Week 2 - Cardiovascular Medicine 2

Question 1

structural heart disease: 2 examples?

Answer 1

heart failure

valvular heart disease

Question 2

structural heart disease: investigations?

Answer 2

ECG - electrocardiogram
chest xray
echocardiogram

Question 3

heart failure: causes? x5

Answer 3

• ischaemic heart disease
• hypertension
• valvular heart disease
• alcohol excess
• numerous other causes

Question 4

heart failure: symptoms?

Answer 4

pump failure, due to:
- fluid accumulation: oedema
lungs -> breathlessness. could occur on exertion or lying flat
- swelling of peripheries: pitting oedema

Question 5

heart failure: presentation?

Answer 5

• gradual onset

- can present acutely to hospital shortness of breath, often during night time while lying flat

Question 6

heart failure: treatment?

Answer 6

1. address underlying cause, e.g:
   - ischaemic heart disease
   - hypertension
   - valvular heart disease
   - alcohol excess + other causes
2. medication
   - diuretics
   - ACE inhibitors
   - angiotensin II antagonists
   - b-blockers
   - digoxin
3. surgical
   - CABG/PTCA for coexisting angina
4. pacemaker

Question 7

heart failure: dental aspects

• polypharmacy?
• NSAIDs?
• patient lying flat?
• what to do when heart failure presenting?

Answer 7

• due to drug side effects, risk of interactions
• cause fluid retention. avoid them
• caution when lying patient flat
• ABCDE approach, potential cardiac arrest, use AED

Question 8

valvular heart disease: which side commonly affected? which valves?

Answer 8

• left side of heart

- aortic and mitral valve

Question 9

valvular heart disease: causes?

Answer 9

• congenital
• infective endocarditis
• rheumatic fever: complication of streptococcus infection), rare
• age-related: most common

Question 10

valvular heart disease:

describe pathophysiology

Answer 10

1. regurgitation
   - loss of valve integrity
   - becomes floppy
   - results in leakage
   - lead to heart failure
2. stenosis
   - narrowing of valve
   - obstruction of flow
   - leads to inadequate output and pump failure

Question 11

valvular heart disease: treatment?

Answer 11

1. medication: treat heart failure
2. surgery: valve replacement
   - porcine (animal tissue)
   - metallic (anticoagulation critical) requires warfarin

Question 12

why is warfarin required when doing valve replacement?

Answer 12

valve is recognized as foreign body, will trigger coagulation, leading to thrombosis (bad). warfarin thins blood and prevents clotting

Question 13

what is INR?

what is the normal INR + INR for metal valves?

Answer 13

• international normalised ratio: test used to monitor the effects of warfarin. blood test that checks how long it takes for blood to clot
• normal INR: 1.1
• for metal valves: 3

Question 14

infective endocarditis: how is it induced?

how can it occur?

Answer 14

• induced by invasive procedures: dental procedures including tooth brushing
• can occur spontaneously: dental caries and gingivitis

Question 15

valvular heart disease: infective endocarditis

• occurs on what type of valves?
• aetiology/due to?

Answer 15

• usually occurs on diseased or prosthetic valves
• trivial bacteraemia:
  strep viridans
  strep faecalis
  staph aureus

Question 16

valvular heart disease: infective endocarditis

- clinical features?

Answer 16

• prolonged febrile illness
• valve degeneration and failure
• embolic disease: brain, skin, anywhere
• immune complex formation: kidney failure

Question 17

valvular heart disease: infective endocarditis

• how to investigate
• treatment?

Answer 17

• blood cultures, echocardiogram

- prolonged course of intravenous antibiotics, surgery may be necessary

Question 18

valvular heart disease: dental aspects

• OH?
• prophylaxis?
• pts at risk of heart failure/collapse?
• pts at risk of endocarditis?

Answer 18

• maintain high standard of OH: avoid surgery if possible, avoid spontaneous bacteraemia
• prophylaxis no longer routinely given
• identify by taking good history, avoid treatment if unstable, caution with pt lying flat
• encourage good OH, practice good preventive dentistry

Question 19

what is sinus rhythm?

Answer 19

normal cardiac rhythm

Question 20

what is abnormal cardiac rhythm?

values for too fast/slow rates?

Answer 20

• arrhythmia: irregular heartbeat
• too fast: > 100/minute
• too slow: < 60/minute
• abnormal beat conduction

Question 21

cardiac arrhythmia: symptoms?

Answer 21

• can be nil
• palpitations
• chest pain
• heart failure
• syncope: loss of consciousness due to fall in BP

Question 22

cardiac arrhythmia: list of conditions?

Answer 22

• atrial fibrillation: irregular
• supraventricular tachycardia: too fast
• bradyarrhythmia: too slow
• ventricular arrhythmia: abnormal conduction

Question 23

cardiac arrhythmia: atrial fibrillation
incidence?
symptoms?
associated with?
managed by what drugs?
increased risk of?

Answer 23

• common: 10% of elderly
• often asymptomatic
• associated with cardiovascular disease: heart failure, angina, HBP
• digoxin, amiodarone, b-blockers, calcium antagonists
• increased risk of stroke: pt should be on anticoagulant

Question 24

tachyarrhythmia:
supraventricular tachycardia (SVT)
- incidence?
- benign? exception in?
- precipitated by?
- symptoms?

Answer 24

• common. often in otherwise healthy people
• usually benign, except in wolf-parkinson white syndrome
• precipitated by caffeine, infections and maybe anxiety
• unpleasant feeling, palpitations, chest pain, breathlessness

Question 25

tachyarrhythmia: supraventricular tachycardia (SVT) - treatment? - prevention?

Answer 25

- vagal manoeuvres e.g. valsava manoeuvre - carotid sinus massage - drugs e.g. adenosine prevention: - drugs - surgery

Question 26

bradyarrhythimia: - heart rate of? - what happens if rate < 40/minute? - causes? x4 - treatment?

Answer 26

- < 60/minute - dizziness and blackout - age, ischaemia, drugs, may be physiological (athletes) - remove underlying cause, usually drugs. pt may require pacemaker

Question 27

cardiac arrhythmia: ventricular arrhythmia - emergency? why? - causes?

Answer 27

- a medical emergency, because it is peri-arrest rhythm | - usually ischaemic heart disease, drugs, congenital, electrolyte disturbance

Question 28

ventricular arrhythmias: 1. ventricular tachycardia: symptoms? 2. ventricular fibrillation?

Answer 28

1. breathlessness, dizziness, chest pain, palpitations, cardiorespiratory arrest 2. always cardiorespiratory arrest

Question 29

ventricular arrhythmias: treatment for both conditions?

Answer 29

- ventricular tachycardia: immediate: hospitalization for defibrillation/drugs long term: drugs, ICD (implantable cardiac defibrillator) - ventricular fibrillation: immediate: defibrillation long term: drugs, sometimes ICD

Question 30

cardiac arrhythmia: dental aspects recognize those at risk via? if unstable? how to recognize unwell patients?

Answer 30

- medical/drug history - avoid treating - light-headed, collapse chest pain breathlessness sweaty, distressed particular concerns; e.g. heart rate <40, >150, history of collapse, hypotension

Question 31

cardiac arrhythmia: dental aspects | management of emergencies?

Answer 31

- ABC: remember oxygen - hospitalization - prepare to manage cardiac arrest: apply AED pads, switch on

Question 32

cardiac arrhythmia: dental aspects pacemakers: what to note? LA?

Answer 32

- identify pts with pacemaker, do not require antibiotic cover, theoretical risk of electric interference - avoid adrenaline containing LA; seek advice