Heart Failure (or Congestive Heart Failure)

Question 1

what age group primarily has heart failure?

Answer 1

primarily a condition of the edlerly

Question 2

what is heart failure?

Answer 2

Heart failure is the inability of the heart to supply enough blood circulation to meet the body’s needs. It manifests as a symptom complex, representing the end stage of many cardiovascular diseases that impair the ventricle’s ability to fill with or eject blood.
- patients with untreated or poorly managed HF are at high risk during dental treatment for cmoplications such as arrest, stroke (cerebrovascular accident), and MI. On encountering such a patient, the dentist must be able to recognize the problem from the history and clinical findings; then the patient can be referred for medical diagnosis and management,a nd the patient’s physician consulted to develop a safe and effective dental management plan.

Question 3

What is characteristics of HF syndrome?

Answer 3

Signs and symptoms of intravascular and intersitital volume overload and/or manifestations of inadequate tissue perfusion.

Question 4

Causes of HF?

Answer 4

may occur due to:

1. impaired myocardial contractility (systolic dysfunction, commonly characterized as reduced left ventricular ejection fraction)
2. increased ventricular stiffness or impaired myocardial relaxation (diastolic dysfunction, which is commonly is associated with a relatively normal LVEF)
3. A variety of other cardiac abnormalities, including obstrcutive or regurgitant valvular disease, intracardiac shunting, or disorders of heart rate or rhythm; or
4. states in which heart is unable to compensate for increased peripheral blood flow or metabolic requirements.

most common cause of heart failure:
coronary heart disease (accounts for 60-75% of cases) 
cardiomyopathy (accounts for about 25% of the cases) 
hypertension
valvular heart disease
myocarditis
infective endocarditis
congenital heart disease
pulmonary hypertension
pulmonary embolism
endocrine disease

Question 5

what is the prognosis for patients with HF?

Answer 5

of patients who survive an acute onset of HF, only 35% of men and 50% of women are alive after 5 years.

Question 6

what is the pathophysiology of HF?

Answer 6

caused by the inability of the heart to function efficiently as a pump, which results in either an inadequate emptying of the ventricles during sytole or an incomplete filling of the ventricles during diastole.
This in turn results in a decrease in cardiac output, with consequent delivery of an inadequate volume of blood to the tissues, or in a backup of blood, causing systemic congestion.
May involve one or both ventricles, usually left first (causing increased pressure and fluid retention, pulmonary hypertension and edema) and then right (causing increased pressure and fluid retention, venous congestion, and peripheral edema). Even if you get symptoms of just right ventricular failure, left is usually involved as well.
CARDINAL MANIFESATIONS OF HF ARE DYSPNEA AND FATIGUE.

Question 7

what are normal ejection fraction at rest?

Answer 7

55% - 70%, although arbitrary, an LVEF of 45%-50% often is used as a threshold value to diagnose left ventricular failure. The outstanding symptom of left ventricular failure is dyspnea, which results from the accumulation or congestion of blood in the pumonary vessels - hence the designation congestive (actue pulmonary edema occurs because of left usually). Left ventricular failure will lead to pulmonary hypertension which increases the work of the right ventricle pumpign against increased pressure, often culminating in right-sided heart failure.
Failure of right ventricle alone is rare and can occur with emphysema.

Question 8

what happens to the ventricle with failure?

Answer 8

dilation and hypertrophy of the ventricle as it attempts to ompensate for its inability to keep up with the workload.

Question 9

when do you get the signs and symptoms of HF?

Answer 9

when the heart no longer functions properly as a pump.

• with decreased cardiac output the renin-angiotensin system and sympathetic nervous system occurs in an attempt to compensate for the loss of function.
• increased heart rate, and myocardial contractility, inceased peripheral resistance, sodium and water retention, redistribution of blood flow to the heart and brain, and an increased efficiency of oxygen utilization by the tissues.

Question 10

symptoms of heart failure

Answer 10

SYMPTOMS
dyspnea (perceived shortness of breath)
fatigue and weakness
orthopnea (dyspnea experienced with patient in recumbent psotion)
paroxysmal nocturnal dyspnea (dyspnea awakening patient from sleep)
acute pulmonary edema (cough or progressive dyspnea)
exercise intolerance (inability to climb a flight of stairs)
fatigue (especially muscular)
dependent edema (swelling of feet and ankles after standing or walking)
report of weight gain or increased abdominal girth (fluid accumulartion; ascites)
right upper quadrant pain (liver congestion)
anorexia, nausea, vomiting, constipation (bowel edema)
hyperventilation followed by apnea during sleep (Cheyne-Stokes respiration)

Question 11

signs of heart failure

Answer 11

rapid, shallow breathing
Cheyne-Stokes respiration (hyperventialation alternating with apnea)
inspiratory rales (crackles)
heart murmur
gallop rhythm
increased venous pressure
enlargement of cardiac silhouette on chest radiograph
pulsus alternans
distended neck veins
large, tender liver
jaundice 
peripheral edema
ascites
cyanosis
weight gain 
clubbing of fingers

Question 12

what is the ASA classification?

Answer 12

ASA Classification:
• Class I:
o No limitation of physical activity.
o Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath).
• Class II:
o Slight limitation of physical activity.
o Comfortable at rest.
o Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath).
• Class III:
o Marked limitation of physical activity.
o Comfortable at rest.
o Less than ordinary activity causes fatigue, palpitation, or dyspnea.
• Class IV:
o Unable to carry on any physical activity without discomfort.
o Symptoms of heart failure at rest.
o If any physical activity is undertaken, discomfort increases.

Question 13

what should you do for dental care?

Answer 13

decompensated (are symptomatic) HF patients are generally not candidates for elective dental care, and treatment is deferred until medical consultation can be obtained. 
Those who are ASA (NYHA classI) are at intermediate risk for occurrence of a serious event. With good functional capacity and reserve (as demonstrated by the ability to climb a flight of stairs) however, they generally can safely undergo andy required treatment with little likelihood of problems. 
Many patients with ASA class II and some with class III receive dental treatment (routine dental treatment) after approval by the physician. 

There can always be the risk of compensated going to decompensated during dental treatment, and the biggest reason is failure to take medication so the dentist must know patient compliance to taking medication.

• stress-free appointments, short
• may not tolerate a supine position and will need semisupine or upright chair position
• for patients taking a digitalis glycoside (digoxin), epinephrine should be avoided, if possible because the combination can potentially precipitate arrhythmias.
• maximum of 0.036mg epinephrine (i.e. two cartriges of 2% lidocaine with 1:100,000 epinephrine) is recommended.
• use of epinephrine-impregnated gingival retraction cord should be avoided
  NSAIDS should be avoided
• nitrous with oxygen supplementation can be used if adequate 02 flow (at least 30%) is maintained.
• some drugs used to manage it can cause dry mouth and oral lesions.