General Medicine

1. Lecture Series Name & ID General Medicine CVS-Presenting features Note: Lecture Notes are for revision purpose only. For acquiring knowledge study of the recommended text books is a must. Dr. J. Satish Kumar, MD, Department of Basic & Medical Sciences, Faculty of Dentistry, AUST

2. Presenting Clinical Features-Intro • Limited range of symptoms in CVS. • Hence careful analysis of the following is must for diagnosis: • the factors that provoke the symptoms • the subtle differences in how they are described by the patient • the clinical findings and • investigations

3. Presenting Clinical Features-Intro • Chest Pain • Breathlessness/Dyspnea • Syncope or presyncope • Palpitation

4. Hall mark of heart diseaseRelationship with exercise Class I No limitation during ordinary activity Class II Slight limitation during ordinary activity Class III Marked limitation of normal activities without symptoms at rest Class IV Unable to undertake physical activity without symptoms; symptoms may be present at rest

5. Hand Gestures in chest pain

6. Chest Pain-Intro • It is a common presentation of cardiac disease. • It can also be a manifestation of • Anxiety • disease of the lungs • the musculoskeletal system or • the gastrointestinal system • ‘Pain' &'discomfort' may be used to mean the same chest pain.

7. Characteristics of ischemic Chest Pain • Site of origin of pain. • located in the centre of the chest • Radiation. • Ischaemic cardiac pain radiates to the neck, jaw, and upper or even lower arms. • Character of the pain. • Dull, constricting, choking or 'heavy', • Usually described as squeezing, crushing, burning or aching but not sharp, stabbing, pricking or knife-like.

8. Characteristics of ischemic Chest Pain • Provocation. • Anginal pain occurs during (not after) exertion and is promptly relieved (in less than 5 minutes) by resting. • The pain may also be brought on or exacerbated by emotion • It tends to occur more readily during exertion, after a large meal or in a cold wind.

9. Characteristics of ischemic Chest Pain • Pattern of onset. • The pain of myocardial infarction takes several minutes or even longer to develop; • Angina builds up gradually in proportion to the intensity of exertion • Associated features. • The pain of myocardial infarction is accompanied by autonomic disturbance like sweating, nausea and vomiting.

10. Chest Pain – Important DD • Cardiac • Myocardial ischaemia (angina) & infarction • Pericarditis • GIT • Oesophageal spasm • Reflux Esophagitis • Respiratory System • Pneumonia • Pneumothorax • Pulmonary embolism • Tuberculosis • Musculoskeletal • Osteoarthritis • Rib fracture/injury • Intercostal muscle injury • Neurological • Prolapsed intervertebral disc • Herpes zoster

11. Dyspnea-Intro • In dyspnea of cardiac origin, severity may vary from an uncomfortable awareness of breathing to a frightening sensation of 'fighting for breath'. • The sensation of dyspnoea originates in the cerebral cortex, based on stimuli arising from receptors in the • lungs • upper airways and • respiratory muscles

12. Causes of cardiac dyspnea • Acute left heart failure • Chronic heart failure • Arrhythmia • Angina equivalent

13. Fainting

14. Common causes of fainting • Vasovagal syncope • This is usually triggered by a reduction in venous return due to prolonged standing, excessive heat or a large meal. • Treatment is often unnecessary but in severe cases β-blockers (may be helpful • Postural hypotension • Relative hypovolaemia (often due to excessive diuretic therapy), • sympathetic degeneration (diabetes mellitus, Parkinson's disease, ageing) and • drug therapy (vasodilators, antidepressants) can all cause or aggravate the problem. • Treatment is often ineffective; however, withdrawing unnecessary medication while advising the patient to wear graduated elastic stockings and get up slowly may be helpful.

15. Palpitation • It describes a wide variety of sensations including an unusually erratic, fast, slow or forceful heart beat and even chest pain or breathlessness. • Palpitation is usually benign. • Most cases are due to an awareness of the normal heart beat, a sinus tachycardia or benign extrasystoles that have been triggered by stress, an intercurrent illness, or the effects of caffeine, alcohol and nicotine. • If severe, low dose of a β-blocker is helpful

16. Dental Perspective in chest pain 1. Properly assess the patient. This should include an assessment by the dentist and also a medical consultation if required. 2. Establish what medications the patient is taking along with the dose and timing and note any potential drug interactions and side effects. 3. Use short appointments (less than one hour), preferably in the morning. 4. Premedication should be considered to alleviate anxiety. The intraoperative use of nitrous oxide and oxygen is also a reasonable strategy for patients with cardiovascular disease, particularly those with ischemic heart disease.

17. 5. Effective local anesthesia is important in order to avoid undue stress during the appointment 6. For patients with angina pectoris, a fresh supply of nitroglycerin should be available at the time of the appointment. 7. Prophylactic nitroglycerin has been shown to be effective in the prevention of both hypertension and angina pectoris during dental treatment. 8. The appointment should be terminated early if the patient becomes overly anxious. In the event of cardiovascular symptoms during dental treatment, all work should be stopped.