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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
QuickTime™ and aTIFF (LZW) decompressor
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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)