This document provides guidance on cardiovascular (CVS) examination for dental practice. It discusses CVS diseases that can be induced or exacerbated by dental procedures. The examination involves taking a history of present illness, past medical history, drug history, family history, and social history. The physical examination includes inspection of general appearance and vital signs, along with detailed examination of pulses, heart sounds, lungs, abdomen, edema, and jugular veins. Differential diagnoses are provided for common CVS symptoms.

1. CVS Examination
Prof Yan-Lynn Myint
MBBS,MMedSc (Int.Med.)
MRCP(UK) FRCP Edin.
YLM 1
14/03/2006

2. Why CVS in Dental practise?
• Dental practise/ procedures that induce
CVS diseases
• CVS diseases that can be exacerbated by
dental procedures
YLM 2
14/03/2006

3. History
• Name, age, sex, address, occupation
• Chief complaints
• HOPI
• PH
• FH/SH
• Personal history
• O & G history
YLM 3
14/03/2006

4. Cardinal/common symptoms
Symptoms CVS causes Other causes
Chest discomfort 1. MI
1. Oesophageal spasm
2. Angina
2. Pneumothorax
3. Pericarditis
3. MS pain
4. Aortic dissection
Breathlessness 1. Heart failure
1. Resp disease
2. Angina
2. Anaemia
3. Pul embolism
3. obesity
4. Pul HT
Palpitation 1. Anxiety
1. Tachyarrhythmia
2. Hyperthyroidism
2. Ectopic beats
3. drugs
Syncope/dizziness 1. Arrhythmias
2. Postural hypertension
1. Simple faints
3. Aortic stenosis
2. epilepsy
4. HOCM
5. Atrial myxoma
oedema 1. Heart failure 1. Nephrotic syndrome
2. Constrictive pericarditis 2. Liver disease
3. Venous stasis 3. drugs
YLM 4
14/03/2006

5. Type of cardiac pain
Type Causes Characteristics
Angina Coronary stenosis (rarely Ppt by exertion, eased by
aortic stenosis, HOCM) rest and/or GTN
Characteristic distribution
Myocardial Coronary occlusion Similar sites to angina,
infarction more severe, persist at rest
Pericarditic pain Pericarditis Sharp, raw or stabbing
Varies with movement or
breathing
Aortic pain Dissection of aorta Severe, sudden onset,
Radiate to back
YLM 5
14/03/2006

6. Angina pectoris
• Site and radiation
• Duration, precipitation and relieving
factors
Aggravating Relieving
•Exertion •Rest
•Emotional excitement •GTN
•Cold weather •Warm up before exercise
•Exercise after meal
• Character, severity
• Special types
6
14/03/2006 – Unstable, crescendo, nocturnal,
YLM

7. Differential Diagnosis
Angina Oesophageal pain
Usu. Ppt by exertion Can be worsened by exertion, but
often present at other time
Rapidly relieved by rest Not rapidly relieved by rest
Retrosternal and radiate to arms Retrosternal or epigastric,
and jaw sometimes radiate to arms or back
Seldom wakes patient from sleep Often wakes patient from sleep
No relation to heartburn (but often Sometimes related to heartburn
have wind)
Rapidly relieved by nitrates Often relieved by nitrates
Typical duration 2-10mins Variable duration
YLM 7
14/03/2006

8. Differential Diagnosis
Angina Myocardial infarction
Site: retrosternal, radiate to arm, As for angina
epigastrium, neck
Ppt by exercise or emotion Often no obvious precipitant
Relieved by rest, nitrates Not relieved by rest, nitrates
Mild/moderate severity Usually severe (may be silent)
Anxiety absent or mild Severe
No increased sympathetic activity Increased sympathetic activity
No nausea or vomiting Nausea and vomiting are common
YLM 8
14/03/2006

9. Pericardial pain
Site Retrosternal, may radiate to left shoulder or back
Prodrome May be preceded by a viral illness
Onset No obvious initial precipitating factor;tends to
fluctuate in intensity
Nature May be stabbing or raw – like sandpaper. Often
described as sharp, rarely as tight or heavy
Made worse by Changes in posture, respiration
Helped by Analgesics, especially NSAIDs
Accompanied by Pericardial rub
YLM 9
14/03/2006

10. Dissection of thoracic aorta
Site Often first felt between shoulder blades, and/or
behind the sternum
Onset Usually sudden
Nature Very severe pain, often described as tearing
Relieved by No, tend to persist. Patient often restless with pain
Accompanied by Hypertension, asymmetric pulses, unexpected
bradycardia, early diastolic murmur, syncope, focal
neurological symtoms and signs
YLM 10
14/03/2006

11. Breathlessness
• Awareness of one own breathing
– Dyspnoea on exertion
– Orthopnoea
– Paroxysmal nocturnal dyspnoea
YLM 11
14/03/2006

12. Palpitation
• Sensation of the heart beating in the chest
YLM 12
14/03/2006

13. Syncope and dizziness
• Postural hypotension
• Arrhythmias
• Left ventricular outflow obstruction
YLM 13
14/03/2006

14. Peripheral oedema
Unilateral
•Deep vein thrombosis
•Soft tissue infection
•Trauma
•Immobility, e.g. hemiplegia
Bilateral
•Heart failure
•Chronic venous insufficiency
•Hypoproteinemia, e.g. nephrotic syndrome, kwashiorkor, cirrhosis
•Lymphatic obstruction, e.g. pelvic tumor, filariasis
•Drugs, e.g. NSAIDs, Nifedipine, amlodipine, fludrocortisone
•IVC obstruction
•Thiamine deficiency (Wet Beri Beri)
•Milroy’s disease
•immobility
YLM 14
14/03/2006

15. CVS disease presenting with
non-cardiac symptoms
System Symptom Causes
•Cerebral embolism
CNS Stroke •Endocarditis
•Hypertension
Jaundice •Liver congestion
GI •2˚to heart failure
Abdominal pain Mesenteric embolism
Renal Oliguria Heart failure
YLM 15
14/03/2006

16. Presenting complaint
• Recent onset
• Slowly progressive
• Functional assessment
YLM 16
14/03/2006

17. Past history
• Rheumatic fever
• Diabetes mellitus
• Hypertension
• Thyroid disease
• Recent dental works
YLM 17
14/03/2006

18. Drug history
Exacerbation of heart failure by β-blockers, some
Dyspnoea CCB, NSAIDs
Dizziness Vasodilators, e.g. nitrates, alpha-blockers, ACEI
Aggravated by thyroxine, drug-induced anaemia, e.g.
Angina aspirin, NSAIDs
•Fluid retention from steroids, NSAIDs
Oedema •Oedema from CCB (nifedipine, amlodipine)
•Tachycardia and/or arrhythmia from thyroxine, beta-2
stimulant (salbutamol),
Palpitation •digoxin toxicity,
•hypokalemia from diuretics, tricyclic antidepressants
YLM 18
14/03/2006

19. Family history
• IHD, HT
• Sudden death at young age
YLM 19
14/03/2006

20. Social history
• Smoking
– CHD, PVD
• Alcohol
– AF, HT
• Caffeine
– palpitation
YLM 20
14/03/2006

21. Occupational history
Occupational exposure associated with CVD
Organic solvents Arrhythmias, cardiomyopathy
Vibrating machine tools Raynaud’s phenomenon
Publicans Alcoholic cardiomyopathy
Occupational exposure exacerbating pre-existing cardiac conditions
Cold exposure Angina, Raynaud’s disease
Deep-sea diving Embolism through foramen ovale
Occupational requirements for high standards of CVS fitness
Pilots, public transport, HGV drivers, armed forces, police
YLM 21
14/03/2006

22. Physical examination
• General examination
– face
• Dyspnoeic or not
• Pallor
• Cyanosis
• Xanthoma, xanthelesma, arcus
– hands
• Signs of infective endocarditis
– Splinter haemorrhage, clubbing, Osler’s nodes,
Janeway’s lesion
– Feet/sacral area
• Oedema, petichial haemorrhage,
YLM 22
14/03/2006

23. Pulses
Fast heart rate (tachycardia, >100/min)
Sinus tachycardia Arrhythmia
•Exercise •Atrial fibrillation
•Pain •Atrial flutter
•Excitement/anxiety •Supraventricular tachycardia
•Fever •Ventricular tachycardia
•Hyperthyroidism
•Medications:
–Sympathomimetics
–vasodilators
YLM 23
14/03/2006

24. Pulses
Slow heart rate (bradycardia, < 60/min)
Sinus bradycardia Arrhythmia
•Sleep •Carotid sinus hypersensitivity
•Athletic training •Sick sinus syndrome
•Hypothyroidism •Second-degree heart block
•Medications: •Complete heart block
–Beta-blockers
–Digoxin
–Verapamil, diltiazam
YLM 24
14/03/2006

25. Causes of irregular pulse
•Sinus arrhythmia
•Atrial extrasystoles
•Ventricular extrasystoles
•Atrial fibrillation
•Atrial flutter with variable response
•Second-degree heart block with variable response
Common causes of atrial fibrillation
•Hypertension
•Cardiac failure
•Myocardial infarction
•Thyrotoxicosis
•Alcohol-related heart disease
•Mitral valve disease
•Infection, e.g. respiratory, urinary tract
•Following surgery, especially cardiothoracic surgery
YLM 25
14/03/2006

26. Blood pressure
• Rest
• Sitting for ambulant
• Support the arm at about heart level
• Apply the cuff
• Inflate the cuff
• Deflate the cuff
• Systolic
• diastolic
YLM 26
14/03/2006

27. Differences between carotid and jugular pulsation
Carotid Jugular
Rapid outward movement Rapid inward movement
One peak per heartbeat Two peaks per heartbeat
palpable Impalpable
Pulsation unaffected by Pulsation diminished by
pressure at the root of neck pressure at the root of neck
Independent of respiration Height of pulsation varies
with respiration
Independent of position Varies with position of
patient
Independent of abdominal Rises with abdominal
pressure pressure
YLM 27
14/03/2006