Cardiology Textbook: Heart Disease & Treatment PDF

**[CARDIOLOGY:]** **[Format of M&S questions:]** - *[Nature]* of **disease** *[with possible]* **causes/predisposing factors/different types**, - **Signs** and **Symptoms** - *[Diagnosis]* (further investigations), - **Complications****Management** *[from a]* **Dental** *[point...

**[CARDIOLOGY:]** **[Format of M&S questions:]** - *[Nature]* of **disease** *[with possible]* **causes/predisposing factors/different types**, - **Signs** and **Symptoms** - *[Diagnosis]* (further investigations), - **Complications****Management** *[from a]* **Dental** *[point of view mainly]* (if recognizing systemic implications will give you higher marks) - For the **Medical Emergencies** *[you will be asked about]* **MANAGEMENT** OF THE **MEDICAL EMERGENCY** **[SIGNS/SYMPTOMS OF HEART DISEASE]** - **Chest Pain** -- *[usually]* *[due]* to **Ischaemia (pain in both arms)** - **Breathlessness** -- *[usually]* **Heart Failure** (bear in mind respiratory) - **Ankle Swelling** -- **Heart Failure (Right Sided)** - **Palpitations** -- **Arrhythmia** - **Feeling Faint** -- **Low Blood Pressure, Arrhythmia** **[SIGNS IN THE CLOTHED PATIENT]** - **General Appearance** - **breathlessness**, **pallor**, **sweating**, **cyanosis** (central, peripheral) - **Pulse** - **Rate**, **Rhythm**, **Volume** (is it **full** or **weak**) (is It **Regular**) - **Blood Pressure** - **Jugular Venous Pressure (JVP)** - *[raised]* in **Heart Failure** (Blood keeps damming backward which causes this pressure) - **Peripheral Oedema** - **Pitting** *[indents]* on **Pressure** **[OTHER SIGNS]** **[HEART SOUNDS]** - **Normal Sounds** - *[closure]* of **Mitral** and **Aortic Valves** - **Additional Sounds** - **murmurs** are *[due]* to **Turbulent Blood Flow** (**pregnancy** *[can cause]* **murmurs** *[that are temporary]*) **[LUNG SOUNDS]** - **Normal Vesicular Breath Sounds** - **Additional Sounds** - **inspiratory crackles** at **Lung Bases** *[indicate]* **Pulmonary Oedema** - **Reduced Breath Sounds**- **Dullness** to *[percussion]* *[indicates]* **Pleural Effusion/Consolidation** **[ISCHAEMIC HEART DISEASE]** - **Heart Disease** *[caused]* by **Coronary Artery Disease** - **Underlying Pathological Processes** - **Atherosclerosis** (narrowing) and **Thrombosis** (blockage) - **Consequences** -- **[Angina]** (narrowing) and **[Myocardial Infarction]** \[MI\] (blockage) - **Acute** **Coronary Syndrome** (unstable angina and/or MI) (*[does not respond]* to **GTN**) (*[Take]* **Angina** **History** to assess) **[MANAGEMENT OF ANGINA]** - **Stop** and **rest** - **GTN spray** (sublingual) to *[shorten]* attack - *[Regular]* **Anti-Anginal Drugs:** - **Beta blockers** e.g. **bisoprolol** - **Nitrates** e.g. **Isosorbide Mononitrate** - **Calcium Channel Blockers** e.g. **Amlodipine** - **Others** -- **Nicorandil** (potassium channel activator) -- **REMEMBER THAT IT** **CAUSES** **GINGIVAL HYPERPLASIA** - **Percutaneous Coronary Intervention** (PCI) (Stent) - **Coronary Artery** **Bypass Graft (**CABG) - \[**Aspirin** 300 mg chewed\] **[RISK FACTORS]** **[Modifiable]** - **Smoking** \[Alcohol\] - **Hyperlipidaemia** - **Hypertension** - **Diabetes****Amlodipine** (**Ca** **Channel Blocker**)- **Gingival Hyperplasia** - **Bendroflumethiazide** (**Thiazide Diuretic**) **[MICROBIOLOGY OF INFECTIVE ENDOCARDITIS (IE)]** **[Types]** - **95% Of Cases** of **Infective Endocarditis** - *[Affect]* the **LEFT SIDE** OF THE **HEART** - **Mitral** = **Aortic Valves** *[affected]* **ACUTE**: - *[Most]* *[often]* *[caused]* by **STAPHYLOCOCCUS AUREUS** - *[Equally]* *[prevalent]* on **NORMAL** and **ABNORMAL Valves** - **Rare** **Specific Forms** - *[Damaged]* **HEART VALVES** - *[Prosthetic]* **HEART VALVES** - *[May present early within]* **60 Days** of **Valve Replacement** or **Late** **Right-Sided** **Endocarditis** in **Intravenous Drug Abuse**: - **5% of cases** - **Tricuspid Valve** - *[Usually]* *[presents]* **Acutely** in **I.V. DRUG ABUSERS** or the **IMMUNOSUPPRESSED** **[RISK FACTORS]** - **IV Drug Abuse** - **Abortion** - **Prosthetic valve** - **Cardiac** / **Urinary** **Catheterisation** - *[Any]* *[invasive]* **Diagnostic** or **[Surgical Procedure]** e.g.: - **Dental** see latest NICE advice - **Urological** **[Incidence of IE - 0.1% of all Cardiac Deaths]** - **Europe** and **USA** is around **1.7 - 6.2 per 100000 person-years** - *[increasing]* in **UK** - **Male** to **Female** 2:1 - **Average Mortality Rate** - **20%:** *[higher]* *[over]* **65 Years** of **Age** **[INFECTING MICROBE INCIDENCE: NATIVE VALVE]** **BACTERIAL ENDOCARDITIS** - *[Most]* **common** - **Damaged** **Valves****Fatty Plaque Deposits** in the **Arteries** *[supplying]* the **HEART**. *[Complete]* **Obstruction** of these **Arteries** *[would lead to]* a **Myocardial Infarction (Heart Attack).** **[AETIOLOGY]** - **Coronary Artery Disease** *[limits]* **Blood Flow** & *[precipitates]* **Symptoms** - *[Increased]* **Oxygen** *[demand]* within **Cardiomyocytes** - *[Narrowing]* of **Coronary Vessels** - *[Reduces]* **Blood Flow** - *[Results]* in **Myocardial Ischemia** that is *[experienced]* as pain - *[Complete]* **obstruction** *[causes]* **MI** **[PRE-DISPOSING FACTORS OF ANGINA/ATHEROSCLEROSIS:]** - *[Unhealthy]* **Diet** - *[Lack]* of **Exercise** - **Smoking** - *[Increasing]* **Age** - *[Increased]* **Alcohol Intake** - **Family history** **[RISK FACTORS OF ANGINA:]** **[MODIFIABLE:]** - **Smoking** & **Alcohol** - **Hyperlipidemia** - **Hypertension** - **Diabetes****Pallor** - *[Often]* *[described]* as **Unbearable** **Severe** *[sense]* of *[strangling]* or **Choking/Tightness** - It can *[happen]* '**Silently'** with **No Symptoms** or **Signs** at the time - **Residual** **Deficit** is a *[marker]* of **Severity** of the **Original Event** (*[amount]* of **Tissue** *[left]* *[behind]*) **[RISK FACTORS:]** - *[Leading]* **cause** is **IHD/CHD** - **Risk** **Factors** *[are that of]* **IHD/CHD/Atherosclerosis** **[ASA & TREATMENT for MYOCARDIAL INFARCTION pts:]** - Pts **0-6 Months** since **MI**: - 50% risk of another MI - **ASA IV** - Pts **6-12 Months** since **MI**: - **20-50% risk** of *[another]* **MI** - **Elective** **Treatment** can be *[performed]* with *[minimal]* **Anxiety** & **Pain** - Pts **1+ Year** since **MI**: - *[Ideal]* to wait **12 months** *[since]* **MI** for **Elective Treatment** - *[Longer]* the *[time]*, *[lower]* the **risk** All **Patients** [require] *[monitoring]*, **effective LA** - AVOID GA IN MI PATIENTS **[DIAGNOSIS:]** - ECG is an important test that should be done within 10 minutes of being admitted to hospital - There are different types of heart attacks that are diagnosed from the ECG findings (ST segment) - STEMI: ST segment elevation myocardial infarction is the most serious form of a heart attack - Blood tests - Cardiac troponin - Echocardiogram - Coronary angiography **[Dental Considerations:]** In general, 6 months post-MI is when the patient is at the greatest risk of a further MI - MI under 6 months: ASA IV - MI over 6 months: ASA III Elective treatment can be carried out after 6 months with minimal pain and anxiety - However, ideally wait 12 months - GA is avoided -- high risk for another MI - NSAIDs used for 3+ weeks can impair beta blockers and ACE inhibitors - Macrolide antibiotics (erythromycin, clarithromycin & azole antifungals) interact with statins to increase muscle damage (rhabdomyolysis) **[Medical Emergency Myocardial Infarction:]** **[SYMPTOMS: ]** - Prolonged & Severe chest pain, Shortness of breath, Fast & slow heart rate, Increased respiratory rate, Low BP, Poor peripheral perfusion, Altered mental state **[MANAGEMENT:]** - ABCDE &Call 999 - Make pt comfortable (sat upright) - Give GTN & Oxygen 15l/min - Aspirin 300mg orally - Check for signs of life CPR **[TREATMENT TO PREVENT MI/STROKE:]** - Aspirin - Statins for high cholesterol - ACEi to decrease BP If known history of angina, GTN 2 activations sublingually should suffice -- no need to call 999 If the chest pain is not relieved within 3 minutes, medical help should be summoned **[THROMBOEMBOLISM:]** A thromboembolism is a blocked artery caused by a blood clot (thrombus) inside of a blood vessel, obstructing the flow of blood through the circulatory system. If the blood supply to a major organ is blocked, the organ will lose some or all of its function. **[Types:]** Venous thromboembolism: occurs in veins -- includes DVT and PE - Deep Vein Thrombosis Thrombus in vein in leg leads to PE - Pulmonary embolism Pulmonary artery blocked, lungs are compromised Arterial thromboembolism: occurs in arteries -- causes ischaemia, includes stroke *[Examples Include:]* **STROKE**: blood supply to the brain is blocked - FAST: face, arms, speech, time to call 999 **PULMONARY EMBOLISM**: blood supply to the lungs is blocked (pulmonary artery) **DEEP VEIN THROMBOSIS**: blood clot in a deep vein of the leg -- main cause of pulmonary embolism (clot breaks off and travels to the lung) - PE and DVT are linked **[SYMPTOMS:]** - Symptoms depends on the type embolism involved - Stroke: - FAST: face, arms, speech, time to call 999 - Pain swelling and tenderness in one leg (usually calf) - Warm skin in area of the clot Red skin - If it develops into a pulmonary embolism breathlessness and chest pain **DENTAL CONSIDERATIONS** **DVT**: - Stop smoking - Anticoagulant therapy for 3-6 months - Avoid treatments - Contact GP for advice - Haemostatic measures - Early in day, early in week - Be careful for NSAIDs **[STROKE:]** A serious life-threatening medical condition that happens when the blood supply to part of the brain is cut off. An atheroma ruptures resulting in blood vessel occlusion. **SYMPTOMS:** - Face: face may have dropped on 1 side, may not be able to smile, - Arms: person cannot life both arms, weakness in one arm - Speech: speech is slurred, garbled, may not understand what people are saying - Time: time to call 999 **[TWO MAIN TYPES:]** - **[Ischaemic]** - 85% of all strokes are ischaemic - Blood clot stops blood supply to the brain - **[Haemorrhagic:]** - Weakened blood vessel supplying the brain bursts **[Transient Ischaemic Attack:]** - Mini-stroke - Blood supply to the brain is temporarily interrupted - Can last a few minutes up to 24 hours - Warning sign for a full stroke in the near future **[Risk factors:]** - Smoking - Hypertension - Obesity - High cholesterol levels - Diabetes - Increased alcohol - Atrial fibrillation (CHADSVASC score) - Increased age - Family history **[DIAGNOSIS:]** - Brain scan should be done within 1 hour of arriving to hospital - CT scan - Can tell which type of stroke you have had - Quicker than MRI scan - MRI scan: - Magnetic radiowaves used **[MEDICAL EMERGENCY -- STROKE]** **[SIGNS & SYMPTOMS:]** - Face: face may have dropped on 1 side, may not be able to smile, - Arms: person cannot life both arms, weakness in one arm - Speech: Slurred, garbled, may not understand what people are saying - Time: time to call 999 **[MANAGEMENT:]** - ABCDE & Call 999 - Oxygen 15l/min & Nil by mouth **[RHYTHMS DISORDERS (E.G., ATRIAL FIBRILLATION):]** Arrhythmias: irregular heartbeat -- heat is out of its usual The main types of arrhythmias: - Atrial fibrillation (AF) - Supraventricular tachycardia - Brachycardia - Heart block - Ventricular fibrillation **[ATRIAL FIBRILLATION (AF):]** Atrial fibrillation is the most common type of arrhythmia, it affects 1% of the population In AF, the heart rate is irregular and can be faster than normal. **SYMPTOMS:** - Many people with AF do not have any symptoms - Chest pain or pressure - Dizziness - Shortness of breath - Fainting or confusion - Rapid and irregular heartbeat - Sweating - Weakness **RISK FACTORS:** - Increased age: over 65 -- risk 5x - High blood pressure - Increased alcohol consumption - Family history - Obesity **DIFFERENT TYPES:** - Paroxysmal AF (lasts 2-7 days) - Persistent AF (lasts over 7 days and required medication) - Permanent AF **[CONFIRMING DIAGNOSIS OF AF:]** ECG Echocardiogram Chest x-ray Blood tests: hyperactive thyroid, anaemia, etc **CHA2DS2-VASc score:** Clinical prediction/algorithm for estimating risk of stroke in people with AF - C: Congestive heart failure/left ventricular dysfunction - H: Hypertension - A2: Over 75 years - D: Diabetes - S2: Stroke/TIA/Thromboembolism - V: Vascular disease (MI) - A: Age 65-74 years - S: Female (sex category) **[INVESTIGATIONS *POST AF DIAGNOSIS:*]** Once diagnosed Assess for complications & investigations to confirm the cause of it: - Bedside tests Observations, Blood pressure & ECG - **[BLOODS ]** - Full blood count, Urea & Electrolytes, thyroid function tests - Cholesterol, Bone profile (Ca2+), Magnesium - Troponin if myocardial infarction is suspected - CRP (C reactive protein) if acute infection is suspected - **[IMAGING ]** - Chest X-ray to assess for acute infection or cardiac failure - CT/MRI if embolic event is suspected - Echocardiography - Transthoracic echocardiography (TTE) & Transoesophageal echocardiography (TOE - TTE Used in newly onset AF - Can identify underlying structural heart defects: - Valvular heart disease or let ventricular dysfunction - TOE Specialised imaging used to clarify structural abnormalities **[TREATMENT:]** *[Restoring]* a **Normal Heart Rhythm**: - Flecainide - Beta-blockers: sotalol *[Controlling]* **Heartbeat** (ensure less than 90/min when resting): - Beta-blockers: atenolol, bisoprolol - Digoxin *[Reducing]* **risk** of **Stroke**: - Aspirin - Clopidogrel - Anticoagulants: - Warfarin - DOACs (Apixaban, Dabigatran, rivaroxaban) **[CATHETHER ABLATION:]** - Destroy diseased parts of the heart **[CARDIOVERSION:]** - Electric shock to heart to restore normal rhythm **[Complications] of AF:** - Heart failure - Stroke x5 - As the heart is beating too fast/irregular, blood may become stagnant in the heart - If blood is stagnant in the heart, increased risk of clotting - Thus 5x increased risk of the stroke **[RATE CONTROL:]** - First-line strategy using a combination of rate-controlling agents - Medications Beta blockers, Ca Blockers & Digoxin **[RHYTHM CONTROL:]** - Aims to restore/maintain heart in normal sinus rhythm either: - Pharmacological: Ca blockers, Beta blockers, K channel blockers - Electrical: DC cardioversion (brief electric shock under light LA) *[Prevention]* of **Thromboembolic** events: - Vit K Antagonists Warfarin (target INR 2-3) - DOAC's Rivaroaban & Apixaban - Left Atrial Appendage Closure (pts where anticoagulation is contraindicated) - CHAD2DS2-VASc scoring *[Assessment]* of **Bleeding** **Risk** in **AF** pts: - **HASBLED** Old tool used to assess bleeding risk - **ORBIT** is now recommended: - Haemoglobin- \ - **Catheter Ablation** - Alternative to long-term anti-arrhythmic drugs to maintain sinus rhythm - Invasive therapy used to prevent AF transfemoral catheter to the left atrium damage atrial tissue & prevent electrical transmission *[Complications]* of **AF**: **[CARDIAC]** - Heart failure - Tachycardia induced cardiomyopathy - Ischemia - Sudden cardiac arrest **[NON-CARDIAC ]** - Thromboembolic event like stroke, TIA, mesenteric ischaemia, ischaemic limb - Collapse - Bleeding events (due to anticoagulation) **Thromboembolism** is a *[major complication]* of **AF** **Thrombus** *[forms]* in the **Atria** - Poor co-ordination of atrial contraction Fibrillating muscle causes stasis of blood - Blood collects in the Left Atrial Appendage (LAA) - LAA acts as a static pouch & is prone to forming a thrombus - Thrombus can break off & lead to a stroke & further complications **[ATRIAL FLUTTER:]** Rapidly fired signals cause the muscles in the atria to contract quickly, leading to a **very fast, steady heartbeat**. Symptoms include: - Dizziness - Fainting - Light-headedness - Palpitations It often turns into AF but is less sinister. Big treatment for atrial flutter is cardioversion: - A small electric shock to the heart to help it get back to a normal rhythm **MAIN DENTAL CONSIDERATIONS OF ARRHYTHMIA'S:** - Avoid stress Can trigger arrhythmias - High risk pts with severe arrhythmias should not be treated in general practice: - Symptomatic pts - Resting pulse \100 or less than 60 & associated with any other arrhythmias - Irregular pulse and bradycardia & wearing a pacemaker - Pacemakers can be disrupted by ionising radiation, ultrasonic and electromagnetic interference (EMI) - If a pacemaker does stop Give CPR in supine position - Use vasoconstrictors with caution - Evaluation by cardiac specialist is advised Pacemakers can be subject to electrical interference (scalers) Check with manufacturer **[HYPERTENSION:]** Hypertension (hight blood pressure) is common, often unrecognised, and potentially lethal. Ideal blood pressure is between 90/60 mmHg and 120/80 mmHg. It is measured using two numbers (systolic/diastolic pressure). Diagnosis: Hypertension is over 140/90 mmHg, based on at least two readings on separate occasions.  **Pre-disposing factors/increase risk:** - Obesity - Increased salt intake - No physical activity - Increased alcohol/caffeine intake - Smoke - Family history - Over 65 years - Stress/anxiety **Risks of having HYPERTENSION:** - MI - Stroke - Heart failure - Kidney disease - Vascular dementia **LIFESTYLE CHANGES:** - Cut salt intake to less than 6g a day - Eat a low fat balanced diet (follow Eat Well guide) - Increase physical activity - Lose weight - Drink less caffeine - Stop smoking **HYPERTENSIONABOVE 140/90** - Treated according to level of BP and overall cardiovascular risk - Treated if persistently more than 200/110 or vascular complications present - Aim of treatment: - Maintain a bp less than 160/90 (90% of hypertension is essential) **CLINICAL PRESENTATION:** - Severe casesSymptomatic - Headache, blurred vision, tinnitus, fatiguability and dizziness - MOSTLY ASYMPTOMATIC - Hypertension increases the risk of heart and kidney disease and stroke *[Features]* of **HYPERTENSION**: - Headache, Visual problems, Tinnitus, Dizziness, Angina, Hypertension on testing, Retinal changes, Left ventricular hypertrophy - Proteinuria, Haematuria, Stroke, Neuropathy, Ischaemic heart disease, Retinopathy *[Aetiology]* of **HYPERTENSION**: - 'Essential' Hypertension: 90% cases - Poly-causal Diagnosis of exclusion - Multiple genetic loci influence - Environmental - Obesity, salt intake, lack of exercise **Aetiology**- **SECONDARY HYPERTENSION** - Relatively rare (10%) - Search if BP very high/poorly controlled/ indicators/young - RENAL PROBLEMS Renal function, electrolytes & pt symptoms can give a clue **Hypertension Classification:** - BP \