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Congestive heart failure

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Definition

Congestive heart failure is the inability of the cardiac muscle to propel sufficient blood to meet the body's needs.
The cardiac output is too low.
It is a clinical syndrome with various causes.

Heart failure can be acute or chronic.
Congestive heart failure may involve the left or the right side of the heart or all chambers of the heart.
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Causes of cardiac failure

  Pathophysiology Aetiology
I. Systolic dysfunction
  1. Due to weak contraction
  2. Due to increased ventricular load
    1. With volume overload
    2. With pressure overload
Coronary heart disease (CHD)
Dilated cardiomyopathy (20%)
Myocarditis

Valvular diseases
Shunts
Valve stenosis
Arterial hypertension
Pulmonary hypertension
II. Diastolic dysfunction
  1. Due to impeded ventricle filling
  2. Due to myocardial hypertrophy
Pericardial tamponade
Constrictive pericarditis
Restrictive cardiomyopathy
III. Arrhytmias Bradycardia/tachycardia

Compensated and decompensated heart failure

The body reacts to the reduced cardiac output with different mechanisms to compensate for the reduced output.
One of the earliest neurohumoral responses is an increased release of catecholamines resulting in an increased heart rate.

Another response to increased demand is to increase the available contractile elements of the cardiac muscle (hypertrophy).
If the organism fails to compensate for the deficit via different response mechanisms or medicinal treatment, this status is referred to as decompensation.

Left-sided heart failure

The left ventricle has a diminished output.
  1. The systemic circulation is undersupplied with blood.
    Symptoms:
    • Reduced performance
    • Weakness, fatigue
  2. Blood flows back into the pulmonary vessels.
    Symptoms:
    • Dyspnea (shortness of breath due to elevated pressure in the pulmonary circulation)
    • Orthopnea (apart from the blood that flows back into the pulmonary vessels, an additional volume of blood is orthostatically displaced into the pulmonary circulation when the patient lies flat, resulting in severe respiratory distress.)
      Sitting up allows the accessory respiratory muscles to work, which provides relief.
    • Cardiac asthma
      Pulmonary congestion leads to nocturnal fits of coughing and respiratory distress
    • Pulmonary oedema
      In severe disease, pulmonary edema may occur, in which case fluids accumulate in the pulmonary alveoli and the exchange of gases is severely obstructed.
      The pressure in the blood vessels consequently becomes greater than both the colloidal osmotic pressure in the blood and the pressure in tissues.
The guiding symptom of left-sided heart failure is dyspnoea

Right-sided heart failure

Isolated right-sided heart failure is rare.
Right-sided heart failure (congestive heart failure) usually occurs secondary to primary left-sided heart failure.
As the pressure in the pulmonary circulation rises, the right ventricle becomes unable to pump the blood efficiently.
This leads to congestion of blood in front of the right ventricle and thus to reflux into the systemic circulation.
Symptoms:
  • Distended veins (neck veins, veins at the tongue base)
  • Weight gain and oedema, especially at the ankles
  • Impaired liver function
  • Impaired renal funtion (excessive urination at night (nycturia)
  • Congestive gastritis
The guiding symptom of right-sided heart failure is oedema formation

Staging of congestive heart failure

Stages according to subjective complaints (New York Heart Association)

  Clinical symptoms
I No symptoms, normal physical exercise tolerance
II Complaints in case of heavy physical exercise
III Complaints in case of light physical exercise
IV Complaints at rest

Risk during dental treatment

Danger of decompensation with secondary:
  • Arrhytmias
  • Pulmonary oedema
  • Cardiac shock

Risk reduction

Physical and psychical relief:
  • Good medication prior to dental treatment
  • Supine positioning
  • Sedation, if necessary
  • Administration of oxygen, if necessary
  • Gentle treatment
  • Minimal excitement

Emergency treatment for acute left-sided heart failure with pulmonary congestion

  • Elevate upper body and lower legs
  • Oral administration of nitroglycerin, if the blood pressure exceeds 90 mm/Hg
    Dose: Have the patient chew 1 capsule, or administer 2 puffs of spray
    One capsule contains 0.8 mg, one spray puff contains 0.4 mg
  • Administer oxygen (4-6 L/min)
  • Obtain venous access
  • I.v. administration of 20-40 mg furosemide (e. g. Lasix®)