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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


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 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.

  • 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- 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.SIGNS

  • ruddy color

  • clubbing of fingers

  • swollen ankles


Congestive heart failure signs1
CONGESTIVE HEART FAILURE- 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.SIGNS

  • weight gain- girth

  • large tender liver

  • jaundice

  • cyanosis


Congestive heart failure7
CONGESTIVE HEART FAILURE 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.

  • OTHER CLINICAL SIGNS

  • ascites

  • distended neck veins

  • peripheral edema

  • “pitting edema”


Congestive heart failure8
CONGESTIVE HEART FAILURE 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.

  • SIGNS OF CHF

  • gallop rhythm

  • pulsus alternans

  • prolonged circulation time

  • cardiac enlargement


Congestive heart failure9
CONGESTIVE HEART FAILURE 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.

  • 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- 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.SYMPTOMS

  • dyspnea

  • paroxysmal nocturnal dyspnea

  • periodic breathing- sleep apnea

  • insomnia

  • orthopnea

  • mental confusion

  • dizziness


Congestive heart failure symptoms1
CONGESTIVE HEART FAILURE- 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.SYMPTOMS

  • weakness, fatigue

  • wheezing, coughing

  • low-grade fever, sweating

  • nausea, vomiting

  • cardiac reserve

  • epistaxis


Congestive heart failure10
CONGESTIVE HEART FAILURE 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.

  • LABORATORY FINDINGS

  • Increased hematocrit, hemoglobin

  • decreased WBC

  • prolonged PT, PTT


Congestive heart failure11
CONGESTIVE HEART FAILURE 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.

  • CLASSIFICATION

  • ventricular dysfunction

  • compensated CHF

  • intractable heart failure


Congestive heart failure12
CONGESTIVE HEART FAILURE 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.

  • COMPLICATIONS

  • infection

  • bleeding

  • MI

  • CVA

  • Cardiac arrest


Congestive heart failure13
CONGESTIVE HEART FAILURE 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.

  • 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 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.

  • DENTAL MANAGEMENT

  • HTN !

  • BLEEDING

    • polycythemia

    • thrombocytopenia

    • low fibrinogen

    • PT, BT


Medical management of congestive heart failure
Medical management of congestive heart failure. 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.

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

asymptomatic patient)Long-acting ACE inhibitor


Congestive heart failure15
CONGESTIVE HEART FAILURE 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.

  • 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 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.

  • 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 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.

  • 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 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.

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 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.

  • DIGITALIS INTOXICATION

  • visual changes ( blurring)

  • nausea, vomiting, anorexia

  • fatigue, weakness, malaisse, drowsiness

  • headaches, neuralgias

  • delirium

  • ARRHYTHMIAS


Congestive heart failure19
CONGESTIVE HEART FAILURE 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.

  • 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 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.

  • lack of response to initial Rx=

  • POOR PROGNOSIS ( 50 % DIE in 5 yrs.)


Congestive heart failure21
CONGESTIVE HEART FAILURE 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.

  • 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 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.

  • 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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