Group 5: DHD 422 DHB

GARMA - Overview & Clinical Examination of CVS

HOI - Diagnostic Tests of CVS & Diagnosis of CAD
MAPA - Medical & Dental Management of Px with CAD
MARALLI - PPT, Pathophysiology & Dental Considerations of CAD

A. Review of Literature
The Cardiovascular System

Overview of the Cardiovascular System

The cardiovascular system consists of the heart, blood vessels, and the approximately 5 liters of blood
that the blood vessels transport. It is an organ system that conveys blood through vessels to and from all
parts of the body, carrying nutrients and oxygen to tissues and removing carbon dioxide and other
wastes.
Functions

● Transportation: The cardiovascular system transports blood to almost all of the body’s tissues.

● Protection: The cardiovascular system protects the body through its white blood cells.

● Regulation: The cardiovascular system is instrumental in the body’s ability to maintain

homeostatic control of several internal conditions.

Cardiovascular System Anatomy

● Heart- The bottom tip of the heart, known as its apex, is turned to the left, so that about 2/3 of
the heart is located on the body’s left side with the other 1/3 on right. The top of the heart,
known as the heart’s base, connects to the great blood vessels of the body: the aorta, vena cava,
pulmonary trunk, and pulmonary veins.

● Blood Vessels
- Arteries- carry oxygenated blood away from the heart.
- Capillaries-distribute the nutrients and oxygen to the body's tissues and remove
deoxygenated blood and waste.
- Venules- (very small veins) merge into veins which carry blood back to the heart.

● Blood is made up of about 45% solids (cells) and 55% fluids (plasma). The plasma is largely water,
containing proteins, nutrients, hormones, antibodies, and dissolved waste products.
- Erythrocytes (red blood cells) are small red disk shaped cells. They contain HEMOGLOBIN, which
combines with oxygen in the lungs and is then transported to the body's cells. The hemoglobin
then returns carbon dioxide waste to the lungs.
- Leukocytes (white blood cells) help the body fight bacteria and infection. When a tissue is
damaged or has an infection the number of leukocytes increases. Leukocytes are formed in the
small ends of bones.
- Thrombocytes (platelets) aid the formation of blood clots by releasing various protein
substances.
Clinical Examination of the Cardiovascular System

The cardiac examination consists of evaluation of

1. The carotid arterial pulse and auscultation for carotid bruits

- Examination of the carotid arterial pulse. Place the patient in the supine position with the trunk
elevated approximately 30 degrees, the head turned slightly toward the side being examined
and the chin elevated. Palpate the carotid artery by gently pressing with the fingertips of the
index, middle, and third fingers at, or hooked around, the medial aspect of the
sternocleidomastoid muscle in the lower half of the neck
- Auscultation of the carotid artery. Lightly apply the bell of the stethoscope over the course of the
carotid artery, from the base of the neck to angle of the jaw, during full expiration.

2. The jugular venous pulse and auscultation for cervical venous hums
- Evaluation of the jugular venous pulse and the carotid artery are best accomplished with the
patient supine, the neck muscles relaxed by placing a small pillow under the head and the trunk
elevated until the maximal internal jugular venous pulsations are visible.
- Estimation of the central venous pressure (CVP). Place the patient in the supine position with the
head slightly elevated on a pillow to relax the sternocleidomastoid muscle. Elevate the trunk by
adjusting the head of the bed so as to maximize the internal jugular venous pulsations and make
them visible above the clavicles.

3. The precordial impulses and palpation for heart sounds and murmurs
- The precordial examination. Consists of inspection and palpation of the anterior chest wall. Ask
the patient to take a deep breath and then to exhale slowly as you look for a discrete area of
apical movement.

4. Auscultation of the heart

- Auscultation of the heart. Auscultation usually begins at the aortic area (upper right sternal
edge). The stethoscope is then moved sequentially to the pulmonary (upper left sternal edge),
tricuspid (lower left sternal edge), and mitral (apex) areas.
Diagnosis Tests of the Cardiovascular System

● Blood test
- A complete cholesterol test checks four types of fats in your blood:

1. Total cholesterol
- The sum of all cholesterol in your blood

2. Low-density lipoprotein (LDL) cholesterol (“bad” cholesterol)

- Too much LDL causes fat to build up in the arteries, which reduces blood flow.
This can lead to a heart attack or stroke.

3. High-density lipoprotein (HDL) cholesterol (“good” cholesterol)

- HDL helps carry away LDL cholesterol and clear your arteries.

4. Triglycerides
- Triglycerides are a type of fat in the blood. High levels of triglycerides are often
associated with diabetes, smoking, and excessive alcohol consumption.

● C-reactive protein (CRP) tests

- C-reactive protein (CRP) is a protein that increases in the blood with inflammation and
infection as well as following a heart attack, surgery, or trauma.
- Studies have suggested that a persistent low level of inflammation plays a major role in
atherosclerosis, the narrowing of blood vessels due to build-up of cholesterol and other
lipids, which is often associated with cardiovascular disease (CVD).

● Noninvasive tests for heart disease

- After completing a physical examination and blood tests, the doctor may order
additional noninvasive tests.

1. Electrocardiogram
- An electrocardiogram (ECG) is a short test that monitors the electrical activity in a
patient's heart. It records this activity on a strip of paper. Check for an irregular
heartbeat or heart damage.

2. Echocardiogram
- An echocardiogram is an ultrasound of the heart. It uses sound waves to create a
picture of the heart. Use it to evaluate heart valves and heart muscles.
 3. Stress test
- Stress test, also called an exercise stress test, shows how your heart works during
physical activity.

4. Carotid ultrasound
- A carotid duplex scan uses sound waves to create pictures of the carotid arteries on
both sides of the neck. Check for a buildup of plaque in the arteries and assess the
risk of stroke.

5. Holter monitor
- The Holter monitor is a type of portable electrocardiogram (ECG). It records the
electrical activity of the heart continuously over 24 hours or longer while the patients
are away from the doctor's office.
- The doctor can use it to check for heart abnormalities that can go undetected on a
normal ECG, such as arrhythmias, or irregular heartbeats.

6. Chest X-ray
- A chest X-ray uses a small amount of radiation to create images of your chest,
including your heart. It can help the doctor determine the cause of shortness of
breath or chest pains.

7. Tilt table test

- A tilt table test attempts to determine the cause of syncope by creating changes in
posture from lying to standing. You will lie flat on a special bed or table with special
safety belts and a footrest while connected to electrocardiogram (ECG) and blood
pressure monitors.

8. CT scan
- A CT scan uses multiple X-ray images to create a cross-sectional image of your heart.
The doctor may use different types of CT scans to diagnose heart disease. For
example, the doctor may use a calcium score screening heart scan to check for
calcium deposits in the coronary arteries. Or they may use coronary CT angiography
to check for fat or calcium deposits in the arteries.

9. Heart MRI
- In an MRI, large magnets and radio waves create images of the inside of the body.
During a heart MRI, a technician creates images of blood vessels and heart while it’s
beating. After the test, the doctor can use the images to diagnose many conditions,
such as heart muscle diseases and coronary artery disease.

● Invasive tests for heart disease

Sometimes noninvasive tests don’t provide enough answers. The doctor may need to use
an invasive procedure to diagnose heart disease.
 1. Coronary angiography and cardiac catheterization
- The doctor inserts a long flexible tube through a blood vessel then they move this
tube toward your heart. Then they’ll use an X-ray to look at your coronary arteries.
They can use this test to look for narrowed or blocked arteries.

2. Electrophysiology study
- This is a test used to evaluate your heart's electrical system and to check for
abnormal heart rhythms. During this test, your doctor feeds an electrode catheter
through your blood vessel to your heart. They use this electrode to send electric
signals to your heart and create a map of its electrical activity.

B. Case Report
Diagnosing Patients with Coronary Artery Disease (CAD)

- The doctor will ask questions about your medical history, do a physical exam and order routine
blood tests. He or she may suggest one or more diagnostic tests as well, including:

1. Electrocardiogram (ECG). It records electrical signals as they travel through your heart.
An ECG can often reveal evidence of a previous heart attack or one that's in progress.

2. Echocardiogram. It uses sound waves to produce images of your heart.

Parts that move weakly may have been damaged during a heart attack or are receiving
too little oxygen. This may be a sign of coronary artery disease or other conditions.

3. Exercise stress test. If your signs and symptoms occur most often during exercise, your
doctor may ask you to walk on a treadmill or ride a stationary bike during an ECG.
Sometimes, an echocardiogram is also done while you do these exercises. This is called a
stress echo. In some cases, medication to stimulate your heart may be used instead of
exercise.

4. Nuclear stress test. This test is similar to an exercise stress test but adds images to the
ECG recordings. It measures blood flow to your heart muscle at rest and during stress.
 5. Cardiac catheterization and angiogram. During cardiac catheterization, a doctor gently
inserts a catheter into an artery or vein in your groin, neck or arm and up to your heart.
X-rays are used to guide the catheter to the correct position. Sometimes, dye is injected
through the catheter. The dye helps blood vessels show up better on the images and
outlines any blockages.
If you have a blockage that requires treatment, a balloon can be pushed through the
catheter and inflated to improve the blood flow in your coronary arteries. A mesh tube
(stent) is typically used to keep the dilated artery open.

6. Cardiac CT scan. It can help your doctor see calcium deposits in your arteries that can
narrow the arteries. If a substantial amount of calcium is discovered, coronary artery
disease may be likely.
A CT coronary angiogram, in which you receive a contrast dye that is given by IV during a
CT scan, can produce detailed images of your heart arteries.

Medical Management of Patients with CAD

- Management of coronary artery disease is aimed at controlling symptoms and slowing or

stopping the progression of disease. The method of treatment is based on many factors
determined by your symptoms, a physical exam, and diagnostic testing. In many cases, if the
blockage is less than 70 percent and not severely limiting blood flow, medications may be the
first line of treatment.

Patients with CAD take medications such as:

● Aspirin – is often used to prevent blood clots forming in the heart arteries in patients with
coronary artery disease. Aspirin has been shown to improve survival after a heart attack.
● Beta blockers – are a class of medications that relax the blood vessels and slow the heart rate. It
thereby improves blood flow to the heart, decreases blood pressure and symptoms of angina,
and has been shown to improve survival after a heart attack.
● Ranolazine (Ranexa) – is a medication used to treat chronic angina. It works by improving blood
flow to the heart and decreases the occurrence of angina attacks. It is used in combination with
other medications.
● Ace inhibitors – are given to patients if they have heart failure, or their heart muscle is not
pumping as well as it should. Ace inhibitors have been shown to improve survival after a heart
attack.
● Lipid management – is essential for all patients with coronary artery disease who have higher
than normal blood lipid levels.
Cardiac Rehabilitation
For many people with coronary artery disease, a cardiac rehabilitation program provides an excellent
opportunity to begin an exercise program, learn about your heart disease, and learn strategies to change
your lifestyle to prevent further progression of your disease.

Dental Management of Patients with CAD

- The primary management goal for the patient with cardiovascular disease during dental therapy
is to ensure that any hemodynamic change produced by dental treatment does not exceed the
cardiovascular reserve of the patient. This is best achieved by minimizing any hemodynamic
alterations during treatment (that is, by maintaining the patient's optimum blood pressure, heart
rate, heart rhythm, cardiac output and myocardial oxygen demand).

- Psychological and physiological stress during periodontal treatment has the potential to
significantly alter hemodynamic stability. Consequently, a stress-reduction protocol is frequently
suggested for patients with significant cardiovascular compromise, which includes the following:

● Shorter appointments, preferably in the morning when the patient is well-rested and has a
greater physical reserve;

● Use of profound local anesthesia to minimize discomfort;

➢ The use of local anesthetic agents with vasoconstrictors in patients with cardiovascular
disease remains controversial. The two most commonly used vasoconstrictors are
epinephrine and levonordefrin. Levonordefrin is only 20 percent as potent as epinephrine;
therefore, its concentration in dental anesthetics is fivefold greater (that is, 1:20,000) than
the most common concentration of epinephrine (1:100,000).

➢ Normal epinephrine release from the adrenal medulla can increase 20- to 40-fold during
stress. Such stress may be induced by pain during dental treatment. Patients receiving local
anesthetic without vasoconstrictor often have significantly impaired pain control compared
with those receiving local anesthetic with epinephrine. For this reason, patients with
cardiovascular disease may be at greater risk of experiencing massive endogenous
epinephrine release secondary to poor local anesthesia than they are from the small
amount of vasoconstrictor used in local anesthetics.

● preoperative or intraoperative conscious sedation or both;

● excellent postoperative analgesia.

C. References:

1. Simon Cotterill (2014), The Cardiovascular System (Heart and blood)

2. Tim Taylor (2020), Cardiovascular System
3. Mark L. Entman (2007), Human Cardiovascular System
4. Joel Felner (1990), An overview of the Cardiovascular System
5. Cleveland Clinic (2019), Coronary Artery Disease: Medical Management
6. Mayo Clinic (2020), Coronary Artery Disease
7. S. Chaudhry et al. (2016), Dental considerations in cardiovascular patients: A practical
perspective
8. S. Singh et al. (2017), Dental Management of the Cardiovascular Compromised Patient: A Clinical
Approach
9. Coronary Heart Disease_ Clinical, Pathological, Imaging, and Molecular Profiles, Zeev Vlodaver,
Robert F.Wilson, Daniel J. Garry
10. V. Kumar et al. (2011), Robbins and Cotran’s Pathologic Basis of Disease, 8th ed.
11. P. Kamdi et al. (2020), Case Report on Coronary Artery Disease