CPR Quiz 5
Which coronary artery causes an anterior infarction and where does this blood supply go?
LAD - left ventricle - this is the most common MI
Which coronary artery causes an lateral infarction and where does this blood supply go?
LCA - left atrium and left ventricle
For example, recent ___ (within the past 7 to 30 days) and _______ are classified as clinical predictors of major risk for perioperative complications.
MI and unstable angina
noninfectious causes of acute pericarditis
MI, CT disorders, drug induced, neoplastic, radiation, trauma, renal failure (uremia), aortic dissection
__________ are the most common cause of pericardial tamponade
Malignant diseases
Regular use of ______ in patients with stable angina is associated with a significant reduction in fatal events, and in patients with unstable angina, ______ decreases the chances of fatal and nonfatal MI.
aspirin
what drugs can you give as platelet aggregation inhibitors in tx of angina
aspirin and clopidogrel (plavix)
It is a build-up of fibrofatty plaque in the wall of arteries. The lesion caused by this fibrofatty buildup is called an ________. An ________ is composed of lipid, smooth muscle, and connective tissue
atheroma
what are the different types of arteriosclerosis ("hardening of the arteries")
atherosclerosis: most important type arteriolosclerosis: hypertension diabetes monckeburg medial sclerosis: rare
Aneurysms lined by ______________ are the most common aneurysms , and the _____________ is the most common location
atherosclerotic plaque, abdominal aorta
main drug categories in the management of angina:
beta-blockers, calcium channel blockers, platelet aggregation inhibitors
The atherosclerotic process results in a narrowed arterial lumen with diminished _________
blood flow and oxygen supply
when would the chest pain be brief vs prolonged:
brief: temporary ischemia of myocardium prolonged: unstable angina or acute MI
why do you need to avoid rapid position changes in the chair for patients with ischemic heart disease
can cause hypotension, change in hemodynamics can potentially affect heart and BP, especially in patients who take nitrates and antihypertensive meds
what should you do for someone that has sudden cardiac arrest and loss of consciousness
basic life support; early administration of oxygen nitrates and aspirin is recommended
Sudden cardiac death is estimated to account for 325,000 deaths annually in the United States and is often, but not always, caused by __________
cardiac arrhythmia
what would you find on a chest xray of someone with cardiac tamponade
cardiomegaly
_____________ can be detected on panoramic images in about one third of patients who have atherosclerosis
carotid calcifications
The troponins and CK-MB are enzymes released only when:
cell death (infarction) or injury occurs.
how is pain relieved in patients with stable angina
cessation of precipitating activity, by rest, or with use of nitroglycerin
what is the key feature of unstable angina pain
changing character (increasing intensity) or pattern of pain
what is a particularly ominous sign that is helpful in distinguishing between stable and unstable angina?
chest pain occurs at rest or during sleep
There is increasing evidence that atherosclerosis is also associated with:
chronic inflammation
which NYHA class is this?: "Cardiac disease, but no symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc."
class I
which NYHA class is this?: "Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity."
class II
which NYHA class is this?: "Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20-100 m). Comfortable only at rest."
class III
which NYHA class is this?: "Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients."
class IV
if you had ischemia/infarction in peripherals, what results?
claudication, gangrene
pathophysiology of pericardial effusions:
compression of the heart-->impaired diastolic filling-->decreased stroke volume; increased filling pressures --> increased cardiac output -because CO = SV x HR, since SV is lowered, HR increases to maintain CO -when compensatory mechanisms fail: hypotension, decreased CO, shock, death
what can lead to ischemia/infarctions
compromise of lumen or thrombosis or hemorrhage into plaque
Signs associated with advanced coronary atherosclerotic heart disease usually reflect the presence of:
congestive heart failure: Distention of neck veins, peripheral edema, cyanosis, ascites, and enlarged liver may be noted.
for patients w/ stable angina or past history of myocardial infarction: what to do about their anxiety?
consider use of peroperative oral sedation (short-acting benzodiazepine) as well as using N2OO2 inhalational sedation intraoperatively
what recent viral infections could cause patients to have acute pericarditis
coxsackie/ echo or adenovirus viral infections
what plays a key role in atherosclerosis?
inflammation - it is an inflammatory disorder of the cellular lining of the arteries
what is the first step of formation of atheromatous plques
inflammatory repair response of the injured arterial intima
__________ itself promotes atherosclerosis even before it produces frank diabetes, and available data corroborate the role of ________ as an independent risk factor for atherothrombosis.
insulin resistance
best graft donor site for coronary artery bypass
internal mammary artery
A dissecting aneurysm is a tear in ___________ (often in an aortic aneurysm)
intima of a blood vessel
what is transmural infarct
involves entire thickness of the myocardium
what complications can happen when atheroma-->thrombosis or hemorrhage into plauque?
ischemia/infarction or emboli
By contrast, a past history of ___________ is considered one of the intermediate risk factors for perioperative complications
ischemic heart disease (i.e., stable [mild] angina and past history of MI)
Symptomatic coronary atherosclerotic heart disease often is referred to as __________
ischemic heart disease.
the effect of HTN on blood vessels is a double whammy. why?
it accelerates atherosclerosis and also causes arteriolosclerosis
hypertensive heart disease manifests how?
left ventricular hypertrophy
it is a build-up of fibrofatty plaque in the wall of arteries. The lesion caused by this fibrofatty buildup is called an atheroma. An atheroma is composed of:
lipid, smooth muscle, and connective tissue
In rare cases, patients with angina or ACS may experience pain referred to the:
neck, shoulder, lower jaw, or teeth
If the degree of ischemia that results from coronary atherosclerosis is significant and the oxygen deficit is prolonged, the area of myocardium supplied by that vessel may undergo _______
necrosis
unstable angina is defined as:
new-onset pain, pain that is increasing in frequency, increasing in intensity, precipitated by less effort than before, or occurring at rest
Do patients with ischemic heart disease, coronary artery stents, or CABG surgery require antibiotic prophylaxis?
no
do most atheromatous plaques produce clinical manifestations
no
do patients with coronary artery stents require antibiotic prophylaxis
no
is unstable angina pain readily relieved by nitroglycerin?
no
should you perform dental care on patients who have had an MI in the past 30 days or who have unstable angina?
no
The extent of involvement in an infarct is reflected in the electrocardiogram (ECG): difference between non-elevated ST segment vs elevated
nonelevated (non-STEMI): cases w/ only partial obstruction to blood flow and limited myocardial necrosis elevated (STEMI): more complete obstruction, profound ischemia, larger area of necrosis
The fact that men are more prone to the clinical manifestations of coronary atherosclerosis is accentuated in ______ populations (e.g., African Americans, Native Americans, Hispanics).
nonwhite; (e.g., African Americans, Native Americans, Hispanics).
has a direct relationship between cardiovascular disease and periodontal disease been established?
not yet
how do you get ST elevation MI (STEMI)
occlusive thrombus -> prolonged occlusion -> ST segment elevated -> cardiac enzymes always elevated! -> STEMI
Cardiovascular disease begins early in life, and autopsy studies have shown that ___ in six American teenagers already has pathologic intimal thickening of the coronary arteries
one
Ischemic symptoms are the result of:
oxygen deprivation secondary to reduced blood flow to a portion of the myocardium.
ischemic myocardial pain results from an imbalance between:
oxygen supply and oxygen demand of the muscle
when would patients with past MIs be candidates vs not for elective dental care
past MI, now asymptomatic: risk is minimal, especially after on month past MI w/ symptoms: defer care past MI <one month ago: defer past MI w/ other clinical risk factors: defer
Studies have confirmed that a ______ history, _____ history, or history in _________ of coronary atherosclerotic heart disease increases the risk for development of the disease at a younger age than that typical for those without such a history
paternal, sibling, both parents
angina is defined in terms of its:
pattern of symptom stability
The final element included in the AHA/ACC Guidelines is the ability of the patient to:
perform basic physical tasks
The same processes that causes acute pericarditis can result in a:
pericardial effusion
when is pericarditis "acute"?
pericardial inflammation <1-2 weeks
Numerous studies have reported an association between _________ and cardiovascular disease
periodontal disease
Most acute coronary syndromes (ACSs, e.g., unstable angina [UA], MI) are caused by _____________ of the vulnerable atheromatous plaque, most commonly of a plaque that did not cause extreme stenosis
physical disruption or fracture
what can you use instead of a gingival retraction cord impregnated with epinephrine
plain cord saturated with tetrahydrozoline HCl 0.05% (Visine; Pfizer, New York, NY) or oxymetazoline HCl 0.05% (Afrin; Schering-Plough, Summit, NJ) provides gingival effects equivalent to those of epinephrine without adverse cardiovascular effects.
MI type 1:
plaque rupture with thrombus
stable angina is pain that is:
predictably reproducible, unchanging, consistent over time
with inward proliferation of the plaque, what happens to the lumen
progressively reduced (stenosis) - blood flow may be chronically decreased and when the demand for oxygen exceeds supply, the outcome is ischemic pain
what is the classic sign of cardiac tamponade called
pulsus paradoxus
slow vs rapid fluid accumulation (pericardial pressure volume loop): which has pericardial pressure that rises rapidly?
rapid fluid accumulation
this type of aneurysm may be associated with marfan syndrome, syphilis
thoracic aortic aneurysm
Early use of ________ drugs may decrease the extent of necrosis and myocardial damage and dramatically improve outcome and prognosis.
thrombolytic antiarrhythmic
rupture of the fibrous cap or ulceration of the fibrous plaque can rapidly lead to:
thrombosis
Patients who experience angina pectoris with exercise are having:
transient myocardial ischemia
Conditions that result in marked rapid fluid accumulation include, for example:
trauma and aortic dissection.
Cardiac serum biomarkers of acute MI include:
troponin I, troponin T, creatine kinase isoenzyme (CK-MB), and myoglobin.
Patients with diabetes have _____- to ____fold higher rates of future cardiovascular events compared with age-matched and ethnically matched nondiabetic patients
two - to eightfold increase
a past history of ischemic heart disease with no other clinical risk factors is associated with how much risk for an adverse event during dental procedures?
unlikely (to be associated w/ significant risk)
Patients with coronary atherosclerosis who experience prolonged pain as a result of myocardial ischemia usually have __________ or are having _________
unstable angina; an acute MI
Also, dentists should be aware that patients who have ischemic heart disease with concurrent ________ and low ejection fraction (<___%) may be at higher risk for major adverse outcomes when invasive procedures are performed
valvulopathology, <50%
Studies have shown, however, that modest quantities of _________ may be used safely even in high-risk patients when accompanied by oxygen, sedation, nitroglycerin, and excellent pain control measures.
vasoconstrictors
The use of _________ in local anesthetics poses potential problems for patients with ischemic heart disease because of the possibility of precipitating cardiac tachycardias, arrhythmias, and increases in blood pressure.
vasoconstrictors
The most common cause of sudden death is:
ventricular fibrillation, a form of abnormal electrical activity resulting from interruption of the heart's electrical conduction system
typical presentation of patients with acute pericarditis
-Patients frequently healthy -Viral illness several days to weeks prior -Fever and "pleuritic" chest pain -Worse on inspiration or with cough -Improved when sitting upright or leaning forward -"Shortness of breath"
what are tram-line calcifications
-can be seen on xrays -associated with encephalotrigeminal hemangiomatosis (sturge-weber syndrome)
symptoms of STEMI
-chest pain at rest -diaphoresis -dyspnea -nausea/vomiting -syncope/sudden death
Multiple prospective studies have clearly documented that, compared with nonsmokers, persons who smoke ___ or more cigarettes daily have a two- to fourfold increase in coronary heart disease
20
The development of an ___________ in a patient who has had an acute MI constitutes an emergency that must be treated aggressively with __________ drugs.
arrhythmia, antiarrhythmic
for patients w/ stable angina or past history of myocardial infarction: how many carpules of 1:100,00 epi at a time and what happens if you use greater quantities
2; may be tolerated well but increase risk
what is the classic triad of tamponade
hypotension, elevated JVP, muffled heart sounds
symptoms of peripheral artery disease (PAD)?
-Initially causes muscle cramping/heaviness/aching with walking a fixed distance -Pain occurs in the muscle group distal to the blocked artery -->Superficial femoral artery blockage causes calf cramping --->Iliac artery blockage causes buttock and thigh cramping --->Progresses to pain at rest and then ultimately to tissue loss
steps to take if your patient is having an MI
Call 911 immediately Get your AED (automated external defibrillator) ready MONA - Morphine, Oxygen, Nitroglycerine, Aspirin o Morphine (unlikely to have in a dental office) Given if nitroglycerin does not relieve pain. o Oxygen (required in all offices; part of your nitrous oxide armamentarium) Administer in patients who are short of breath, have signs of heart failure or are hypoxic (per ACLS.com) o Nitroglycerin, 0.3-0.4mg sublingual (will have in emergency kit) Up to 3 doses (time 0; after 5 minutes if symptoms persist, a final time at 10 if symptoms persist) The EMTs should be on their way o Aspirin (160-325mg) Crushed or chewed to facilitate absorption Prevents thrombus formation
What items in the patient's history and physical exam make you suspicious of referred cardiac pain?
Jaw or tooth pain that is increased with exertion is characteristic of non-odontogenic toothache of cardiac origin (aka "cardiac toothache"). o Toothache pain that is relieved with rest (or nitroglycerin) is another characteristic of cardiac toothache that is not present in this case. All pulpal, periodontal, and periapical tests were normal (i.e. there is no identifiable odontogenic cause for the toothache). Multiple cardiovascular risk factors o Obesity o Hyperlipidemia o DM2 o Smokinghistory
What is the earliest serum marker for an acute MI? What is the major limitation of this test?
Myoglobin o Levels rise within 2-3 hours of an MI It is of limited use as a solo test because myoglobin levels may increase with damage to non-cardiac muscle tissue (e.g. skeletal muscle). o Non-specifictest o Cannot identify WHERE muscle damage occurred
Ischemia means literally "____________"
"to hold back blood"
signs of coronary atherosclerotic heart disease?
-clinical appearance may be entirely normal -most signs relate to other underlying cardiovascular conditions (e.g., heart failure) -BP may be elevated w/ rate/rhythm abnormalities -diminished peripheral pulses in lower extremities -C3, C4 carotid calcifications possible in panoramic radiographs (risk markers for MIs)
acute pericarditis: physical exam
-friction rub: scratchy murmur, three components (two systolic and one diastolic), bell at the left sternal border, leaning forward at held exhalation, notoriously fleeting
etiologies of acute pericarditis?
-idiopathic -viral (e.g., HIV) -bacterial (staph, strep)
-tissue hypoxia without necrosis: _______ -myocardial necrosis: ___________
-ischemia -infarction
pharmacologic management of patients with stable angina pectoris
-nitrates -beta blockers -calcium channel blockers -antiplatelet agents
what happens in AAA
-results in loss of elastin/collagen, the aorta becomes weak and stiff -intra-aortic pressure causes dilation of the aorta -defined by vessel diameter 1.5x the size of the adjacent normal vessel -involves all 3 layers of the aortic wall
development of fatty streak:
-seen in normal arteries, even in kids -significance unclear -initially lipid-laden macrophages (foam cells) and T cells -later smooth-muscle hyperplasia -fibrous cap walls off lesion (healing response) -covers a mixture of leukocytes, lipid, and debris -expand at their shoulders by means of continued leukocyte adhesion and entry
acute pericarditis therapy:
-supportive: anti-inflammatory and pain relief -anti-inflammatories: NSAIDs, steroids, colchicine, narcotics
PAD: differentiate non-urgent claudication vs critical limb ischemia (urgent)
-urgent is rest pain, minor and major tissue loss
MI type 2:
-vasospasm or endothelial dysfunction -fixed atherosclerosis and supply-demand imbalance -supply-demand imbalance alone (a condition other than acute plaque rupture/thrombosis contributes to an imbalance between myocardial oxygen supply and demand)
Assessment of risk for the dental management of patients with ischemic heart disease involves three determinants:
1. Severity of the disease 2. Stability and cardiopulmonary reserve of the patient (i.e., the ability to tolerate dental care) 3. Type and magnitude of the dental procedure
what are the three major things that atherosclerosis can cause?
1. block blood flow through vessels, leading to ischemia and infarction 2. cause thrombi (blood clots) or hemorrhage into the atheromatous plaque. these can also cause ischemia or infarction, or may break free (embolize) and block a blood vessel at a distant site 3. cause gradual weakening of the blood vessel wall, leading to an outpouching (aneurysm) that is at risk of rupture causing major bleeding or death
atheroma has what three complications?
1. compromise of lumen 2. thrombosis or hemorrhage into plaque 3. erosion and gradual destruction of the vessel wall
It has been shown that morbidity and mortality increase linearly with blood pressures greater than ______
115/75 mm Hg
Troponins are first detectable __ to __ hours after the onset of an acute MI
2 to 4
Patients who are taking warfarin for anticoagulation can safely undergo dental or surgical procedures, provided that the international normalized ratio (INR) is ____ or less
3.5 ; should be performed within 24 to 72 hrs within scheduled invasive procedure depending on level of INR stability
the prevalence of metabolic syndrome among adults in the United States is estimated to be about __%, which increases with age
34%
The energy expended in performing these tasks is measured in metabolic equivalents of tasks (METs), which is a measure of oxygen consumption. Studies have shown that a person who cannot perform at a minimum of a ___ MET level is at increased risk for a cardiovascular event. Climbing a flight of stairs requires a ___-MET effort; thus, a person who cannot climb a flight of stairs without chest pain or shortness of breath is at increased risk.
4
A ruptured aortic aneurysm has about a __% mortality rate.
40
Patients with PAD are ___ times more likely to die from heart attack or stroke than are age matched patients without PAD.
5
Most cardiac arrest survivors have structural heart disease; nearly __% have coronary artery disease
75%
What associated abnormalities of the aorta should you consider in a patient with aortic valve stenosis and regurgitation?
Approximately 50% of patients with a bicuspid aortic valve will have enlargement of the ascending aorta, and the enlargement can involve the aortic arch.
________, in daily doses of 75 to 325 mg, is recommended for all patients with acute and chronic ischemic heart disease, regardless of the presence or absence of symptoms
Aspirin
_______ is the thickening of the intimal layer of the arterial wall caused by the accumulation of lipid plaques
Atherosclerosis
Testing for levels of __________, which is produced largely by the left ventricle, also aids in determining the extent of ventricular damage and the prognosis of heart failure.
B-natriuretic peptide
_______ is also found after injury to skeletal muscle and other tissues. However, elevated levels are usually considered to be the result of an MI
CK-MB
___________ is a life-threatening condition caused by a pericardial effusion that raises pericardial pressure.
Cardiac tamponade
____________ is a common location for peripheral vascular disease
Carotid artery stenosis - occurs at carotid bifurcation due to shear stress along the wall
________ is the most important symptom of coronary atherosclerotic heart disease
Chest pain
_____________ is the single most important modifiable risk factor for coronary heart disease
Cigarette smoking
A Berry Aneurysm is most commonly an aneurysm in the _____________ in the cerebral arteries
Circle of Willis
__________ can develop as a complication of coronary atherosclerotic heart disease
Congestive heart failure
_________ is the leading health problem in the United States and the world
Coronary atherosclerotic heart disease
True or False - Local anesthetic agent with epinephrine is contraindicated in a patient with unstable angina
False - Though anesthesia should be limited when providing urgent/emergent care, up to 2 carpules of 2% lidocaine with 1:100,000 epinephrine are considered to be safe (36 μg epinephrine); 3% mepivicaine without epinephrine is another alternative.
side effects of calcium channel blockers
Gingival overgrowth, dry mouth, lichenoid eruptions (rare)
side effects of clopidogrel
Increased bleeding time. Vasoconstrictor interactions: none
side effects of aspirin
Increased bleeding, but not clinically significant with daily doses ≤325 mg. Vasoconstrictor interactions: none
_____________ is one of the most significant risk factors for coronary atherosclerotic heart disease
Increased blood pressure
___________ is the term used to describe a cluster of pathologic findings consisting of obesity, insulin resistance, low HDL cholesterol, elevated triglycerides, and hypertension, all of which are risk factors for atherosclerosis. The recognized importance of this clinical syndrome as a setting for the development of atherosclerosis reflects a synergistic effect of the multiple risk factors.
Metabolic syndrome
what drug should be avoided in pts with established hypertension and coronary artery disease, especially those whose cardiac history includes an MI?
NSAIDs - can increase risk for subsequent MI (only naproxen did not increase risk)
are mortality and complications higher with NSTEMI or UA?
NSTEMI
cardiac tamponade: hemodynamics:
Normal ↑ volume in the right ventricle with inspiration → septum to the left → ↓ left ventricular stroke volume → transient ↓ blood pressure < 10 mmHg Tamponade Compression of ventricles → exaggerated septal shift to left Pulsus paradoxus >15 mmHg May have palpable disappearance of radial pulse with inspiration
claudication is usually associated with what type of disease?
PAD
__________ may be present in patients with coronary atherosclerotic heart disease with normal or abnormal rhythm.
Palpitations of the heart (disagreeable awareness of the heartbeat)
______ and _______ smoking apparently convey minor risk for development of heart disease.
Pipe and cigar
Which coronary artery causes an inferior infarction and where does this blood supply go?
RCA - right atrium and right ventricle
___________ is an option for patients with stable or unstable angina. Available procedures for ___________ include percutaneous transluminal coronary angioplasty, stents, and coronary artery bypass grafting.
Revascularization
ECG in acute coronary syndromes: Non-ST elevation infarction (NSTEMI)
ST depressions or T wave inversions, usually without Q waves
The anatomic location of the infarct determines the leads in which the _________ appear
ST elevations
ECG in acute coronary syndromes: ST elevation infarction (STEMI)
ST elevations, followed Q waves and T wave inversions
what changes on the ECG do partially occlusive thrombi cause
ST segment depression and/or T wave inversion, or no significant ECG changes (it depends)
do you get elevation of CK-MB and/or troponin levels in UA or NSTEMI
STEMI
complications of hypertension - target organ damage:
TIA (transient ischemic attack), stroke; retinopathy; peripheral vascular disease; LVH (left ventricular hypertrophy), CHD, HF; renal failure
if you had ischemia/infarction in carotids, what results?
TIA, cerebral infarcts
A 56-year-old man complains of anterior chest tightness after walking uphill, climbing more than one flight of stairs, and after eating large meals. When he experiences chest tightness he also develops shortness of breath and associated pain in the left upper arm. The symptoms are relieved after a few minutes of rest. What are potential cardiovascular conditions that could be causing his symptoms?
The differential diagnosis for angina includes coronary atherosclerosis with 60% or greater narrowing, severe aortic valve stenosis, severe aortic valve regurgitation, and hypertrophic cardiomyopathy (HCM) with dynamic outflow obstruction.
______ of all deaths among patients with diabetes result from coronary heart disease.
Three fourths
ECG in acute coronary syndromes: Noninfarction subendocardial ischemia (including classic angina)
Transient ST depressions
ECG in acute coronary syndromes: Transient transmural ischemia (coronary vasospasm)
Transient ST elevations sometimes followed by T wave inversions
treatment for patient with pericarditis
Treatment is supportive for patients with viral or idiopathic pericarditis. Anti- inflammatory medications are the mainstay, usually non-steroidal anti- inflammatory agents. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of therapy. These agents have a similar efficacy, with relief of chest pain in about 85-90% of patients within days of treatment. A full-dose NSAID should be used, and treatment should last 7-14 days. Some patients require more aggressive anti-inflammatory therapy such as steroids or colchicine. Corticosteroids should not be used for initial treatment of pericarditis unless it is indicated for the underlying disease, the patient's condition has no response to NSAIDs or colchicine, or both agents are contraindicated. Occasional patients require the addition of narcotics for pain relief.
_______ assays are the most sensitive and specific in differentiating cardiac muscle damage from trauma to skeletal muscle or other organs and are virtually absent in the plasma of normal persons and are found only after cardiac injury.
Troponin
side effects of cardioselective beta blockers
Vasoconstrictor interactions: minimal effect with sympathomimetics; normal use
____________ is the most common vascular abnormality seen in community practice
Venous insufficiency
what happens in coronary artery bypass graft
With CABG, a segment of artery or vein is harvested or released from a donor site; it is then grafted to the affected segment of coronary artery, thus bypassing the area of occlusion
berry aneurysms almost always occur at ________________, where the vessel wall is especially weak, and is often due to a congenital weakness that may be worsened by hypertension
a branching point of an intracranial artery
for patients w/ stable angina or past history of myocardial infarction: Use of excessive amounts of epinephrine with nonselective beta-blockers can potentially cause ______________; avoid the use of:
a spike in blood pressure and appears to be dose dependent; epinephrine-impregnated retraction cord.
if you had ischemia/infarction in mesentery, what results?
abdominal angina, bowel infarct
pulsatile abdominal mass may be this aneurysm
abdominal aortic aneurysm
what is AAA and what is it caused by
abdominal aortic aneurysm - caused by inflammation and degradation of the aortic wall
The term __________ describes a continuum of myocardial ischemia that ranges from unstable angina at one end to non-ST segment MI at the other.
acute coronary syndrome
what is the most common cause of pericardial disease
acute pericarditis
at what point is there a rapid reduction in the gender difference for risk of coronary atherosclerosis?
after menopause for women
what are some diseases that can precipitate or worsen angina?
anemia, obesity, hyperthyroidism, sleep apnea
if you had ischemia/infarction in coronaries, what results?
angina, MI
for patients w/ stable angina or past history of myocardial infarction: what to do if patient is taking aspirin or other antiplatelet medicine
anticipate increased bleeding but no modification required
high cardiac risk surgeries
aortic and other major vascular surgery
Patients with ________ have a greater incidence of coronary atherosclerotic heart disease and more extensive lesions.
diabetes mellitus
patients who have ______ develop the condition at an earlier age than the typical person who doesn't have it
diabetes mellitus
side effects of nitrates (Treatment for management of angina)
dry mouth, orthostatic hypotension, headache, no vasoconstrictor interactions
Drugs used in the treatment of ischemic heart disease may produce oral changes such as:
dry mouth, taste aberrations, and stomatitis.
Increased pericardial pressure compresses the heart and requires a commensurate rise in ____________ to allow adequate cardiac output.
end ventricular pressure
Thus, a dentist should not prescribe __________ to patients who take either HMG-CoA reductase inhibitors (e.g., simvastatin, atorvastatin, pravastatin) or CCBs
erythromycin or clarithromycin
what is a foam cell
fat-laden M2 macrophages (when macrophages take up LDL) that serve as the hallmark of early stage atherosclerotic lesion formation. They are an indication of plaque build-up, or atherosclerosis, which is commonly associated with increased risk of heart attack and stroke as a result of arterial narrowing and hardening.
Of interest, women and men report different symptoms of MI, with fewer women experiencing chest pain but more often experiencing:
fatigue, dyspnea, and gastrointestinal complaints (e.g., heartburn)
what happens after plaque ruptures
fibrous cap tears, platelet adhesion, activation of coagulation cascade, results in clot or thrombus formation, sudden expansion of lesion = blood flow through affected artery may become compromised or completely blocked
CCBs can induce _____________ when plaque control is less than optimal and is more prominent at anterior interproximal sites.
gingival overgrowth
For patients at all levels of cardiac risk, the use of _______________ should be avoided because of the rapid absorption of a high concentration of epinephrine and the potential for adverse cardiovascular effects
gingival retraction cord impregnated with epinephrine
Atherosclerosis is a contributing factor to about _______ of all deaths in modern society, especially heart attacks, strokes, and aneurysms.
half
how to diagnose cardiac tamponade
history, physical exam, echocardiography
what are some main risk factors for cardiovascular disease
hypertension, smoking, hyperlipidemia, (diabetes?)
what happens when compensatory mechanisms fail for pericardial effusions
hypotension, decreased CO, shock, death
Elevation in serum lipid levels is a major risk factor for atherosclerosis. Increased levels of ____________ cholesterol pose the greatest risk for coronary atherosclerosis, whereas increased levels of __________ cholesterol have been shown to reduce the risk
low-density lipoprotein (LDL), high-density lipoprotein (HDL)
What infection is spread by ticks and can be associated with acute infectious pericarditis?
lyme disease
malignant hypertension causes:
malignant arteriolosclerosis - small arteries w/ smooth muscle proliferation = onion-skin appearance
_____ are at higher risk than _____ for having a heart attack or fatal coronary heart disease, and ______ are at highest risk.
men > women; black men highest risk
One method of decreasing the occurrence of restenosis with percutaneous transluminal coronary angioplasty involves the use of a thin, expandable, ___________ positioned by the balloon and expanded against the plaque and vessel wall, then left in place.
metallic mesh stent
Atheroma formation is initiated by adherence of _______ to an area of injured or altered endothelium.
monocytes
Troponins are proteins derived from the breakdown of:
myocardial sarcomeres
where does physiologic injury occur as a result of? (in development of atheromatous plaques)
result of disturbed blood flow at bending points or bifurcations (branch points) in the artery
what can erosion and gradual destruction of the vessel wall after atheroma cause?
risk of rupture and exsanguination
what is the predominant cause of acute coronary syndrome (ACS) and heart attack?
rupture of an atherosclerotic plaque
definitive diagnosis of MI requires how much testing?
serial testing (every 6-8 hrs) over several days
During the first several weeks after an infarction, the conduction system of the heart may be unstable, and patients are prone to ______ and ______. A pacemaker may be used in patients who have severe myocardial damage and resultant heart failure.
serious arrhythmias and reinfarction
Based on the assessment of medical risk, the type of planned dental procedure, and the stability and anxiety level of the patient, general management strategies for patients with stable angina or a past history of MI without ischemic symptoms (intermediate risk category) and no other risk factors should include the following:
short appointments in the morning, comfortable chair position, reduced stress environment with oral sedation or nitrous oxide-oxygen sedation, pretreatment vital signs, availability of nitroglycerin, profound local anesthesia, limited amount of vasoconstrictor, avoidance of epinephrine-impregnated retraction cord, and effective postoperative pain control
what is the approximate size of discomfort felt in angina pectoris and where may it radiate ?
size of a fist; may radiate to shoulder, left or right arm, beck or lower jaw
slow vs rapid fluid accumulation (pericardial pressure volume loop): which leads to stretching that accommodates volume
slow
characteristics for stable vs unstable angina
stable: a consistent, recurring, unchanging pattern brought on by exertion or stress that typically subsides within 5 to 15 minutes with rest or use of nitroglycerin unstable: worsening chest pain with a pattern of increasing severity, frequency, or duration. if pain is unremmitting after 15 min, MI should be assumed
what is malignant hypertension associated with:
stage 2 hypertension and BP > 160/110 mmHg
subendocardial vs transmural myocardial infarct
subendocardial is a "partial thickness" and transmural is a "full thickness"
Pathologic, horizontal ST segment depression that occurs with exercise (note increased HR):
subendocardial ischemia
at what % occlusion of the artery do you see symptoms vs acute coronary events
symptoms: 75% acute coronary event: 50%
Peripheral artery disease is a reflection of ____________ and is an important marker for ____
systemic atherosclerosis, CAD
Pericarditis is one of the defining clinical features of ______________, and may affect up to 30% of patients at some point in their illness.
systemic lupus erythematosus
In general, _______ blood pressure is more strongly related to the incidence of cardiovascular disease than is _______ blood pressure, especially in older adults
systolic > diastolic
side effects of non selective beta blockers
taste changes, lichenoid reactions, orthostatic hypotension, increase in BP possible with sympathomimetics
in the days before antibiotic therapy, what was the most common aneurysm?
tertiary syphilis
The most common site for a berry aneurysm is:
the Anterior Communicating Artery
why could periodontal disease be associated with cardiovascular disease
the chronic inflammatory burden of perio disease may lead to impaired functioning of the vascular endothelium
what happens in plaque rupture
the fibrous cap tears, allowing arterial blood to enter the lipid core, where contact with tissue factor and collagen induces platelet adhesion and aggregation and activation of the coagulation cascade.
the area of necrosis is also called:
the infarct
distinction between unstable angina and non-STEMI (non-ST-elevation MI)?
whethe or not there is necrosis/infarction
are abdominal aortic aneurysms associated with hypertension?
yes
has tooth scaling been associated with decreased risk of cardiovascular disease outcomes
yes
does atherosclerosis usually occur in certain areas and what are they?
yes - brain, heart, aorta, peripheral arteries
should you use morphine in STEMI or non-STEMI patients
yes for STEMI; in non-STEMI patients it's been associated with increased mortality rate and should be avoided in these patients
for patients w/ stable angina or past history of myocardial infarction: if patients' stable angina is relieved by nitrates, can they receive routine dental care?
yes; have nitroglycerin available
Clinical Predictors of Increased Perioperative Cardiovascular Risk: Myocardial Infarction, Heart Failure, or Death --- MINOR clinical risk factors:
• Advanced age (>70 years) • Abnormal ECG (left ventricular hypertrophy, left bundle branch block, ST-T wave abnormalities) • Rhythm other than sinus (e.g., atrial fibrillation) • Uncontrolled systemic hypertension (≥180/110 mm Hg)
Clinical Predictors of Increased Perioperative Cardiovascular Risk: Myocardial Infarction, Heart Failure, or Death --- INTERMEDIATE clinical risk factors:
• History of ischemic heart disease • History of compensated or previous heart failure • History of cerebrovascular disease • Diabetes mellitus • Renal insufficiency
Clinical Predictors of Increased Perioperative Cardiovascular Risk: Myocardial Infarction, Heart Failure, or Death --- MAJOR clinical risk factors:
• Unstable coronary syndromes • Acute or recent MI * * The American College of Cardiology National Database Library defines recent myocardial infarction (MI) as occurring after 7 days but within 1 month (at or before 30 days) before the procedure and acute MI as occurring within 7 days. associated with important ischemic risk as indicated by clinical signs and symptoms or by noninvasive study• Unstable or severe angina (Canadian class III or IV) †May include "stable" angina in patients who are unusually sedentary. • Decompensated heart failure (NYHA class 4: worsening or new-onset heart failure) • Significant arrhythmias • High-grade AV block • Mobitz type 2 AV block • Third-degree AV block • Symptomatic ventricular arrhythmias in the presence of underlying heart disease • Supraventricular arrhythmias with uncontrolled ventricular rate • Symptomatic bradycardia • Newly recognized ventricular tachycardia • Severe valvular disease • Severe aortic stenosis • Symptomatic mitral stenosis
