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CARDIOVASCULAR > Cardiovascular disease > Flashcards

Cardiovascular disease Flashcards

1
Q

Why do we need to know about cardiovascular disease as dentists?

A

Cardiovascular problems are the 2nd most common medical condition in periodontal patients

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2
Q

What could go wrong in terms of cardiovascular problems in the dental chair?

A
  • Develop chest pain (angina or MI)
  • Develop a tachycardia (get palpitations or breathlessness) or bradycardia (get dizzy, blackout)
  • Develop heart failure (breathlessness, sometimes very acute and very severe)
  • Suddenly die (Ventricular tachycardia or fibrillation)
  • Get endocarditis (don’t worry, they’ll be out of your surgery by then)
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3
Q

What questions should be asked when faced with patients with definite or possible cardiovascular disease?

A
  • Will they tolerate my treatment? Almost always yes they will
  • Will my treatment complicate their condition or treatment? Very Rarely
  • Will their condition or treatment complicate my treatment? Often, particularly bleeding risk
  • Should I tell anyone about them? Yes; if you uncover cardiac symptoms (chest pain, breathlessness, blackouts, dizziness) or signs (irregular pulse, high/low BP, swelling)
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4
Q

What are the 4 categories of what can go wrong with a heart?

What are the consequences of each malfunction?

A

Myocardium (ventricles pump blood) - malfunction leads to HEART FAILURE

Valves - can leak or get infected - malfunction leads to HEART FAILURE or ENDOCARDITIS (if infected)

Conduction system - ARRHYTHMIA (tachycardia = too fast) (bradycardia = too slow)

Coronary blood supply - malfunction leads to ANGINA or MYOCARDIAL INFARCTION

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5
Q

What is classified as heart failure?

What are the common causes of heart failure? (5)

A

Anything that affects the efficiency of the pump (and reduce cardiac output) causes heart failure.

Common causes: previous heart attacks (MI), high blood pressure, genetic causes, drugs (chemotherapy/alcohol), idiopathic (unknown cause)

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6
Q

What is used as the standard assessment of pump function?

A

transthoracic echocardiography (ultrasound)

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7
Q

What are the symptoms of heart failure and how does it occur?

A

Reduced cardiac output increases fluid pressure in lungs (called left heart failure), or reduces venous return to the heart via vena cava (called right heart failure) and compensatory responses cause fluid retention and vasoconstriction. This causes;

  • Breathlessness (due to increased fluid pressure in lungs)
  • Swelling in ankles (increased fluid pressure in venous system)
  • Also; dizziness, tiredness, weight loss
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8
Q

What are some clinical signs of heart failure?

A

Low blood pressure

High pulse rate

Crepitations in lungs (crackles when listened to with a stethoscope)

Raised jugular venous pressure (seen in jugular vein in neck)

Pitting ankle oedema (swollen ankles)/ ascites (build up of fluid in the abdomen)

BUT swollen ankles can be due to a lot of things.

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9
Q

What happens when the valves go wrong?

What are the causes of valve disease? (5)

A

When valves go wrong (regurgitant or stenosed) it causes the same symptoms as heart failure.

CAUSES:

  • Degeneration (happens naturally)
  • Rheumatic fever
  • Congenitally abnormal valve
  • Endocarditis
  • Papillary muscle rupture after MI
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10
Q

What happens during more severe aortic stenosis?

A

Aortic valve (normally thin) is thickened due to calcium deposits.

Doesnt open very well = orifice area is much smaller which strains the heart and builds up pressure.

This is effectively an epidemic currently.

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11
Q

What is INFECTIVE ENDOCARDITIS?

What are the symptoms?

Who are more at risk of it?

What causes it? Which 2 organism types usually cause it?

A

Like a really bad systemic infection (night sweats, fever, rigors, weight loss) but with the bonus of infected lumps flying around your blood stream (causing embolic complications) and your heart valves being eaten away (causing valve regurgitation and heart failure)

Can happen to anyone, but more likely in artificial valves, abnormal valves, elderly, intravenous drug abusers, and in people with previous endocarditis.

A large range of possible organisms, but usually Streptococcal or Staphlococcal

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12
Q

What does infective endocarditis cause? (2)

A

valve damage and embolisation

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13
Q

How is cardiac rhythm measured?

What do most rhythm abnormalities show?

A

Proper cardiac function is orchestrated by the electrical conduction system of the heart.

The cardiac rhythm and conduction is examined by the Electrocardiogram; usually measured from the surface of the body but more detailed intracardiac ECGs are used in Electrophysiology studies

Most rhythm abnormalities are too fast (tachycardia, anything >100bpm) or too slow (bradycardia <60bpm). Tachycardias and bradycardias are treated very differently.

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14
Q

What are the 3 main tachycardias and their effects?

A

Ectopic beats (extra beats that the ventricles throw into a normal rhythm) - often seen in most people. More common in any heart disease. Symptoms are palpitations/skipped beats. These are rarely significant.

Atrial fibriliation (present in 25% of people over 80). Can be caused by anything affecting heart or lungs (hypertension, heart failure, valve disease, age, alcohol, obesity, lung disease, hyperthyroidism). symptoms are palpitations, breathlessness or dizziness. They increase the risk of stroke.

Atrial flutter (same causes and symptoms as atrial fibrilation). Increases risk of stroke.

These bottom two can often be asymptomatic. First sign would tend to be an irregular pulse (probably too fast).

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15
Q

What are the types and causes of bradyarrhythmia?

A
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16
Q

What is the commonest cause of death worldwide?

A

coronary artery disease

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17
Q

What are the risk factors of coronary artery disease?

A
  • Smoking
  • High cholesterol
  • High blood pressure
  • Diabetes
  • Overweight
  • Poor diet
  • Lack of physical activity
  • Other atherosclerotic conditions (stroke, peripheral vascular disease)
  • Family history
  • Genetics
  • Male sex
  • Age
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18
Q

What is angina caused by?

A

When coronary artery plaque becomes obstructive and reduces flow, this can cause angina.

The “plaque/s” that cause angina are stable; there is a strong fibrous cap protects the blood from exposure to the lipid (cholesterol) core of the lesion, this is good as it prevents thrombosis (prevents the blood from clotting).

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19
Q

What is angina? What are the symptoms?

What is it precipitated by?

A

Angina is a recurrent feeling of chest pressure/ heaviness/ pain/ indigestion, sometimes radiating to the arm, neck, or back.

Angina is almost always precipitated by exertion or stress (circumstances where the heart needs a greater blood supply)

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20
Q

How long does angina last?

How dangerous is it?

A

Angina rarely lasts more than 10 minutes, and rarely is at rest

Angina itself isn’t dangerous. However “unstable angina” (increasing frequency, duration, or onset at rest) is a sign of risk and warrants immediate assessment.

Unstable angina may mean that plaque has been ruptured and a blood clot may be forming

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21
Q

Pt gets chest pain at rest and increasingly frequently. What do you do?

A

Sign of unstable angina.

Considered a medical emergency.

Should be admitted for assessment.

22
Q

What causes myocardial infarction?

How is it different to angina?

A

MI occurs when an atherosclerotic plaque in a coronary artery ruptures, triggering thrombus formation.

Caused by a change in the plaque.

This causes permanent death of some myocardium (unlike angina)

23
Q

What are the features of MI (myocardial infarction)?

How does it differ from angina?

A

MI can occur at any time; at rest, on exertion, while asleep, etc.

MI usually causes chest discomfort similar to angina; it is not always severe.

Angina rarely lasts more than 10minutes; MI pain tends to last longer

MI can be immediately fatal or the damage can lead to lifelong heart failure

24
Q

What are different methods of assessing whether somebody has coronary artery disease? (3)

Give some pros and cons for these methods

A

EXERCISE ECG - easy but inaccurate (50% of women would show the same changes without having coronary artery disease)

MYOCARDIAL PERFUSION SCAN - slightly more accurate. Patient gets injected with a radiolabelled tracer.

ANGIOGRAPHY - either by CT (more common) or invasive (only do this for possible MI, in case stenting needed)

If you find coronary artery disease on a CT angiogram you still need to do invasive

25
Q

How can we treat coronary artery disease?

Will this improve the prognosis?

A
  • Lifestyle modification; stop smoking, take more exercise, eat heart healthy diet (5-7 veg/fruit/d, low processed food, oily fish, olive oil, nuts/seed), lose weight
  • Cholesterol lowering (statin treatment usually)
  • Antiplatelets (usually Aspirin) lowers MI risk
  • Address other risk factors; blood pressure, diabetes

These improve the prognosis but dont reduce the frequency of angina

26
Q

What are the main medications used to reduce angina attacks caused by C.A.D? (3)

What if these medications arent working?

A

Nitrates

Beta blockers

Calcium channel blockers

If they dont work / there are severe side effects, undertake stenting or coronary artery bypass grafting.

27
Q

How can you tell if it is a MI or just trapped wind?

(2 key investigations)

A

ECG on arrival - look for elevation of the S-T segment. If pt has it, they’ll be having an STEMI (S-T Elevated Myocardial Infarction)

…BUT this can be normal but the pt may still be having an MI (NSTEMI - N=non)

Serum troponin - take levels on arrival and 6hrs later. A lot of events can make this rise, but if pt comes in with chest pain its likely theyve risen due to MI

28
Q

How do you manage STEMI and NSTEMI?

A
  • Immediate dual antiplatelet therapy (DAPT; aspirin plus Ticagrelor, Prasugrel, or Clopidogrel) and pain relief. Paramedics usually give the Aspirin and opiates.
  • Anticoagulation for 24-72hrs; Heparin, Fondapariux or similar
  • Both STEMI and NSTEMI should have angiography and if possible stenting; STEMI immediately, NSTEMI within 72hrs or sooner if complications
29
Q

If there is a medical emergency and suspected MI in a dental practice and pt is waiting for emergency services, will giving them oxygen be detrimental?

A

YES as it causes constriction of coronary arteries which worsens blood flow. Do not give pt oxygen if their blood oxygen levels aren’t low (if they’re not literally breathless).

Nitrates are useless for MI because it isnt angina

30
Q

What can be used as secondary prevention for the management of STEMI and NSTEMI?

A
  • DAPT for a year then Aspirin alone, Statin, Betablocker for a year, ACE inhibitor, and treatment of any complication (heart failure, arrhythmia, etc).
  • Cardiac rehabilitation; exercise, education, diet, smoking cessation
31
Q

What is the most important way of investigating heart failure?

A

Transthoracic echocardiography to detect ventricular impairment.

A newer option is a blood test for elevated serum B-type Natriuretic Peptide (BNP)

Other tests = cardiac MR

32
Q

What are the 2 key drugs in treating heart failure?

What do some heart failure patients also benefit from?

A

ACE inhibitors and Beta blockers

Some pts benefit from cardiac resynchronisation therapy (CRT) - a special form of pacemaker

33
Q

How is valve disease usually investigated?

Give another method of investigation and pros and cons?

A

Diagnosis usually by transthoracic echocardiography – although good for valves, this is not good for seeing coronary artery disease

Transoesophageal echocardiography gives better images particularly of mitral valve but is not pleasant for the patient

34
Q

In which two valves are problems most commonly seen?

A

aortic valve and mitral valve

35
Q

How can valve disease be treated?

What is used for aortic stenosis specifically?

A

If valve disease is symptomatic (usually breathlessness) then valve intervention is probably appropriate (done by cardiothoracic surgeon, not cardiologist)

Valve can be replaced with metallic prosthesis, biological prosthesis (tissue from animal or human donor) which requires open heart surgery on bypass.

For aortic stenosis we now sometimes use TAVI (transcatheter aortic valve implantation)

36
Q

If metallic prosthesis is used for valve replacement, what is required lifelong?

A

Metallic valves require lifelong warfarin, and this can only be stopped if bridged with Heparin. (Anticoagulation for e.g. AF can often be stopped without bridging Heparin).

37
Q

How can arrhythmias be investigated?

A

Diagnosis made by ECG at the time of symptoms (easier said than done; often needs multiple 24hr recordings, home recorders, smartphone apps or implanted loop recorder)

Other investigations look for causes (echo for heart failure, valve disease, angio for coronary artery disease, family screening/testing for genetic conditions etc)

38
Q

What is the standard sequence an ECG records?

A
39
Q

What almost always works for a patient about to die of ventricular tachycardia?

A

defibrillation

40
Q

How do the ECGs differ from normal to severe tachycardia?

A

The closer together the QRS complexes, the faster the heart rate

41
Q

How is atrial fibrilation and atrial flutter treated?

(both tachyarrhythmic cases)

A

Slow the rate with betablockers, digoxin, or calcium channel blockers.

Anticoagulate with Warfarin or NOAC if high stroke risk (calculate CHADS2-VASc score)

42
Q

How are ventricular tachycardia and ventricular fibrilation treated?

(both cases of tachyarrhythmia)

A

Usually requires immediate DC Cardioversion (shock).

Recurrence prevented by regular anti-arrythmic drugs; betablockers, Amiodarone.

Common to require Implantable Cardioverter Defibrillator unless having acute MI

43
Q

How can supraventricular tachycardia be treated?

A

Attacks can be terminated by vagal manoeuvers, iv Adenosine, DC Cardioversion (electric shock).

Recurrent attacks can be reduced by regular anti-arrythmic drugs; betablockers, Flecainide, Amiodarone, etc.

Can usually be cured by invasive ablation, requires Electrophysiological study

44
Q

How can ectopic beats be treated?

A

Reassurance. Sometimes betablockers

45
Q

How can bradyarrhythmias be treated?

A

Pacemaker insertion - use a dual chamber pacemaker.

This treats bradyarrhythmia but does nothing for tachycardia or VF.

46
Q

What does an implantable cardioverter/defibrilator do?

A

Treats ventricular tachycardia or VF.

Can also pace bradycardias

47
Q

What can CRT (cardiac resynchronisation therapy) do?

A

Treats heart failure.

Can also pace bradycardia (CRT-P)

48
Q

When should you defer treatment of patients due to heart problems?

A
  • Recent MI (within 6 weeks); defer until 3-6 months post MI, longer if possible.
  • Frequent attacks of disabling tachycardia
49
Q

Pt comes in with stable angina. Should you defer treatment?

A

No, but if the patient has started experiencing increasing pain or pain at rest then that could be.

50
Q

Pt has stable heart failure. Do you defer treatment?

A

Stable heart failure (breathless on exertion but can lie flat at night, is on treatment) is not a reason to defer (if already diagnosed and treated)

BUT increasing breathlessness and/or oedema may be.

51
Q

Pt is awaiting stents or bypass/valve surgery. Can you proceed with treatment?

A

Yes, if they are stable.

CARDIOVASCULAR (3 decks)

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