Download congestive heart failure

Increased CV risk( MI)for
dentistry
EXTREME
 Recent MI
 Unstable angina
 Uncompensated CHF
 Significant arrhythmias ( ventricular)
 Severe valvular disease
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– AHA. 2002. Circulation. 105:10.
Increased CV risk( MI) for
dentistry
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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
FAILURE
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
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CONGESTIVE HEART
FAILURE
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
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(COMPLICATIONS)
CONGESTIVE HEART
FAILURE
COMPLICATIONS
 infection
 bleeding
 MI
 CVA
 Cardiac arrest
 Renal failure
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(Causes)
CONGESTIVE HEART
FAILURE
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
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CONGESTIVE HEART
FAILURE
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
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CONGESTIVE HEART
FAILURE
SIGNS OF CHF
 gallop rhythm
 pulsus alternans
 prolonged circulation time
 polycythemia
 cardiac enlargement
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By far the most dangerous foe we
have to fight is apathy - indifference
from whatever cause, not from a lack
of knowledge, but from carelessness,
from absorption in other pursuits,
from a contempt bred of selfsatisfaction.
Sir William Osler,1900
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CONGESTIVE HEART
FAILURE
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
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CONGESTIVE HEART
FAILURE- SIGNS
ruddy color
 clubbing of fingers
 swollen ankles
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CONGESTIVE HEART
FAILURE- SIGNS
weight gain- girth
 large tender liver
 jaundice
 cyanosis
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CONGESTIVE HEART
FAILURE
OTHER CLINICAL SIGNS
 ascites
 distended neck veins
 peripheral edema
 “pitting edema”
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CONGESTIVE HEART
FAILURE
SIGNS OF CHF
 gallop rhythm
 pulsus alternans
 prolonged circulation time
 cardiac enlargement
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CONGESTIVE HEART
FAILURE
COMPENSATORY ADJUSTMENTS
 Increase peripheral resistance
 increase blood flow to heart and brain
 increase erythropoietic activity
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– Thrombocytopenia
– polycythemia
– Leukopenia
(symptoms)
CONGESTIVE HEART
FAILURE- SYMPTOMS
dyspnea
 paroxysmal nocturnal dyspnea
 periodic breathing- sleep apnea
 insomnia
 orthopnea
 mental confusion
 dizziness
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CONGESTIVE HEART
FAILURE- SYMPTOMS
weakness, fatigue
 wheezing, coughing
 low-grade fever, sweating
 nausea, vomiting
 cardiac reserve
 epistaxis
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CONGESTIVE HEART
FAILURE
LABORATORY FINDINGS
 Increased hematocrit, hemoglobin
 decreased WBC
 prolonged PT, PTT
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CONGESTIVE HEART
FAILURE
CLASSIFICATION
 ventricular dysfunction
 compensated CHF
 intractable heart failure
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CONGESTIVE HEART
FAILURE
COMPLICATIONS
 infection
 bleeding
 MI
 CVA
 Cardiac arrest
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CONGESTIVE HEART
FAILURE
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
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CONGESTIVE HEART
FAILURE
DENTAL MANAGEMENT
 HTN !
 BLEEDING
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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
FAILURE
MEDICAL MANAGEMENT for MILD
CHF
 decrease exertion; physical activity
 loading dose of digitalis
 cut down NaCl
 drug side effects and interactions
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CONGESTIVE HEART
FAILURE
MANAGEMENT for MODERATE CHF
 decrease exertion; physical activity
 digitalis, diuretics, K+
 lasix, apresoline, isordil, minipress
 COUMARIN
 drug side effects and interactions
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CONGESTIVE HEART
FAILURE
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 !!
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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
FAILURE
DIGITALIS INTOXICATION
 visual changes ( blurring)
 nausea, vomiting, anorexia
 fatigue, weakness, malaisse, drowsiness
 headaches, neuralgias
 delirium
 ARRHYTHMIAS
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CONGESTIVE HEART
FAILURE
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Complications from diuretics, vasodilators
Complications from ACEI
xerostomia, dehydration
nausea, vomiting, headaches
dizziness, weakness
orthostatic hypotension
lichenoid lesions
orthostatic hypotension
CONGESTIVE HEART
FAILURE
lack of response to initial Rx=
 POOR PROGNOSIS ( 50 % DIE in 5 yrs.)
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CONGESTIVE HEART
FAILURE
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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
FAILURE
MEDICAL CONSULTATION
 COUMARIN- bleeding, PT and BT
 ARRHYTHMIAS
 short, non-stressful appointments
 STOP if patient has symptoms !!
 upright chair position
 sedation ( N2O2)
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