Cardiac Arrhythmia & Congestive Heart Failure

Cardiac Arrhythmia & Congestive Heart Failure

DENTALMANAGEMENTOF THE MEDICALLYCOMPROMISED PATIENT
Mosul university- College of dentistry-oral & maxillofacial surgery department
Dr.Ziad H. Delemi B.D.S, F.I.B.M.S (M.F.)

Mosul university- College of dentistry-oral & maxillofacial surgery department

Cardiac Arrhythmia
Arrhythmia: describes any abnormality in the rate, regularity or site of origin of the cardiac impulse, or where there is a disturbance in the conduction of that impulse such that the normal sequence of atrial and ventricular activation is altered.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Causes of Arrhythmias
Primary cardiovascular diseases (ischemic heart dis. ,congestive heart failure, rheumatic heart dis. ,mitral valve prolapse, open heart surgery).Pulmonary disorder, obstructive lung dis., pneumonia.Other…. Anaphylaxis, increased intracranial pressure, Hodgkin's disease, Anemia, hyperthyroidism, myxedema , obstructive jaundice, febrile illness, infection, drug-related side effects, electrolyte imbalances.

Mosul university- College of dentistry-oral & maxillofacial surgery department

What is an ECG?
Electrocardiogram graphic recording of the electrical activity produced by the conduction system and the myocardium (tissue) of the heart Cheap diagnostic tool



Mosul university- College of dentistry-oral & maxillofacial surgery department
12 Lead ECG

Mosul university- College of dentistry-oral & maxillofacial surgery department

Types of cardiac arrhythmias
Isolated ectopic beats (premature beats). Bradycardias (sinus, heart block). Tachycardias(sinus, atrial or ventricular fibrillation, atrial flutter). Preexitation syndrome (WPW). Cardiac arrest (ventricular fibrillation, ventricular asystole).

Mosul university- College of dentistry-oral & maxillofacial surgery department

Signs
Asymptomatic Slow heart ( less 60 beats/ min.). Fast heart (more than 100 beats/min) Irregular heart rate
Palpitation Fatigue Dizziness syncope Congestive heart failure Angina Cardiac arrest
symptoms

Mosul university- College of dentistry-oral & maxillofacial surgery department

History Physical examination Electrocardiogram Echocardiogram Stress test (in selected patients)
Diagnosis

Mosul university- College of dentistry-oral & maxillofacial surgery department

Treatment of cardiac arrhythmias
Drug used: Digoxin. Quinidine Propranolol Lidocaine Verapamil Warfarin, adjunctive to prevent thrombosis. Pacemaker : is electric device that can control heart`s rhythm by artificial electric discharge


Mosul university- College of dentistry-oral & maxillofacial surgery department
Pacemaker

Mosul university- College of dentistry-oral & maxillofacial surgery department

Dental management / precautions
Stress reduction protocol( premedication, short morning appointment, nitrous oxide…..).No more than 2 cartridge of anesthetic . no epinephrine in gingival retraction cord.No epinephrine in control local bleeding.Avoid GENERAL ANESTHESIA.Avoid electrical equipment(pulp tester, motorized dental chair, cavitron) due to pacemaker.Manage underlying cardiac problem( need for prophylaxis against infective endocarditis)

Mosul university- College of dentistry-oral & maxillofacial surgery department

Dental management/during procedure / life threatening
Stop procedure. Evaluate vital signs( BP, pulse rate, mental alertness). Call for medical assistance. Administer oxygen. Give nitroglycerin sublingual tablets ( chest pain) Perform vagal maneuver (gaging reflex) or carotid massage( glossopharyngeal reflex) in case of hypotension and tachycardia. cardiopulmonary resuscitation in cardiac arrest.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Failure of the heart to pump adequate amount of blood to the tissues After an M.I., the cardiovascular system tries to maintain adequate blood flow by: Slight increase in heart rate (C.O. = H.rate x stroke volume) Slight increase in systemic vascular resistance Fluid retention (done by the kidney)
Congestive Heart Failure

Mosul university- College of dentistry-oral & maxillofacial surgery department

Signs of congestive heart failure
Rapid, shallow breathing Chyne-stokes respiration Heart murmur Cardiac enlargement (CXR) Peripheral edema Ascites Cyanosis Weight gain Distended neck veins


Mosul university- College of dentistry-oral & maxillofacial surgery department
Symptoms of congestive heart failure
Dyspnea (breathlessness) Orthopnea (dyspnea in recumbent position) Paroxysmal nocturnal dyspnea (awake in sleep) Fatigue & weakness Low grade fever Cough Anorexia Dizziness, confusion

Mosul university- College of dentistry-oral & maxillofacial surgery department

CHF: Treatment
Medical Oxygen Diuretics for excess fluid Cardiotonic drugs to improve pumping efficiency (Digitalis) Low sodium diet; possibly supplemental potassium

Mosul university- College of dentistry-oral & maxillofacial surgery department

Device Therapy
Implantable Cardioverter-Defibrillators (ICD) Cardiac Resynchronization Therapy (CRT) Left Ventricular Assist Devices (LVAD)

Mosul university- College of dentistry-oral & maxillofacial surgery department

Potential problems related to dental care
Sudden death due to cardiac arrest or arrhythmia M.I., C.V.A., infective endocarditis Drug side effects: Orthostatic hypotension (diuretics, vasodilators) Arrhythmias (digoxin) Nausea , vomiting (digoxin, vasodilators ) Palpitation (vasodilators)

Mosul university- College of dentistry-oral & maxillofacial surgery department

Oral complications
Infection Bleeding Petechiae Ecchymosis Drug related: xerostomia lichinoid mucosal lesions


Mosul university- College of dentistry-oral & maxillofacial surgery department
Dental management of the patient with congestive heart failure
Patient evaluation if untreated or uncontrolled avoid elective dental care Consultation with physician patient with Digitalis use Adrenalin cautiously (maximum 0.036 mg) & avoid gag reflex , avoid Erythromycin Use semi supine or upright chair position Watch for orthostatic hypotension, assist patient Short , stress free appointments Avoid general anaesthesia