is interventional cardiac electrophysiology. So my purpose and my obligation is to maintain the integrity of electrical circuit. So I started out as an internist, became a cardiologist, then eventually an electrophysiologist. The bottom line here is that there are things in our healthcare system that's very disabling. The bottom line here is congestive heart failure, sudden cardiac death, atrial fibrillation. But my purpose today is to literally explain to you that obstructive sleep apnea is the true silent killer. We try to forward my slides here. My slides are stuck. It's not advancing. So let's see here. Perfect. I have no conflict of interest to disclose. Again, obstructive sleep apnea, the true silent killer. I want you to really take this into heart. For me, as a cardiac arrest guy, I put in pacemakers and defibrillators. Like prior to this talk, I had two procedures this morning, one on a 43-year-old with cardiac arrest, and I put a defibrillator in him just to ensure his livelihood and his overall quality of life after he had a cardiac arrest at work. That is the aftermath of something that happened. But the key thing here is all about prevention. So objectives are, I want you to really assimilate this. As a cardiologist, electrophysiologist, I know the data, and everything that I'm talking about tonight is evidence-based. But I feel that this type of information and data will serve you well in terms of your practice. I'm not asking you to be a physician. I'm not asking you to be a cardiologist, but I'm asking you to take heed in terms of information so you can express those concerns to your respective team members, your physician, your mid-level providers, and your patients. So first and foremost, we want to look at the normal heart function. To know what the difference is between a heart attack and a cardiac arrest and a stroke, there are three big, huge gaps there. People think a cardiac arrest and a heart attack are the same. We'll go through that. Heart failure is the pink elephant in the road. That's my report card and my physician's report card. If we fail to reduce heart failure and re-emission rate, we failed as a physician. But I feel that you hold the power of screening, access to care, and modifying these patient population early on while I get the chance to put a defibrillator in, yet I didn't get a chance to prevent it. So who's more powerful, the person or the group or the team that has the screening power? Lastly, we'll talk about atrial fibrillation in terms of just knowledge base, something that you can digest, something that's palatable, and something that you can assimilate. Secondly, reviewing the consequences of obstructive sleep apnea and progression of heart failure. And lastly, I'm gonna give you the AADSM toolbox for success. How are we gonna bridge that gap to bring you and I to be a solid team so that we can modify these key disease epidemic so that we can promote quality of life and outcome for our patients? To begin with, you don't have to be a cardiologist to understand that, hey, we have a heart. And when I look at this, and when I talk to the cardiologist from an EP standpoint, so we go a few years more than our general cardiologists to really control electricity. As you know already, if you have to drive a car, turn off your phone, buy a house without lights, that's sort of impossible at this time. But for our heart, it's 24 seven. And I'm gonna give you here my cursor. The cursor, if you can see my cursor, if it works. Let's see here. So the cursor, you can see that the heart has an electrical circuit that starts from the SA node. And on the left side, it's blue because there's no oxygen. It's excess blood goes to the lung and it goes to the left side, which is the left H on the left ventricle. I want you to focus on a few things here to take away. Because you're seeing patients with a heart that's pulsating, has electricity. And when you're doing surgery, when you're doing cleanings, when you're doing modification of an oral appliance, you're dealing with a circuit that is dependable. But I want you to know a few things. So the sinus node is where the beacon of life starts, 60 to 100 beats per minute. It goes to the AV node. AV means atrium and ventricle. You got two atriums and two ventricles. And as the circuit comes down to the left ventricle, the left ventricle contracts. And when it pumps out, it pumps out about half or 50% of what's in it. So I want you to remember that when the left side pumps, it pumps out 52% of what's in it. And that's a normal ejection correction. It ejects out. And on the right-hand side, that PQRS is just an electrical impulse that you have. So if everybody holds their two fingers and feel the pulse, that's that QRS. You feel that pulse, 60 to 100. If it's lower than 60, it's slow. That's called bradycardia. If it's faster, it's called tachycardia. So that beacon is the key to our success. And I'll tell you, as I go through this discussion, the goal here is to prove to you that you hold literally the beacon to prevent sudden cardiac arrest. But first, let's go through the basic heart disease, the leading cause of death in the US, almost 660,000 per year. The cost is profound, $360 billion. Coronary artery disease, blockages within the blood vessels themselves, 360 death in 2019. And the word myocardial infarction is a heart attack, a blockage within the blood vessels that serve to deliver blood to a tissue. And one every 40 seconds, 800,000 in the US. One in five heart attack is silent. So if you say a heart attack is silent, then the cause of the heart attack is the true silent killer. So I want you to keep that in mind now, because there's a huge gap between what you do and I do. However, together, we can bridge that gap. Actually, you and I should be on the same team, but there's no discussion about how we bridge that. We just keep this in isolation. So therefore, the patient becomes literally at risk for all of these disease states. This is a busy slide, but I want you to go through and follow the donut. Think of this as a donut. The donut is your blood vessel that feeds your heart. So this is coronary artery disease. It begins with a healthy blood vessel. Suddenly you have buildup and you follow my cursor. And then the last three donuts are buildup. And if it builds up too much, then it blocks or prevent blood flow, causing chest pain, fatigue, shortness of breath. And for women and elderly, you may not get chest pain at all. You just get fatigue and shortness of breath without a reason. And those people may have a heart attack just based on those two symptoms themselves. A hundred women go to the ER with a heart attack, 50% had chest pain, the rest fatigue and shortness of breath. So in the red, cardiac mortality. Once you build that up, it restricts blood flow. So therefore guys, my plumbers, my interventional cardiologists that I called up, I said, hey, there's a heart attack. Patient most likely has a blockage. So they come in, they do an angiogram, they put a stent or they bypass. But that blockage came from somewhere. And I'm telling you now, that blockage comes from asphyxiation, lack of oxygenation that occurs in the bedroom. But cardiologists like myself and electrophysiologists, we deal with after the fact, but our preventive measure is pretty weak at this point. So therefore the team needs to include providers and colleagues that really take prevention on a whole different level. So this is a take-home slide. There's a few slides here that I want you to really emboss, ingrain into your brain. So let's take the middle slide. That middle panel there is an electrical circuit. So when somebody drops with a cardiac arrest and they're young, could be an athlete, next thing you know, somebody comes in and shock them. You don't shock a blockage to unblock a blood vessel. You shock an electrical circuit that goes at 250 beats per minute. Remember that one screen that I had with the heart, the left ventricle, when it pumps too fast, it doesn't have time to fill with blood before it pumps out. And when it pumps fast, it's pumping empty before nothing goes to the brain, nothing feeds the heart, and you literally go down like a rag doll and you got to shock those patients out. And when those patients drop, their risk literally of death is above 90%. So I don't know anything in this world at this point. Let's talk about COVID-19. Your risk of death is 0.2%. The risk of cancer, well, nobody drops dead from cancer immediately. It's a very sobering, very sad journey, but you have time to say, I love my loved ones. There's preparation. While cardiac arrest, there's a huge void within a split second. I don't know of anything in healthcare that takes you down in a split second. How often? 550,000. Heart attack, that's a blockage preventing blood flow. Chest pain, angina is the term used for heart pain. So when you have heart pain, but remember, angina can be fatigue and shortness of breath. So if you have fatigue and shortness of breath, patients come in fatigued and shortness of breath without a good reason other than I'm depressed, I'm anxious, I'm gaining weight. But you've been like that for a while now, but why are you more short of breath and fatigue in the last two days? So if somebody like that sitting on your table or your chair and you're dealing with this issue, prevention, understanding, and this is an opportunity to facilitate that process of referral to a physician or to a cardiologist so that we can optimize their care. Stroke wise, there's a blockage or a clot going from the heart to the brain, causing mental status changes, poor swallowing called dysphagia, blurred vision, a facial droop. So again, these are three different entities and we wanna know these entities. And I literally put it into a cliff note mentality for you. You may not see this at all, but if you see something like this, it looks like chicken scratches, aren't they? But the first three beats, it's a regular, but then it's like 250 beats per minute. This is ventricular tachycardia. This is the deadly heart rhythm that drops someone. This is the rhythm that requires a shock. So this is VT. So when you're thinking about somebody's going down, this is what guys like myself deal with when we put a defibrillator in someone. Second slide that you need to really ingrain is almost 600,000 sudden cardiac death on the red panel on the right side. The rest, stroke, lung cancer, breast cancer, doesn't even come close. So again, these are the epidemics that I'm dealing with, but I think collectively we should be dealing with together is because we're dealing with patients that have this, that walk into my office and your office all day long. So the discussion is, how can we collectively modify this disease state? Another slide, again, the red bar, sudden cardiac death, profound numbers. We are all involved. So therefore, this is something that we, I'm just putting facts together, evidence-based that you look at and you might turn a face to it, but look at COVID-19. Oh my God, two years, crazy, right? But then nobody talks about cardiac arrest. Nobody talks about, discuss about that patient that dropped during COVID and nobody did CPR because they were afraid of getting COVID while the death rate was 0.2%. So a rhythm, just remember VT, the word VT, ventricular. So that's in the ventricle, left ventricle, normal injection is 52%. And the lower your ejection fraction, the higher your risk of cardiac arrest. VT, ventricular tachycardia, something that's fast in the ventricle. Quick stats here, adults, children, let's focus on the adults out of the hospital, cardiac arrest, 350,000. The rest 550,000. The difference, that's in hospital. Majority occurs at home, no witnesses. Remember, no witnesses, silent, silent. So if it's at home, no witnesses, behind closed doors, you gotta think about apnea. That's why the most common hours of sudden death is 10 p.m. to 6 a.m. I think most of us are sleeping. Children occurs at home, again, silent. Let's dive into congestive heart failure a bit here. This is, I can safely say my success as a cardiologist is how I modify congestive heart failure. So I ordered my first sleep study about 20 years ago because I knew that I cannot be successful at modifying this disease state if I didn't go after sleep apnea. That's where people die the most, during sleep. If I didn't even know about apnea or congestive heart failure, I'm just putting Legos together, two and two, and this is where we're at. 550,000 death annually, 11 million physician visits annually. I would love to know how many visits in a dental office. I'm pretty sure more if you really think about it. So again, your power of prevention is huge. I cannot be successful without my colleagues in the dental field being a part of it, participating. But when you participate now with this data in your mind, in your mindset, in the clarity, it makes it a very powerful, meaningful discussion. So bottom line is if somebody asks you, what's the most common diagnosis upon discharge from a hospital? The answer is CHF, congestive heart failure. Annual cost, 30 billion. Medicare, private insurance. This is their pink elephant right here. Every cost, every saving, every revenue cycle, every model now is based on CHF. Three pictures here. Obviously the slides will be with you so that you can review, but the middle picture is key. Normal, normal is 52%. I'm hitting this home again. To the left is systolic. So you have a systolic blood pressure and a diastolic blood pressure. For the systolic heart failure is, if you look on this side here, the left is big. See the normal, the left is smaller. There's some muscles nice and thick and it's squeezed really nicely. On the systolic side, it's big, boggy, and it's thin. It's barely pumping. That ejection fraction is less than 52. That's called systolic weakness. This weakness in systole. The right side panel is diastolic heart failure. Hey, I'm pumping fine, but I'm too thick, therefore I'm not efficient. And I think of two things at this point in 2022, tonight during this talk, and it's snowing outside in Chicago. The two things I think about, hypertension, sleep apnea, diastolic. Systolic, what I think about, heart disease, chemotherapy, toxin, virus, especially COVID-19. But what causes this to make things worse? Silence, killer, sleep apnea. Think about that. Keep that in mind. You know apnea. You're the expert in apnea. I'm the expert in heart. Therefore we combine the two with relevant data. It's powerful. I am so sorry, and I'm gonna apologize for this slide. It's a nice slide to me, but I want you to focus on the left side. So when they say New York Heart Association Classification, NYHA. So if you know heart failure, you have a low ejection fraction or normal. And they say, what is the symptom of heart failure? So if you discuss things with me and you go, Dr. Nguyen, I have class two. So the classifications are, class one, I'm climbing Mount Everest. I'm doing a lot, and I barely feel anything. I'm awesome. I'm strong. That's class one, ideal, perfect. Class two, I feel mild symptom, fatigue, shortness of breath, a little winded, and I'm doing a whole lot. Class three, I'm feeling moderately symptomatic, and I'm barely doing anything. You don't wanna be there. That means my medication, my therapy is not working. They may be non-compliant with their CPAP or their oral appliance, or they're not using their CPAP and nobody's given them an oral appliance. Class four is you're ready for a transplant. So we want people between one and two, not three and four. Three and four means a lot of work. So the discussion is, I know heart failure. I'm not making the diagnosis as a dental sleep expert, but I'm sharing you my concerns because I know the data and I know the definition, and I know my patient. I think that's the key. That's the beauty of understanding classification and picking out the key classification to describe a patient. This is really quick. Your heart is weak. It could be a non-blockage, non-ischemic cause. Could be valve disease. You got narrow valve or too many leaks of your valves. You can have myocardial toxins like chemotherapy, infection like COVID-19, hypertension, sleep apnea. Sleep apnea should be also under coronary artery disease as well, because from a cellular standpoint, asphyxiation and suffocation is never a good thing, isn't it? And it's like me presenting tonight and holding my breath. So sleep apnea, sleep apnea. This is a patient that I put a defibrillator in. And if you follow my cursor, this is a person that has an injection fraction of less than 25%. Risk of death is about five to 7% per day. They call it per year, but you don't know when that happens. So therefore it's per day. This is a defibrillator. So I put one lead into the right atrium. So you know where the right atrium, remember that blue? And then one into the right ventricle. So if the patient goes into VT, it will look at it. And if it terminates on its own, it'll back off. But if it continues, it's gonna try to pace it out. And if it can't, it will shock that patient to restore normal rhythm. The patient doesn't have time to have somebody take him to the hospital without having all that. Now, quick slides, whirlwind approach. The key thing here is the first two bars, a prevalence of sleep apnea. So now we're gonna dive in. We know about VT. We know about cardiac arrest. We know about heart failure. We know about sudden cardiac death. There are distinctions and they're different. Now let's look at the prevalence. These are the things that you can teach me, but I just want to share with you that I have some common knowledge. So hopefully we can assimilate and come out of this discussion with tools to be more powerful in modifying these disease states. The first two bars, bottom line is, if you got heart failure, you got sleep apnea. The chances of having sleep apnea is huge, 50 plus percent. Second slide, just focus on the American College of Cardiology. This is what we want to do. We put it out there in neon. You know, I'm saying it's right there, billboard. Number one, recommend screening, uncontrolled hypertension. Everything that I see is uncontrolled. We're so uncontrolled in the U.S. that when you see a normal blood pressure, you think it's low. That's how bad it is. Normal blood pressure is 120 over 80. Stage two is anything above 140. So stage one is 130 to 140. I see it all the time. So therefore this is an opportunity for screening on a whole different level. But if you don't take a vital or you didn't ask the patient, hey, have you had a blood pressure check? Can you bring the last three days before you see me today in my dental office? That would be so awesome if we can do that. So recurrent atrial fibrillation. I'm not asking you to make a diagnosis of AFib and we'll talk about AFib. But if somebody tells you, hey, Dr. McGorry, Dr. Braga, hey, you know what? I have palpitations. I feel a little irregularity in my heart rate. So, hey, you need to go to your internist and they may have to get an EKG on you. And then if they get the EKG and they find AFib, you just prevented a stroke. That's the key. That's the bottom line. So knew your heart class two, three, ventricular tachycardia or you had a defibrillator and it shocked you for AFib or VT, please do a sleep apnea evaluation. They went to the ER, the cardiologist took care of, put them on a ton of drugs, sent them home and no sleep apnea evaluation. It's a terrible thing. After a stroke, if you have a clot, not a clot, you're asphyxiated and you have an injection fraction of 35%, barely blood going to your brain. So if you have a stroke and you have AFib, where is that screening? Heart attack, arrhythmia. And in the red below there, you know that already, mild to moderate, I'm saying we know that 24 seven, but that opportunity for screening, I don't think you even scratched the surface in that. Last, this is just quick stuff here just to give you some evidence-based stuff. For me, I reviewed a ton of studies, but I pull things out that you can digest. And we may go through a billion of them, but if we don't know two solid ones, then we missed the point. So the results are, if you take 7,000 individuals and you look at self-reported sleep health composites and you compare the two and say, how many of these actually have heart disease? There's a linear relationship. You don't really need a research to tell you that from a heart standpoint, because I know that, but to see sleep composites and looking at dimensions of satisfaction, alertness, timeliness, how often you're insomniac and not sleep, duration, and put it together, one may be important, but a combination of two, three, or four, it's solid in terms of predictability of heart disease. Race moderation makes sense, right? Because if you look in the US, African-American, Hispanics, Asians, in terms of order and respectiveness are high risk in heart disease based on genetics. Now you put sleep apnea on something like that, it's predictable. Surprisingly, no significant moderation by sex. But we'll talk about that in later discussion. I have a lot to talk about with women's health, and I think it's huge in the dental world. So heart failure was reduced. So let's focus on now on key points, trigger finger right now, going through this. Heart failure with low ejection fraction, less than 52%. Bottom line, CHF patients around the world, 52%. If you got heart failure, you got sleep apnea. You gotta make that connection from the get-go. So personally, I'm about 132 pounds. I'm gonna be 54 this August. I'm always on the go, as you can tell already, and I have sleep apnea. So if somebody looking for weight in me, and a BMI of 22, you're not gonna, actually 20, you're not gonna find weight. There's no way a physician telling me I'm gonna go home and lose weight. And on top of that, you know, Asians, we have low nasal bridge. So therefore, if I wear a mask, it's gonna leak everywhere. I use an oral appliance. If I don't use an oral appliance, the next day you probably don't wanna be near me when I'm doing surgery. I'm cranky, and I don't feel well. But last night, since I'm doing a talk today, last night I use it. So I'm here, I have all the energy in the world. So just the last three parts here, heart failure with normal ejection fraction. And remember, that's diastolic heart failure. 48% of the patient had an AHI of 15. Again, I'm just reiterating, re-emphasize the data. And I think you know the data. I'm just reminding all of us that it's right there. It's hitting us in the face, yet we're not talking. This is a beautiful slide just for, I know all of you are really interested in the consequences of cellular dysfunction. And I want you to focus on the endothelial cells and the hypoxia, obviously, asphyxiation and sympathetic drive. So when you have endothelial cells, these cells that line the blood vessel that I showed you that builds up to cause a clot, a blockage, causing a heart attack, those cells, if they're not happy and they're not flexible, they're actually going to chew up, ingest cholesterol and not spit it out until it cracks. And when it cracks, it's a massive heart attack. And on top of that, if there's endothelial dysfunction from a cellular standpoint, that blood vessel just squeezes really hard. So when you squeeze a blood vessel with volume in it already, what do you think the blood pressure is going to be? High, and it's going to cause clots, and it's going to be inflamed. So again, patients with apnea have increase in heart rate, hypertension, increase in heart rate or blood pressure, hypertension, heart rate, atrial fibrillation, leading to strokes, leading to heart disease. So we're pretty good at dealing with after the fact, but you hold the power to the screening and prevention. This is the piece de resistance. This is the key slide that I'm hopeful that if you can just take your phone out and just take a click at it and go back to the Academy's website and take the slide and etch this in your brain. You see obstructive sleep apnea is in to the left here. And cellularly causes inflammation, hypoxia, autonomic disarray, and an increase in thoracic pressure. That's what it does. And in doing so, it causes hypertension. And here it creates this whole facet of congestive heart failure to where the amount of costs, revenue, patient mortality, morbidity is just nuts. Yet, and then AFib. Yet we treat the AFib, we treat the hypertension, we treat the congestive heart failure, but forget about the cause. So you see, we made the link that congestive heart failure leading to cardiac arrest, but what leads to obstructive sleep apnea if you miss this disease entity. So slowly but surely, we're proving the fact that the true silent killer is what happens in the bedroom. It's silent. We're not even there. We're not even knocking on anybody's doors to say what's going on. And if you're completely obstructed, you think you're gonna snore? When you're completely obstructed, there's nothing to come out to snore. So let's hit AFib, a few more slides and we're done. So AFib, the left atrium, AFib lives in the left atrium on the left side, the red. And that when it quivers like this, at 300 beats per minute, blood sloshes back and forth and it cause a clot. And the left side, the problem with the left side is that it goes straight to the brain. So there's a five-fold increase in stroke. Hence patients with AFib, they're on blood thinners and you have to take them off blood thinners if you're gonna do certain dental procedures that may cause bleeding. And we'll talk about AFib one day in terms of the nitty gritty so that you can be very well versed in it in literally 15 minutes. What are the associated condition for AFib? High blood pressure and think sleep apnea. High blood pressure and think sleep apnea. In between, we can go through all those, you know, the entities and the ideologies, but keep it simple, hypertension, sleep apnea. So if you see a female or a male clenching their chest in your office or complained of it prior to when you take a history, palpitations, shortness of breath, fatigue, angina. And when you see down here, you might go, hey, I'm a dentist. I don't make a diagnosis of AFib and look at EKG, but I just wanna prove to you when somebody says my pulse is irregular, I'm having palpitation, I just want to count this. You see from here to here, first to the second is long, probably the same, shorter, longer, shorter, longer, shorter and longest. So therefore it's irregular. So not only that you complain of irregularity, but it is legitimized and also be objective in the EKG. I'm not gonna go through this slide. So if you have time, go to the classifications of AFib, but one day I'm gonna give you a crash course in AFib and you're gonna know AFib really quickly at this level. So we're gonna go into a case scenario that you're gonna see that you may not think about, but I want you to think about the history. To me, testing is great, positive or negative, but the history is the key. So 62-year-old Caucasian female, history of fatigue, shortness of breath, palpitation, AFib had an ablation, but she's now having palpitation. Obviously the ablation didn't work. Dementia, depression, hypertension, and she was diagnosed with sleep apnea five years ago and she's non-compliant with CPAP. Her ejection fraction is 35%. You got this history. It's in your history. My internist may not even understand the connection here. So as a physician, I don't expect my internist to know everything about congestive heart failure like a cardiologist. That's why they refer to the cardiologist. And I don't expect my cardiologist to know everything about an ejection fraction and ICDs and heart failure therapy to a technology standpoint. Therefore they refer to us. So why put yourself in a position to where you are based on your success and your liability on someone telling you the diagnosis without understanding the diagnosis? And literally within the last 40 minutes, we can go through this and you know the diagnosis so that you can report this, converse this, and discuss this with your patient because it's so meaningful. It gives them confidence to say, this is a place to be to prevent. And then when you're dealing with a primary care physician or you go with a cardiologist, we're gonna go, this is awesome because you're helping me to get a better report card to reduce cardiac arrest, congestive heart failure, and be really preventive to prevent a stroke if somebody has an irregular heartbeat like AFib. The physical examination here, obviously, you know, no brainer, 165 or 92. Heart is irregular. Labs, this BNP, BNP is a beta natriuretic peptide. That's all you need to know is BNP is a protein that's released when you have heart failure. 100 is normal. This is 1,200. And the angiogram, EF of 35%. So you go EF of 35%, heart failure, palpitation had AFib, but it's back. She's having palpitation and she's not using her CPAP. But everybody's gonna do a left heart cath, possibly a stent, maybe a bypass, but then there's, on the left heart cath, there's no blockages, so there's nothing to bypass, but blood pressure is high. So she's at stroke risk again after having the first one. So the patient comes in as a train wreck, but hey, you know what? She's fine. You know, she's a little slow. She has fatigue, some shortness of breath, and we'll take care of her needs. But what she truly need is to treat for sleep apnea. She's demonstrated that CPAP hasn't worked because she doesn't wanna use it. She's too short of breath, but nobody gave her an alternative. And until she came into my office and we put an oral appliance on her, and now her legs are less swollen. She talks, she actually looks at me in the eye and she has a very meaningful conversation, and she smiles sometimes. Her medication, metoprolol, all the good stuff for heart failure. We gave her a water pill and she peed to get rid of water so that she can breathe better. So what is the differential diagnosis? So we've gone through the lecture. So you know, hey, and then on this rhythm here, look, it's a regular fat, wide, narrow, wide, narrow. You know it's AFib. EF of 35%, less than 52, which is normal, congestive heart failure. Sleep apnea, it's a done deal. You're not making the diagnosis. You're expressing a concern that these could be the disease entity. So Dr. Nguyen, I'm referring this patient to you. I just wanna make sure the patient's not gonna get re-admitted to the hospital. And I got that from my dental colleague. How powerful is that? And that needs to be what documented in a case discussion when I'm dealing with the patient, when I'm dealing with my team, my heart failure team at a hospital. Now I know who I'm going to talk to when it comes to patient care. Number two, what is the normal ejection fraction? No brainer now, 52%. So last two slides, take home message. These are the things that I see that is a problem that disconnects you and I until today. So gaps and barriers preventing the prescription and use of oral appliance. I cannot be successful unless you do your job. My job is to put a defibrillator, congestive heart failure reduction, reduce that person who drops dead while pumping gas and has three kids at home and he's only 37. So number one is dentists often relies on a medical diagnosis from a physician. I don't want you to rely on a diagnosis. I want you to understand the diagnosis. And what I gave you today is the top notch diagnosis that even an internist may have a problem dealing with from a knowledge standpoint, not because they're less is because this is not their field. Therefore it's an information that makes you powerful. It's not a making a diagnosis, it's informational. Physicians are less versed in the efficacy of oral appliance yet we tell you we know everything yet we're not versed. And we learn about oral appliance through our CPAP supplier. That's a conflict of interest, isn't it? We need you to come out and teach us about oral appliance. Physicians are naive to the significance of occlusive changes and long-term effects of appliance on dentition. You're the expert. You're the only physician that truly looks into the mouth as an infectious disease. The rest, we don't. And we're missing out. So we need to learn that from you. But from my end, I was scratching my head for the last 20 years. I said, you know, patients coming in, you're doing everything, what's missing? And I've learned it's so easy. It's missing, but what's easy, it requires a lot of sophistication, a lot of training. And that's where you step in. As the dental sleep expert, physicians have lower expectations of OA effectiveness or appliance effectiveness because we don't know the data. The efficacy has been tried and true. There are multiple, there's hundreds of data points there, but we've failed to read, to understand because we think we know, but I think that's where the team needs to be a bit more robust to include our dental colleagues. Dentists follow their patients annually and generally replaces or applies 35 years. I think you need to see that patient at least one more time, be more rigorous, right? And that rigorousness, I think it's cool nowadays after two years with virtual health, virtual dentistry wasn't today. It's been there for a while. Take advantage of that. 10 seconds, how do you feel? Any depression, anxiety, you feel sad? Are you taking your medications by the way? And then how's your blood pressure? Literally 10 seconds. Just doing that puts you on a level that nobody else is doing because everybody thinks that it's not their job. To me, it is your job because why you are the king of prevention. You get the patient first. CPAP providers are generally more actively involved. Yeah, compliance, use more CPAP. But if I want to really understand our appliance, we need to be really active in looking at surveys, engaging with the patient and hopefully develop a dental heart wellness program. I think tonight is a dental heart wellness program. And I'm hopeful that this is helpful but I think this is so critical because it really bridged the gap between you and I. And I can tell you right now, I didn't realize that there was a gap until I really look into this and I go, why would an electrophysiologist diagnose apnea after a cardiac arrest and the patient's is 70 years old? What happened in the first five decades? How sad is that? Lastly, this is the toolbox. So I kind of created, I'm a visual kind of person. So the AADSM toolbox, there's hammers and pliers and everything that you need to build a home, to build security, safety, and healthcare. I want for all of us to discuss with patients and respective healthcare provider implications of untreated sleep apnea at this level. An ejection fraction, knowing heart failure, knowing sudden death. This is the data. If you know the slide set, you know the data. Demonstrate proficiency in baseline knowledge. Incorporate bottom line fundamental cardiovascular health knowledge. So if you ask and you talk to me, then you say, doctor, when this patient comes in with a low ejection fraction, I notice on there and now they're breathing a little bit hard. We put a cap on, we put a crown, we fix the oral appliance, we advance. And you know what I noticed in the last few weeks, there's less swelling. So I just want to kind of touch base with you because the patient did tell me that you saw him six months ago, because I don't see my patients every month. It's every three to six months, but you saw the patient. You just bridge the gap. But if you saw the patient and you say, you know what, there's increased swelling. So I better get that patient in early. So I don't want that patient together. We have prevented a reemission, which is a huge bottom line. That's my report card for success. So next perform routine health survey. Ask the patient how you feel. You know, are you taking your medication? And I can tell you right now, I want you, if you have a pen or a virtual pen, write this down on this virtual notepad. My biggest problem right now for cardiovascular is this. Patient comes in with heart failure. The problem is they're not compliant with their medication. That's why they're feeling worse and they're going back to the hospital. But if they feel well, because they're treated for sleep apnea, they feel energized. I guarantee you, they're going to be more compliant. So the five and six, be more up to date with healthcare trends. And so tonight, you know, my audience, I'm hopeful that we are up to date now together. And I think that if we do this correctly, we can reduce sudden cardiac death. And that's my motivation for all of this, is to educate, reduce sudden death, modify congestive heart failure. And the bottom line here is, it's not only for our patients, but for ourselves. We've got to take care of ourselves as well, especially post COVID. Thank you so much for your time and allowing me to share my concerns and my passion with you. Thank you. Thank you so much, Dr. Nguyen. That was an amazing lecture. I absolutely loved it. All right, so if any audience member has a question for our speaker and are using the full screen mode, you'll need to exit the screen to access the ask button to submit a question. I'll be asking the questions from the top down. So please make sure to use the upvote feature to move your favorite questions up the list. Also in some instances, your question may be answered by a moderator in writing, in which case you'll see a notice under your question with the phrase, TAP-C moderators answer. All right, so going from the top question here, hold on one second. My computer just moved out here. Here we go. How do we start these conversations if we're reaching out to an MD when they fall into one of these categories outlined by American College of Cardiology? Slide 20. That's our most asked question, Dr. Wynne. And that in regards to, you asked that again? Yeah. In reference to? So they're calling it in reference to, it says slide 20. So it says, how do we start these conversations if we're reaching out to a doctor, an MD, when they fall into one of these categories outlined by the American College of Cardiology? Yes. So say, for example, it's very simple. Nowadays, the physicians don't have time to discuss a whole lot. They see their patients for five minutes and they bring them back in three months. When you see the patient and you notice there is hypertension, nowadays, the patient's office, like mine, and a lot of these offices have mid-level providers, nurse practitioners and PAs, physician assistants. They're very extremely vociferous and purposeful in terms of ordering a sleep apnea evaluation and dealing with hypertension. Everyone in medicine right now, including the physicians, and you're not aware of this, including the nurse practitioner, they are being judged on a monthly basis on how they modify reduction in re-emission, stroke and heart failure. So when you approach this and you basically said, I saw the patient, the patient is hypertensive. She's not doing well. She's having problems breathing. I'm hopeful that you can actually see this patient early because she was re-emitted several times to the hospital already. So now you really have to get into the history of the patient, but now you understand what's the focus, blood pressure, heart failure history, and also their complaints of palpitations or their rhythm disturbance problem. Those are the three things that you wanna focus on to modify. And when you talk to the physicians and you add these three outliers into the discussion, I guarantee you, they may say, hey, you're virtually in their brain. You're wasting my time, but tell me more. I think that's the key. And if that doesn't work, I'm hopeful that these patients that you're dealing with, you also know who's included in the team. Is there a cardiologist on the team? Is there a nurse practitioner of cardiology service on the team? If you can't get through to one, you have to start going up in the chain of command. And as you go up in the chain of command, I guarantee you, even if I don't know you, I will listen because right now I'm thinking re-emission, re-emission, re-emission, heart failure. Great. Okay, our second question is, when we treat patients that have high blood pressure and are on beta blockers, once we've achieved resolution of the apnea via oral appliances, how would the cardiologist manage the medication? Would they change it at all? Basically, they've had patients that have asked questions like, do I need medication changes now that my sleep apnea is under control? That's a great question. I love that question. So if the patient doesn't have congestive heart failure, that medication, once you treat apnea with an oral appliance then obviously those medications can be down or decremented and possibly taken off because the apnea caused the hypertension. However, if the patient has heart failure and a rhythm disturbance that they use the beta blocker to slow their heart rate down, you may not get away with reducing the beta blocker, or basically discontinuing the beta blocker, but possibly reducing the medication to have a less of a side effect from the beta blocker like fatigue. Got it, great. And then what is the best way for dentists to screen for risk of SCA? Sudden cardiac deaths. Yes. So the first thing here is number one is that you know the middle age men and women are at the highest risk for coronary disease. And we'll talk about it one day in terms of the risks. And then the key risk here is smoking, hypertension, heart disease already, family history, gender male. Family history is the key. If any one of your patients have a family history of cardiac arrest, that patient who sits in front of you is at risk. And if they tell you, I have a cardiologist and my heart's not working well, and you just told me from the other question, they're on a beta blocker, ask more questions. So just that itself gives you intuition and the first trigger to say, is this a cardiac arrest risk patient? So as I modify their apnea, I want to include the physician, the cardiologist into the discussion. And this is a beautiful way of actually incorporating sort of actively wedging yourself, proactively wedging yourself into a team effort and you hold the critical aspect of prevention. You actually started the discussion to save this patient's life. Great, okay. So the next is if patients are diagnosed with mild obstructive sleep apnea and have a low AHI of let's say 5.5 or six, many times they're told by the physician that it's mild and it's nothing to worry about. What are your thoughts about this? Do you think that an AHI of 5.5 warrants treatment? That's another intangible question. And I can safely say before I answer that question, my AHI is 3.7 and I'm treated, why? I'll just give you a really crude analogy, right? If somebody takes, it has to be an appropriate analogy. So if I am 24 seven taking, you know, not resting, taking care of patients, flying the stealth bomber on a daily basis, always having to have 100% input energy and everything else, give all I got, right? So if somebody says, why don't you stop breathing for a minute? Is that bad? Or should I stop breathing for five minutes? Is it worse? So to me, apnea, AHI does not relate, it doesn't have any concept to your bottom line, to where you're at. If you're hanging by the string because your ejection fraction is 35%, you have heart failure, you just had bypassed, one event is too many, let alone five, right? So therefore, this is where the history is important. My sleep docs are reading sleep studies, oh, five, okay. And they never seen the patient, they're just reading sleep studies. So their recommendation just in generality is to lose weight yet the patient's, you know, BMI of 22, he didn't even know the patient. So the beauty of what you do is that you're not doing an oral appliance on someone you didn't see, right? You're not reading a sleep study and doing an oral appliance at somebody that you didn't meet. So the power goes back, you are facing with a patient that you have a history, that you see the morphology, you see the phenotype, you examine the mouth. So therefore, again, you hold the power to prevention, but at 5.5 with the right history, you can save that person's life. That's the bottom line. So do not discredit the 5.5. And I'm gonna add this too. So how do you know if that was a good night? Great. Great. So, and if you have a sudden, yeah, if you have a sudden cardiac death risk, so one goes a long way, five, it's huge. To me, if there's apnea and there is a history, there is a risk, you gotta modify it no matter what. Got it. Great. I think we have time for one last question. Yes. Okay. So it is, we know untreated OSA as measured with AHI increases the risk for cardiovascular events. Do we know that once OSA is treated as measured by reduced AHI, actually reduces the risk for events or are cardiologists interested in other metrics too? Yeah. So we have a lot of metrics now in terms of, say for example, I'll just make a very simple example of hypertension. So hypertension, there's a normal 120 over 80 plus one, you know, stage one, stage two. Stage two is greater than 140. So if we can modify that, take that OSA, take care of it with an oral appliance or a means of reducing OSA, we reduce hypertension, that automatically reduces cardiac arrest profoundly, reduces heart disease profoundly, reduce sudden cardiac death. And I told you already, the most common cause of atrial fibrillation is hypertension. The data is profound. Nobody is crossing your data with my data and say, where do we merge and where we have that in common? So to me, it's not even a guesswork. It's based on evidence-based all day long.

obstructive sleep apnea

cardiovascular conditions

congestive heart failure

sudden cardiac death

atrial fibrillation

collaboration between dentists and physicians

oral appliances

screening for sleep apnea

patient care