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Edison Academy Oral Surgery Heart failure and Cardiac Arrhythmias By _ Dr. Jaber Zaid Heart Failure Heart failure (HF), also known as congestive heart failure (CHF), defined by (ACC\AHA) as a complex clinical syndrome that can result from any structural or functional cardiac disorder that i...

Edison Academy Oral Surgery Heart failure and Cardiac Arrhythmias By _ Dr. Jaber Zaid Heart Failure Heart failure (HF), also known as congestive heart failure (CHF), defined by (ACC\AHA) as a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood which leads to blood output insufficient to meet the body requirement. Note Prevalence is 1-3% of the general population and 10% among the elderly population. The prognosis is poor, 25-50% of the patients die within 5 years.  Causes  ischemic heart diseases (the most common cause)  congenital heart diseases  hypertension  pulmonary hypertension  pulmonary embolism  myocarditis  infective endocarditis  cardiomyopathies  valvular heart diseases  endocrine diseases  chronic anemia  arrhythmias. Classification Stage A: The American Heart Association and the patients with risk factors that predispose to HF but with no left ventricular hypertrophy or American College of Cardiology (AHA/ACC) dysfunction (structural heart disease). classify heart failure into 4 stages: (reflecting Stage B: the fact that HF is a progressive disease patients with risk factors that predispose to HF and whose outcome can be modified by early with left ventricular hypertrophy or dysfunction but with no symptoms. identification and treatment). Stage c: patients with past or present symptoms of HF with structural heart Stage D: patients with refractory HF who require specialized care. Classification 01 Class I no limitation of physical activity, no signs or Based on severity of symptoms and the amount of symptoms with ordinary activity. effort needed to elicit symptoms, another classification was developed by the NewYork Heart Association 02 Class ii slight limitation of the physical activity but the (NYHA); it is complementary to the previous system. patients remains comfortable at rest. 03 Class iii The term compensated HF is used marked limitation of activity but the patients when neurohumoral responses are comfortable at rest. eliminate the symptoms while the symptomatic HF is termed as decompensated HF. 04 Class iv symptoms are present at rest and physical activity exacerbates the symptoms. Signs and Symptoms  Dyspnea (perceived shortness of breath).  Fatigue and weakness (especially muscular).  Orthopnea (dyspnea in recumbent position)  Paroxysmal nocturnal dyspnea (dyspnea that awakens patient from sleep)  Acute pulmonary edema (cough or progressive dyspnea)  Exercise intolerance (inability to climb a flight of stairs)  Dependent peripheral edema (swelling of feet and ankles after standing or walking)  Report of weight gain or increased abdominal girth (fluid accumulation; ascites) Signs and Symptoms  Right upper quadrant pain (liver congestion)  Anorexia, nausea, vomiting, constipation (bowel edema)  Cheyne-Stokes respiration (hyperventilation alternating with apnea during sleep)  Heart murmur.  Increased venous pressure.  Enlargement of cardiac silhouette on chest radiograph  Pulsus alternans; a regular rhythm with alternating strong and weak ventricular contractions.  Distended neck veins.  Cyanosis  Clubbing of fingers Diagnosis Heart failure is diagnosed clinically and by chest Normal heart radiography (cardiomegaly), echocardiography ECG and biochemistry. Echocardiography determines the stroke volume (SV; the amount of blood that exits the ventricles with each heartbeat), the end-diastolic volume (EDV; the amount of blood at the end of diastole), and the SV in proportion to the EDV (the ejection fraction; EF). Normally, the EF should lie between 50 and 70% but, in cardiac failure, it is < 40%. Enlarged heart Management The management depends on the stage (NYHA) of the disease but the general lines of treatment are:  General measures; rest, control of stress, salt restriction and controlling hypertension, anemia or. any underlying causes  Angiotensin-converting enzyme inhibitors ACE-I; like enalapril and lisinopril.  Angiotensin II receptor blockers; like losartan and valsartan.  Vasodilators like isosorbide dinitrate plus hydralazine.  Diuretics like furosemide and spironolactone.  Digoxin may be helpful when failure is associated with atrial fibrillation.  Supplemental oxygen may be required.  Heart transplantation. Dental management  Identification of patients with a history of heart failure, those with undiagnosed heart failure, or The risk of treating a patient with symptomatic heart those prone to developing heart failure is the first failure is that symptoms could abruptly worsen and step in risk assessment, this is accomplished by result in acute failure, a fatal arrhythmia, stroke, or obtaining a thorough medical history, including a myocardial infarction. pertinent review of systems, and measuring and evaluating vital signs (i.e., pulse rate and rhythm, blood pressure, respiratory rate).  For patients with symptoms of untreated or uncontrolled heart failure, defer elective dental care and refer to physician.  For patients diagnosed and treated for heart failure 1) Confirm status with patient or physician. 4) NYHA class II (and some class III patients), obtain 2) Identify underlying cardiovascular disease (i.e., consultation with physician for medical clearance and coronary artery disease, hypertension, cardiomyopathy, provide routine care. valvular disease), and manage appropriately. 5) NYHA (some class III and class IV) patients obtain 3) New York Heart Association (NYHA) class I patients consultation with physician; consider treatment in a (asymptomatic), routine care can be provided. special care or hospital setting.  Drug considerations: 1) For patients taking digitalis, avoid adrenalin; if considered essential, use cautiously (maximum 0.036 mg adrenalin or 0.20 mg levonordefrin), which is no more than 2 cartridges containing 1:100.000 adrenalin or 1: 20.000 levonordefrine with care to avoid intravascular injection; avoid gag reflex; avoid erythromycin and clarithromycin, which may increase the absorption of digitalis and lead to toxicity. 2) For patients with NYHA class III and IV congestive heart failure, avoid use of vasoconstrictors; if use is considered essential, discuss with physician. 3) Avoid adrenalin-impregnated retraction cord.  Schedule short, stress-free appointments.  Use semisupine or upright chair position.  Watch for orthostatic hypotension, make position or chair changes slowly, and assist patient into and out of chair.  Avoid the use of nonsteroidal antiinflammatory drugs (NSAIDs) because they can exacerbate symptoms of heart failure.  Watch for signs of digitalis toxicity (tachycardia, hypersalivation, visual disturbances) which if it occurs the patient must be referred to physician promptly.  Nitrous oxide/oxygen sedation may be used with a minimum of 30% oxygen.  The dentist should be aware that even these HF patients with NYHA class I should not be considered “mild” because they indeed could be decompensated during dental treatment.  Watch for signs of digitalis toxicity (tachycardia, hypersalivation, visual disturbances) which if it occurs the patient must be referred to physician promptly.  Nitrous oxide/oxygen sedation may be used with a minimum of 30% oxygen.  The dentist should be aware that even these HF patients with NYHA class I should not be considered “mild” because they indeed could be decompensated during dental treatment.  Oral Manifestations Cardiac Arrhythmias Causes No oral manifestations are related to Are broadly classified as: Arrhythmia is simply defined as disturbance of heart failure but some drugs can cause: heartbeat including disturbance rhythm, rate or Cardiac 1) Dry mouth in patients taking diuretics or conduction pattern of the heart, in which there As in MI, mitral valve diseases, vasodilators. is cardiomyopathy, 2) Angioedema of lip, face, or tongue, taste pericarditis, or aberrant changes, burning mouth in patients taking ACE abnormal electrical activity in the heart. 15- conduction pathways. inhibitors. 17% of the population may have arrhythmias 3) Lichenoid reactions in patients taking ACE inhibitors and the prevalence increases with age. It has Non-Cardiac and Beta blockers. been shown that potentially 4) Increased gag reflex and hypersalivation in Caffeine, smoking, alcohol, fever, patients fatal arrhythmias can be precipitated by strong respiratory, autonomic, taking Digitalis. endocrine diseases, hypoxia or emotion such as anxiety or anger, as well as by 5) Lupus like lesions and lymphadenopathy in electrolyte disturbances. patients various drugs, both of which can be Surgery is sometimes implicated. taking vasodilators. precipitated by dental treatment.  Classification 01 03 02 Rate Site of origin into: tachycardia Mechanism into: supraventricular and bradycardia. into: automaticity, and ventricular re-entry and arrhythmias. fibrillation.  Clinical Features Signs include Symptoms include slow (less than 60 beat/min) palpitation, fatigue, dizziness, or fast (more than syncope, 100 beat/min heart rate, angina pectoris, dyspnea and irregular rhythm. those related to congestive heart failure (e.g., Shortness of breath, Orthopnea, Peripheral edema). Note The primary tool for diagnosis of arrhythmia is electrocardiogram (ECG). MEDICAL MANAGEMENT 01 PHYSICAL MANEUVERS In supraventricular arrhythmias, pressure on the neck may increase parasympathetic stimulation to the heart inhibiting electrical conduction through the AV nodes. 02 ANTIARRHYTHMIC DRUGS These are divided into 4 classes: class I are sodium channel blockers, class II drugs are beta blockers, class III drugs act on potassium channels and prolong the duration of action potential, while class IV drugs are calcium channel blockers. 03 DEFIBRILLATION OR CARDIOVERSION 04 PACEMAKERS Which is a subcutaneously implanted generator in the left infraclavicular area, it produces an electrical impulse that is transmitted by a lead inserted into the heart via subclavian vein to an electrode in contact with endocardial or myocardial tissue. 05 IMPLANTED CARDIOVERTER-DEFIBRILLATOR (ICD) which is similar to pacemaker. Both are subject to electromagnetic interferences (EMI). ICDs are capable not only of delivering a shock but also of providing antitachycardia pacing (ATP) and ventricular bradycardia pacing. 06 RADIOFREQUENCY CATHETER ABLATION In which a catheter is introduced through the vein to the area which is the source of arrhythmia, radiofrequency energy is then delivered that cause irreversible tissue destruction. 07 SURGERY 08 ANTICOAGULANTS DENTAL MANAGEMENT Stress associated with dental treatment or excessive amounts of injected adrenalin may lead to life threatening cardiac arrhythmias in susceptible dental patients. The keys to successful dental management of patients prone to developing a cardiac arrhythmia and those with an existing arrhythmia are identification and prevention. 1 Patients with cardiac arrhythmias may be identified Medical history to identify: type of arrhythmia, treatment, presence of by the following: A pacemaker or defibrillator and stability. The dentist may need to consult with physician to obtain or verify this information. Risk for arrhythmia is increased in the presence of other cardiovascular or B pulmonary disease. Patient does not report an arrhythmia, but may be taking one or more of C the antiarrhythmic drugs. D The presence of symptoms that could be caused by arrhythmias. Vital signs are suggestive of arrhythmia (rapid pulse rate, slow pulse rate, E irregular pulse). Refer patient to physician if signs or symptoms are present that are suggestive of a cardiac arrhythmia or other cardiovascular disease. 2 3 Cardiac arrhythmias that may be associated Elective dental treatment is avoided in such with major perioperative risk during dental cases, only urgent care is provided and treatment include: preferably in hospital, the following should be considered: a) High-grade atrioventricular (AV) block. a) Consult with physician. b) Symptomatic ventricular arrhythmias in the b) Provide limited care only for pain control, presence of underlying heart disease. treatment of acute infection, or control of c) Supraventricular arrhythmias with bleeding. uncontrolled ventricular rate. c) Intravenous line. d) Sedation Note e) Electrocardiogram (ECG) monitoring Other types of cardiac arrhythmias are associated f) Pulse oximeter with intermediate or minor perioperative risk during g) Blood pressure monitoring dental treatment in such cases elective dental treatment is allowed. h) Avoid or limit adrenalin. 4 Stress and anxiety reduction a) Establish good rapport. b) Schedule short, morning appointments. c) Ensure comfortable chair position. d) Provide preoperative sedation (short-acting benzodiazepine night before and/or 1 hour before appointment). e) Administer intraoperative sedation (nitrous oxide/oxygen). f) Obtain pretreatment vital signs. g) Ensure profound local anesthesia. h) Provide adequate postoperative analgesia. 5 The use vasoconstrictors The use of vasoconstrictors in local anesthetics poses potential problems for patients with arrhythmias because of the A possibility of precipitating cardiac tachycardia or another arrhythmia. A local anesthetic without vasoconstrictor may be used as needed. B Vasoconstrictors should be avoided in patients taking digoxin because of the potential for inducing arrhythmias. For patients at major risk for arrhythmias, the use of vasoconstrictors should be avoided, but if their use is considered C essential, it should be discussed with the physician. If a vasoconstrictor is deemed necessary, patients in the low- to intermediate-risk category and those taking nonselective betablockers can safely be given up to 0.036 mg of epinephrine(two cartridges containing 1:100,000 epinephrine); D intravascular injections should be avoided. Greater quantities of vasoconstrictor may well be tolerated, but increasing quantities are associated with increased risk for adverse cardiovascular effects. E You can also record a video inside the editor! Go to 'Uploads' and click on 'Record yourself'. 6 Patients who are taking Warfarin a) Should have current international normalized ratio (INR) (within 24 hours of surgical procedure). b) If INR is within the therapeutic range (INR, 2.0-3.5), dental treatment, including minor oral surgery, can be performed without stopping or altering the drug. c) Local measures include gelatin sponge or oxidized cellulose in sockets, suturing, gauze pressure packs, preoperative stents, and tranexamic acid or aminocaproic acid mouth rinse and/or to soak gauze. 7 Patients with pacemakers a) Antibiotic prophylaxis to prevent bacterial endocarditis is not recommended. b) Avoid the use of electrosurgery and ultrasonic scalers. 8 Patients taking Digoxin a) Watch for signs or symptoms of toxicity (e.g., hypersalivation). b) Avoid adrenalin or levonordefrine.  Edison Academy Thank You At the end of this lecture, I would like to thank you for your attention. I hope the information presented has enriched your knowledge and inspired you to continue learning and developing in the field of dentistry. Always remember that a healthy smile begins with diligent care. Best of luck in your professional journey!