CHD PDF - Coronary Heart Disease

Coronary heart disease CA L/O/G/O Professor Monir Bahgat Introduction Medical notes Definition Medical notes Definition - Angina pectoris (AP): occurs when the metabolic demands of the heart exceed the ability of the coronary arteries to supply adequate...

Coronary heart disease CA L/O/G/O Professor Monir Bahgat Introduction Medical notes Definition Medical notes Definition - Angina pectoris (AP): occurs when the metabolic demands of the heart exceed the ability of the coronary arteries to supply adequate blood flow and oxygen to the heart: o Stable angina occurs when oxygen demand exceeds oxygen supply on exertion but relieved by rest. o Unstable angina occurs when oxygen demand exceeds oxygen supply at rest. Medical notes Definition - Myocardial infarction (MI): occurs when the blood flow through the coronary arteries is blocked by a thrombus and the muscle cells supplied by the blocked vessels die. Medical notes Definition - Acute coronary syndromes (ACS) include: - Unstable angina and - MI. Medical notes Etiology - Most of the myocardial ischemia is caused by atherosclerosis. - Risk factors include: - Non-modifiable: - Family history of IHD.. - Aging. - Male sex. FAM Medical notes Etiology - Most of the myocardial ischemia is caused by atherosclerosis. - Risk factors include: - Modifiable: - Hypertension. - Obesity HOLDS - Lipid disorders (Dyslipidemia). - DM. - Smoking - Sedentary lifestyle  Medical notes Epidemiology - CHD is a major cause of death and disability in developed countries. - Although CHD-related mortality is decreasing worldwide, CHD remains the cause of ≥1/3 of all deaths in patients >35 years.  Medical notes Clinical picture - Chest pain which is squeezing, retrosternal pain that radiates to the left arm, right arm, or both, and to the jaw. Medical notes Clinical picture AP Lasts for 1-5 minutes. Is precipitated by 4 Es: Exertion Eating Exposure to cold, or Emotional stress. Is relieved by rest or nitroglycerine. Medical notes Clinical picture MI - Is intense & constant for 30-60 minutes.  Revision Chest pain that occurs when the metabolic demands of the heart exceed the ability of the coronary arteries to supply adequate blood flow and oxygen to the heart is called: 1. Angina pectoris. 2. Stable angina. 3. Unstable angina. 4. Acute myocardial infarction.  Revision Chest pain that occurs when the metabolic demands of the heart exceed the ability of the coronary arteries to supply adequate blood flow and oxygen to the heart is called: 1. Angina pectoris. 2. Stable angina. 3. Unstable angina. 4. Acute myocardial infarction.  Revision Chest pain that occurs when the blood flow through the coronary arteries is blocked by a thrombus and the muscle cells supplied by the blocked vessels die is called: 1. Angina pectoris. 2. Stable angina. 3. Unstable angina. 4. Acute myocardial infarction.  Revision Chest pain that occurs when the blood flow through the coronary arteries is blocked by a thrombus and the muscle cells supplied by the blocked vessels die is called: 1. Angina pectoris. 2. Stable angina. 3. Unstable angina. 4. Acute myocardial infarction.  Revision Acute coronary syndromes does NOT include: 1. Stable angina. 2. Unstable angina. 3. Acute myocardial infarction (ST-segment elevation). 4. Acute myocardial infarction (non-ST-segment elevation).  Revision Acute coronary syndromes does NOT include: 1. Stable angina. 2. Unstable angina. 3. Acute myocardial infarction (ST-segment elevation). 4. Acute myocardial infarction (non-ST-segment elevation).  Revision Modifiable risk factors for atherosclerosis include: 1. Aging. 2. Positive family history of ischemic heart disease. 3. Dyslipidemia. 4. Male sex.  Revision Modifiable risk factors for atherosclerosis include: 1. Aging. 2. Positive family history of ischemic heart disease. 3. Dyslipidemia. 4. Male sex.  Revision In patients aged more than 35 years, coronary heart disease remains the cause of at least: 1. 1/20 of all deaths. 2. 1/10 of all deaths. 3. 2/3 of all deaths. 4. 1/3 of all deaths.  Revision In patients aged more than 35 years, coronary heart disease remains the cause of at least: 1. 1/20 of all deaths. 2. 1/10 of all deaths. 3. 2/3 of all deaths. 4. 1/3 of all deaths.  Revision Stable angina lasts for: 1. 1-5 minutes. 2. 1-5 hours. 3. 30-60 minutes. 4. 30-60 seconds.  Revision Stable angina lasts for: 1. 1-5 minutes. 2. 1-5 hours. 3. 30-60 minutes. 4. 30-60 seconds. Medical notes Investigations - Investigations for a risk factor: e.g., lipid profile. Medical notes Investigations AP - ECG and Exercise stress testing. Medical notes Investigations AP - Stress echocardiography. - Myocardial perfusion scintigraphy: - Thallium. - Technetium. Medical notes Investigations AP - Coronary angiography. Medical notes Investigations AP - Coronary angiography. Medical notes Investigations AP - Coronary angiography. Medical notes Investigations MI - ECG. - Cardiac biomarkers: - Troponin I & T, - CK & CK-MB, and - Myoglobin. - Cardiac imaging including: - Coronary angiography.  Medical notes Treatment - Treatment of risk factors: - e.g., lifestyle & statins for dyslipidemia. Medical notes Treatment AP o Sublingual nitroglycerine: The mainstay of treatment. o Anti-platelets: low-dose aspirin (80-325 mg/d) or clopidogrel. o Beta-blockers or long-acting heart rate-slowing CCBs. o Revascularization therapy. Medical notes Treatment MI o Initial goal is restoration of perfusion: ✓ Medical: Thrombolytic therapy ▪ e.g., tissue-plasminogen activator (t-PA). ✓ Mechanical: ▪ Percutaneous coronary intervention (PCI). ▪ Coronary artery bypass graft (CABG) surgery. Medical notes Treatment MI o Next goals are: ✓ Restoration of normal activities, ✓ Prevention of complications, and ✓ Modifying lifestyle & risk factors. Dental notes  Dental notes - As a rule, treatment should be delayed for: ✓ 3-6 months post-MI. ✓ 3 months post-CABG surgery.  Dental notes - Epinephrine 1:100,000 should be limited to a maximum of two cartridges.  Dental notes - Antibiotic prophylaxis is not required for coronary stents.  Dental notes - Aspirin and NSAIDs are contraindicated in patients who take warfarin because of an increased risk for bleeding. - Any morphine analogue can be used but only for a few days. - Extra-strength paracetamol with warfarin may increase INR. - So, the recommended analgesic is Regular strength paracetamol.  Dental notes - Both prescription and Over-the-counter (OTC) NSAIDs have a black box warning about the increased risk for CV events.  Dental notes - If a patient is suspected to have an MI on a dental visit, then the emergency medical system should be activated. - Have the patient lie down on the floor and assess the airway, breathing, and circulation (ABCs) and monitor vital signs.  Dental notes - Dental drug-drug interaction: e.g., clarithromycin is an enzyme inhibitor, which will decrease the metabolism of warfarin, thus increasing warfarin blood levels.  Dental notes INR Guidelines for Dental Treatment: - All patients should have an INR < 4. - Acceptable range of 2 - 3 in patients with: - Pulmonary embolus. - Deep vein thrombosis (DVT). - AF. - Bi-leaflet mitral value. - Acceptable range INR 3 - 4 in patients with: - Mechanical heart valves. - Recurrence of embolism while on warfarin.  Revision Stable angina is characterized by: 1. Elevated serum troponins. 2. Elevated serum CK-MB. 3. Abnormal exercise stress ECG. 4. ST segment elevation on resting ECG.  Revision Stable angina is characterized by: 1. Elevated serum troponins. 2. Elevated serum CK-MB. 3. Abnormal exercise stress ECG. 4. ST segment elevation on resting ECG.  Revision The mainstay of treatment of stable angina is: 1. Clopidogrel. 2. Sublingual nitroglycerine. 3. Warfarin. 4. Propranolol.  Revision The mainstay of treatment of stable angina is: 1. Clopidogrel. 2. Sublingual nitroglycerine. 3. Warfarin. 4. Propranolol.  Revision Dental treatment should be delayed for: 1. 3-6 days after myocardial infarction. 2. One week after myocardial infarction. 3. 3 months after CABG surgery. 4. 3 days after CABG surgery.  Revision Dental treatment should be delayed for: 1. 3-6 days after myocardial infarction. 2. One week after myocardial infarction. 3. 3 months after CABG surgery. 4. 3 days after CABG surgery.  Revision A dentist prescribed clarithromycin to a patient who is taking warfarin, this is expected to: 1. Decrease warfarin blood levels. 2. Increase warfarin blood levels. 3. Not affect warfarin blood levels. 4. Markedly decrease warfarin blood levels.  Revision A dentist prescribed clarithromycin to a patient who is taking warfarin, this is expected to: 1. Decrease warfarin blood levels. 2. Increase warfarin blood levels. 3. Not affect warfarin blood levels. 4. Markedly decrease warfarin blood levels.  Revision 20 In a patient with atrial fibrillation, an acceptable range of INR for dental treatment is: 1. 1-2. 2. 2-3. 3. 3-4. 4. 4-5.  Revision 20 In a patient with atrial fibrillation, an acceptable range of INR for dental treatment is: 1. 1-2. 2. 2-3. 3. 3-4. 4. 4-5. Thank You! L/O/G/O Professor Monir Bahgat