Increased CV risk( MI)for dentistry

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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. 10510.

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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. 10510.
• Advanced age

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CONGESTIVE HEART FAILURE

• A symptom complex caused by or contributed by by
  several disorders
• HTN gt 75
• ASCVD gt 50
• RHD gt 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. gt 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)

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CONGESTIVE HEART FAILURE

• COMPLICATIONS
• infection
• bleeding
• MI
• CVA
• Cardiac arrest
• Renal failure (Causes)

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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 self-satisfaction. 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
• Thrombocytopenia
• polycythemia
• Leukopenia
  (symptoms)

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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
• polycythemia
• thrombocytopenia
• low fibrinogen
• PT, BT

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Medical management of congestive heart failure.
Pharmacologic treatment. NYHA class I CHF (
ejection fraction gt40 asymptomatic
patient) Long-acting ACE inhibitor
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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 (gt4.0 mEq/L)Consider adding
metozalone, 5-10 mg every other day (when
furosemide dose exceeds 160 mg/day)
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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

• Complications from diuretics, vasodilators
• Complications from ACEI
• xerostomia, dehydration
• nausea, vomiting, headaches
• dizziness, weakness
• orthostatic hypotension
• lichenoid lesions
• orthostatic hypotension

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CONGESTIVE HEART FAILURE

• lack of response to initial Rx
• POOR PROGNOSIS ( 50 DIE in 5 yrs.)

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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

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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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