Page 6 - GP Spring 2022

Dental Management of a Patient with Cardiovascular Disease:
Heart Failure (HF) and Left Ventricular Assist Device (LVAD)

By Ricardo I. Carreon, Juhee Kim, Angela De Bartolo, DDS and Analia Veitz-Keenan, DDS

Abstract

Clinical Dilemma and Dental Implications
Heart failure (HF) is a condition in which the heart is unable to pump blood as efficiently as it should to meet the metabolic demands of
the body. It usually results from an abnormality in cardiac structure, function, rhythm, or conduction. Preload is the blood volume in the
ventricle prior to systole. Afterload is the amount of pressure the heart muscle needs to exert to eject blood during contraction. Stroke
volume is the total volume ejected on each cycle of systolic contraction. In patients with heart failure, increased preload, increased
afterload, and decreased contractility lead to decreased stroke volume and, ultimately, decreased cardiac output. Decreased contrac-
1,2
tility dilates the left ventricle, causing the heart muscle to weaken and become thin, ultimately unable to pump blood. Thus, HF arises
when the heart is no longer able to maintain a sufficient supply of oxygenated blood for metabolic requirements . HF often occurs in
1
elderly patients with multiple comorbidities such as diabetes, COPD, smoking, and hypertension. The risk of HF increases when these
comorbidities are poorly controlled. Common signs and symptoms of HF are myocardial dysfunction, shortness of breath, cognitive
3
disorders, and decreased muscle strength leading to slower walking speed and decreased mobility.
2,4
Medications often prescribed to control HF are antihypertensive drugs such as beta-blockers, angio-
tensin-converting enzyme inhibitors (ACE-I), calcium channel blockers (CCB), and angiotensin II
receptor blockers (ARB). 5,6
Although HF can be controlled with medications, end-stage heart failure may require more treatment
than medications alone. Patients with advanced heart failure usually undergo heart transplantation
or open-heart surgery to place implantable devices such as a left ventricular assist device (LVAD)
(Figure 1) and an implantable defibrillator. Due to the limited availability of donor organs, treatments
involving implantable devices like LVADs are increasing to manage end-stage heart failure. LVAD is
a mechanical pump that assists the heart in efficiently pumping blood from the left ventricle. Patients
7
with LVADs are managed periodically by an LVAD specialized team. 8
There are dilemmas and controversies regarding dental treatment in patients with cardiovascular
disease. Some of the concerns involve whether the use of local anesthetic with vasoconstrictor is
advisable for certain cardiovascular conditions, the need for antibiotic prophylaxis prior to invasive Figure 1. Left Ventricular Assisted
procedures, potential medication interactions, and side effects (Table 1), as well as any antithrom- Device (LVAD) 22
Figure 1. Left Ventricular Assisted Device (LVAD)
botic therapy and its impact on the risk of bleeding and control using local hemostatic measures. Madhero88, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia
Commons
This case presentation will review clinical considerations for a dental patient addressing many of the concerns already mentioned.
References
Table 1. Medications Interactions and Dental Considerations
1. Parmley W. W. Pathophysiology of congestive heart failure. The American journal of cardiology.
1985;56(2), 7A–11A. https://doi.org/10.1016/0002-9149(85)91199-3.
Name Dental Considerations
2. Skrzypek, A., Mostowik, M., Szeliga, M., Wilczyńska-Golonka, M., Dębicka-Dąbrowska, D., &
Aspirin Risk of prolonged bleeding Nessler, J. Chronic heart failure in the elderly: still a current medical problem. Folia medica
Cracoviensia. 2018;58(4), 47–56.
Digoxin Use vasoconstrictor with caution due to the risk of cardiac arrhythmias 3. Bui, A. L., Horwich, T. B., Fonarow, G. C. Epidemiology and risk profile of heart failure. Nature
reviews, Cardiology. 2011;8(1), 30–41. https://doi.org/10.1038/nrcardio.2010.165.
Metoprolol Rare: Xerostomia, dysgeusia 4. Frolova E. V. Kardiologiia, 58(Suppl 8), 4–11. 2018.
Trelegy Ellipta (Fluticasone- Frequent: localized infections (candida albicans) in the mouth and pharynx
Umeclidinium- Vilanterol)
Ventolin HFA Infrequent: unpleasant taste, glossitis, sinusitis, xerostomia
Rare: dysgeusia, tongue ulcers
Warfarin Increased risk of bleeding, mouth ulcers, taste disturbance.

Antibiotic use (macrolides, quinolones, cotrimoxazole, penicillins, cephalosporins) is
associated with a two-fold risk of bleeding.
Clonazepam Rare: candidiasis, jaw pain, fungal infections, tongue swelling, orthostatic hypotension
Concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression,
coma, and death.
Percocet (oxycodone- Acetaminophen may increase levels and enhance anticoagulant effects of Vitamin-K antagonists (warfarin).
acetaminophen)
Synthroid (levothyroxine) Risk of potentially life-threatening CV effects due to overtreatment.

History of CV disease is a risk factor.

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