The Cardiovascular System

The Cardiovascular System 

In Brief • Cardiovascular disease is common. • Pain and anxiety increase cardiac load and increase the risk of precipitating angina/arrhythmias. • A thorough history will usually elicit the fact that the patient has cardiovascular disease (summarised in Table 2.2). • Examination of the patient may reveal cardiovascular disease—cyanosis (central/peripheral), shortage of breath, abnormalities in the pulse, finger clubbing, splinter haemorrhages or ankle oedema. • Drugs used in the treatment of cardiovascular disease impact on patient 

This book examines aspects of general medicine and surgery which are of relevance to dental practice. The approach is standardised by considering systems under common headings, e.g. history, examination, commonly prescribed drugs and aspects relating to general and local anaesthesia and management in the dental surgery. The first chapter considers the cardiovascular system.

2.1 Introduction Cardiovascular disease is common and it is inevitable that any practitioner dealing with patients will encounter it. In 1984 it was estimated that 2% of all adult dental patients were receiving antihypertensive therapy [1, 2]. This figure has risen, and in 1997 it was reported that up to 13% of patients in a dental hospital setting and 5% of those attending dental practice were receiving antihypertensive drugs [3]. There may be a well-established previous history of cardiovascular disease. The incidence increases with age such that, by the age of 70, all patients will have some degree of cardiovascular disease (this may be very minor and subclinical or the origin not recognised by the patient, e.g. calf claudication, a sign of peripheral vascular disease). Risk factors for cardiovascular disease are shown in Table 2.1. In the history it is clearly important to assess the degree of compensation that the patient has managed to achieve, i.e. how badly the patient is affected by their condition in terms of signs, symptoms and activity. The efficacy of medication is also important. Some patients may be taking aspirin on a regular basis. Specific enquiry is important due to aspirin’s effects on blood clotting.

2.2 Relevant Points in the History

2.2.1 Chest Pain

The purpose of questioning here is not to try to be diagnostic but to gain an idea as to whether a cardiovascular cause for the pain may be likely, since some patients may be unaware of their condition but nevertheless be at risk. Features which make the pain unlikely to be cardiac in origin are pains lasting less than 30 s however severe, stabbing pains, well-localised left submammary (under the breast) pain and pains which continually vary in location. A chest pain made better by stopping exercise is more likely to be cardiac in origin than one that is not related (see myocardial infarction and angina). Pleuritic pain is sharp and made worse on inspiration, e.g. in pulmonary embolism. Shingles (Varicella zoster) may cause pain following a particular nerve territory. The characteristic rash is preceded by an area of hyperaesthesia. Oesophagitis may cause a retrosternal pain which is worse on bending or lying down. However, oesophageal pain, like cardiac pain, may be relieved by sublingual nitrates, e.g. glyceryl trinitrate (GTN).

Table 2.2 Relevant points in the history with reference to cardiovascular system • Chest pain • Angina • Myocardial infarction • Hypertension • Medication, e.g. aspirin, warfarin • Syncope • Shortage of breath/exercise tolerance • Cardiac rate/rhythm • Cardiomyopathy • Coronary artery bypass graft • Valve replacements • Congenital disorders • Cardiac transplants • Rheumatic fever • Infective endocarditis • Venous/lymphatic disorders

Hyperventilation may produce chest pain. Gallbladder and pancreatic disease may also mimic cardiac pain. Musculoskeletal pain is often accompanied by tenderness to palpation in the affected region.