BMS10-1021 Clinical Introduction to the Cardiovascular System PDF

An Introduction to Cardiovascular Disease in relation to Dentistry Dr Abgeena Khan Specialty Doctor Oral Medicine Clinical scenario 1 A patient requiring a biopsy A 55 year old man presented to the oral medicine clinic with one year history of a white patch on the tongue. Medical and social history...

An Introduction to Cardiovascular Disease in relation to Dentistry Dr Abgeena Khan Specialty Doctor Oral Medicine Clinical scenario 1 A patient requiring a biopsy A 55 year old man presented to the oral medicine clinic with one year history of a white patch on the tongue. Medical and social history Hypertension Hypercholesterolaemia Medications – Captopril (ACE inhibitor) Atenolol (β-blocker) Aspirin Simvastatin Smoker 20 / day Alcohol intake 25 units / week Examination Differential diagnosis Includes – Frictional keratosis Lichen planus Candidosis Squamous cell carcinoma Plan Incisional biopsy Pre-op blood pressure 174/98 Hypertension Persistently raised blood pressure > 140/90 mm Hg 5-10% population Most common cause of preventable disease in developed world Normally detected between 20-50 years of age Primary/ Essential hypertension: Genetic Environmental Obesity Alcohol Salt intake Stress Secondary hypertension Renal disease Pregnancy Endocrine disease Drugs Coarctation of the aorta Diagnosing hypertension Measurement of blood pressure on at least - 3 occasions over 3 month period. Treatment 1 Primary / Essential General advice Weight loss Increased exercise Reduce alcohol Stop smoking Reduce salt intake Secondary hypertension Treatment of cause Treatment 2 Medical treatment A ACE Inhibitors Angiotensin II receptor blockers (captopril) (candesartan) B β-blockers (atenolol) C Ca channel blockers (nifedipine) D Diuretics (bendroflumethiazide) Hypertension - complications Heart failure Stroke – cerebrovascular accident (CVA) Coronary artery disease / Myocardial infarction (MI) Renal failure Peripheral vascular disease Hypertension – Dental relevance 1 Minimise stress and pain to minimise further increase in bp which may precipitate CVA, MI No problem with adrenaline in LA (as long as intravascular injection avoided) Controlled hypertensive – treat as normotensive Uncontrolled hypertensive (>140/90mmHg) – delay elective treatment. Refer to GP Severe hypertension (>180/110mmHg) – Refer urgently to GP or hospital Post-operative bleeding more likely Patient likely to be taking aspirin Hypertension – Dental relevance 2 Oral manifestations ACE inhibitors β-blockers Loss of taste Angioedema Lichenoid reactions Lichenoid reactions Ca channel blockers Gingival overgrowth Diuretics Xerostomia Scenario 1 - Revised plan Incisional biopsy postponed Review appointment arranged Patient was advised to see GP to have blood pressure optimised At review appointment blood pressure 130/84 Incisional biopsy performed Outcome Histology Keratosis with mild dysplasia Management Smoking cessation advice Alcohol moderation advice Monitor Clinical scenario 2 Patient who takes aspirin requiring extraction History A 58 year old man presented to the department of Acute dental care with a four month history of pain affecting the lower left quadrant Initially intermittent Now constant affecting sleep Scenario 2 Medical and social history Hypertension Angina Medications Bendroflumethiazide GTN spray when necessary Aspirin Stopped smoking 5 years ago Alcohol intake 5 units / week Examination Grossly carious lower left 2nd molar Diagnosis Irreversible pulpitis Options discussed RCT or extraction Decision to extract Aspirin Haemostasis requires the following – Vasoconstriction Platelet plug Coagulation Aspirin – anti-platelet What additional measures may we consider to help achieve haemostasis? Additional measures to achieve haemostasis Minimise trauma Haemostatic material in socket Extra pressure Sutures Post-op instructions Ensure haemostasis Scenario 2 - outcome Extraction performed uneventfully with additional precautions Scenario 3 Patient who takes warfarin requiring a biopsy History A 34 year old lady presents to the oral medicine clinic with a 3 month history of a lump on the lower lip. The lump varied in size, appearing to disappear at times only to return after a few days. Scenario 3 Medical and social history She had a history of a DVT 4 months earlier while taking OCP Regular medication – Warfarin Smoker 5/day Alcohol – nil Examination Fluctuant lump lower lip Warfarin Vasoconstriction Platelet plug Coagulation Warfarin – oral anticoagulant Taken for many reasons – DVT, PE, AF, CVA Monitored by International Normalised Ratio (INR) For DVT this is usually between 2-3 Deep Vein Thrombosis Thrombus – ‘clot’ in blood vessels Risk factors Immobility Surgery Malignancy Obesity Long flights Pregnancy OCP Smoking Hypercoagulable states Clinical features Swollen Warm Red Tender Risk Pulmonary embolism (PE) Management of patient on warfarin Historical advice Stop warfarin for 3 days prior to extraction Why don’t we recommend this any more? Surgical management of patients on warfarin Current advice For the extraction of up to three teeth, or one surgical extraction no alteration of the regime is required, provided the INR is less than 4.0 Oral surgery Yr 5 - additional learning resources Scenario 3- outcome INR checked and found to be 2.4 Excisional biopsy of the lower lip lump performed Additional precautions taken as before Procedure completed uneventfully Post-op instructions given Histology Mucocele Lip healed well with no further episodes of swelling Scenario 4 Unexpected complication A 25 year old man presents with a six month history of a white lesion on the tongue. Medical and social history Completely fit and well No regular medications Non-smoker Alcohol 10 units / week Scenario 4- Examination Scenario 4 Provisional diagnosis Plan Papilloma Excisional biopsy Pre-op blood pressure 120/75 Excisional biopsy Proceed with the excisional biopsy During preparation of local anaesthetic syringe patient became light headed, pale, sweaty, nauseous and then lost consciousness. Faint Patient laid flat so that feet are higher than head Clothing loosened Patient recovered fully in 2-3 minutes Excisional biopsy completed Patient allowed home Faint Syncope Very common – esp young males Most common medical emergency in dental surgery Often brought on by - stress, pain, fear Brief loss of consciousness, collapse May lead to fitting if patient not laid flat Recovery usually within 2-3 mins (if not reconsider diagnosis) Faint – points to consider What is a faint? What causes the loss of consciousness? What is the pulse like during a faint? Why does lying the patient flat aid recovery? How may this be avoided in the future? Extra reassurance and time Ensure patient has eaten prior to procedure or give glucose drink Postural hypotension Low blood pressure which occurs when changing posture, typically when standing up Light headed / dizzy / collapse More common in the elderly and patients taking antihypertensive medication Important with these patients to sit them up slowly from lying position Cardiovascular scenarios DVT Hypertension Faint Antihypertensive drugs Postural Hypotension Biopsy in patient taking anticoagulants Extraction in patient taking antiplatelets Recent Oral Medicine case A 75 year old man with a history of angina treated with angioplasty with stent insertion presented with a 3 month history of ulceration of the tongue. Ischaemic heart disease Inadequate O2 supply to meet demands of the heart Most common cause of death in Western world accounting for 35% of total mortality. Aetiology – atheromatous plaque within coronary arteries – constriction to blood flow. Risk of plaque rupturing leading to acute thrombus - MI Ischaemic heart disease – risk factors Unmodifiable Age Male gender Family history Modifiable Hyperlipidaemia Smoking Hypertension Diabetes Obesity Lack of exercise High alcohol intake Stress OCP Angina – clinical features Severe, crushing central chest pain Radiation - down left arm, neck, jaw Provoked – exercise, emotion Relieved in mins – rest, Glyceryl trinitrate (GTN) Unstable angina Increasing rapidly in severity Occurs at rest Angina - treatment Modify risk factors Medical Nitrates (GTN) β-blockers Ca channel blockers K channel activators Surgical Angioplasty (stent insertion) Coronary Artery Bypass Graft (CABG) Myocardial infarction – clinical features Severe, crushing central chest pain (lasts > 15 mins) Radiation - down left arm, neck, jaw Shortness of breath Nausea & vomiting Sweating Pale Tachycardia Number of events per 40 years practice in E&W BDJ 1999;186:72-79 Fits/seizures Swallowed object Asthma event Diabetic event Angina Drug reaction Cardiac arrest MI CVA Inhaled object 2.75 1.52 1.31 1.02 0.98 0.89 0.13 0.11 0.09 0.06 Faints not included 756 GDPs 6062 yrs in practice Mean 2 events per GDP (range 0-33) 1 emergency event for every 4.5 years in practice in E&W 1 death every 758 years 1/19 chance of death in 40 year career Practical medical emergencies training Londec (London Dental Education Centre) - Waterloo Simulated surgery with iStan – medical emergency training mannequin which is wirelessly controlled from control room. IHD – dental relevance 1 Dental treatment may precipitate angina / MI - need to minimise stress and pain May present as jaw pain May use GTN prophylactically Unstable angina – delay elective treatment until controlled Likely to be taking aspirin Oral manifestations of drugs β-blockers – lichenoid reactions Ca channel blockers – gingival overgrowth K channel activators Nicorandil – oral ulceration Nicorandil - oral ulceration Basic Sciences Teaching Remember Dental relevance of blood pressure & cardiac output Dental relevance of IHD Dental relevance of haemostasis Oral manifestations of antihypertensive medication