Cardiology GP

Question 1

When would you suspect Familial Hypercholesterolaemia?

Answer 1

Adults with random or fasting total cholesterol > 7.5 mmol/L.

People with tendon xanthomata.

Family history of premature coronary heart disease (before age 60 in a first-degree relative or before 50 in a second-degree relative).

• First-degree relative: biological parents, siblings, and children.
• Second-degree relative: biological grandparent, uncle, aunt, niece, nephew, half sister, or half brother.

https://cks.nice.org.uk/hypercholesterolaemia-familial#!diagnosisadditional/-376615

Question 2

Where would you look for Tendon Xanthomata?

Answer 2

Tendo xanthomata re most commonly found on the dorsum (knuckles) of the hands and in the Achilles tendons, and may rarely be present on the extensor hallucis longus and triceps tendons.

Appear in people with heterozygous familial hypercholesterolaemia (FH) from 20 years of age onwards (unless the person was started on a statin early in life), but are often evident in homozygous FH from childhood.

Are hard, non-tender, nodular enlargements of tendons.

May become inflamed in the Achilles tendons (sometimes presenting as chronic Achilles tenosynovitis, which may be exacerbated by a statin).

Not yellow, overlying skin is of normal colour.

Highly suggestive of FH, but their absence does not exclude FH.

Other types of xanthomata (such as xanthelasmata on the eyelids) and premature corneal arcus may occur in people with FH, but they are less specific.

Question 3

Which patients are at highest risk of infective endocarditis?

Answer 3

Patients at highest risk of infective endocarditis

• any prosthetic heart valves (transcatheter valves, bioprostetic valves, homografts)
• previous infective endocarditis
• some types of congenital heart disease (any cyanotic congenital, any congenital repaired with prosthetic material <6 mo ago, lifelong of residual shunt or regurgutation)

Question 4

When are dental procedures seen as high risk (for infective endocarditis)?

Answer 4

Dental procedures are seen as high risk if they involve

• manipuation of gingival region incl extractiona and scaling,
• of periapical region incl root canal, or
• perforation of mucosa (except LA injection)

Question 5

Guidance for patients at high risk of endocarditis?

Answer 5

• antibiotic prophylaxis with Amox 3g (Clind 600mg if pen allergic) stat taken 1 hr before high risk dental procedures
• good oral hygiene with at least yearly dental review
• infection control including disinfection of cutaneous wounds, curative antibiotics for any focus of bacterial infection
• discourage tattooing or piercing

http://www.bmj.com/content/358/bmj.j3942