Increased CV risk( MI)for dentistry

1. Increased CV risk( MI)for dentistry • EXTREME • Recent MI • Unstable angina • Uncompensated CHF • Significant arrhythmias ( ventricular) • Severe valvular disease • AHA. 2002. Circulation. 105:10.

2. Increased CV risk( MI) for dentistry • 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

3. 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

4. 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 (COMPLICATIONS)

5. CONGESTIVE HEART FAILURE • COMPLICATIONS • infection • bleeding • MI • CVA • Cardiac arrest • Renal failure (Causes)

6. 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

7. 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

8. CONGESTIVE HEART FAILURE • SIGNS OF CHF • gallop rhythm • pulsus alternans • prolonged circulation time • polycythemia • cardiac enlargement

9. 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 self-satisfaction.Sir William Osler,1900

11. 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

12. CONGESTIVE HEART FAILURE- SIGNS • ruddy color • clubbing of fingers • swollen ankles

14. CONGESTIVE HEART FAILURE- SIGNS • weight gain- girth • large tender liver • jaundice • cyanosis

15. CONGESTIVE HEART FAILURE • OTHER CLINICAL SIGNS • ascites • distended neck veins • peripheral edema • “pitting edema”

16. CONGESTIVE HEART FAILURE • SIGNS OF CHF • gallop rhythm • pulsus alternans • prolonged circulation time • cardiac enlargement

18. CONGESTIVE HEART FAILURE • COMPENSATORY ADJUSTMENTS • Increase peripheral resistance • increase blood flow to heart and brain • increase erythropoietic activity • Thrombocytopenia • polycythemia • Leukopenia (symptoms)

19. CONGESTIVE HEART FAILURE- SYMPTOMS • dyspnea • paroxysmal nocturnal dyspnea • periodic breathing- sleep apnea • insomnia • orthopnea • mental confusion • dizziness

20. CONGESTIVE HEART FAILURE- SYMPTOMS • weakness, fatigue • wheezing, coughing • low-grade fever, sweating • nausea, vomiting • cardiac reserve • epistaxis

21. CONGESTIVE HEART FAILURE • LABORATORY FINDINGS • Increased hematocrit, hemoglobin • decreased WBC • prolonged PT, PTT

22. CONGESTIVE HEART FAILURE • CLASSIFICATION • ventricular dysfunction • compensated CHF • intractable heart failure

23. CONGESTIVE HEART FAILURE • COMPLICATIONS • infection • bleeding • MI • CVA • Cardiac arrest

24. 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

25. CONGESTIVE HEART FAILURE • DENTAL MANAGEMENT • HTN ! • BLEEDING • polycythemia • thrombocytopenia • low fibrinogen • PT, BT

26. Medical management of congestive heart failure. Pharmacologic treatment. NYHA class I CHF ( ejection fraction >40% ; asymptomatic patient)Long-acting ACE inhibitor

27. CONGESTIVE HEART FAILURE • MEDICAL MANAGEMENT for MILD CHF • decrease exertion; physical activity • loading dose of digitalis • cut down NaCl • drug side effects and interactions

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

29. 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 !!

30. 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)

31. CONGESTIVE HEART FAILURE • DIGITALIS INTOXICATION • visual changes ( blurring) • nausea, vomiting, anorexia • fatigue, weakness, malaisse, drowsiness • headaches, neuralgias • delirium • ARRHYTHMIAS

32. CONGESTIVE HEART FAILURE • Complications from diuretics, vasodilators • Complications from ACEI • xerostomia, dehydration • nausea, vomiting, headaches • dizziness, weakness • orthostatic hypotension • lichenoid lesions • orthostatic hypotension

33. CONGESTIVE HEART FAILURE • lack of response to initial Rx= • POOR PROGNOSIS ( 50 % DIE in 5 yrs.)

34. CONGESTIVE HEART FAILURE • 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

35. 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)