Implications in Dental Care I Flashcards by J L

Definition of congestive heart failure
 \_\_\_\_ clinical syndrome
 Involves \_\_\_\_ disorders
of the heart
 Impairs\_\_\_\_ of blood from the heart or \_\_\_\_ of the heart

complex
structural/functional
ejection
filling

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congestive heart failure
 ____ progressive condition
 Muscles of the heart are ____
 Cannot pump adequate ____ blood to the body
 Represents the ____ of many cardiovascular diseases

chronic
weak
oxygen-rich
end stage

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Epidemiology of CHF
 Singled out as an ____
 ____ patients 65 years and above have CHF
 In 2013, approx. ____ million Americans with HF
 Approximately ____ million people with HF worldwide

epidemic
4 in 5
5
23

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Epidemiology of CHF

 Prevalence increases with ____
 Prevalence -25% higher in ____ compared with Caucasians
 Projected to rise over next 40 years- with estimated 772,000 new cases

age

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Etiology – any disease that weakens the heart

 \_\_\_\_ disease
 Hypertension
 Dilated \_\_\_\_
 Coronary artery disease
 \_\_\_\_
 Untreated valvular dx
 Myocarditis
 \_\_\_\_
 Congenital heart disease
 \_\_\_\_
 Diabetes

ischemic heart
cardiomyopathy
infective endocarditis
pulmonary embolism

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Compensatory mechanism and its sequlae- in response to diseases affecting the heart

 ____- contractile cells of the heart muscles become more in number
 ____- the heart becomes larger because the heart muscle stretches
 ____- heart pumps faster to increase oxygen output

hyperplasia
hypertrophy
tachycardia

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Compensatory mech. (contd)
 Increased ____- from narrowing of blood vessels
 Blood is diverted from less important body organs e.g. ____
 Kidneys retain more ____ and electrolyte leading to increased ____ volume.
 Congestion of fluids occur in tissues – already weakened heart has to do more ____

BP
kidney
water
interstitial
work

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Left sided HF
 Left sided heart failure with reduced ejection fraction (____ failure)- muscles of left ____ are weak and can’t produce enough force to pump oxygenated blood out to the tissues (reduced ____)
 Left sided heart failure with preserved ejection fraction (____ failure)- left ventricles muscles do not ____ adequately to fill with blood
 Oxygenated blood is backed up in the ____, pulmonary artery and ____
 Leads to ____

systolic
ventricle
cardiac ouput
diastolic
relax
left atrium
lungs
congestion

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Right sided heart failure
 Caused by progressive ____ failure.
 Fluids are backed up in the lungs, ____.
 Consequently right side of the heart (Right ____ and right ____ are affected)
 Pulling of blood and interstitial fluids in ____ and organs

left sided
pulmonary vein
atrium
ventricles
body tissues

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CHF- signs and symptoms
 ____ especially ankle and knees (pitting edema)
 GI/liver- ascites
 ____- as a result of fluid collecting in the lungs (pulmonary ____)
 Coughing from pulmonary edema
 ____
 Orthopnea

edema
shortness of breath
hypertension
fatigue

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Classification of HF- NYHA
 Class I : No limitation of ____. No dyspnea, ____, or palpitations with ordinary physical activity
 Class II : ____ limitation of physical activity. Patients experience ____, palpitations, and dyspnea with ordinary physical activity but are comfortable at ____.

physical activity
fatigue

slight
fatigue
rest

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NYHA classification
 Class III : ____ limitation of activity. Less than ordinary physical activity results in ____, but patients are comfortable at ____.
 Class IV : Symptoms are present with the patient at ____, and any physical exertion ____ the symptoms.

marked
symptoms
rest
rest
exacerbates

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Compensated and Decompensated heart failure

 Compensated heart failure – patient is usually ____ because heart compensates to increase ____
 Decompensated heat failure- patient has worsening symptoms (e.g. ____, edema, ____, SOB)

asymptomatic
cardiac output
dyspnea
ascites

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Role of Dentists in managing CHF patients

 A major risk in providing dental treatment for a patient with symptomatic HF is that the symptoms could abruptly worsen with resultant acute failure, a fatal arrhythmia, stroke, or MI.
 Identification of patients with a history of HF, those with undiagnosed HF, or those prone to developing HF is the first step in ____ and in avoiding an untoward event.

risk assessment

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Legal implication for dentists
 Treating dentists remain ____ accountable for decisions to treat patients, whether or not they
obtain a consultations from patients physician
 The ____ is just one of the sources for obtaining the necessary information dentists use to make decisions and render treatment.

legally

medical consult

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Dental considerations in treating a patient with CHF

 Patients with untreated or mismanaged CHF at risk for stroke/CVA, MI, TIA or cardiac arrest in a dental chair.
 Its important to know the ____ leading to the CHF. e.g. uncontrolled HBP versus cardiac valve diseases.

cardiac conditions

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Management of patients with CHF
 Monitor ____ and vital signs at every visit
 Short ____ or ____ appointments

BP
early morning
early afternoon

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Local Anesthesia
 Achieve and maintain excellent anesthesia in order to reduce ____ and prevent cardiac crisis.
 Use of epinephrine (1 : 100,000) at a dose of no more than ____ carpules in local anesthetics generally causes no problems
 Clinicians should provide good ____ control

stress
2
postoperative pain

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Management of patients with CHF
 The use of epinephrine or other pressor amines (either in ____ or as agents to control bleeding) must be ____.
 Note if the patient has any need for antibiotic prophylaxis
 Pts may require ____

gingival retraction cord
avoided
anxiolytics

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Management of patients with CHF
 No elective dental treatment for patients in the 1st ____ months after an MI
 Ensure you have access to ____ for patients with risk of angina
 No ____ for patients with angina- because they will not be able to report an angina episode

6
nitrates
sedation

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Dysrhythmia
 Abnormality in heart rate, rhythm (regularity) or site of origin of cardiac impulses
 Problems with ____ and/or ____ of cardiac impulses- (results in altered ventricle and atrial sequence).
 Some are life threatening

generation

conduction

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 Could be present in ____ patients occasionally – result of anxiety, fever, rapid blood loss or strenuous exercise
 Typically present in patients with ____

healthy

cardiac diseases

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Causes of dysrhythmia
 \_\_\_\_, fever, strenuous exercise
 Side effect of \_\_\_\_ (tea, coffee, or soda), chocolate, tobacco (\_\_\_\_)
 Primary heart diseases
 Pulmonary disease- \_\_\_\_ and pneumonia

stress
caffeine
paroxysmal supraventricular tachycardia
embolism

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Causes of dysrhythmia
 Autonomic disorders e.g. \_\_\_\_
 Systemic disorders- e.g. \_\_\_\_ (hyperthyroidism)
 Drug-related side effects
 \_\_\_\_ imbalance

autonomic neuropathy
thyroid problems
electrolyte

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Types of Dysrhythmia  Based on rate:  ____  Bradycardia  Based on rhythm  ____  Ventricular

tachycardia | supraventricular

``` Types of dysrhythmia  Based on conduction: SA node and AV node ____ heart block  2nd degree heart block ____ heart block ```

1st degree | 3rd degree

Types of dysrhythmia- Rate and Rhythm • Tachycardia – ____ – from Atria – ____- from Ventricles • Bradycardia

supraventricular dysrhythmia | ventricular dysrhythmia

Tachycardia- Ventricular  Ventricular fibrillation  ____ ventricular contractions ____

premature | long qt syndrome

``` Tachycardia- supraventricular Arises from the atria:  ____  Atrial fibrillation  ____ tachycardia  Premature supraventricular tachycardia  ____ syndrome ```

atrial flutter paroxysmal supraventricular wolff-parkinson-white

``` A.fib  Arises from the atrium  Epidemiology:  Most ____ arrhythmia  Affects ____% of worldwide population  3-6 million people in USA ```

common | 1-2

A. fib- signs  Heart rate- ____ beats/minute  No discrete ____ on EKG  ____ heart beat  Usually associated with ____, RHD, ____, Ischemic heart disease  Pts at high risk of ____ events including cerebrovascular accident

``` 400-650 P wave irregularly irregular HTN thyrotoxicosis thromboembolic ```

``` Signs and symptoms of A.Fib Symptoms  ____,  fatigue  ____  Syncope  ____ ```

palpitations dizziness angina

A fib. Risk assessment |  ____ score used to assess stroke risk

CHA2DS2 VASc

``` CHA2DS2 VASc  C- congestive heart failure -____  H- hypertension -___  A- Age (≥ 75yrs)- ___  D- Diabetes -___  S- previous stroke, TIA - ___  V- vascular peripheral disease- ___  A- Age -64-74 years -___  Sex category –females-___ ```

``` 1 1 2 1 2 1 1 1 ```

``` CHA2DS2 VASc score  Has a total score of ____  The higher the total score, the higher the risk of ____.  Score of 2 and more need for ____ therapy. ```

9 stroke anticoagulant

A. Fib- thromboembolic episode prevention  Patients on A. fib are on anticoagulants to prevent thromboembolic episodes  ____or the newer oral anticoagulants

warfarin (coumadin)

Warfarin- anticoagulant  Warfarin decreases blood clothing - blocks an enzyme ____  Dose ____ needed from patient to patient- metabolism varies  Warfarin has interactions with foods (herbs & spices), medication (____, antibiotics), alcohol, etc  Side effect is bleeding including ____, GI bleeding (especially with ____ use)  Lab monitoring required- ____ time (INR)  Warfarin antidote- ____, FFP

``` vitamin K epoxide reductase adjustment metronidazole intracranial hemorrhage NSAIDs prothrombin vitamin K ```

Novel oral anticoagulants  Direct thrombin- ____  Factor Xa inhibitors - ____, apixaban, ____  50% less risk of ____  Fewer requirements for dose ____  No clear interactions with ____, fewer medication interaction

``` dabigatran rivaroxaban edoxaban intracranial hemorrhage adjustment food ```

Novel oral anticoagulants  No ____ monitoring required  No specific ____  Significantly more ____ than warfarin

laboratory antidote expensive

Risks in a dental setting- Pts with A, Fib  High risk of ____ event in a dental office in patients with A. Fib.- especially with increased ____ and/or excessive Local Anesthetic agent with ____

ischemic stress vasoconstrictor

V. Fib  - ____  -ventricles contracting rapidly but ____

lethal | ineffectively

``` Predisposing factors: V. Fib ____  rheumatic heart disease,  ____  blunt cardiac trauma,  ____  cardiac surgery,  ____  cardiac catheterization. ```

coronary artherosclerosis anaphylaxis mitral valve prolapse digitalis intoxication

``` Bradycardia  Less than 60 beats/minute  Types:  ____  ____  ____ ```

sinus bradycardia conduction block sick sinus syndrome

``` How to test for dysrhythmias  ____  Stress test  ____  Cardiac catheterization ```

electrocardiogram | echocardiogram

Medical management  Medications- e.g. ____, calcium channel blockers,  Pacemakers- detects an abnormal rhythm and with the help of electric impulses prompts the heart to beat normally  Surgery  ____ (implantable cardiac defibrillator)- delivers shock

b-adrenergic antagonists | cardioversion

What the dentist need to be aware of – Pts with dysrhythmia ```  Patients with uncontrolled dysrhythmia are at risk for:  ____  Heart failure  ____ In a dental office as a result of: Dental treatment associated ____ Excessive amounts of ____ ```

myocardial infarction death stress/anxiety vasoconstrictors

Dental management of patients with pacemakers Low or little risk: Diagnostic ____, dental drill, motor for chair, ____, electric pulp testers, ____ lights, and electric toothbrushes Moderate potential risk: Patients with older pacemakers may be at risk with ____ and dental motors. High potential risk: ____ units, ultrasonic cleaners, and ____ scaling devices

``` radiation amalgamator curing pulp testers electrosurgery ultrasonic ```

``` Request cardiology consult  ____ notes  EKG, echo, stress test, chest xray  Labs including ____ and CMP  NB: don’t ask for ____ for dental treatment ```

encounter CBC cardiology clearance

Dental management of dysrhythmias: Allaying patients fear  Explaining what will be ____ to patient is important  Use of ____ sedation  Use of short acting ____ the night prior to and/or 1 hour before dental procedure.

done nitrous oxide anxiolytics

Dental management of dysrhythmias: Minimize stressful situations  ____ appointments  Continuously ____ patient to see if patient is becoming tired  Complex procedures should be performed in ____ appointments

short morning/early afternoon assess multiple

Dental management of dysrhythmias : avoid excessive use of vasoconstrictors and Local anesthetic agents  ____ before giving LA  No use of epinephrine containing ____  No more than ____ cartridges of LA containing epinephrine (1 in 100,000)  Avoid elective dental treatment in patients with decompensated arrhythmias (e.g. V. Fib.)  In patients with severe decompensated arrhythmia avoid LA with ____ completely if treatment is needed.  Ensure good pain control

aspirate gingival retraction cord 2 epinephrine

If patient is on blood thinners- A. fib especially  What type of blood thinners are they on- Coumadin or newer oral anticoagulants  Monitor INR if on coumadin- should between ____  For the newer oral anticoagulants- ____ not needed  Assess risk of bleeding based on dental procedure to be performed

2-3 | INR monitoring

Low risk- continue with therapeutic anticoagulant therapy ``` • ____ scaling • ____ restorations • Local anesthetic injections- local infiltrations, ____ block • Prosthetic procedures- ____, wax try-ins • INR ```

``` supra-gingival simple mental nerve impressions 4 ```

Moderate bleeding risk- continue with therapeutic dose of anticoagulants: * Local anesthesia by ____ or other regional nerve blocks or floor of mouth infiltrations * ____ scaling and root surface instrumentation * ____ crown and bridge preparations * ____. Standard root canal treatment * ____ extractions * Incision and drainage of ____ * ____

``` inf alveolar subgingival subgingival endodontics simple swellings biopsies ```

``` High risk- adjust anticoagulant dose or temporarily ____ • ____ extractions • ____ surgery- e.g. crown lengthening • ____surgery • Extensive ____ surgery ```

``` discontinue multiple periodontal alveolar bone maxillofacial ```

Dental management- Dysrhythmias  Monitor ____, heart rate before start of dental treatment  Avoid ____ for postoperative pain control  Ensure good local ____ for patients on blood thinners - Pressure pack, ____, hemostatic agent (surgicel, gelatin sponge, tranexamic mouth rinse, bone wax)

BP NSAIDs hemostasis suturing

``` In case of emergency  ____ procedure!  Check ____  Call code ____  Evaluate vital signs- ____, heart rate, rhythm intermittently  Evaluate patient ____ – also muscle tone, facial drooping, slurring of speech  Place in ____ position  Angina- sublingual ____, ____mg Aspirin  Administer oxygen if O2 saturation ```

``` stop ABC blue blood pressure alertness trendelenburg nitroglycerin 325 95 CPR ```

Summary  Congestive heart failure is a ____ progressive disease that can affect both heart structure and function.  Types include ____ sided failure  Patients with uncontrolled CHF are at risk of developing ____, MI, stroke or death in the dental office  Require ____ and ____ to prevent an emergency.

``` chronic left and right TIA medical consult dental management ```

Summary  Dysrhythmias can result from problems with ____, rhythm or ____.  Patients with uncontrolled dysrrhythmias are at risk of ____, stroke and death in a dental office  Most common dysrhythmia is ____. It arises ____. Can lead to blood clots in the heart and in distant sites like the brain causing a ____  Patients with Afib are on ____

``` heart rate conduction MI Afib supraventricular stroke (CVA) anticoagulants ```

Summary  Good ____ management, pain control and ____ needed.  ____ monitoring might be indicated.  Avoid ____, and ____ as much as possible in these group of patients.

``` stress epinephrine INR NSAIDS COX-2 inhibitors ```