CONGESTIVE HEART FAILURE - University of Minnesota
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Transcript CONGESTIVE HEART FAILURE - University of Minnesota
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
ANY CHF ( walking flight of stairs)
ANY arrhythmias
IDDM
CVA
Renal disease
HTN
-AHA. 2002. Circulation. 105:10.
Advanced age
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
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
FAILURE
COMPLICATIONS
infection
bleeding
MI
CVA
Cardiac arrest
Renal failure
(Causes)
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
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
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 selfsatisfaction.
Sir William Osler,1900
QuickTime™ and a
TIFF (LZW) decompressor
are needed to see this picture.
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
CONGESTIVE HEART
FAILURE- SIGNS
ruddy color
clubbing of fingers
swollen ankles
CONGESTIVE HEART
FAILURE- SIGNS
weight gain- girth
large tender liver
jaundice
cyanosis
CONGESTIVE HEART
FAILURE
OTHER CLINICAL SIGNS
ascites
distended neck veins
peripheral edema
“pitting edema”
CONGESTIVE HEART
FAILURE
SIGNS OF CHF
gallop rhythm
pulsus alternans
prolonged circulation time
cardiac enlargement
CONGESTIVE HEART
FAILURE
COMPENSATORY ADJUSTMENTS
Increase peripheral resistance
increase blood flow to heart and brain
increase erythropoietic activity
– Thrombocytopenia
– polycythemia
– Leukopenia
(symptoms)
CONGESTIVE HEART
FAILURE- SYMPTOMS
dyspnea
paroxysmal nocturnal dyspnea
periodic breathing- sleep apnea
insomnia
orthopnea
mental confusion
dizziness
CONGESTIVE HEART
FAILURE- SYMPTOMS
weakness, fatigue
wheezing, coughing
low-grade fever, sweating
nausea, vomiting
cardiac reserve
epistaxis
CONGESTIVE HEART
FAILURE
LABORATORY FINDINGS
Increased hematocrit, hemoglobin
decreased WBC
prolonged PT, PTT
CONGESTIVE HEART
FAILURE
CLASSIFICATION
ventricular dysfunction
compensated CHF
intractable heart failure
CONGESTIVE HEART
FAILURE
COMPLICATIONS
infection
bleeding
MI
CVA
Cardiac arrest
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
CONGESTIVE HEART
FAILURE
DENTAL MANAGEMENT
HTN !
BLEEDING
–
–
–
–
polycythemia
thrombocytopenia
low fibrinogen
PT, BT
Medical management of
congestive heart failure.
Pharmacologic treatment.
NYHA class I CHF ( ejection fraction >40% ;
asymptomatic patient)
Long-acting ACE inhibitor
CONGESTIVE HEART
FAILURE
MEDICAL MANAGEMENT for MILD
CHF
decrease exertion; physical activity
loading dose of digitalis
cut down NaCl
drug side effects and interactions
CONGESTIVE HEART
FAILURE
MANAGEMENT for MODERATE CHF
decrease exertion; physical activity
digitalis, diuretics, K+
lasix, apresoline, isordil, minipress
COUMARIN
drug side effects and interactions
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 !!
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)
CONGESTIVE HEART
FAILURE
DIGITALIS INTOXICATION
visual changes ( blurring)
nausea, vomiting, anorexia
fatigue, weakness, malaisse, drowsiness
headaches, neuralgias
delirium
ARRHYTHMIAS
CONGESTIVE HEART
FAILURE
Complications from diuretics, vasodilators
Complications from ACEI
xerostomia, dehydration
nausea, vomiting, headaches
dizziness, weakness
orthostatic hypotension
lichenoid lesions
orthostatic hypotension
CONGESTIVE HEART
FAILURE
lack of response to initial Rx=
POOR PROGNOSIS ( 50 % DIE in 5 yrs.)
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
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)