Pathology of Cardiovascular System

Question 1

List the common and important diseases affecting the heart and vascular tree (6)

Answer 1

• Ischaemic heart disease 
• Hypertensive heart disease 
• Congenital heart disease 
• Valvular heart disease
• Infective endocarditis 
• Rhythm disturbances – Based on ECG
➢ Idiopathic long QT syndrome 
➢ Coronary Acute Syndrome – ST segment change

Question 2

What is the disease associated with the symptom - chest pain

Answer 2

Ischaemic heart disease, pericarditis – inflammation of
the pericardium, aortic dissection – tear in aorta,
respiratory, GI, muscular

Question 3

What is the disease associated with the symptom - Breathlessness – Shortness of breath on exertion,
orthopnoea, paroxysmal nocturnal dyspnoea, wheeze

Answer 3

Heart failure, ischaemia, respiratory

Question 4

What is the disease associated with the symptom - palpitations

Answer 4

Rhythm disorders, functional problem – hypertrophies,

anaemia – causing ↓ blood O2, hyperthyroidism

Question 5

What is the disease associated with the symptom - Syncope

Answer 5

Rhythm disorders, valvular disease, vasovagal, postural

hypotension, neurological

Question 6

What is the disease associated with the symptom - fatigue

Answer 6

Heart failure

Question 7

What is the disease associated with the symptom - Oedema, organomegaly

Answer 7

Heart failure, valvular disease

Question 8

What is the disease associated with the symptom - cyanosis

Answer 8

Congenital heart disease, left heart failure

Question 9

What is in the general examination for CVD (5)

Answer 9

General 
Face 
Hands 
Pulse 
Precordium
Peripheral Vascular status

Question 10

What are you looking for in the GENERAL examination for CVD

Answer 10

❖ Age & sex, rich/poor 
❖ Cared/Uncared for 
❖ Obesity/Cachexia 
❖ Pallor/Cyanosis/Jaundice sclera
❖ Comfort/Breathlessness

Question 11

What are you looking for in the FACE examination for CVD

Answer 11

❖ Pale/Plethoric – Red faced
▪ MALAR FLUSH is the redness of cheeks seen in MITRAL STENOSIS – causes CO2 RETENTION & VASODILATION
❖ ARCUS SENILIS
▪ Lipid deposits that occur due to hypercholseterolemia
▪ Pale ring at the periphery of the iris
❖ XANTHALESMA
▪ Yellow plaques at inner part of the eye
▪ Can be an indication of hyperlipidemia, but not always
❖ Mouth breathing
▪ Due to apnoea

Question 12

What are you looking for in the HAND examination for CVD

Answer 12

❖ Cold/Warm
❖ Finger clubbing
▪ ↑ in soft tissue around the ends of fingers & toes causing nail base to become convex
▪ Occurs in cyanotic CHD, right to left shunts, bacterial endocarditis
❖ Palmar creases
▪ Pale indicate anaemia
❖ Splinter haemorrhages
▪ Indication of thromboembolic phenomenon, trauma, bacterial endocarditis
❖ Tobacco staining
▪ Indicates high risk of atherosclerosis

Question 13

What are you looking for in the PULSE examination for CVD

Answer 13

❖ ARTERIAL pulse obtained at right radial artery
❖ Rate
▪ Beats/minute (BPM) – should be an EVEN number
❖ Rhythm
▪ Regular or irregular? Regularly irregular?
► Seen in sinus arrhythmia, second degree heart block
o Irregularly irregular
► Seen in atrial fibrillation

Question 14

What are the investigations used for CVD (6)

Answer 14

• Blood pressure
➢ Measure SYSTEMIC BP & JUGULAR VENOUS PRESSURE
➢ ↑ JVP indicates RIGHT HEART FAILURE

• Auscultation
➢ Listen to RATE and any NEW/CHANGING MURMURS

• Chest X-ray
➢ Identify SIZE of heart and CALCIFICATION (normally on valves)

• Fluoroscopy
➢ Identify ARTERIES (stenosis) & PATENCY

• ECG

• Echocardiography
➢ Observe blood FLOW & DYNAMICS

Question 15

What are the macroscopic changes in ischemic heart disease?

Answer 15

➢ Infarcted area becomes PALE
➢ 12 months post MI (assuming survival):
▪ Infarcted area replaced with fibrous tissue is thinner as does NOT CONTRACT – not bulky
▪ DILATION of ventricle due to inefficient pumping

Question 16

What are the microscopic changes in ischemic heart disease?

Answer 16

➢ Tissue becomes NECROTIC → INFLAMMATORY CELL INFILTRATION

(macrophages, fibroblast, neutrophils) → GRANULATION TISSUE → FIBROSIS

Question 17

What are the 2 types of MI

Answer 17

➢ ST elevation MI

➢ Non-ST elevation MI

Question 18

What are the 2 main anatomical patterns of MI

Answer 18

Transmural myocardial infarction

Subendocardial myocardial infarction

Question 19

What is transmural myocardial infarction?

Answer 19

OBSTRUCTION or OCCLUSION of a coronary
artery
FULL thickness damage to cardiac muscle Seen as a ISCHAEMIA throughout the DIAMETER of the artery

Question 20

What is subendocardial myocardial infarction?

Answer 20

GLOBAL HYPERPERFUSION of ALL 3 coronary
arteries
Can occur when patients lose blood → cannot
maintain BP → flow to heart is reduced
PARTIAL thickness damage to cardiac muscle
Seen as PATCHY ischaemia underneath the
MYOCARDIUM

Question 21

What is the macroscopic appearance of infective endocarditis?

Answer 21

Yellow plaque attached to atrium

Plaque present in left atrium and valves

Question 22

What is the macroscopic appearance of atherosclerosis?

Answer 22

Aorta MAINTAINS FLOW by acting as shock absorber
Aorta reserves energy to CONTRACT when heart is in
DIASTOLE
Plaque build-up HARDENS artery, causes DILATION and LOSES ELASTICITY

Question 23

How would you prepare for, prevent and manage emergencies in the dental surgery?

Answer 23

❖ Patient may collapse from angina or MI as anxious
❖ Local Anaesthetic:
▪ Adrenaline in LA is used to make the LA more PROFOUND
▪ 1/80 000 part adrenaline in Lignocaine, does not cause heart palpitations
▪ Scandanest (no adrenaline) is used to prevent litigations

Question 24

How would you anticipate and avoid exacerbating the medical comorbidity, in particular through drug interactions

Answer 24

❖ Analgesic with anti-coagulants

Question 25

How would you modify the treatment plan to take account of limitations in dental treatment options in the face of the medical status

Answer 25

❖ Suturing of pockets in patients on anti-coagulants