CVD - cardiac failure

Question 1

Define heart failure:

Answer 1

Heart failure: a clinical syndrome of symptoms e.g. breathlessness, fatigue and signs (oedema, crepitations) resulting from structural and/or functional abnormalities of cardiac function which leads to reduced cardiac output or high filling pressures at rest or with stress.

Essentially heart not able to adequately pump blood around body.

Question 2

List some causes of heart failure:

Answer 2

Inadequate blood supply to myocardium:

• myocardial infarction
• ischaemic heart disease

Hypertensive heart disease:

• hypertension

Heart Valve disease

• acquired valvular disease
• congenital valvular disease

Disease of myocardium:

• dilated cardiomyopathy
• hypertrophic cardiomyopathy (genetic)
• alcohol related cardiomyopathy

Cardiac arrhythmias:

• atrial fibrillation, fast heart beat

Question 3

How does heart failure present?

Symptoms due to fluid overload and congestion include:

Answer 3

Often gradual onset in a patient with other coexisting CVD

Symptoms due to fluid overload and congestion:

• fatigue
• breathlessness - on exertion and lying flat (orthopneoa)
• peripheral oedema
• sometimes during night - lying flat (paroxysmal nocturnal dyspnoea)

Question 4

How is heart failure diagnosed and investigated?

Answer 4

• history and examination
• blood tests: BNP test - hormone secreted by heart, increased during heart failure
• echocardiography - cardiac ultrasound
• ECG

Question 5

How is heart failure treated?

Answer 5

1. Address underlying cause
   - lifestyle changes, GTN spray, blood pressure control using antihypertensives, valve replacement
2. Treat symptoms:

HF - Reduced ejection fraction: should be on an ACE inhibitor or angiotensin II receptor antagonist, loop diuretics are mainstay treatment also

• diuretics, ACE inhibitor or angiotensin II receptor antagonist, beta blockers, aldosterone antagonist, Digoxin, sacubitril/valsartan, devices

HF - Preserved ejection fraction:

• loop diuretics

Question 6

Give examples of implanted devices in HF:

Any considerations for devices?

Answer 6

• implantable cardioverter defibrillators (ICD)
• cardiac resynchronisation therapy (CRT): pacemaker with or without defibrillator

Check compatibility of your dental therapy with the device!

Question 7

List some oral side effects of medical treatments used for HF:

Answer 7

Diuretics: xerostomia

ACE inhibitors: oral lichenoid reactions, glossitis

Angiotensin II receptor antagonists: taste disturbances

Beta blockers: xerostomia, lichenoid reactions

Spironolactone: xerostomia

Question 8

List some surgical treatments of HF:

Answer 8

If co-existing angina:

• CABG
• percutaneous transluminal coronary angioplasty

Consider valve surgery

Rarely transplant

Question 9

What are some dental aspects of HF?

Answer 9

• avoid treatment if symptoms unstable
• caution when lying flat
• postural hypotension is common due to meds
• polypharmacy: side effects, may be on antiplatelets or anticoagulants, risk of interactions
• avoid NSAIDs: cause fluid retention
• find out if they have a pacemaker, ICD or CRT device and check safety with dental equipment
• acute heart failure may present in surgery: ABCDE approach, potential cardiac arrest, use AED