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)

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]) Systolic or diastolic Systolic or diastolic High output or low output High output or low output Left or right sided Left or right sided Acute or chronic Acute or chronic

Systolic HF Inability of heart to contract strongly enough to provide adequate blood flow to periphery Inability of heart to contract strongly enough to provide adequate blood flow to periphery Diastolic HF Abnormal relaxation of myocardium resulting in reduced filling of ventricle Abnormal relaxation of myocardium resulting in reduced filling of ventricle Systolic dysfunction: - EF < 50%; results from reduced left ventricular function - EF < 50%; results from reduced left ventricular function - Increased preload - Increased preload - Most cases of CHF - 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 Coronary Heart Disease/MI Hypertension Valvular Heart Disease ArrhythmiasMyocarditisCardiomyopathy Infective Endocarditis Congenital Heart Disease Pulmonary Hypertension Endocrine Disorders (thyroid disease) MI is a leading cause

Sequelae of Heart Failure Right Heart Failure Right Heart Failure Systemic venous congestion (distended neck veins, enlarged liver, peripheral edema, ascites) Systemic venous congestion (distended neck veins, enlarged liver, peripheral edema, ascites) Left Heart Failure Pulmonary edema (Dyspnea)

Symptoms of Heart Failure Compensated (Asymptomatic) Uncompensated (Symptomatic) Fatigue Fatigue Dyspnea Dyspnea Orthopnea Orthopnea Paroxysmal Nocturnal Dyspnea Paroxysmal Nocturnal Dyspnea Ankle Edema Ankle Edema Weight Gain Weight Gain Note: patients with a very low EF may have no symptomsEF

Laboratory Findings of CHF BP: elevated BP: elevated Chest x-ray: heart enlarged Chest x-ray: heart enlarged ECG: arrhythmia ECG: arrhythmia Serum chemistries: Serum chemistries: electrolytes: elevated electrolytes: elevated liver function tests (AST, ALT, bilirubin): elevated liver function tests (AST, ALT, bilirubin): elevated Renal function tests (BUN, creatinine): elevated Renal function tests (BUN, creatinine): elevated C-reactive protein: if > 3 mg/L increased risk for MI 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) 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 Stress test: diminished capacity Arterial blood gas levels: hypoxia (< 95%) and acid-base imbalance Arterial blood gas levels: hypoxia (< 95%) and acid-base imbalance

Functional Classification of Heart Failure (NYHA) Class I : No limitation of physical activity. No dyspnea, fatigue, or palpitations with ordinary physical activity 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 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 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 Class IV : Symptoms present at rest and any physical activity exacerbates the symptoms

To Prevent Heart Failure lower high blood pressure; lower high blood pressure; lose extra weight; lose extra weight; quit smoking, alcohol use, illegal drug use quit smoking, alcohol use, illegal drug use control irregular or too-fast heart rhythms; control irregular or too-fast heart rhythms; correct too-low or too-high thryoid function; correct too-low or too-high thryoid function; lower bad cholesterol and raise good cholesterol; lower bad cholesterol and raise good cholesterol; if diabetic, control blood sugar; 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, restore lost blood flow with bypass surgery or angioplasty if possible;bypassangioplastybypassangioplasty 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 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;ACE inhibitorARB beta-blockerACE inhibitorARB beta-blocker if have reduced EF, take a beta-blocker and an ACE inhibitor even if you have no symptoms; if have reduced EF, take a beta-blocker and an ACE inhibitor even if you have no symptoms;EF if have significant heart valve dysfunction, get surgical repair; if have significant heart valve dysfunction, get surgical repair; perform regular echocardiograms in people who have had chemotherapy; perform regular echocardiograms in people who have had chemotherapy;echocardiograms

Medical Management of Heart Failure 1.Decreased cardiac output CO 2.Decreased ejection fraction - repair of diseased valves - repair of diseased valves 3.Fluid overload 4.Overweight 5.HTN Main Problems requiring treatment

Medical Management of Heart Failure Treatment of underlying disease Treatment of underlying disease Life-style modifications Life-style modifications Drug therapy Drug therapy ACE inhibitors ACE inhibitors - Or angiotensin receptor blockers Beta Blockers (Coreg, Toprol-XL, or bisoprolol) Beta Blockers (Coreg, Toprol-XL, or bisoprolol) Diuretics Diuretics - Or direct-acting vasodilators Nitrates Nitrates Digitalis Glycosides Digitalis Glycosides Heart transplant Heart transplant

Less frequently used today, because recent trial indicates no benefit in survival, but can improve symptoms 1 st line drugs Used in combination with 1 st line drugs

ACE inhibitors (ACEI) - (Oral Meds) Benazepril - Lotensin Benazepril - Lotensin Captopril - Capoten Captopril - Capoten Enalapril - Vasotec Enalapril - Vasotec Fosinopril - Monopril Fosinopril - Monopril Lisinopril - Prinivil Lisinopril - Prinivil Moexipril - Univasc Moexipril - Univasc Quinapril - Accupril Quinapril - Accupril Perindopril erbumine - Aceon Perindopril erbumine - Aceon Ramipril - Altace Ramipril - Altace 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. 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 Adv effects: cough, angioedema, oral burning

Diuretics Common thiazide diuretics Common thiazide diuretics Chlorothiazide (Diuril) Chlorothiazide (Diuril) Indapamide (Lozol) Indapamide (Lozol) Metolazone (Zaroxolyn) Metolazone (Zaroxolyn) Common loop diuretics Common loop diuretics Bumetanide (Bumex) Bumetanide (Bumex) Ethacrynic acid (Edecrin) Ethacrynic acid (Edecrin) Furosemide (Lasix) Furosemide (Lasix) Common potassium-sparing diuretics Common potassium-sparing diuretics Amiloride (Midamor) Amiloride (Midamor) Eplerenone (Inspra) Eplerenone (Inspra) Spironolactone (Aldactone Spironolactone (Aldactone

Drug Therapy - Digitalis Glycosides Action: Increases the force and velocity of myocardial contraction Digoxin (Lanoxin) Digitoxin (Crystodigin) Purple foxglove - digitalis

Drug Considerations – Digitalis Glycosides Vasoconstrictor Interaction: concurrent use may increase the risk of cardiac arrhythmias – avoid if possible Vasoconstrictor Interaction: concurrent use may increase the risk of cardiac arrhythmias – avoid if possible Oral Manifestations: increased gag reflex, nausea/vomiting Oral Manifestations: increased gag reflex, nausea/vomiting Other Considerations: Other Considerations: macrolide antibiotics (erythromycin) can increase bioavailability of DG resulting in toxicity; avoid these drugs macrolide antibiotics (erythromycin) can increase bioavailability of DG resulting in toxicity; avoid these drugs watch for DG toxicity (tachycardia, N/V, hypersalivation, vision changes, fatigue, HA) watch for DG toxicity (tachycardia, N/V, hypersalivation, vision changes, fatigue, HA)

ACC/AHA Guidelines for perioperative cardiovascular evaluation for noncardiac surgery Clinical predictors of increased perioperative cardiovascular risk (major, intermediate, minor) Clinical predictors of increased perioperative cardiovascular risk (major, intermediate, minor) Major risk: Decompensated CHF Major risk: Decompensated CHF Intermediate risk: Compensated or prior CHF Intermediate risk: Compensated or prior CHF Minor risk: Inability to climb 1 flight of stairs with a bag of groceries Minor risk: Inability to climb 1 flight of stairs with a bag of groceries

Dental Management Considerations (Heart Failure) For undiagnosed pt with symptoms of HF: avoid elective care; refer to physician For undiagnosed pt with symptoms of HF: avoid elective care; refer to physician For patients with diagnosed HF: For patients with diagnosed HF: Class I (asymptomatic): routine care Class I (asymptomatic): routine care Class II (mild symptoms with exertion): elective care OK and recommend consultation with physician 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 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 Stress management protocol ID underlying disease (CHD, HBP, RHD) and manage appropriately ID underlying disease (CHD, HBP, RHD) and manage appropriately Semisupine or upright chair position Semisupine or upright chair position Take BP, monitor with pulse oximeter, watch for orthostatic hypotension Take BP, monitor with pulse oximeter, watch for orthostatic hypotension Drug Considerations Drug Considerations If taking digitalis, avoid vasoconstrictors if possible If taking digitalis, avoid vasoconstrictors if possible If taking nonselective β-blocker, use vasoconstrictor cautiously If taking nonselective β-blocker, use vasoconstrictor cautiously Watch for digitalis toxicity Watch for digitalis toxicity

Other Drug Considerations Patients on spironolactone should have potassium levels checked more often and every time a drug dose is changed. Patients on spironolactone should have potassium levels checked more often and every time a drug dose is changed.spironolactone Patients on digoxin need dig level testing. Patients on digoxin need dig level testing.digoxin Patients on Coumadin (warfarin) need INR testing. Patients on Coumadin (warfarin) need INR testing.CoumadinINRCoumadinINR Patients on amiodarone need thyroid and lung function testing. Patients on amiodarone need thyroid and lung function testing.amiodarone