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Congestive heart failure (CHF) is the inability of the heart to deliver an adequate supply of oxygenated blood to meet the metabolic demands of the body.

 

Causes:

  • Left ventricular heart failure

    • Poor myocardial function as a result of ischemic heart disease and myocardial infarction

    • Long-standing hypertension

    • Cardiomyopathy

    • Valvular insufficiency (valvular regurgitation)

  • Right ventricular heart failure

    • Most common - left ventricular heart failure which results in pulmonary hypertension which increases the work of the right ventricle

 

Cardinal Signs of Heart Failure

  • Dyspnea and fatigue

 

  • Compensated heart failure - No symptoms

  • Decompensated heart failure - Symptomatic

  • Most common reason for decompensation during dental treatment is the patient's failure to take medications

 

Congestive Heart Failure

Introduction

Risks to the dental patient

Management During Treatment

The dentist should be concerned about CHF because it indicates significant cardiac dysfunction.  Increased stress from undergoing dental treatment can result in the following:

 

  • Arrhythmia

  • Angina

  • Emergency situation:  Decompensation to a cardiac crisis which may progress to cardiac arrest

Questions to Ask 

Medical consultation with the patient's cardiologist is advised for any patient with congestive heart failure.

Ask the physician for information about the following:

  • NYHA classification

  • Level of control

  • Compliance with medications and other recommendations

  • Overall stability

 

Prevention 

  • Thorough medical history

  • ​Take blood pressure

  • Stress reduction protocol, including oral or inhalation sedation

  • Anesthesia/epinephrine:  

    • Achieve and maintain excellent anesthesia to reduce stress and prevent cardiac crisis.  

    • No more than 2 cartridges of local anesthesia with 1:100,000 epinephrine.  

  • Chair position that is comfortable for patient.  Patient need for more upright position which may indicate less control over disease.

Post-Operative Care

Provide good post-operative pain control.

References

Dental Management of the Medically Compromised Patient.  Little, Falace, Miller and Rhodus. 8th Edition

Medical Consultation Recommended 

  • What is the cause of your congestive heart failure?

  • How often do you see your physician?

  • Did you take your medications today?  Do you take your medications every day as directed?

  • Do you have a history of shortness of breath?

  • How many pillows do you sleep on (orthopnea)? > 2 pillows indicates orthopnea.

  • Can you walk up two flights of stairs without dyspnea, fatigue or palpitations?

  • Do you have dyspnea, fatigue or palpitations when you are at rest?

  • How do you feel about dental treatment? Do you feel anxious or fearful?

  • Do you have an implanted pacemaker and/or defibrillator?

  • Do you have a prosthetic valve?

Signs & Symptoms of Left Ventricular Failure

Signs & Symptoms of Right Ventricular Failure

  • Pulmonary vascular congestion

  • Pulmonary edema 

  • Dyspnea (most common symptom with CHF)

    • Orthopnea - worsened by recumbent or semi-recumbent position

    • Paroxysmal nocturnal dyspnea - patient awakens from sleep gasping for area

  • Exercise intolerance

  • Fatigue (muscle)

  • Pulsus alternans 

  • Cheyne-Stokes respiration 

    • periodic respiration, with cycles of respiration that are increasingly deeper then shallower with possible periods of apnea. Typically, over a period of 1 minute, a 10-20 second episode of apnea or hypopnea occurs followed by respirations of increasing depth and frequency. The cycle then repeats itself.

Other Findings

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