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

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increased cv risk mi for dentistry
Increased CV risk( MI)for dentistry
  • EXTREME
  • Recent MI
  • Unstable angina
  • Uncompensated CHF
  • Significant arrhythmias ( ventricular)
  • Severe valvular disease
        • AHA. 2002. Circulation. 105:10.
increased cv risk mi for dentistry1
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
congestive heart failure
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
congestive heart failure1
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)
congestive heart failure2
CONGESTIVE HEART FAILURE
  • COMPLICATIONS
  • infection
  • bleeding
  • MI
  • CVA
  • Cardiac arrest
  • Renal failure (Causes)
congestive heart failure3
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
congestive heart failure4
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
congestive heart failure5
CONGESTIVE HEART FAILURE
  • SIGNS OF CHF
  • gallop rhythm
  • pulsus alternans
  • prolonged circulation time
  • polycythemia
  • cardiac enlargement
slide9

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

congestive heart failure6
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
congestive heart failure signs
CONGESTIVE HEART FAILURE- SIGNS
  • ruddy color
  • clubbing of fingers
  • swollen ankles
congestive heart failure signs1
CONGESTIVE HEART FAILURE- SIGNS
  • weight gain- girth
  • large tender liver
  • jaundice
  • cyanosis
congestive heart failure7
CONGESTIVE HEART FAILURE
  • OTHER CLINICAL SIGNS
  • ascites
  • distended neck veins
  • peripheral edema
  • “pitting edema”
congestive heart failure8
CONGESTIVE HEART FAILURE
  • SIGNS OF CHF
  • gallop rhythm
  • pulsus alternans
  • prolonged circulation time
  • cardiac enlargement
congestive heart failure9
CONGESTIVE HEART FAILURE
  • COMPENSATORY ADJUSTMENTS
  • Increase peripheral resistance
  • increase blood flow to heart and brain
  • increase erythropoietic activity
    • Thrombocytopenia
    • polycythemia
    • Leukopenia (symptoms)
congestive heart failure symptoms
CONGESTIVE HEART FAILURE- SYMPTOMS
  • dyspnea
  • paroxysmal nocturnal dyspnea
  • periodic breathing- sleep apnea
  • insomnia
  • orthopnea
  • mental confusion
  • dizziness
congestive heart failure symptoms1
CONGESTIVE HEART FAILURE- SYMPTOMS
  • weakness, fatigue
  • wheezing, coughing
  • low-grade fever, sweating
  • nausea, vomiting
  • cardiac reserve
  • epistaxis
congestive heart failure10
CONGESTIVE HEART FAILURE
  • LABORATORY FINDINGS
  • Increased hematocrit, hemoglobin
  • decreased WBC
  • prolonged PT, PTT
congestive heart failure11
CONGESTIVE HEART FAILURE
  • CLASSIFICATION
  • ventricular dysfunction
  • compensated CHF
  • intractable heart failure
congestive heart failure12
CONGESTIVE HEART FAILURE
  • COMPLICATIONS
  • infection
  • bleeding
  • MI
  • CVA
  • Cardiac arrest
congestive heart failure13
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
congestive heart failure14
CONGESTIVE HEART FAILURE
  • DENTAL MANAGEMENT
  • HTN !
  • BLEEDING
    • polycythemia
    • thrombocytopenia
    • low fibrinogen
    • PT, BT
medical management of congestive heart failure
Medical management of congestive heart failure.

Pharmacologic treatment. NYHA class I CHF ( ejection fraction >40% ;

asymptomatic patient)Long-acting ACE inhibitor

congestive heart failure15
CONGESTIVE HEART FAILURE
  • MEDICAL MANAGEMENT for MILD CHF
  • decrease exertion; physical activity
  • loading dose of digitalis
  • cut down NaCl
  • drug side effects and interactions
congestive heart failure16
CONGESTIVE HEART FAILURE
  • MANAGEMENT for MODERATE CHF
  • decrease exertion; physical activity
  • digitalis, diuretics, K+
  • lasix, apresoline, isordil, minipress
  • COUMARIN
  • drug side effects and interactions
congestive heart failure17
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 !!
medical management of congestive heart failure1
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 failure18
CONGESTIVE HEART FAILURE
  • DIGITALIS INTOXICATION
  • visual changes ( blurring)
  • nausea, vomiting, anorexia
  • fatigue, weakness, malaisse, drowsiness
  • headaches, neuralgias
  • delirium
  • ARRHYTHMIAS
congestive heart failure19
CONGESTIVE HEART FAILURE
  • Complications from diuretics, vasodilators
  • Complications from ACEI
  • xerostomia, dehydration
  • nausea, vomiting, headaches
  • dizziness, weakness
  • orthostatic hypotension
  • lichenoid lesions
  • orthostatic hypotension
congestive heart failure20
CONGESTIVE HEART FAILURE
  • lack of response to initial Rx=
  • POOR PROGNOSIS ( 50 % DIE in 5 yrs.)
congestive heart failure21
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
congestive heart failure22
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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