CV Disease I and II

Question 1

What could go wrong, relating to the CV system?

Answer 1

MI, angina = chest pain
Tachycardia = palpitations, breathlessness
Bradycardia = dizzy, blackout
Heart failure
Die = ventricular tachycardia, fibrillation
Endocarditis

Question 2

What questions should you ask when faced with pts with definite or possible CV disease?

Answer 2

Will they tolerate treatment?
Will my treatment complicate their condition or treatment?
Will their condition or treatment complicate my treatment?
Should I tell anyone about them? - Yes if cardiac symptoms or signs

Question 3

List the functions and consequences of malfunction of the myocardium, valves, conduction system and coronary blood supply

Answer 3

Myocardium = heart failure
Valves = heart failure, endocarditis
Conduction system = Arrhythmia (tachy, brady, sudden death)
Coronary blood supply = angina, myocardial infarction

Question 4

List the common causes of heart failure

Answer 4

Previous MI, high BP, genetic causes, drugs (chemo), idiopathic

Question 5

Name the standard assessment of pump function

Answer 5

Transthoracic endocardiography

Question 6

Symptoms of heart failure?

Answer 6

Reduced CO = increase fluid pressure in lungs, reduces venous return to the heart via vena cava, fluid retention and vasoconstriction = Breathlessness (increased fluid pressure in lungs)
Swelling (increased fluid pressure in venous system)
Dizziness, tiredness, weight loss

Question 7

Clinical signs of heart failure?

Answer 7

Low BP
High pulse rate
Crepitations in lungs
Raised jugular venous pressure
Pitting ankle oedema

Question 8

What causes the same symptoms as heart failure?

Answer 8

Regurgitant or stenosed valves

Question 9

What causes valve disease?

Answer 9

Degeneration
Rheumatic fever
Congenitally abnormal valve
Endocarditis
Papillary muscle rupture after MI

Question 10

What is infective endocarditis?

Answer 10

Systemic infection, infected lumps in blood stream causing embolic complications and heart valves damage = valve regurgitation and heart failure
= night sweats, fever, rigors, weightloss

Question 11

When is infective endocarditis more likely?

Answer 11

Artificial valves, abnormal valves, elderly, IV drug abusers, previous endocarditis

Question 12

What organisms usually cause infective endocarditis?

Answer 12

Streptococcal, staphlococcal

Question 13

What does infective endocarditis cause?

Answer 13

Valve damage and embolisation

Question 14

Types of arrhythmia?

Answer 14

Tachycardia >100bpm

Bradycardia <60bpm

Question 15

ECQ - What does P measure?

Answer 15

Atrial depolarisation

Question 16

What does QRS measure?

Answer 16

Ventricular depolarisation

Question 17

What does the T wave indicate?

Answer 17

Ventricular repolarisation

Question 18

Closer QRS complexes indicate what?

Answer 18

Faster HR

Question 19

Name the types and symptoms of Tachyarrhythmia

Answer 19

Atrial fibrillation - palpitations, dizziness
Atrial flutter - as above
Supraventricular tachycardia (SVT) - palpitations
Ventricular tachycardia - palpitations, sudden death
Ventricular fibrilation - sudden death
Ectopic beats - palpitations, skipped beats

Question 20

Types and symptoms of bradyarrhythmia?

Answer 20

Sinus bradycardia - tiredness
Slow atrial fibrillation - tired/dizziness
2nd degree heart block - dizziness
Complete heart block - tired/dizziness/sudden death
Asystole - sudden death

Question 21

Risk factors for coronary artery disease?

Answer 21

Smoking
High cholesterol
High BP
Diabetes
Overweight
Poor diet
Stroke, peripheral vascular disease
Family history
Genetics
Male
Age

Question 22

What causes angina?

Answer 22

When coronary artery disease becomes obstructive

Question 23

How does angina prevent thrombosis?

Answer 23

The plaque is stable = strong fibrous cap protects the blood from exposure to the liquid core of the lesion

Question 24

What is angina?

Answer 24

Recurrent feeling of chest pressure/heaviness/pain/indigestion, sometimes radiating to arm, neck or back

Question 25

What is unstable angina?

Answer 25

Increasing frequency of pain, duration or onset at rest = risky

Question 26

When does a MI occur?

Answer 26

When an atherosclerotic plaque in a coronary artery ruptures = thrombus formation = permanent dead of some of the myocardium

Question 27

When to know the difference between angina and an MI?

Answer 27

Angina rarely lasts more than 10 mins - MI pain is longer

Question 28

How to tell if someone has coronary artery disease

Answer 28

Exercise ECG: inaccurate Myocardial perfusion scan: more accurate Angiography: by CT or invasive angiography

Question 29

How to treat coronary artery disease?

Answer 29

``` Lifestyle modification: Stop smoking, exercise, healthy diet, weightloss Cholesterol lowering Antiplatelets Address risk factors ```

Question 30

How to treat CAD if it's causing angina?

Answer 30

CAD treatment plus Medication to reduce anginal attacks - nitrates If medication not working/side effects; stenting or coronary artery bypass grafting

Question 31

How to investigate heart failure?

Answer 31

Transthoracic echocardiography to detect ventricular impairment Tests for elevated serum B-type natriuretic peptide (BNP) Cardiac MR

Question 32

How to treat heart failure?

Answer 32

``` ACE inhibitors, betablockers, aldosterone antagonists, diuretics, ivabradine Correction of other causes (anaemia) Manage complications (arrhythmia) CRT (pacemaker type) ```

Question 33

How to investigate valve disease?

Answer 33

Transthoracic echocardiography | Transoesophageal echocardiography = better image of mitral valve, unpleasant for pt

Question 34

How to treat valve disease?

Answer 34

Symptomatic = valve surgery - Metallic valves = requires lifelong warfarin, only stopped if bridged with heparin Aortic stenosis = TAVI

Question 35

How to investigate arrhythmia?

Answer 35

Diagnosis by ECG at time of symptoms | Look for causes - valve disease, family testing

Question 36

What devices can be fitted to treat bradyarrhythmia?

Answer 36

Dual chamber pacemaker

Question 37

What devices can be fitted to treat ventricular tachycardia or VF?

Answer 37

Implantable cardioverter/defibrillator

Question 38

What device treats heart failure?

Answer 38

Cardiac resynchronisation Therapy (CRT)

Question 39

When should you defer dental treatment?

Answer 39

Increasing pain with stable angina Increasing breathlessness and oedema with stable heart failure Recent MI (6 weeks) - defer until 3-6 months post MI Frequent attacks of disabling tachycardia Pt awaiting stents or bypass or valve surgery = if stable, can do treatment

Question 40

How to investigate MIs?

Answer 40

Troponin count ECG Chest pain

Question 41

What ECG and troponin features are present with different types of MI?

Answer 41

NSTEMI and STEMI = raised troponin STEMI - Elevated S-T NSTEMI - Normal ST or depressed ST or T wave inversion

Question 42

How to manage MIs?

Answer 42

Both = Immediate dual anticoagulation therapy (aspirin and clopidogrel) and pain relief (aspirin and opiates) - Avoid O2 and nitrates Anticoagulation for 24-72hrs (heparin) STEMI = Angiography and stenting (but thrombolyse preferred if available) immediately NSTEMI = Angiography and PCI (stenting) within 72hrs or sooner if complications - takes longer to diagnose due to troponin non-sensitive test taking 6-12hrs)

Question 43

Secondary prevention of MI?

Answer 43

Dual antiplatelet therapy for a yr, then aspirin alone, statin, beta blocker, ACE inhibitor Clopidogrel 1 month after STEMI, 1 yr after NSTEMI Cardiac rehab, exercise, education, smoking cessation, diet