Implications in Dental Care I Flashcards
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
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
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
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
AA
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
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
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
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
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
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
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
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
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
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
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
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
Management of patients with CHF
Monitor ____ and vital signs at every visit
Short ____ or ____ appointments
BP
early morning
early afternoon
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
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
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
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
Could be present in ____ patients occasionally – result of anxiety, fever, rapid blood loss or strenuous exercise
Typically present in patients with ____
healthy
cardiac diseases
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
Causes of dysrhythmia Autonomic disorders e.g. \_\_\_\_ Systemic disorders- e.g. \_\_\_\_ (hyperthyroidism) Drug-related side effects \_\_\_\_ imbalance
autonomic neuropathy
thyroid problems
electrolyte
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
