ● Usually on more ____ diuretics and ____

moderate exertion potent cardiac glycosides

Patient at high risk ● ____ despite therapy ● Often on ____ doses of medications, including vasodilators ● Has significant ____ dysfunction

symptomatic escalating cardiac

Cardiac Arrhythmias Isolated ectopic beats ●  ____ atrial beats ●  Premature ventricular beats Bradycardias ●  Sinus ____ ●  Heart block ``` Tachycardias ●  Sinus ____ ●  Atrial flutter ●  Atrial fibrillation ●  Ventricular tachycardia ●  Ventricular fibrillation ```

premature bradycardia tachycardia

Signs and Symptoms of Cardiac Arrhythmias ``` Signs ●  Slow heart rate (less than ____ beats per minute) ●  Fast heart rate (greater than ____ beats per minute) ●  Irregular heart rate ●  ____ ●  Congestive heart failure ●  Cardiac arrest ``` ``` Symptoms ●  Palpitations ●  Fatigue ●  Dizziness ●  Angina ```

60 100 syncope

Dental Management of the Patient at Risk for Cardiac Arrhythmia ● Reduce ____ ● Avoid excessive amounts of epinephrine (

anxiety 3 cardiac anesthesia