Dental Management of Patients with Heart Failure

1. Dental Management of Patients with Heart Failure

2. 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)

3. 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

4. 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

5. 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

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

7. Common Causes of HF 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

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

9. Symptoms of Heart Failure 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

10. Laboratory Findings of CHF • 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

11. Functional Classification of Heart Failure (NYHA) • 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

12. To Prevent Heart Failure • 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;

13. Medical Management of Heart Failure • Decreased cardiac output CO • Decreased ejection fraction • - repair of diseased valves • Fluid overload • Overweight • HTN Main Problems requiring treatment

14. Medical Management of Heart Failure • 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

15. 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

16. ACE inhibitors (ACEI) - (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

17. Diuretics • 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

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

19. Drug Considerations – Digitalis 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)

20. 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

21. Dental Management Considerations (Heart Failure) • 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

22. Stress management protocol • 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

23. Other Drug Considerations • 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.