Australian Dental Journal 2002;47:(1):66-67
A case report of acute heart failure caused by a patient
delaying taking his diuretic medication
Abstract patient – usually semi-upright, sometimes upright.1
Acute heart failure is a life-threatening medical Also stop if the patient appears to be becoming
emergency, most commonly occurring as an distressed or fatigued, and limit the duration of
immediate or delayed complication of acute appointments. Further, the total amount of adrenaline
myocardial infarction (AMI), or resulting from used in local anaesthesia should not exceed about a
severe hypertension or valvular defects (stenosis or quarter of the maximum dose for a healthy patient, and
incompetence). Occasionally it is caused by patients’ where possible use local anaesthetic with felypressin
non-compliance with medication orders. instead. If extensive treatment is needed or the CHF is
In this case the patient had a history of three not well controlled, the patient should be treated as a
previous AMIs, controlled hypertension, and
medically monitored case.
controlled congestive heart failure (CHF) for which
he took two 40mg frusemide tablets (a very potent Acute heart failure results in acute pulmonary
oral diuretic) each morning. Because he had oedema which is characterized by sudden transudation
experienced bladder discomfort during the latter of fluid from the pulmonary capillaries into the alveolar
stages of previous appointments he decided to delay spaces with onset of increasing dyspnoea.3,4 Under these
taking the diuretic until after his appointment and conditions, the patient may be in a state of panic and
acute heart failure ensued.
may resist attempts to be laid back. The patient may
Key words: Acute heart failure, case report. prefer to sit forward placing their hands on their knees
(Accepted for publication May 2001.) with arms straightened in order to maximize the
volume of each inspired breath. The upright position
also allows fluid in the alveoli to concentrate at the base
of each lung, permitting greater diffusion of oxygen
and carbon dioxide to occur.1,2 The patient most likely
Patients with congestive heart failure (CHF) may will be almost unable to talk, the respiratory rate will
easily become decompensated from, inter alia, be double or more and may be associated with
emotional stress or overexertion, resulting in acute wheezing and a moist cough with frothy sputum.
heart failure.1,2 Both these factors have relevance for the Cyanosis will soon become apparent. It is obvious very
dental patient with CHF, i.e., dental anxiety, especially early that this is a life-threatening medical emergency
if the patient also undergoes stressful exertion just prior and Emergency Medical Services (000) must be
to the appointment, e.g., has to walk quickly to get to summoned urgently as, untreated, cardiac arrest will
the appointment on time, etc. Non-compliance with occur.
medication orders is an occasional cause. It is
Dental management of this situation includes leaving
recommended that CHF patients should be questioned
the patient sitting upright and administering low-
at the beginning of each appointment particularly to
pressure oxygen through a soft facemask at the
ascertain any recent change in symptoms (especially
maximum flow rate possible (8-15 litres per minute).
increasing dyspnoea), when they last saw their medical
Glyceryl trinitrate (GTN) can be administered – this
practitioner, and ensure that the patient is taking
will cause moderate systemic venous dilation and there-
his/her medication as instructed.1 Contact the patient’s
fore reduce the venous return (and consequently the
medical practitioner if concerned about anything.1 As
cardiac preload) and partially alleviate the situation but
CHF patients are usually not comfortable when fully
should not be used if the systolic BP is less than
reclined, the operator must adapt by treating these
100mm.3 One dose (preferably GTN spray) can be
patients in the most comfortable position for the
given and can be repeated in 5-10 minutes, up to a
maximum of three doses, depending on the situation.3
*Senior Lecturer (Oral and Maxillofacial Surgery) and Medical Medical management is IV frusemide (40-80mg)
Officer, School of Dentistry, The University of Queensland. immediately, which may be repeated in 15 minutes.3,5
66 Australian Dental Journal 2002;47:1.
CA S E R E P O RT emergency was declared, including calling 000. Oxygen
A 54-year-old overweight male had a periodontal was administered with a soft facemask and after
appointment (quadrant scaling) at 9am with a post- checking the BP a sublingual dose of GTN was given
graduate student. His past medical history was and then IV frusemide (40mg). The patient very quickly
significant, i.e., three previous AMIs (15 years, five started to improve and could soon talk in short
years and eight months previously); controlled sentences and within 10 minutes his respiratory distress
hypertension; controlled CHF; and non-insulin had completely settled. At no time did he experience
dependant diabetes. He had had no previous episodes chest pain. He was transported to hospital, stabilized
of acute heart failure. there and discharged within 48 hours.
His current medication was two 40mg frusemide In conclusion, this emergency was caused by a
tablets in the morning (oral frusemide causes diuresis to patient with controlled CHF deciding to delay taking
occur within about an hour, and the effect lasts for 6-8 his daily diuretic dosage until after his dental
hours), a potassium supplement, two different drugs
for hypertension, an oral hypoglycaemic drug and
aspirin as an antithrombotic agent. His medical
1. Weaver T, Eisold JF. Congestive heart failure and disorders of the
practitioner had been advised of his dental treatment heart beat. Dent Clin North Am 1996;40:543-561.
when the treatment plan was initially made. 2. Jolly D. Evaluation of the medical history. Dent Clin North Am
This was his third appointment and he had 1994;38:361-380.
experienced bladder discomfort during the latter stages 3. Malamed SF. Medical emergencies in the dental office. 5th edn.
of the previous appointments (45 minutes) which he Sydney: Mosby, 2000:225-240.
hadn’t mentioned to the operator. He therefore decided 4. Guly U, Richardson D. Acute medical emergencies. Tokyo: Oxford
University Press, 1996:37-39.
to delay taking the frusemide tablets, which should
5. Moskowitz L. Cardiac disease and hypertension. Dent Clin North
normally have been taken at about 7am, until after his Am 1999;43:495-512.
appointment but didn’t tell the operator – nor did the
operator enquire before commencing treatment as there Address for correspondence/reprints:
had been no apparent problems during the previous Dr PJ Chapman
appointments. School of Dentistry
Within seconds of sitting in the chair (which was The University of Queensland
upright) and before treatment had commenced he was 200 Turbot Street
experiencing increasing breathing difficulty and an Brisbane, Queensland 4000
Australian Dental Journal 2002;47:1. 67