Cardiovascular Medicine Flashcards
Acute Coronary Syndromes definition
occurs when theres a sudden reduced blood flow to the heart
How can ACS occur
ischaemia [reduced blood flow to the heart, inadequate oxygen tissue delivery], blood vessel occlusion
Unstable angina [ischaemia], which prolonged can lead to infarction - heart attack [STEMI/NSTEMI]
Signs and symptoms of ACS
chest pain/discomfort spreading to back/jaw/shoulder/left arm, abdomen pain mistaken for indigestion, shortness of breath, light-headedness, sweating, nausea
Risk factors of ACS
old age, family history of heart disease, smoking, diabetes, hypertension, high cholesterol, obesity
Most common cause of ACS
thrombus in an artery with atherosclerotic plaque. [unstable angina]
can be coronary artery embolisms [mitral/aortic stenosis, endocarditis]
unstable angina
heart doesnt get enough blood flow/oxygen, atherosclerotic plaque, clot on surface but isnt fully occluding the artery. reversible, little cardiac muscle death so normal troponin levels
STEMI
ST segment elevation mycordial infarction. full thickness of cardiac muscle wall is affected, atherosclerotic clot which has increased and occluded vessel completely so no blood or oxygen can pass, effects large area of heart
troponin elevated
NSTEMI
no ST elevation, interior layer of cardiac muscle death, partial blockness, not full area of heart
Diagnosis of NSTEMI
ECG - ST elevation not present
Blood test - test for troponin, elevated levels but not as much as STEMI
partial blockage of coronary artery
Diagnosis of STEMI
ECG - elevation of ST segment
Blood test - elevated troponin levels. px needs a test as soon as they arrive at the hospital and one 24 hours later. if it is raised - clear MI
full blockage of coronary artery
Immediate management of ACS
- antiplatelet therapy = 300mg aspirin
- analgesics
- anti-thrombin therapy
- supplemental oxygen
Immediate management of ACS
- antiplatelet therapy = 300mg aspirin
- analgesics
- anti-thrombin therapy
- supplemental oxygen
STEMI management
thrombolysis - medications or minimally invasive procedure to break up blood clots and prevent new clots forming
PCI - minimally invasive procedures used to open clogged coronary arteries. by restoring blood flow, tx can improve symptoms of blocked arteries such as chest pain/shortness of breath [percutaneous coronary intervention]
unstable angina management
admission to hospital for bed rest with continuous monitoring
low dose aspirin, clopidogrel
angiography within 24-48hrs to see sight of blockage
Drug therapy after confirmed MI
anticoagulants - warfarin, slow down process of making clots
beta-blockers - reduce heart rate and blood pressure [bisoprolol]
ace-inhibitors - decrease chemicals which can tighten blood vessels so blood flows smoother and heart can pump more efficiently [lisinoprol]
statins - helps lower LDL cholesterol, lowers risk of hardening and narrowing arteries [simvastatin]
NSTEMI management
angiography within 24-48hrs to see site of blockage
Angina
chest pain caused by reduced blood flow to the heart muscles
angina signs + symptoms
signs - often none, anaemia, hyperthyroidism
symptoms - no pain at rest, pain with exercise, pain relieved by rest
angina investigations
ECG done while resting + exercising [shows ischaemia], eliminate other disease, angiography, echocardiography
angina treament
reduce oxygen demands of heart [BP, venous filling pressure afterload and preload by medications]
correct mechanical issues [failing heart valves]
increase oxygen delivery to tissues [dilate blocked/narrowed tissues]
CABG [coronary artery bypass grafting]
live within limits, modify risk factors [smoking, obesity]
angina risk factors
alcohol use, drug use, stress, smoking, obesity
CABG
diverts blood around narrowed or clogged parts of major arteries to improve blood flow and oxygen delivery to the heart
major surgery [mortality risk], limited benefit of 10 years, less effective in smoker
angina drug therapy
- aspirin = reduce MI risk
- diuretics, calcium channel agonists, ACE inhibitors, beta blockers = hypertension
- nitrates = reduce heart filling pressure
- emergency treatment GTN [glyceryl trinitrate] spray/tab = reduces preload, sublingual administration due to FPM
peripheral vascular disease
angina of the tissues, usually in lower limbs, pain of exercise but relief on rest
limitation of functions, poor wound healing, tissue necrosis, may lead to amputation
aggravated by CV risk factors, risk of MI
ischaemia
blood flow and oxygen is restricted/reduced
infarction
death of the tissues due to restriction/reduced oxygen and blood flow [clot or narrowing]
drugs used to prevent further CV disease
antiplatelets, lipid lowering, anticoagulants, diuretics, ace-inhibitors
drugs used to reduce symptoms of CV disease
ace-inhibitors, nitrates, diuretics
dental implications of CV disease
medications px are on can affect tx, anticoagulants/antiplatelets will reduce clotting and increase bleeding so high risk procedures like extractions need to be considered carefully / planned with GP
hypertension
raised blood pressure outwith the normal for that population
hypertension risk factors
age, stress, family history, drugs, obesity
causes of hypertension
can be hard to define/assess, varies from person-person, usually no triggers found
can be from renal artery stenosis, endocrine tumours, Crohn’s, Conn’s
signs/symptoms of hypertension
usually none, may get headache, mini MI
investigations for hypertension
urinalysis, BP, serum lipids, ECG, serum biochemistry
treatment of hypertension
trying to get back to population level
modify risk factors = smoking, exercise, less salt in diet
single daily drug dose = thiaxide diuretic, beta blocker, calcium channel agonist, ace-inhibitor
monitor over time, tx will change
consequences of hypertension
stroke risk, ACS risk, heart failure, renal failure, accelerated atherosclerosis
heart failure
output of the heart is incapable of meeting the demands of the tissues
aetiology of heart failure
MI, myocarditis, atrial fibrillation, heart block, hypertension, aortic stenosis, drugs [beta blockers, corticosteroids], valve overload
left heart failure
most common - heart cannot pump blood around the body
left heart failure symptoms
dyspnoea, tachycardia, low BP, low volume pulse
lung and systolic effects
right heart failure
cannot pump blood to the lungs, fluid can go to the veins, right ventricle to weak to pump to lungs
right heart failure symptoms
swollen ankles, ascites, raised JVP, enlarged liver, poor GI absorption, venous pressure elevated
congestive heart failure
both right and left side heart failure
high vs low output failure in heart failure
high - demands increased beyond capacity of pump [anaemia, thyrotoxicosis]
low - pump is failing and not strong enough to pump blood around the body [MI, valve disease]
treatment of heart failure
acutely;
loop diuretics to get rid of fluids
give oxygen and morphine
chronic;
improve myocardial function, treat the cause - hypertension/valve disease/arrhythmia
drug therapy - diuretics [increase salt and water loss], ace-inhibitors [reduce salt/water retention], nitrates [reduce venous filling pressure]
stop negative inotropes - BETA BLOCKERS - they cause heart failure and reduce blood flow
causes of valve replacements
congenital abnormalities [down syndrome, aortic valve is bicuspid and tricuspid], MI, rheumatic fever, dilation of aortic root
valve has become narrowed [aortic stenosis]
valve has become leaky [aortic regurgitation]
which are the most commonly replaced valves
aortic and mitral valve
due to stenosis, where valve is narrowed and regurgitation occurs
mitral - back into heart, mitral - back into lungs
metal valve replacement
longer clinical life, require warfarin coagulation, antibiotic prophylaxis consideration [dental treatment, endocarditis risk], makes a ticking noise
tissue valve replacement
shorter clinical life, no need for coagulation medication [+ for children], consider antibiotic prophylaxis, silent action, good for elderly as if they have metal and on warfarin and fall = high bleed risk
dental implications of valve replacements
will be on anticoagulation medications, follow SDCEP guidance, need to know before extraction, cannot stop WARFARIN
antibiotic prophylaxis
taking antibiotics before tx to decrease the chance of infection
what are pacemakers used to treat
bradyarrhythmia
bradyarrhythmia
heart is beating slow, can be through heart block or drug-induced by beta blockers
tachyarrhythmia
heart is beating too fast
how do pacemakers work
they keep the heart rate at a minimum level, they do not pace if the heart rate is above a certain level, it is a sensing and pacing circuit
it is placed in the chest wall with wires passing through blood vessels into the ventricle
risk of pacemakers
electrical field can cause them to shut down - MRI, induction/ultrasonic scaler, electrosurgery units
atrial fibrillation
irregular and abnormally fast heart rate
atrial fibrillation signs + symptoms
dizzy, short of breath, tired, heart palpitations, heart pounding/fluttering, pulse faster than normal
atria contracting randomly and heart muscle cannot relax between contractions, reducing efficacy and performance
endocarditis
inflammation/infection of the endocardium - the inside surface of heart and heart valves
what causes endocarditis
microbial colonisation, mainly oral steptoccoci
how does oral treatment cause endocarditis
oral treatment causes a release of bacteria into circulation, this bacteria colonisation arises at the heart as a consequence - dental care is influenced by this risk
which dental procedures are an endocarditis risk
any which involve the manipulation of the dento-gingival junction and causes a bacteraemia and release a large number of oral streptococci into the blood stream
- extractions, periodontal therapy, gingival surgery, implants, restoration in gingivae or marix used
signs + symptoms of endocarditis
fever, heart murmur, skin manifestations [patches on skin, lines on nails, spots on palms/soles] headaches, night sweats
diagnosis of endocarditis
blood cultures over several days to test bacteria, listen to heart, CRP test
effects of having endocarditis
long-term antibiotics treatment, cardiac valve damage and dysfunction, risk of death, with second diagnosis comes high mortality risk
what to do when you have a px with high risk endocarditis
identify them, work on prevention of oral disease and excellent oral hygiene, remove sepsis load [deal with carious teeth]
procedures with px at high endocarditis risk
consider antibiotics prophylaxis - decision made by px physician, communicated to dentist in writing
Montgomery - all effects must be discussed, informed consent, consequences of prophylaxis route or not
avoid risk activity like piercings
3g amoxicillin 1 hour before procedure
