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- 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 ( N 2 O 2 )