Dental Management Of Patients With Chf 351m6m

CASE REPORT

DentalmanagementofpatientwithCongestiveheartfailure: A case report and a review of the literature. Arjay Nino S. Dulay Department of Dentistry, University of the Philippines – Philippine General Hospital, Manila Philippines Univeristy of the East, College of Dentistry, Manila Philippines

KEYWORDS Congestive Heart Failure; Compensated CHF; Digoxin

Summary Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to deliver oxygen rich blood to the body. Congestive heart failure can be caused by diseases that weaken the heart muscle, diseases that cause stiffening of the heart muscles, or diseases that increase oxygen demand by the body tissue beyond the capability of the heart to deliver adequate oxygenrich blood. The prevalence of heart failure increases with age; it is approximately 1% at age 50 and 5% at age 75.7 Four out of five cases of heart failure occur in persons 65 years of age or older.6 Thus the condition requires a more specific management in dealing with the dental procedure the patient has to undergo. This case study presents a 67- year old male patient suffering from Congestive heart failure of 4 year duration, who has undergone an elective dental surgical procedure.

Introduction Congestive Heart Failure is a clinical syndrome that results from the progressive process of remodeling, in which mechanical and biochemical forces alter the size, shape, and function of the ventricle’s ability to pump enough oxygenated blood to meet the body’s metabolic requirements. CHF presents the end stage of many underlying types of cardiovascular diseases that ultimately lead to heart failure. CHF may be defined as a systemic syndrome produced by failing myocardium or a significant increase in the left-ventricular end-diastolic pressure despite normal cardiac function.4 The prevalence of heart failure increases with age; it is approximately 1% at age 50 and 5% at age 75.7 Four out of five

cases of heart failure occur in persons 65 years of age or older.6 Heart failure is the most common cause of hospitalization in this age group, and nearly half of elderly patients with a discharge diagnosis of heart failure are reitted within 6 months.6 Men are more likely to be affected by heart failure than are women, probably because the incidence of ischemic heart disease is greater in men than in women.1, 2 Roughly 9 out of 10 patients with a diagnosis of heart failure survive for 1 year.3 However, only 5 out of 10 patients are alive 5 years after diagnosis, and the quality of life is impaired in many of these patients.3 Death is sudden in 40% of patients, suggesting that it is the result of serious ventricular arrhythmia.2

Congestive heart failure is the end stage of disproportion between the required hemodynamic load and the capacity of the heart to handle the load. This imbalance can occur with chronic increase in the load or damage to the myocardium. Chronic congestive heart failure usually evokes compensatory adjustments consisting of increased peripheral resistance, redistribution of blood flow to the heart and brain, and an increased efficiency of oxygen utilization by the tissues.4 Heart failure usually occurs in The first stage involves ventricular dysfunction with the development of a gallop rhythm. The second stage consists of congestive failure with dyspnea, pulmonary congestion, and peripheral edema. The third stage, termed compensated heart failure, is the control or elimination of the clinic signs and symptoms of congestion by medical therapy. 4 stages.8

Patients with untreated heart failure or poorly managed response to it are at high risk during dental treatment for such complication as infection, cardiac arrest, cerebrovascular accident, myocardial infarction. 4

Case report A 67-year old male patient came to the infirmary complaining of pain on the right anterior area of his maxillary jaw. According to the patient of 6 months duration and is throbbing and intermittent in nature; the patient was diagnosed with chronic periapical infection of tooth number 14 with chronic periodontitis. Past medical history revealed that the patient is suffering from hypertension, chronic obstructive pulmonary disorder, and chronic kidney insufficiency; and the patient was diagnosed with congestive heart failure 4 years prior. Patient is under the care of a physician and regularly attends check up in an outpatient

setting. The patient is also religiously taking several medications indicated to control debilitating symptoms of the condition. The extraoral examination was within normal limits with no evidence of lymphadenopathy. Intraoral examination revealed several teeth with large restoration. His periodontal condition and oral hygiene is relatively poor. Adequate recommendation from the patient’s attending physician was needed to push through with the elective dental procedure. The patient was given an early morning appointment. Patient was given adequate but minimal anesthetic; when the effect of the anesthetic was profound and extraction of tooth 14 was done atraumatically as possible. Patient was prescribed with analgesic and was given appropriate post operative instructions prior to discharge. A week after the surgery patient was seen for check up; extraction site is site was healing normally and without complications.

Discussion The New York Heart Association has devised a classification of heart disease grades the severity of CHF.5 The following classification is useful in following the course of disease and assessing the effects of therapy. It can also be used to aid in dental management of patients. Class I: No limitation of physical activity. No dyspnea, fatigue, or palpitations with ordinary physical activity. Class II: Slight limitation of physical activity. These patients have fatigue, palpitations, and dyspnea with ordinary physical activity but comfortable at rest. Class III: Marked limitation of activity. Less than ordinary physical activity results in symptoms, but patients are comfortable in rest.

Class IV: Symptoms are present at rest, and any physical exertion exacerbates the symptoms. Patients with uncontrolled or untreated congestive heart failure are not a candidate for elective dental care and should be referred to their physician for immediate care. Once congestive heart failure is in control, they should be encouraged to return for the resumption of dental care. Patients who are NYHA I and II can receive routine outpatient dental care. Many class III may receive treatment in an outpatient setting after approval of their physician. Some class III and all class IV are best treated in a special care facility such as a hospital.4 Current medications should be identified as should underlying conditions. Appropriate management adjustment for these conditions should be made. Special consideration for patients taking digitalis; use of Epinephrine in local anesthetics should be in caution (maximum 0.036mg; 2 cartridges of 2 % Lidocaine with 1:100, 000 epinephrine); also the use of Erythromycin which can lead to increase absorption of digitalis.4 Patients under good control and with no complications can receive routine dental care. Short, stress free appointments are advised. Patients with class II through IV CHF may not tolerate a supine chair position because of pulmonary edema and will need a semisupine or upright chair position. The dentist must be able to detect these patients, based on history and clinical findings, refer them for medical diagnosis and management, and work closely with the physician to develop a dental management plan that will be effective and safe for the patient.4

References 1. American Heart Association. Heart Disease and Stroke Statistics—2004 Update.Dallas, TX: American Heart Association; 2003. Available at http://www.americanheart.org/able /heart/1079736729696HDSStats2004Update REV3-19-04.pdf. 2. Johnson JA, Parker RB, Patterson JH. Heart failure. In: DiPiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy: A Pathophysiologic Approach. 5th ed. New York, NY: McGraw-Hill; 2002:185-218 3. Konstam M, Dracup K, Baker D, et al. Clinical Practice Guideline Number 11: Heart Failure: Evaluation and Care of Patients with Left-Ventricular Systolic Dysfunction. Rockville, Md: U.S. Department of Health and Human Services, Agency for Health Care Policy and Research; June 1994. AHR Publication No. 94-0612. 4. Little, J., Falace, D, et al. Dental Management of the Medically Compromised Patient. Congestive Heart Failure, 144-160, 6th ed, Missouri, 2002. 5. McCall D. Congestive heart failure. In Stein JH, editor: Internal Medicine, ed 5, St Lious, 1997, Mosby. 6. Masoudi FA, Havranek EP, Krumholz HM. The burden of chronic congestive heart failure in older persons: magnitude and implications for policy and research. Heart Fail Rev.2002;7:9-16. 7. National Heart, Lung, and Blood Institute. Facts about heart failure. Available at: http://www.nhlbi.nih.gov/health/public/hear t/other/hrtfail.htm. Accessed June 9, 2004 8. Schlant RC, Sonnenblinck EH. Pathophysioloy of heart failure. In Schlant RC, Aleander RW editors: Hurst’s the heart, arteries and veins, ed 9, New York, 1998, McGraw-Hill.