Cardiovascular Disease Overview

Cardiovascular Disease

• Cardiovascular disease (CVD) is a group of disorders affecting the heart and blood vessels.
• In the UK, 7.6 million people live with CVD, with 450 deaths daily and 100,000 hospital admissions annually due to heart attacks.
• Every 5 minutes, 1 person experiences a stroke.
• The annual healthcare cost of CVD in the UK is £9 billion.

Types of Cardiovascular Disease

• Coronary heart disease
• Cerebrovascular disease
• Peripheral vascular disease
• Deep vein thrombosis and pulmonary embolism
• Valvular heart disease
• Congenital heart disease

Risk Factors for Cardiovascular Disease

• Lifestyle factors:
  • Unhealthy diet (high in salt)
  • Physical inactivity
  • Obesity
  • Smoking
  • Alcohol
• Other factors:
  • Hypertension
  • High cholesterol
  • Diabetes
  • Kidney disease
  • Age
  • Gender
  • Ethnicity
  • Family history

Atherosclerosis

• A common disorder underlying CVD.
• Characterised by narrowing of arteries due to the build-up of plaques (atheroma).
• Restricts oxygen-rich blood flow to organs.
• Triggered by endothelial damage, initiating a chronic inflammatory response.

Stages of Atherosclerosis

• Endothelial injury or dysfunction: Initial damage to the inner lining of the artery.
• Fatty streak: Lipids accumulate beneath the damaged endothelium.
• Inflammatory response: White blood cells are recruited, leading to foam cell formation.
• Plaque progression: Smooth muscle cells migrate, connective tissue increases, calcification occurs, platelets adhere, and a fibrous cap forms.
• Plaque disruption: The plaque can rupture, triggering a blood clot.

Atherosclerosis - Risk Factors

• Physical stress on arteries: Turbulent blood flow, especially where arteries branch.
• Smoking/air pollution: Circulation of reactive oxygen radicals.
• Dyslipidaemia: High total cholesterol, high LDLs, low HDLs.
• Chronically elevated blood glucose levels.

Atherosclerosis - Complications

• Thrombosis: Complete blockage of the artery by a blood clot.
• Infarction: Impaired blood flow leads to tissue death.
• Embolus: A blood clot that travels to a coronary artery or artery supplying the brain.
• Ischaemic heart disease, Angina, Myocardial infarction (heart attack), Cerebrovascular disease (stroke), Aneurysm, Peripheral vascular disease

Ischaemic Heart Disease

• Ischaemia: Restriction of blood supply to tissues.
• Ischaemic (coronary) heart disease: Caused by atherosclerosis and hypertension.
• Leads to angina pectoris and myocardial infarction.
• Infarction can cause acute circulatory failure, loss of cerebral blood supply, and death.
• Risk factors: Age, smoking, hyperlipidaemia, diabetes, hypertension.

Hyperlipidaemia

• High blood cholesterol, potentially familial.
• Associated with: Age, gender, inactivity, being overweight, low dietary fibre, smoking, ethnicity, low socioeconomic status, and other diseases (hypertension, diabetes, chronic kidney disease).
• Management focuses on lowering LDL levels and raising HDL levels through lifestyle modifications and, if necessary, statins.

Angina Pectoris

• Severe chest pain caused by narrowed coronary arteries.
• Myocardial ischaemia leads to increased blood lactic acid.
• Associated with squeezing, crushing, gripping substernal pain (may radiate to the left arm or jaw).
• Can be stable or unstable.

Angina Pectoris - Management

• Relieved by rest or glyceryl trinitrate (GTN) medication.
• GTN stimulates vasodilation, resolving pain in 2-3 minutes.
• Other medications may be required: Aspirin, calcium channel blockers, beta blockers, ACE inhibitors, statins.
• Angioplasty or surgery to place stents or perform a coronary artery bypass graft may be necessary.

Myocardial Infarction

• Heart attack or coronary thrombosis.
• Sudden injury caused by blockage of a coronary artery.
• Rupture of a vulnerable atheromatous plaque.
• Ischaemia leads to necrosis (tissue death) of the myocardium.

Myocardial Infarction - Clinical Presentation

• Severe, central crushing pain radiating to the left arm or jaw.
• May start at rest and persist.
• Restlessness, facial pallor, sweating, nausea, vomiting, confusion, and apprehension.
• 10-20% of patients experience no pain (silent infarctions).
• Women may present with atypical symptoms.
• Death can occur soon after the onset of chest pain due to ventricular fibrillation and cardiac arrest.

Myocardial Infarction - Management

• Immediate hospital admission for:
  • Comfortable position
  • GTN spray (if known angina)
  • Dispersible aspirin 300mg chewed (unless clear evidence of allergy)
  • Oxygen (if patient hypoxaemic)
  • ECG, blood tests, echocardiogram
  • Thrombolytic therapy
  • Analgesics
  • Anticoagulants
  • ACE inhibitors
  • Sedative
  • Bed rest
  • Surgery

Myocardial Infarction - Complications

• Outlook depends on the time between onset and treatment.
• Acute complications: Cardiac dysrhythmias, cardiac failure, and pericarditis.
• Later complications: Angina, thromboembolism, aneurysm, cardiac rupture.
• Longer-term complications: Post-MI syndrome (Dressler’s syndrome), shoulder-hand syndrome, psychological problems, and depression.

Cardiac Arrest - Consequences

• Cardiac arrest is a serious event.
• Cerebral hypoxia causes respiratory arrest and brain injury.
• Survivors may experience personality changes, memory and speech impairment, involuntary movements, and incontinence.

Cardiac Arrest

• Cardiopulmonary arrest.
• Abrupt loss of heart function, breathing, and consciousness.
• Electrical malfunction causing the heart to stop beating, preventing oxygen-rich blood from being pumped to the brain, lungs, and other organs.
• May occur after myocardial infarction but often has other causes.

Cardiac Arrest - Management

• The longer the arrest, the less the chance of restoring a healthy life.
• Chain of survival:
  • CPR to provide circulatory support.
  • AED (if shockable rhythm present - ventricular fibrillation or pulseless ventricular tachycardia).

Maintaining Emergency Care Knowledge

• Dental professionals should continuously update their knowledge to provide excellent care for patients in an emergency.

Cardiovascular Diseases

• Coronary Heart Disease: Blockage in coronary arteries limits blood flow to the heart muscle.
• Cerebrovascular Disease: Affects blood vessels supplying the brain, including stroke and transient ischemic attacks (TIAs).
• Peripheral Vascular Disease (PVD): Affects blood vessels outside the heart and brain, often in legs and feet. May lead to intermittent claudication, poor wound healing, and amputation.
• Deep Vein Thrombosis (DVT) & Pulmonary Embolism: Blood clots in deep veins, potentially traveling to the lungs.
• Valvular Heart Disease: Damage or dysfunction of heart valves (stenosis, regurgitation, prolapse).
• Congenital Heart Disease: Heart defects present from birth, such as septal defects, transposition of great vessels, and tetralogy of Fallot.

Atherosclerosis

• Stages of Atherosclerosis:

  • Endothelial Injury: Damage to artery lining caused by factors like hypertension or smoking.
  • Fatty Streak: Lipid accumulation beneath the damaged endothelium.
  • Inflammatory Response: White blood cells and foam cells form.
  • Plaque Progression: Smooth muscle cells migrate, calcification occurs, and a fibrous cap forms.
  • Plaque Disruption: Plaque rupture leads to thrombosis and potential heart attacks.

• Complications of Atherosclerosis:

  • Thrombosis: Blood clots that block arteries.
  • Infarction: Tissue death due to lack of oxygen.
  • Embolus: A clot or plaque fragment that travels to block heart or brain arteries, causing heart attack or stroke.
  • Ischaemic Heart Disease: Reduced blood supply to heart tissue, leading to angina or heart attack.

• Risk Factors for Atherosclerosis:

  • Physical Stress: Turbulent blood flow, especially at artery branches.
  • Smoking/Air Pollution: Circulation of reactive oxygen species.
  • Dyslipidaemia: High LDLs and low HDLs.
  • Chronic Elevated Blood Glucose: Associated with diabetes.

Ischaemic Heart Disease

• Conditions associated with Ischaemic Heart Disease:

  • Angina Pectoris: Chest pain caused by narrowed coronary arteries, classified as stable (triggered by exertion) or unstable (may occur at rest).
  • Myocardial Infarction (Heart Attack): Sudden blockage of coronary arteries, leading to heart muscle death.

• Risk Factors for Ischaemic Heart Disease:

  • Age: Risk increases with age.
  • Smoking: Damages arteries and promotes atherosclerosis.
  • Hyperlipidaemia: High cholesterol levels increase plaque formation.
  • Hypertension: High blood pressure accelerates arterial damage.

Hypertension (High Blood Pressure)

• Types of Hypertension:

  • Primary (Essential) Hypertension: 90% of cases with no known cause, associated with age, obesity, and high salt intake.
  • Secondary Hypertension: 10% of cases, resulting from diseases such as renal or endocrine disorders.

• Risk Factors for Hypertension:

  • Genetic and Familial Tendencies: Runs in families.
  • Obesity: Increases strain on heart and arteries.
  • High Salt Intake: Raises blood pressure by causing water retention.
  • Stress: Psychological stress can raise blood pressure.

• Complications of Hypertension:

  • Stroke: Increased risk of cerebral blood vessel rupture or blockage.
  • Heart Failure: Chronic high pressure weakens the heart.
  • Vision Loss: Damage to blood vessels in the retina.
  • Vascular Dementia: Cognitive impairment caused by reduced blood flow to the brain.

Risk Factors for Cardiovascular Disease

• Lifestyle Factors:

  • Unhealthy Diet: High in saturated fats, salt, and sugars can lead to obesity and atherosclerosis.
  • Smoking: Damages arterial walls and promotes atherosclerosis.
  • Alcohol: Excessive consumption raises blood pressure and contributes to obesity.
  • Physical Inactivity: Leads to obesity and poor cardiovascular fitness.

• Other Factors:

  • Hypertension: High blood pressure accelerates arterial damage.
  • High Cholesterol: Elevated LDL cholesterol contributes to plaque buildup.
  • Diabetes: Chronic high blood sugar damages arteries.
  • Family History: Genetic predisposition to cardiovascular diseases.

Myocardial Infarction (Heart Attack)

• Symptoms of Heart Attack:

  • Severe, crushing pain in the center of the chest, potentially radiating to the left arm or jaw.
  • Other signs include sweating, nausea, vomiting, restlessness, confusion, and paleness.
  • Silent Infarctions: Around 10-20% of patients may not experience pain.

• Management of Heart Attack:

  • Call emergency services immediately.
  • Position the patient comfortably.
  • Use glyceryl trinitrate (GTN) spray for known angina.
  • Administer 300 mg of dispersible aspirin if not allergic.
  • Provide oxygen if needed and be ready for CPR.

• Complications of Heart Attack:

  • Immediate: Cardiac arrhythmias, cardiac failure, pericarditis.
  • Long-term: Risk of angina, aneurysms, cardiac rupture, psychological problems like depression.

Cerebrovascular Disease (Stroke & TIA)

• Types of Stroke:

  • Ischaemic Stroke: Caused by a clot (embolism or thrombosis) obstructing a cerebral artery.
  • Haemorrhagic Stroke: Caused by a blood vessel rupture, leading to bleeding in the brain.
  • Transient Ischaemic Attack (TIA): Also called a mini-stroke, symptoms last less than 24 hours but indicate a high risk of future stroke.

• Signs of Stroke: Use the FAST test (Face drooping, Arm weakness, Speech difficulties, Time to call emergency services).

Peripheral Vascular Disease

• Causes of Peripheral Vascular Disease:

  • Often caused by atherosclerosis, narrowing or blocking arteries in the limbs.

• Symptoms of Peripheral Vascular Disease:

  • Pain in the legs (intermittent claudication), weak pulses, skin changes, slow wound healing.
  • Advanced cases may lead to amputation due to poor circulation.

• Vein Involvement in Peripheral Vascular Disease:

  • Varicose Veins: Dilated veins, usually in the legs, causing pain and discomfort.
  • DVT: Blood clots in deep veins, potentially traveling to the lungs, causing pulmonary embolism.

Cardiac Arrest

• Definition of Cardiac Arrest: A sudden loss of heart function, breathing, and consciousness due to electrical malfunction.

• Management of Cardiac Arrest:

  • Immediate CPR (cardiopulmonary resuscitation) to maintain blood flow to vital organs.
  • Use of AED (Automated External Defibrillator) if the heart's rhythm is shockable (ventricular fibrillation or tachycardia).
  • Fast medical intervention is critical for survival.

Clinical Considerations in Dental Care for CVD Patients

• Considerations:

  • Detailed medical history review, especially regarding medications (e.g., anticoagulants).
  • Be prepared for potential medical emergencies during dental procedures.
  • Modify dental treatments to reduce stress (e.g., morning appointments, short sessions).
  • Pay attention to postural changes to prevent dizziness or fainting.
  • Communicate with the patient's GP or cardiologist when necessary.

• Emergency Preparedness:

  • Dentists must stay updated on CPR and AED use to manage cardiovascular emergencies during treatment.