Dental management of patients with heart failure
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Dental Management of Patients with Heart Failure. What is Heart Failure?. A symptom complex due to the inability of the heart to function efficiently as a pump - there is a disproportion between the hemodynamic demand and the capacity of the heart to handle the demand ( Supply ≠ Demand).

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Dental management of patients with heart failure

Dental Management of Patients with Heart Failure


What is heart failure
What is Heart Failure?

A symptom complex due to the inability of the heart to function efficiently as a pump - there is a disproportion between the hemodynamic demand and the capacity of the heart to handle the demand

( Supply ≠ Demand)


What is heart failure1
What is Heart Failure?

  • HF occurs when the heart is unable to pump enough blood to meet the oxygen requirements of the body

  • Nearly 10% of populations > 70 years of age will have HF

  • Overall mortality close to 20%

  • HF risk factors:

    • CAD and its sequelae

    • HTN - Myocarditis,

    • Cardiomyopathy - Valvular heart diseases

    • Pericardial disease - Pulmonary embolism


Types and classifications of h f measured by ejection fraction ef
Types and Classifications of H.F(measured by ejection fraction [EF])

  • Systolic or diastolic

  • High output or low output

  • Left or right sided

  • Acute or chronic


Systolic hf
Systolic HF

Diastolic HF

  • Inability of heart to contract strongly enough to provide adequate blood flow to periphery

  • Abnormal relaxation of myocardium resulting in reduced filling of ventricle

Systolic dysfunction:

- EF < 50%; results from reduced left ventricular function

- Increased preload

- Most cases of CHF


If Heart does not contract well (systolic HF) traffic (blood) piles up before the heart (lungs and periphery).


Common causes of hf
Common Causes of HF (blood) piles up before the heart (lungs and periphery).

Coronary Heart Disease/MI

Hypertension

Valvular Heart Disease

Arrhythmias

Myocarditis

Cardiomyopathy

Infective Endocarditis

Congenital Heart Disease

Pulmonary Hypertension

Endocrine Disorders (thyroid disease)

MI is a leading cause


Sequelae of heart failure

Right Heart Failure (blood) piles up before the heart (lungs and periphery).

Systemic venous congestion (distended neck veins, enlarged liver, peripheral edema, ascites)

Left Heart Failure

Pulmonary edema (Dyspnea)

Sequelae of Heart Failure


Symptoms of heart failure
Symptoms of Heart Failure (blood) piles up before the heart (lungs and periphery).

Compensated (Asymptomatic)

Uncompensated (Symptomatic)

  • Fatigue

  • Dyspnea

  • Orthopnea

  • Paroxysmal Nocturnal Dyspnea

  • Ankle Edema

  • Weight Gain

Note: patients with a very low EF may have no symptoms


Laboratory findings of chf
Laboratory Findings of CHF (blood) piles up before the heart (lungs and periphery).

  • BP: elevated

  • Chest x-ray: heart enlarged

  • ECG: arrhythmia

  • Serum chemistries:

    • electrolytes: elevated

    • liver function tests (AST, ALT, bilirubin): elevated

    • Renal function tests (BUN, creatinine): elevated

    • C-reactive protein: if > 3 mg/L increased risk for MI

    • Cardiac natriuretic peptides (BNP): adjunctive test to rule out HF in acute setting (increased risk of HF if > 100 pg/mL)

  • Stress test: diminished capacity

  • Arterial blood gas levels: hypoxia (< 95%) and acid-base imbalance


Functional classification of heart failure nyha
Functional Classification of Heart Failure (NYHA) (blood) piles up before the heart (lungs and periphery).

  • Class I: No limitation of physical activity. No dyspnea, fatigue, or palpitations with ordinary physical activity

  • Class II: Slight limitation of physical activity. Fatigue, palpitations and dyspnea with ordinary physical activity but comfortable at rest.

  • Class III: Marked limitation of activity. Less than ordinary physical activity results in symptoms but comfortable at rest.

  • Class IV: Symptoms present at rest and any physical activity exacerbates the symptoms


To prevent heart failure
To Prevent Heart Failure (blood) piles up before the heart (lungs and periphery).

  • lower high blood pressure;

  • lose extra weight;

  • quit smoking, alcohol use, illegal drug use

  • control irregular or too-fast heart rhythms;

  • correct too-low or too-high thryoid function;

  • lower bad cholesterol and raise good cholesterol;

  • if diabetic, control blood sugar;

  • if had a heart attack, restore lost blood flow with bypass surgery or angioplasty if possible;

  • if had a heart attack (even if long ago), take an ACE inhibitor or ARB, and also take a beta-blocker to reduce risk of heart failure down the road, even if you have no symptoms and even if your EF is normal;

  • if have reduced EF, take a beta-blocker and an ACE inhibitor even if you have no symptoms;

  • if have significant heart valve dysfunction, get surgical repair;

  • perform regular echocardiograms in people who have had chemotherapy;


Medical management of heart failure
Medical Management of Heart Failure (blood) piles up before the heart (lungs and periphery).

  • Decreased cardiac output CO

  • Decreased ejection fraction

    • - repair of diseased valves

  • Fluid overload

  • Overweight

  • HTN

Main Problems requiring treatment


Medical management of heart failure1
Medical Management of Heart Failure (blood) piles up before the heart (lungs and periphery).

  • Treatment of underlying disease

  • Life-style modifications

  • Drug therapy

    • ACE inhibitors

      - Or angiotensin receptor blockers

    • Beta Blockers (Coreg, Toprol-XL, or bisoprolol)

    • Diuretics

      - Or direct-acting vasodilators

    • Nitrates

    • Digitalis Glycosides

  • Heart transplant


Less frequently used today, because recent trial indicates no benefit in survival, but can improve symptoms

Used in combination with 1st line drugs

1st line drugs


Ace inhibitors acei oral meds
ACE inhibitors (ACEI) - no benefit in survival, but can improve symptoms(Oral Meds)

  • ACEI block an enzyme that is necessary to produce renin that causes blood vessels to tighten. As a result, they relax blood vessels and lower BP.

  • Adv effects: cough, angioedema, oral burning

  • Benazepril - Lotensin

  • Captopril - Capoten

  • Enalapril - Vasotec

  • Fosinopril - Monopril

  • Lisinopril - Prinivil

  • Moexipril - Univasc

  • Quinapril - Accupril

  • Perindopril erbumine - Aceon

  • Ramipril - Altace


Diuretics
Diuretics no benefit in survival, but can improve symptoms

  • Common thiazide diuretics

    • Chlorothiazide (Diuril)

    • Indapamide (Lozol)

    • Metolazone (Zaroxolyn)

  • Common loop diuretics

    • Bumetanide (Bumex)

    • Ethacrynic acid (Edecrin)

    • Furosemide (Lasix)

  • Common potassium-sparing diuretics

    • Amiloride (Midamor)

    • Eplerenone (Inspra)

    • Spironolactone (Aldactone


Drug therapy digitalis glycosides
Drug Therapy - Digitalis Glycosides no benefit in survival, but can improve symptoms

Action: Increases the force and velocity of myocardial contraction

Digoxin (Lanoxin)

Digitoxin (Crystodigin)

Purple foxglove - digitalis


Drug considerations digitalis glycosides
Drug Considerations – no benefit in survival, but can improve symptomsDigitalis Glycosides

  • Vasoconstrictor Interaction: concurrent use may increase the risk of cardiac arrhythmias – avoid if possible

  • Oral Manifestations: increased gag reflex, nausea/vomiting

  • Other Considerations:

    • macrolide antibiotics (erythromycin) can increase bioavailability of DG resulting intoxicity; avoid these drugs

    • watch for DG toxicity (tachycardia, N/V, hypersalivation, vision changes, fatigue, HA)


Acc aha guidelines for perioperative cardiovascular evaluation for noncardiac surgery
ACC/AHA Guidelines for perioperative cardiovascular evaluation for noncardiac surgery

  • Clinical predictors of increased perioperative cardiovascular risk (major, intermediate, minor)

    • Major risk: Decompensated CHF

    • Intermediate risk: Compensated or prior CHF

    • Minor risk: Inability to climb 1 flight of stairs with a bag of groceries


Dental management considerations heart failure
Dental Management Considerations (Heart Failure) evaluation for noncardiac surgery

  • For undiagnosed pt with symptoms of HF: avoid elective care; refer to physician

  • For patients with diagnosed HF:

    • Class I (asymptomatic): routine care

    • Class II (mild symptoms with exertion): elective care OK and recommend consultation with physician

    • Class III or IV (symptoms with minimal activity or at rest): avoid elective care; if treatment necessary, manage in consultation with physician; consider referral to a special patient care setting; avoid use of vasoconstrictors


  • Stress management protocol evaluation for noncardiac surgery

  • ID underlying disease (CHD, HBP, RHD) and manage appropriately

  • Semisupine or upright chair position

  • Take BP, monitor with pulse oximeter, watch for orthostatic hypotension

  • Drug Considerations

    • If taking digitalis, avoid vasoconstrictors if possible

    • If taking nonselective β-blocker, use vasoconstrictor cautiously

    • Watch for digitalis toxicity


Other drug considerations
Other Drug Considerations evaluation for noncardiac surgery

  • Patients on spironolactone should have potassium levels checked more often and every time a drug dose is changed.

  • Patients on digoxin need dig level testing.

  • Patients on Coumadin (warfarin) need INR testing.

  • Patients on amiodarone need thyroid and lung function testing.


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