CONGESTIVE HEART

FAILURE

IS CHF AN ACTUAL MEDICAL

DIAGNOSIS?

CHF is the common end point for many

forms of cardiac disease and typically
is a progressive condition that carries
an extremely poor prognosis

Congestive Heart Failure

The inability of the heart to supply
enough blood circulation to meet the
bodys needs.
Results in accumulation of
extravascular fluids

Cardiac catheterization is used to study the various

functions of the heart.

Congestive Heart Failure

5 million cases in the US
550,000 new conditions/year
300,00 deaths per year
In all age groups CHF is the fourth
most common medical condition

Congestive Heart Failure

Poor prognosis
50% death rate by year 5
50 60% death rate within one year if
symptoms are severe

Who Gets CHF?

Heart failure can happen to
anyone, but it is more common
in:
People 65 years of age and older
African Americans

CHF in African Americans

African Americans are more likely to
have heart failure and suffer more
severely from it:
Develop symptoms at an earlier age
Have their heart failure get worse faster
Have more hospital visits
Die from heart failure

Gender differences in CHF

Men also have a higher rate of heart
failure than women.
But in actual numbers, more women
have heart failure because many
more women live into their 70s and
80s when heart failure is common.

Congestive Heart Disease

Caused by the inability of the heart to
function efficiently as a pump

Physiology Terms You MUST

Understand
Preload
Afterload
Stroke Volume
Cardiac Output
Baroreceptor Reflex
Renin-Angiotensin System

Brief Overview

Poor pumping
mechanism leads to:
Incomplete filling of the
ventricles during diastole
Decrease in cardiac output
Inadequate blood volume to
tissues
Increased systemic congestion

Poor pumping
mechanism leads to:
Inadequate emptying of the
ventricles during systole.
Ejection fraction- percentage of
blood pumped out of the left ventricle
during systole
Normal-55-70%
CHF-45-50% and below

Cardinal Manifestations of CHF:

Fatigue
Dyspnea
Congestion of
pulmonary vessels

Congestive Heart Disease

The Heart
two pumps in a
series
connected via
pulmonary and
systemic circulation
each side of heart
has 2 valves which
maintain one sided
blood flow

Congestive Heart Disease

Right ventricle pumps large volumes of
blood at low pressure through the
pulmonary circulation
Left ventricle is a thick walled and
pumps at higher pressure and is more
effected by disease processes

NYHA CHF Classification

Class I (asymptomatic)
No limitation of physical activity

Class II
Slight limitation of physical activity

Class III
Marked limitation of activity

Class IV
Symptoms at rest

American Heart Association/

American College of Cardiology
Stage A
Patients have risk factors predisposing to HF but no
symptoms
CAD, HTN, DM
Stage B
Risk factors plus LVH and/or dysfunction
Stage C
Past or present symptoms of HF with heart damage
Stage D
Patients have severe HF needing advanced treatment or
end of life care

CAUSES OF CHF
Most common
underlying cause
Coronary Artery
Disease (CAD)

Increased vascular
resistance
Hypertension in 75%
of CHF patients
HTN is not a primary
cause however

Causes of CHF
Dilated or hypertrophic
cardiomyopathy
Idiopathic
Alcohol abuse
Hereditary
cardiomyopathy
Viral infection

Hypertensive Heart Disease:

Myocardial Hypertrophy
Left ventricular hypertrophy: LV outflow obstruction or
increased peripheral vascular resistance thickened LV wall

Right ventricular hypertrophy (cor pulmonale):

RV load increased due to pulmonary resistance dilated RV chamber

Other Causes of CHF

Valvular heart
disease
Myocardial
Infarction
Myocarditis
Infective
Endocarditis

Congenital heart
disease
Pulmonary
hypertension
Pulmonary
embolism
Endocrine disease

Cardiomyopathies
Dilated: symmetrically
enlarged (2-3x normal) with
dilation in all chambers
Hypertrophic: ventricular
hypertrophy without dilation,
often asymmetrical septal
hypertrophy
Restrictive: often bilateral
ventricular hypertrophy without
dilation (but atria are often
dilated bilaterally)-Ventricular
wall is stiffer

Congestive Heart Disease

Left sided heart failure
HTN
Aortic disease
Mitral disease
Coronary heart disease

Congestive Heart Disease

Right sided
heart disease
Most common
cause is
left sided failure
Cor pulmonale

SIGNS and SYMPTOMS OF

CHF
LHF-Pulmonary
Dyspnea
Orthopnea
Paroxysmal
nocturnal dyspnea
Pulmonary
hypertension

RHF-Systemic
Distended jugular

veins
Peripheral edema
Liver pain
Weight gain

PND
Paroxysmal nocturnal dyspnea
An attack of sudden and severe
shortness of breath that awakens the
patient from sleep, usually within 1 to
3 hours after the patient goes to bed
and resolves within 30 minutes after
the patient arises often gasping for air.

Orthopnea
Positional
dyspnea
worsened by a
recumbent or
semirecumbent
position

PND / Orthopnea
Due to increased venous return
encouraged by the semi-reclined position
resulting in increases in pulmonary
venous pressure and alveolar edema
Cheyne-Stokes Breathing
Alternating cycles of hyperventilation and
apnea

Side Effects of Heart Failure

Renin-Angiotensin system stimulated
Sympathetic Nervous system stimulation
Results in:
Increased heart rate/contractility of heart
Increased peripheral resistance
Sodium / Water retention (Rales/Crackles)
Blood redistribution to heart and brain
Increased efficiency of oxygen use by
tissues

What is the difference?

Compensated

Decompensated

Pitting Edema

+1

+2

+3

+4

Symptoms of Heart Failure

Dyspnea

Fatigue and weakness

Orthopnea

Paroxysmal nocturnal dyspnea

Acute pulmonary edema

Exercise intolerance

Dependent edema (after standing or

walking)

Report of weight gain or increased

abdominal girth (fluid accumulation;
ascites)

Right upper quadrant pain (liver congestion)

Anorexia, nausea, vomiting, constipation

(bowel edema)

Hyperventilation followed by apnea during

sleep (Cheyne-Stokes respiration)

Signs of CHF
Displaced Apical pulse
Mitral regurgitation
S3 / S4 Gallop
Pulsus Alternans

Pulsus Alternans
Arterial blood pressure
wave form
Most accurate measure
of blood pressure per
heart beat
Pulsus Alternans =
alternating strong and
weak beats

Laboratory Findings
Tests for Diagnosis:
Chest X-Ray
ECG
Echocardiogram
Ventriculography
Stress Test
Holter Monitoring
Cardiac Catherization

INCREASED VASCULAR
RESISTANCE
PRIMARY CAUSE
Hypertension
75% of cases

Aortic Stenosis
Coarctation of the Aorta

DECREASED MYOCARDIAL
FUNCTION
Ischemic heart disease
Infiltrative diseases
Amyloidosis

Metabolic disorders
Hypothyroidism

Pharmacologic suppression
Propanolol

INCREASED BLOOD
VOLUME
Valvular insufficiency
Aortic or mitral valve insufficiency

Atrial or Ventricular septal defect

Chronic renal failure with fluid
retention

EXCESSIVE METABOLIC
DEMAND
Severe anemia
Thyrotoxicosis

MEDICAL MANAGEMENT OF
THE CHF PATIENT
Stage A: Patients at High Risk for HF, but
without Structural Heart Disease or
Symptoms of HF
Treatment of hypertension, encourage smoking
cessation, treatment of lipid disorders,
encouragement of regular exercise, discourage
alcohol intake, illicit drug use, and control of
metabolic syndrome
ACE inhibitors or ARBs as appropriate for treatment
of vascular disease or diabetes

MEDICAL MANAGEMENT OF
THE CHF PATIENT
Stage B: Patients with Structural Heart
Disease, but without Signs or Symptoms of
HF
All measures for stage A, plus
ACE inhibitors (or ARBs) as appropriate
Beta blockers as appropriate

MEDICAL MANAGEMENT OF
THE CHF PATIENT
Stage C: Patients with Structural Heart
Disease with Previous or Current Symptoms
of HF
All measures for stages A and B, dietary salt
restriction, plus
Drugs for routine use: diuretics, ACE inhibitors, beta
blockers
Drugs in selected patients: aldosterone antagonists,
ARBs, digitalis, hydralazine-nitrates
Devices in selected patients: biventricular pacing
device, implantable defibrillator

MEDICAL MANAGEMENT OF
THE CHF PATIENT
Stage D: Patients with Refractory HF
Requiring Special Interventions
Appropriate measures from stages A, B, and C
Heart transplant recipients: chronic inotropes,
permanent mechanical support, experimental drugs
or surgery
Compassionate end-of-life care/hospice care

DRUGS USED IN THE

TREATMENT OF CHF
Diuretics
Chlorothiazide, Furosemide, Potassiumsparing

Cardiac Glycosides
Digoxin, Digitalis

Afterload Reducing Agents

ACE-inhibitors, Vasodilators

Most Common Side effect- xerostomia

Cardiac Glycosides used in

CHF
Digoxin (Digitalis, Lanoxin,
Lanoxicap)
Increases force and velocity of cardiac
contraction
Decreases conduction rate of A-V node
Oral Manifestations
Increased gag reflex (impressions)
Xerostomia
Increased caries

Digitalis Toxicity
Digitalis Toxicity
Symptoms & Signs
Visual changes (unusual)
Halos or rings of light
around objects
Seeing lights or bright
spots
Changes in color
perception
Blind spots in vision
Blurred vision

Confusion

Loss of appetite
Nausea, vomiting,
diarrhea
Palpitations
Irregular pulse

ACE-Inhibitors used in CHF

Shown to increase life expectancy
Enalopril - Vasotec
Captopril - Capoten
Lisinopril - Prinivil, Zestril
Quinapril - Accupril
Oral Manifestations
Cough
Oral ulceration, burning pain of mucosa
Angioedema

Vasodilators used in CHF

Hydralazine - Apresoline
Prazosin Minipres (a-blocker)
Oral manifestations
Dry mouth
Lupus-like lesions

Be sure to read Table 6-1

COMPLICATIONS OF DRUGS
USED TO TREAT CHF
Diuretics
Hypokalemia, dehydration, xerostomia

Cardiac Glycoside Overdose

Life threatening arrhythmia

Vasodilators
Orthostatic hypotension

Drug Side-Effects in CHF

Orthostatic hypotension
Diuretics and vasodilators

Arrythmias
Digoxin

Nausea, vomiting
Digoxin and vasodilators

Palpitations
Digoxin and vasodilators

Risks of Dental Treatment

Untreated or Poorly Managed CHF
Cardiac Arrest (Arrhythmia)
CVA
MI

Medical Considerations
Thorough Medical History !!!!!
Review of systems (Cardiopulmonary)
Vital Signs
Pulse, rate, rhythm, BP, resirations

Identification of all medicines taken

DENTAL EVALUATION OF
THE CHF PATIENT (ROS)
Ability to walk up stairs
Sleeping on increased number of
pillows
Shortness of breath
Breathlessness when flat
Swollen ankles
Ask if diagnosed with a murmur

DENTAL EVALUATION OF
THE CHF PATIENT
Mortality Rate - 50% at five years
Patient at low risk
History of mild congestive heart failure
Asymptomatic on therapy
Usually on diuretics, with or without
cardiac glycosides

DENTAL EVALUATION OF
THE CHF PATIENT
Patient at Moderate risk
History of moderately severe CHF
Asymptomatic at rest but
symptoms on exertion
Usually on more potent diuretics
and cardiac glycosides

DENTAL EVALUATION OF
THE CHF PATIENT
Patient at High Risk
Symptomatic despite therapy (Refractory
heart failure)
Often on escalating doses of medications,
including vasodilators

Dental Management of the

CHF Patient
Keep patient in upright or 45o position
Establish NYHA classification
Check medications
Cautious use of epinephrine
Check for digitalis toxicity
Watch for orthostatic hypotension
Short morning appointments

Before Any Treatment, Make

Sure The Benefits Outweigh
The Risks Involved To The
Patient!

MANAGEMENT OF CHF AND ACUTE

PULMONARY EDEMA
Sit patient upright
Administer oxygen
Nasal cannula preferred

Record vital signs

BP, heart rate and rhythm, respiratory rate

Alleviate apprehension
Summon medical assistance

Local Anaesthetic in CHF

Patients
Class I and II (NYHA)
Maximum 0.036 mg of epinephrine
0.20 mg of levonordephrine

Class III and IV (NYHA)

Avoid vasoconstrictors