Dental ManagementDental Management of of

Patients with Heart FailurePatients with Heart Failure

What is Heart Failure?What is Heart Failure?A symptom complex due A symptom complex due to the inability of the to the inability of the heart to function heart to function efficiently as a pump - efficiently as a pump - there is a disproportion there is a disproportion between the between the hemodynamic demand hemodynamic demand and the capacity of the and the capacity of the heart to handle the heart to handle the demand demand

( Supply ( Supply ≠ ≠ Demand)Demand)

What is Heart Failure?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 diseasesPericardial disease - Pulmonary embolism

Types and Classifications of H.FTypes and Classifications of H.F (measured by ejection fraction [EF])(measured by ejection fraction [EF])

Systolic or diastolicSystolic or diastolic

High output or low outputHigh output or low output

Left or right sidedLeft or right sided

Acute or chronicAcute or chronic

Systolic HFSystolic HF

Inability of heart to Inability of heart to contract stronglycontract strongly enough to provide enough to provide adequate blood adequate blood flow to peripheryflow to periphery

Diastolic Diastolic HFHF

Abnormal Abnormal relaxationrelaxation of of myocardium myocardium resulting in resulting in reduced fillingreduced filling of of ventricleventricleSystolic dysfunction:Systolic dysfunction:

- - EF < 50%; results from EF < 50%; results from reduced left ventricular reduced left ventricular functionfunction - Increased preload- Increased preload - Most cases of CHF- Most cases of CHF

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

periphery).periphery).

Common Causes of HFCommon Causes of HF

Coronary Heart Disease/MICoronary Heart Disease/MI

HypertensionHypertension

Valvular Heart DiseaseValvular Heart Disease

ArrhythmiasArrhythmias

MyocarditisMyocarditis

CardiomyopathyCardiomyopathy

Infective EndocarditisInfective Endocarditis

Congenital Heart DiseaseCongenital Heart Disease

Pulmonary HypertensionPulmonary Hypertension

Endocrine Disorders (thyroid Endocrine Disorders (thyroid disease)disease)

MI is a leading cause

Sequelae of Heart FailureSequelae of Heart Failure Right Heart Right Heart

FailureFailure Systemic Systemic

venous venous congestion congestion (distended (distended neck veins, neck veins, enlarged liver, enlarged liver, peripheral peripheral edema, edema, ascites)ascites)

Left Heart Left Heart FailureFailure Pulmonary Pulmonary

edema edema (Dyspnea)(Dyspnea)

Symptoms of Heart FailureSymptoms of Heart Failure

Compensated (Asymptomatic)Compensated (Asymptomatic)

Uncompensated (Symptomatic)Uncompensated (Symptomatic) FatigueFatigue DyspneaDyspnea OrthopneaOrthopnea Paroxysmal Nocturnal DyspneaParoxysmal Nocturnal Dyspnea Ankle EdemaAnkle Edema Weight GainWeight Gain

Note: patients with a very low EF may have no symptoms

Laboratory Findings of Laboratory Findings of CHFCHF

BPBP: elevated: elevated Chest x-rayChest x-ray: heart enlarged: heart enlarged ECGECG:: arrhythmia arrhythmia Serum chemistries:Serum chemistries:

electrolytes: elevatedelectrolytes: elevated liver function tests (AST, ALT, bilirubin): elevatedliver function tests (AST, ALT, bilirubin): elevated Renal function tests (BUN, creatinine): elevatedRenal function tests (BUN, creatinine): elevated C-reactive protein: if > 3 mg/L increased risk for MIC-reactive protein: if > 3 mg/L increased risk for MI Cardiac natriuretic peptides (BNP): adjunctive test to rule Cardiac natriuretic peptides (BNP): adjunctive test to rule

out HF in acute setting (increased risk of HF if > 100 out HF in acute setting (increased risk of HF if > 100 pg/mL) pg/mL)

Stress testStress test: diminished capacity: diminished capacity Arterial blood gas levels:Arterial blood gas levels: hypoxia (< 95%) and acid-base hypoxia (< 95%) and acid-base

imbalanceimbalance

Functional Classification of Heart Functional Classification of Heart Failure (NYHA)Failure (NYHA)

Class IClass I:: No limitation of physical activity. No No limitation of physical activity. No dyspnea, fatigue, or palpitations with ordinary dyspnea, fatigue, or palpitations with ordinary physical activityphysical activity

Class IIClass II:: Slight limitation of physical activity. Slight limitation of physical activity. Fatigue, palpitations and dyspnea with Fatigue, palpitations and dyspnea with ordinary physical activity but comfortable at ordinary physical activity but comfortable at rest.rest.

Class IIIClass III:: Marked limitation of activity. Less Marked limitation of activity. Less than ordinary physical activity results in than ordinary physical activity results in symptoms but comfortable at rest.symptoms but comfortable at rest.

Class IVClass IV:: Symptoms present at rest and any Symptoms present at rest and any physical activity exacerbates the symptomsphysical activity exacerbates the symptoms

To Prevent Heart FailureTo Prevent Heart Failure lower high blood pressurelower high blood pressure;; lose extra weightlose extra weight;; quit smoking, alcohol use, illegal drug usequit smoking, alcohol use, illegal drug use control irregular or too-fast heart rhythmscontrol irregular or too-fast heart rhythms;; correct too-low or too-high thryoid functioncorrect too-low or too-high thryoid function;; lower bad cholesterol and raise good cholesterollower bad cholesterol and raise good cholesterol;; if diabetic, control blood sugarif diabetic, control blood sugar;; if had a heart attack, restore lost blood flow with if had a heart attack, restore lost blood flow with bypassbypass surgery surgery

or angioplasty if possibleor angioplasty if possible;; if had a heart attack (even if long ago), take an ACE inhibitor or if had a heart attack (even if long ago), take an ACE inhibitor or

ARB, ARB, and alsoand also take a beta-blocker to reduce risk of heart failure take a beta-blocker to reduce risk of heart failure down the road, even if you have no symptoms and even if your EF down the road, even if you have no symptoms and even if your EF is normalis normal;;

if have reduced EF, take a beta-blocker if have reduced EF, take a beta-blocker andand an ACE inhibitor an ACE inhibitor even if you have no symptomseven if you have no symptoms;;

if have significant heart valve dysfunction, get surgical repairif have significant heart valve dysfunction, get surgical repair;; perform regular perform regular echocardiogramsechocardiograms in people who have had in people who have had

chemotherapychemotherapy;;

Medical Management of Heart Medical Management of Heart FailureFailure

1.1.Decreased cardiac output CODecreased cardiac output CO

2.2.Decreased ejection fractionDecreased ejection fraction - repair of diseased valves- repair of diseased valves

3.3.Fluid overloadFluid overload

4.4.OverweightOverweight

5.5.HTNHTN

Main Problems Main Problems requiring requiring treatmenttreatment

Medical Management of Medical Management of Heart FailureHeart Failure

Treatment of underlying diseaseTreatment of underlying disease Life-style modificationsLife-style modifications Drug therapyDrug therapy

ACE inhibitorsACE inhibitors- Or angiotensin receptor blockers- Or angiotensin receptor blockers

Beta Blockers Beta Blockers (Coreg, Toprol-XL, or bisoprolol)(Coreg, Toprol-XL, or bisoprolol) DiureticsDiuretics

- Or direct-acting vasodilators- Or direct-acting vasodilators NitratesNitrates Digitalis GlycosidesDigitalis Glycosides

Heart transplantHeart transplant

Less frequently used today, because recent trial indicates no benefit in survival, but can

improve symptoms

1st line drugsUsed in combination with 1st line drugs

ACE inhibitors (ACEI) - ACE inhibitors (ACEI) - (Oral (Oral

Meds)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 - Perindopril erbumine - Aceon Aceon

Ramipril - Altace Ramipril - Altace

ACEI block an ACEI block an enzyme that is enzyme that is necessary to necessary to produce renin that produce renin that causes blood causes blood vessels to tighten. vessels to tighten. As a result, they As a result, they relax blood vessels relax blood vessels and lower BP.and lower BP.

Adv effects: cough, Adv effects: cough, angioedema, oral angioedema, oral burningburning

DiureticsDiuretics Common thiazide diureticsCommon thiazide diuretics

Chlorothiazide (Diuril) Chlorothiazide (Diuril) Indapamide (Lozol) Indapamide (Lozol) Metolazone (Zaroxolyn) Metolazone (Zaroxolyn)

Common loop diureticsCommon loop diuretics Bumetanide (Bumex) Bumetanide (Bumex) Ethacrynic acid (Edecrin) Ethacrynic acid (Edecrin) Furosemide (Lasix) Furosemide (Lasix)

Common potassium-sparing diureticsCommon potassium-sparing diuretics Amiloride (Midamor) Amiloride (Midamor) Eplerenone (Inspra) Eplerenone (Inspra) Spironolactone (AldactoneSpironolactone (Aldactone

Drug Therapy - Digitalis Drug Therapy - Digitalis GlycosidesGlycosides

Action: Increases the Action: Increases the force and velocity force and velocity of myocardial of myocardial contractioncontraction

Digoxin (Lanoxin)Digoxin (Lanoxin)

Digitoxin Digitoxin (Crystodigin)(Crystodigin)

Purple foxglove - digitalis

Drug Considerations – Drug Considerations – Digitalis GlycosidesDigitalis Glycosides

Vasoconstrictor Interaction: concurrent use may Vasoconstrictor Interaction: concurrent use may increase the risk of cardiac arrhythmias – avoid if increase the risk of cardiac arrhythmias – avoid if possible possible

Oral Manifestations: increased gag reflex, Oral Manifestations: increased gag reflex, nausea/vomitingnausea/vomiting

Other Considerations: Other Considerations: macrolide antibiotics (erythromycin) can increase macrolide antibiotics (erythromycin) can increase

bioavailability of DG resulting inbioavailability of DG resulting in toxicity; avoid these toxicity; avoid these drugs drugs

watch for DG toxicity (tachycardia, N/V, hypersalivation, watch for DG toxicity (tachycardia, N/V, hypersalivation, vision changes, fatigue, HA)vision changes, fatigue, HA)

ACC/AHA Guidelines for ACC/AHA Guidelines for perioperative cardiovascular perioperative cardiovascular

evaluation for noncardiac surgeryevaluation for noncardiac surgery Clinical predictors of increased Clinical predictors of increased

perioperative cardiovascular risk perioperative cardiovascular risk (major, intermediate, minor)(major, intermediate, minor) Major riskMajor risk: Decompensated CHF: Decompensated CHF Intermediate riskIntermediate risk: Compensated or prior : Compensated or prior

CHFCHF Minor riskMinor risk: Inability to climb 1 flight of : Inability to climb 1 flight of

stairs with a bag of groceriesstairs with a bag of groceries

Dental Management Dental Management Considerations (Heart Failure)Considerations (Heart Failure)

For undiagnosed pt with symptoms of HF: For undiagnosed pt with symptoms of HF: avoid elective care; refer to physicianavoid elective care; refer to physician

For patients with diagnosed HF:For patients with diagnosed HF: Class IClass I (asymptomatic): routine care (asymptomatic): routine care Class IIClass II (mild symptoms with exertion): elective care (mild symptoms with exertion): elective care

OK and recommend consultation with physician OK and recommend consultation with physician Class III or IVClass III or IV (symptoms with minimal activity or at (symptoms with minimal activity or at

rest): rest): avoid elective careavoid elective care; if treatment necessary, ; if treatment necessary, manage in consultation with physician; consider manage in consultation with physician; consider referral to a special patient care setting; avoid use referral to a special patient care setting; avoid use of vasoconstrictorsof vasoconstrictors

Stress management protocolStress management protocol

ID underlying disease (CHD, HBP, RHD) and ID underlying disease (CHD, HBP, RHD) and manage appropriatelymanage appropriately

Semisupine or upright chair positionSemisupine or upright chair position

Take BP, monitor with pulse oximeter, watch Take BP, monitor with pulse oximeter, watch for orthostatic hypotensionfor orthostatic hypotension

Drug ConsiderationsDrug Considerations If taking digitalis, avoid vasoconstrictors if possible If taking digitalis, avoid vasoconstrictors if possible

If taking nonselective If taking nonselective ββ-blocker, use -blocker, use vasoconstrictor cautiouslyvasoconstrictor cautiously

Watch for digitalis toxicity Watch for digitalis toxicity

Other Drug ConsiderationsOther Drug Considerations

Patients on spironolactone should have Patients on spironolactone should have potassium levels checked more often and potassium levels checked more often and every time a drug dose is changed. every time a drug dose is changed.

Patients on digoxin need dig level testing. Patients on digoxin need dig level testing. Patients on Coumadin (warfarin) need INR Patients on Coumadin (warfarin) need INR

testing. testing. Patients on amiodarone need thyroid and Patients on amiodarone need thyroid and

lung function testing. lung function testing.