acute coronary systems

Question 1

cvs risk factors

Answer 1

hormones, family history, genetics, smoking, diet, lack of exercise, diabetes, obesity, socio-economic

Question 2

primary prevention

Answer 2

stop the onset by giving advice/ treatment

Question 3

secondary prevention

Answer 3

preventing consequences post early diagnosis

Question 4

interconnected nature of cardiovascular disease lies within

Answer 4

there are vessels everywhere in the body

Question 5

ischemia

Answer 5

blood flow & oxygen restricted to the certain part of the body

Question 6

infarction

Answer 6

tissue death due to inadequate blood supply to the area

Question 7

narrow vessels called

Answer 7

atheroma

Question 8

exceeded oxygen in blood vessels

Answer 8

builds lactic acid

Question 9

most common areas of infarction

Answer 9

• Heart - coronary artery atheroma
• Limb - femoral & popliteal arteries
• Brain - carotid arteries

Question 10

main symptom of angina

Answer 10

tightness of the chest, exercise brought, relived by rest; dizziness, fatigue, nausea, shortness of breath

Question 11

angina cause

Answer 11

atherosclerosis of coronary arteries supplying blood to the heart muscles

Question 12

prevention of stable angina

Answer 12

low dose aspirin to reduce MI risk, diuretics, statins, ace inhibitors and beta blockers, lifestyle changes

Question 13

coronary artery bypass

Answer 13

to improve blood flow

Question 14

emergency angina treatment

Answer 14

GTN (glycerol trinitrate) under the tongue for first pass metabolism

Question 15

GTN mode of action

Answer 15

GTN reduces the cardiac workload by relaxing the vessels, matching oxygen delivery to work and give relief to a patient

high venous contraction during angina increases the work so you need to reduce the preload or afterload

Question 16

stemi symptoms

Answer 16

chest pain, often described as crushing or pressure-like feeling, radiating to the jaw and/or left arm, difficulty breathing, nausea

Question 17

acute coronary syndromes

Answer 17

stemi, nstemi, stable and unstable angina

Question 18

stemi treatment

Answer 18

PERCUTANEOUS CORONARY INTERVENTION (pci) = angioplasty within 3 hours and thrombolisers therapy

Question 19

what is stemi

Answer 19

blockage of the coronal artery
reflected by ecg ST segment elevation and rise in troponin

Question 20

what is nstemi

Answer 20

non-st-elevation - partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle

Question 21

management of unstable angina

Answer 21

asririn, nitrates, beta blockers, statins, calcium channel blockers

Question 22

angina signs

Answer 22

hyperdynamic circulation, anaemia, hyperthyroidism

Question 23

investigations for angina

Answer 23

ecg resting and after exercise, angiography

Question 24

treatment for hypertension within angina

Answer 24

diuretics, Ca channel blockers, ace inhibitors, beta blockers

Question 25

antiplatelet drugs

Answer 25

asprin and clopidogrel - inhibit platelet aggregation - decreases stroke and MI risk

Question 26

aspirin risk dentistry

Answer 26

prolong the bleeding time following dental extraction

Question 27

oral anticoagulants

Answer 27

warfarin and apixaban, taken to inhibit a clotting effect warfarin is a vitamin k antagonist

Question 28

warfarin dentistry

Answer 28

prolonged bleeding, INR has to be 2-4, avoid ID block, NSAIDs and fluconazole

Question 29

apixaban

Answer 29

short half life and can be given as a short course for DVT, postpone extraction till after

Question 30

statins are

Answer 30

lipid lowering drugs e.g. simvastatin, inhibit cholesterol synthesis in the liver so they reduce total cholesterol and LDL-cholesterol

Question 31

do not prescribe statins with

Answer 31

antifungals

Question 32

beta blockers

Answer 32

stop arrhythmias leading to cardiac arrest (Ventricular fibrillation – VF) reduces heart muscle excitability, prevent increase in heart rate, reduce heart efficiency * Atenolol – selective - β1 only * Propranolol – non-selective – β1 and β2

Question 33

diuretics

Answer 33

remove salt and water from body, can lead to Na+/K+ imbalance if not monitored carefully and can lead to dry mouth in the elderly

Question 34

nitrates

Answer 34

Short acting – Glyceryl Trinitrate (GTN) - reduces chest pain through first pass metabolism Long acting – Isosorbide Mononitrate - prevention of angina

Question 35

calcium channel blockers

Answer 35

block calcium channels in smooth muscle - relaxation and vasodilation e.g. Nifedipine, amlodipine (-pine)

Question 36

ca channel blockers in dentistry

Answer 36

can lead to gingival hyperplasia in some, need to keep good OH

Question 37

angiotensin converting enzyme (ACE) inhibitors

Answer 37

many on the market (-pril ending) * Enalapril * Ramapril * Lisinopril inhibit conversion of angiotensin I to angiotensin II prevents aldosterone dependent reabsorption of salt and water. reduce blood pressure reduce excess salt and water retention

Question 38

what are STEMI implications for his routine dental care of this diagnosis?

Answer 38

reduce anxiety and ensure right LA is given, be ready for BLS

Question 39

dental treatment after stent placement

Answer 39

should be at least 6 weeks after the surgery, might consider antibiotic prophylaxis

Question 40

patient 1 takes warfarin for atrial fibrillation.

Answer 40

patients on warfarin need to have an international normalised ratio (INR) check done within 72 h of the extraction; if they have an unstable INR this time interval drops to 24 h. If the INR falls within the range 1—4, it is deemed safe to carry out the extraction. (Care should be taken at the upper end of this range, especially if multiple teeth or surgical procedures may be necessary.) Local measures should also be employed such as packing the socket with a haemostatic agent, eg oxidised cellulose or collagen sponge, or resorbable gelatin sponge, and the socket should be sutured. Good postoperative instructions should be given and nonsteroidal anti-inflammatory drugs (NSAIDs) should not be prescribed Postoperative tranexamic acid mouthwash may also be considered

Question 41

patient 2 takes aspirin after a myocardial infarction

Answer 41

patient 2 takes aspirin and usually extractions can be carried out without any ill effect. If excessive bleeding occurs on removal of the tooth, it would be prudent to pack and suture the socket as in patient 1 and prescription of NSAIDs should be avoided

Question 42

patient 3 takes aspirin and clopidrogrel after placement of a cardiac stent.

Answer 42

clopidrogrel and aspirin may cause postoperative bleeding, so it is good practice to pack and suture all sockets as in patient The prescription of NSAIDs should be avoided, but postoperative tranexamic acid mouthwash may be considered. There is no preoperative blood test that is recommended

Question 43

patient 4 takes aspirin and dipyridamole for stroke prevention.

Answer 43

Dipyridamole and aspirin are a less potent combination than clopidrogrel and aspirin, and patients can be safely managed in the same manner as those on aspirin alone

Question 44

patient 5 takes dabigatran etexilate (a thrombin inhibitor) for atrial fibrillation.

Answer 44

Dabigatran etexilate is a new thrombin inhibitor. It differs from warfarin in that vitamin K is not an effective reversal agent, and the drug’s action is not monitored by measuring the INR. It has a much shorter half-life of 12— 17 h, but this depends on renal activity. In patients with poor renal function the half-life is increased As there are no guidelines at present on how to manage patients on these drugs who require surgical procedures in dentistry, it would be sensible to liaise with the patient’s haematologist about management. It would seem prudent to check the patient’s renal function if possible because this will give an indication of the drug’s half-life. It is also suggested that the patient should be treated as late as is feasibly possibly after administration of the drug, eg if the patient takes it at night, then treat the following afternoon. Local measures such as packing, suturing and postoperative administration of tranexamic acid mouthwash are also suggested

Question 45

list three medical conditions for which patients may be prescribed warfarin.

Answer 45

Atrial fibrillation Prosthetic heart valves Deep vein thrombosis Pulmonary embolus Cerebrovascular accident Antiphospholipid syndrome

Question 46

drugs that interact with warfarin

Answer 46

* Fluconazole — enhances anticoagulant effect * Metronidazole — enhances anticoagulant effect * Carbamazepine (epilepsy) — reduces anticoagulant effect

Question 47

what type of drug is tranexamic acid? how is it administered and when would it be used?

Answer 47

tranexamic acid is an ANTIFIBRINOLYTIC agent used topically as a mouthwash or by soaking swabs in it and getting the patient to bite on them can also be given orally or intravenously used to prevent and control bleeding especially during and after the procedure.

Question 48

What are the dental implications of the following findings in a patient’s medical history: (a) The patient is taking glyceryl trinitrate (GTN).

Answer 48

GTN is a vasodilator and also reduces left ventricular work by reducing venous return. Reducing stress by providing good anaesthesia and not subjecting patients to long appointments will minimise the likelihood of the patient having an attack. In addition,the patient should take GTN at the start of an appointment.

Question 49

What are the dental implications of the following findings in a patient’s medical history: The patient is taking nifedipine.

Answer 49

Nifedipine is a calcium-channel blocker used to treat hypertension. Hypertensive patients are at increased risk of other cardiovascular disease. Routine dental treatment may need to be postponed if the patient’s blood pressure is greater than 160/110 mmHg. Hypertensive patients are more likely to have EXCESSIVE BLEEDING following extractions. Ca+ Channel Blockers can cause gingival hyperplasia.

Question 50

You are carrying out a dental extraction on a 70-year-old man in your practice. He pushes your hand away and tells you to stop leaning on his chest (which you are not doing). What is the likely diagnosis?

Answer 50

Angina

Question 51

What other symptoms may he be experiencing?

Answer 51

The patient may also be experiencing: * Central chest/retrosternal pain * Band-like chest pain * Pain radiating to the mandible/left arm

Question 52

How would you proceed in this situation?

Answer 52

Management of ischaemic chest pain: 1 Stop the procedure 2 Make the patient sit up 3 Administer sublingual GTN 4 Administer oxygen

Question 53

The pain continues and becomes more severe. He becomes pale, clammy and feels nauseous. What has happened?

Answer 53

The ischaemic chest pain has progressed from angina (reversible) to MYOCARDIAL INFARCTION (irreversible).

Question 54

How would you proceed?

Answer 54

call for help from nursing staff call 999 prepare for BLS 30 compressions to 2 rescue breaths 15 l of oxygen use defibrillator if possible