increased cv risk( mi)for dentistry

Increased CV risk( MI)for Increased CV risk( MI)for dentistrydentistry

EXTREME Recent MI Unstable angina Uncompensated CHF Significant arrhythmias ( ventricular) Severe valvular disease

– AHA. 2002. Circulation. 105:10.

Increased CV risk( MI) for Increased CV risk( MI) for dentistrydentistry

MODERATE previous MI ANY angina ANY CHF ( walking flight of stairs) ANY arrhythmias IDDM CVA Renal disease HTN -AHA. 2002. Circulation. 105:10.

Advanced age

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

A symptom complex caused by or contributed by by several disorders

HTN > 75 % ASCVD > 50% RHD > 21% severe= 40-60% 1 yr. Survival MAY NOT BE DIAGNOSED ! Spectrum of severity and morbidity

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

U.S. > 2.5 million cases 500,000 new cases per year 50 % 5-yr. survival 30-50% of deaths from CHF = sudden

cardiac death severe- 50 % have serious ventricular

arrhythmias (COMPLICATIONS)

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

COMPLICATIONS infection bleeding MI CVA Cardiac arrest Renal failure (Causes)

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

Failure of the heart as a pump to provide adequate circulation to the body

chronic increase in cardiac load damage to the myocardium COMBINATION Serious imbalance between hemodynamic

load and capacity of the heart to handle it

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

decreased myocardial function: ASCVD, MI, drugs, thyroid, amyloidosis

increased vascular resistance: HTN, aortic stenosis

increased blood volume: valvular insufficiency, renal failure

excessive metabolic demand: anemia, thyrotoxicosis

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

SIGNS OF CHF gallop rhythm pulsus alternans prolonged circulation time polycythemia cardiac enlargement

By far the most dangerous foe By far the most dangerous foe we have to fight is apathy - we have to fight is apathy - indifference from whatever indifference from whatever

cause, not from a lack of cause, not from a lack of knowledge, but from knowledge, but from

carelessness, from absorption carelessness, from absorption in other pursuits, from a in other pursuits, from a contempt bred of self-contempt bred of self-

satisfaction.satisfaction.

Sir William Osler,1900Sir William Osler,1900

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CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

SIGNS OF CHF pulsus alternans = alteration in stroke volume in

every other cardiac cycle = low ejection fraction( ~15 % !)

and advanced CHF CHF indicator = ejection fraction

CONGESTIVE HEART CONGESTIVE HEART FAILURE- FAILURE- SIGNS

ruddy color clubbing of fingers swollen ankles

CONGESTIVE HEART CONGESTIVE HEART FAILURE- FAILURE- SIGNSSIGNS

weight gain- girth large tender liver jaundice cyanosis

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

OTHER CLINICAL SIGNS ascites distended neck veins peripheral edema “pitting edema”

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

SIGNS OF CHF gallop rhythm pulsus alternans prolonged circulation time cardiac enlargement

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

COMPENSATORY ADJUSTMENTS Increase peripheral resistance increase blood flow to heart and brain increase erythropoietic activity

– Thrombocytopenia– polycythemia– Leukopenia (symptoms)

CONGESTIVE HEART CONGESTIVE HEART FAILURE- FAILURE- SYMPTOMSSYMPTOMS

dyspnea paroxysmal nocturnal dyspnea periodic breathing- sleep apnea insomnia orthopnea mental confusion dizziness

CONGESTIVE HEART CONGESTIVE HEART FAILURE- FAILURE- SYMPTOMSSYMPTOMS

weakness, fatigue wheezing, coughing low-grade fever, sweating nausea, vomiting cardiac reserve epistaxis

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

LABORATORY FINDINGS Increased hematocrit, hemoglobin decreased WBC prolonged PT, PTT

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

CLASSIFICATION ventricular dysfunction compensated CHF intractable heart failure

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

COMPLICATIONS infection bleeding MI CVA Cardiac arrest

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

DENTAL MANAGEMENT nature and course of underlying cause(s)

(i.e., RHD, CHD, ASCVD) accompanying CVD ( i.e., Ischemic HD,

arrhythmias, murmurs, etc.) other systemic disease ( i.e. IDDM, etc.) Ejection fraction

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

DENTAL MANAGEMENT HTN ! BLEEDING

– polycythemia– thrombocytopenia– low fibrinogen– PT, BT

Medical management of congestive heart failure.

Pharmacologic treatment.

NYHA class I CHF ( ejection fraction >40% ; asymptomatic patient)

Long-acting ACE inhibitor

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

MEDICAL MANAGEMENT for MILD CHF

decrease exertion; physical activity loading dose of digitalis cut down NaCl drug side effects and interactions

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

MANAGEMENT for MODERATE CHF decrease exertion; physical activity digitalis, diuretics, K+ lasix, apresoline, isordil, minipress COUMARIN drug side effects and interactions

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

MANAGEMENT for SEVERE CHF decrease exertion; physical activity digitalis, furosemide, ethacrynic acid thiazide diuretics, triampterene venous dilator for congestion atrial dilator for weakness NO ROUTINE DENTAL TREATMENT !!

Medical management of congestive heart failure

Furosemide ( 20-120 mg)(watch for hypokalemia and gout)

Long-acting ACE inhibitors( enalapril 5-10 mg 2 x/day) Potassium chloride supplementation (>4.0 mEq/L)Consider adding metozalone, 5-10 mg every other day

(when furosemide dose exceeds 160 mg/day)

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

DIGITALIS INTOXICATION visual changes ( blurring) nausea, vomiting, anorexia fatigue, weakness, malaisse, drowsiness headaches, neuralgias delirium ARRHYTHMIAS

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

Complications from diuretics, vasodilators Complications from ACEI xerostomia, dehydration nausea, vomiting, headaches dizziness, weakness orthostatic hypotension lichenoid lesions orthostatic hypotension

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

lack of response to initial Rx= POOR PROGNOSIS ( 50 % DIE in 5 yrs.)

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

MEDICAL CONSUTLATION establish : level of severity, underlying CVD,

medications, level of control,contraindications, bleeding

CLOSE MONITORING !!! vitals, Rxs, etc. Digitalis intoxication orthostatic hypotension careful with epinephrine

CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

MEDICAL CONSULTATION COUMARIN- bleeding, PT and BT ARRHYTHMIAS short, non-stressful appointments STOP if patient has symptoms !! upright chair position sedation ( N2O2)