1. HEART FAILURE

2. FUNCTIONS OF HEART : Pumping blood. Secret atrial Natriuretic polypeptide (BNP).

3. HEART FAILURE definition: HF in ability of the heart to pump adequate amount of blood to meet the metabolic need of the body.  most patient with systolic heart failure have low ejection fraction,(less than 55%).

4.  is a complex clinical syndrome that represents the end stage of many of the cardiovascular disease.  Coronary artery disease is the commonest cause of heart failure.  Associated with a risk of sudden death ( 6 to 9 times higher than seen in the general population).  HF regarded as major cause of morbidity and mortality. Only 50% of patients are alive 5 years after diagnosis.

5. The incidence of HF is 2-4% between 35 and 64 years, and 10% in patients over 65 years. Heart failure accounts for 5% of admissions to hospital medical wards.

6. Type of HF

7. TYPES OF HEART FAILURE: Classify as Left ventricular failure. right ventricular failure. biventricular failure (congestive heart failure). or Systolic heart failure. diastolic heart failure.

8. Pathophysiology:

9. PATHOPHYSIOLOGY:  Left ventricular failure inability of the left ventricle to a pump adequate amount of blood into aorta and systemic arterial circulation,.  results in inadequate emptying of the left ventricles during systole or incomplete filling of the ventricles during diastole.  with subsequent pulmonary venous congestion and pulmonary edema.  In right ventricular failure : it result in  systemic venous congestion and peripheral edema.

10. COMPENSATORY MECHANISM Local changes: dilation and hypertrophy of the ventricle. neurohurmonral responses: stimulation of the renin- angiotensin system Antidiuretic hormone secretion. sympathetic nervous system activation.

13. THE EFFECTS OF THESE RESPONSES INCLUDE:  increased heart rate  increase myocardial contractility.  increased peripheral resistance.  sodium and water retention.  redistribution of blood flow to the heart and brain.  compensated HF : asymptomatic patient.  decompensated HF. Symptomatic patient.

14. CAUSES OF HEART FAILURE  Most Common Causes of Heart Failure  Coronary heart disease.  Hypertension.  Valvular heart disease. Infective endocarditis  Myocarditis. Cardiomyopathy.  Congenital heart disease.  Pulmonary hypertension.

15. CAUSES OF LEFT HEART FAILURE ischaemic heart disease (the most common cause) systemic hypertension. mitral and aortic valve disease. Cardiomyopathies. Myocarditis.

16. CAUSES OF RIGHT SIDE HEART FAILURE  left heart failure  chronic lung disease (cor pulmonale)  pulmonary hypertension(PE &MVD).  tricuspid valve disease  pulmonary valve disease  CHD with left-to-right shunts (e.g. atrial or ventricular septal defects)  isolated right ventricular cardiomyopathy

17. CLINICAL FEATURES  Left side heart failure  SOB on exertion.(SOB at rest in severe HF).  Orthopnea is dyspnea, which is precipitated or worsened by a recumbent position.  Paroxysmal nocturnal dyspnea (PND) ( is an attack of sudden, severe shortness of breath that awakens the patient from sleep, usually within 1 to 3 hours after the patient goes to bed, and resolves within 10 to 30 minutes after the patient arises.  fatigue is a common, nonspecific symptom of HF.

19. PHYSICAL SIGNS OF LV FAILURE:  Tachycardia.  Cardiomegaly demonstrated by displaced apex beat..  Auscultation reveals :3 rd & 4 th heart sound a gallop rhythm.  Dilatation of the mitral anulus results in functional mitral regurgitation.  Crackles are heard at the lung bases.  alternating cycles of rapid, deep breathing (hyperventilation) and periods of central apnea, called Cheyne-Stokes respiration

20. RIGHT SIDE HEART FAILURE: CLINICAL FEATURES Symptoms fatigue. breathlessness. anorexia and nausea,abdominal pain. leg edema.

21. PHYSICAL SIGNS  jugular venous distension (± v waves of tricuspid regurgitation)  tender smooth hepatic enlargement  dependent pitting oedema  development of free abdominal fluid (ascites)  pleural transudates (commonly right-sided).  Jaundice.  Dilatation of the right ventricle produces cardiomegaly and may give rise to functional tricuspid regurgitation. Tachycardia and a right ventricular third heart sound are usual.

23. LAB INVESTIGATION:  Blood tests - full blood count, liver biochemistry, urea and electrolytes, cardiac enzymes AND plasma lipid measurment.  thyroid function.  Chest X-ray.  Electrocardiogram - evidence of ischaemia, hypertension or arrhythmia.  Echocardiography.  Natriuretic peptide (B-type NP (BNP) or N terminal (NTproBNP)). A normal plasma level excludes heart failure.

24.  Stress echocardiography.  Nuclear cardiology. Radionuclide angiography (RNA) provides accurate measurements of left, and to a lesser extent, right ventricular ejection fractions, cardiac volumes and regional wall motion. . Cardiac catheterization  Cardiac biopsy for infiltrative disease, e.g. amyloid

25. NYHA FUNCTIONAL CAPACITY CLASSIFICATION OF HEART FAILURE  Class I: No limitation of physical activity. No dyspnea, fatigue, or palpitations with ordinary physical activity.extra ordinary work.  Class II: Slight limitation of physical activity. These patients have fatigue, palpitations, and dyspnea with ordinary physical activity but are comfortable at rest.

26.  Class III: Marked limitation of activity. Less than ordinary physical activity results in symptoms, but patients are comfortable at rest.  Class IV: Symptoms are present at rest, and any physical exertion

31. ACC & AHA STAGING OF HEART FAILURE  Stages A patients at high risk for (HF) but without structural heart disease or symptoms of HF). such as CAD high BP and DM but who do not have any symptoms of HF. Or any structural changes.  The stages B patients at high risk for (HF) with structural heart changes like left ventricular hypertrophy (LVH) or dilatation but asymptomatic.

32. Stage C represent patients present symptoms of HF and associated with underlying structural heart disease. stage D designates patients with refractory HF(end stage HF) who might be eligible for specialized, advanced treatment.

33. MANEGEMENT: Depend on : Stage of HF. Underlying causes, Associated risk factors. Associated Comorbidity.

34. STAGE A :  Treat hypertension.  encourage smoking cessation.  treat lipid disorders.  encourage regular exercise,.  discourage alcohol intake.  Avoid drug like NSAID.  Treat hypertension.  Good control of DM

35. STAGE B Provide all measures for stage A. ACE inhibitors (or ARBs) in appropriate patients. Beta-blockers in appropriate patients.carvidelol.

36. STAGE C Provide all measures for stages A and B. dietary salt restriction. use of ACE inhibitors beta-blockers. Add diuretics.frusemide,aldactone,thiazide Venodilator drug iosordil.

37. STAGE D Provide appropriate measures from stages A, B, and C. Use heart transplant. chronic inotropes. permanent mechanical support. CRT,ICD

38. WHAT ARE THE COMPLICATIONS OF DENTAL CARE IN UNCONTROLLED HF. symptoms could abruptly worsen and result in acute failure with increasing SOB. fatal arrhythmia. cardiac arrest stroke. myocardial infarction.

39. DENTAL CARE OF HF. The dentist must be able to identify these patients with HF on the basis of history and clinical findings. refer them for: medical diagnosis. identify the underlying cause. Proper management.

40. All medications that are being taken should be identified as well. Determine the functional capacity of patient with HF according to NYHA classification.

41. Those with class I can be managed in out patient clinic. Those with classes II, III, and IV).

42. patients who are NYHA class I may receive routine outpatient dental care. Many patients who are NYHA class II may undergo routine treatment in an outpatient setting after approval from the physician. while patient with NYHA class III & and class The dentist must make a determination the benefits of treatment outweigh the risks. generally they are not candidates for elective dental care, and treatment should be deferred until medical consultation can be obtained. They are best treated in a special care facility, such as a hospital dental clinic with continuous monitoring.

43. GENERAL MEASURES FOR ALL PATIENTS :

44. Schedule short, stress-free appointments. Patients with HF may not tolerate a supine chair position because of pulmonary edema and will need a semi supine or upright chair position. Watch for orthostatic hypotension, make position or chair changes slowly, and assist patient into and out of chair. avoid gag reflex.

45. THE END

46. DRUG CONSIDERATION  For patients taking digitalis, avoid epinephrine;(it aggravate arrhythmia) if considered essential, use cautiously (maximum 0.036 mg epinephrine of 2% lidocaine with 1:100,000 epinephrine) or 0.20 mg levonordefrin).  avoid erythromycin and clarithromycin, which may increase the absorption of digitalis and lead to toxicity.  Avoid the use of nonsteroidal anti inflammatory drugs (NSAIDs) because they can exacerbate symptoms of HF.

47. For patients with NYHA class III and IV congestive heart failure, avoid use of vasoconstrictors; if use is considered essential, discuss with physician. Avoid epinephrine-impregnated retraction cord. Nitrous oxide plus oxygen may be used for sedation. Nitrous oxide/oxygen used with a minimum of 30% oxygen

48. THE END

49. DENTAL CARE FOR PATIENT WITH HF

50. MEDICAL MANAGEMENT