EVALUATION Evaluation for hypertension has three objectives: 1. to assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment. 2. to reveal identifiable causes of high BP. 3. to assess the presence or absence of target organ damage and cardiovascular disease (CVD)

TARGET ORGAN DAMAGE Heart Left ventricular hypertrophy Angina or myocardial infarction Heart Failure Brain Stroke or transient ischemic attack Chronic kidney disease Peripheral artery disease Retinopathy

The relationship between BP and risk of CVD events is continuous, consistent, and independent of other risk factors. The higher the BP, the greater is the chance of heart attack, heart failure, stroke, and kidney disease. The risk of developing CVD doubles for every increment of 20 mm Hg Systolic (SBP) or 10 mm Hg of Diastolic (DBP). The risk of dying of ischemic heart disease and stroke increases progressively and linearly when blood pressure exceeds 115/75 mm Hg.

The JNC-8 panel confirms that the >140/90 mmHg definition for hypertension remains the standard for diagnosis for individuals who do not have additional comorbidities.

Older than 50 years, SBP > 140 mmHg is a much more important CVD risk factor than DBP. 80-90% risk of developing hypertension by the age of 80 to 85 years. SBP of 120–139 mmHg or DBP of 80–89 mmHg: considered as pre-hypertension and requires promoting lifestyle modification to prevent CVD.

Undiagnosed hypertension has been proven to shorten a life-span by 10-20 years

ESSENTIAL / PRIMARY HYPERTENSION Causative factors are unknown about 90-95% of all hypertensive cases

Identifiable cause in 5-10% of all cases of HTN adults Disorders associated with secondary disease renal parenchymal disease renovascular diseases Cushing's syndrome Obstructive sleep apnea primary hyperaldosteronism pheochromocytoma Thyroid Disorders hyperparathyroidism

MEASUREMENT Proper technique for obtaining accurate blood pressure measurements mandates; Patient should be seated quietly for at least 5 minutes in a chair. Feet on the floor, and arms supported at heart level. An appropriate-sized cuff, a cuff bladder that encircles at least 80% of the arm, to ensure accuracy. At least two measurements should be taken during the visit

Oral manifestations ARTERIAL HYPERTENSION Antihypertensive drugs are able to induce a series of adverse effects with the oral cavity, these includes: # Xerostomia (DIURETICS like furosemide) # Lichenoid reactions (adrenergic blocking agents like propanolol) # Burning mouth sensation (angiotensin -converting enzyme inhibitors like Captopril) # Loss of taste sensation (angiotensin -converting enzyme inhibitors like Captopril) # Gingival hyperplasia, (calcium antagonists Nifedipine ‘Adalat’) # Extraoral manifestations such as sialadenosis (adrenergic blocking agents)

Blood Pressure Classification BP Classification SBP mmHg DBP mmHg Normal < 120 and < 80 Pre-hypertension* 120-139 or 80-89 Stage 1 Hypertension 140-159 or 90-99 Stage 2 Hypertension > 160 or > 100 *newly recognized, requiring lifestyle modifications

Hypertension Clinical Manifestations • Frequently asymptomatic until severe and target organ disease has occurred Fatigue, reduced activity tolerance Dizziness Palpitations, angina Dyspnea

Hypertension: Complications Complications are primarily related to development of atherosclerosis (“hardening of arteries”), or fatty deposits that harden with age

Hypertension Diagnosis • Diagnosis requires several elevated readings over several weeks (unless > 180/110) • BP measurement in both arms - Use arm with higher reading for subsequent measurements

Hypertension Diagnosis Ambulatory BP Monitoring For “white coat” phenomenon, hypotensive or hypertensive episodes, apparent drug resistance

Treatment Goals Goal is to reduce overall cardiovascular risk factors and control BP by the least intrusive means possible BP < 140/90 In patients with diabetes or renal disease, goal is < 130/80

Benefits of Lowering BP Average Percent Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50%

Hypertension Collaborative Care • Lifestyle Modifications - Weight reduction - Dietary changes (DASH diet) - Limitation of alcohol intake (< 2 drinks/day for men; < 1/day for women) - Regular physical activity - Avoidance of tobacco use - Stress management

Hypertension Collaborative Care • Nutritional Therapy: DASH Diet = Dietary Approahes to Stop HTN - Sodium restriction - Rich in vegetables, fruit, and nonfat dairy products - Calorie restriction if overweight

Hypertension: Drug Therapy β – adrenergic blockers (suffix “olol”) (metoprolol, propranolol) Block β – adrenergic receptors ↓ HR, ↓ inotropy, reduces sympathetic vasoconstriction) Side effects Bradycardia, hypotension, heart failure, impotence

Hypertension: Drug Therapy Calcium Channel Blockers Block movement of calcium into cells, causing vasodilation Side effects Brdaycardia, heart block

Hypertension: Drug Therapy ACE Inhibitors (suffix “pril) Enalapril, captopril Prevents conversion of angiotensin I to angiotensin II, thereby preventing the vasoconstriction associate with A II. Side effects Hypotension, cough

Hypertension: Drug Therapy Thiazide-type Diuretics Inhibit NaCl reabsorption Side effects: Electrolyte imbalances: ↓ Na, ↓ Cl, ↓ K** (advise K rich foods) Fluid volume depletion (monitor for orthostatic hypotension) Impotence, decreased libido

Hypertension: Drug Therapy Adrenergic Inhibitors Reduce sympathetic effects that cause HTN by: Reducing sympathetic outflow Blocking effects of sympathetic activity on vessels Side effects Hypotension Varied, depending on specific drug

Hypertensive Crisis Clinical Manifestations - Hypertensive encephalopathy (H/A, N & V, seizures, confusion, coma) - Renal insufficiency - Heart failure - Pulmonary edema

Hypertensive Crisis • Severe, abrupt elevation in BP • The rate of  in BP is more important than the absolute value • Most common in patients with a history of HTN who have failed to comply with medications or who have been under-medicated

Hypertensive Crisis Nursing and Collaborative Management Hospitalization - IV drug therapy - Monitor cardiac and renal function - Neurologic checks - Determine cause - Education to avoid future crises

ARTERIAL HYPERTENSION

ARTERIAL HYPERTENSION Dental management - A well controlled hypertensive patients does not pose a risk in clinical practice. - Consultation with the supervising physician is advisable in order to know the degree of hypertension control and the medication prescribed at that time. - The patient is to be instructed to take his or her medication as usual on the day of dental treatment. - Prior to such treatment, the patient blood pressure should be recorded, and if the values are found to be high ( ≥ 180/110) , the visit should be postponed until adequate pressure control is achieved - Cautious use of epinephrine in local anesthetic in patients taking non-selective b-beta blockers or peripheral adrenergic antagonists.

ARTERIAL HYPERTENSION Dental management - Because some antihypertensive agents tend to produce orthostatic hypotension, sudden changes in chair position during dental treatment should be avoided. - It is preferable for the visits to be brief and in the morning. - The prescription of anxiolytic agents may prove necessary in particularly anxious patients (5-10 mg of diazepam the night before and 1-2 hours before the appointment) before dental treatment, or altaernatively sedation with nitrous oxide may be considered. - Vasoconstrictor use should be limited, taking care not to exceed 0.04 mg of adrenaline (2 carpules containing 1.8 ml of anesthetic with adrenalin 1: 100,000)

ARTERIAL HYPERTENSION Dental management - A good local anesthetic technique should be performed, avoiding intravascular injection and using a maximum of two anesthetic carpules with vasoconstrictor. If more anesthesia is needed, it should be provided without vasoconstrictor. Absorbable suture are to be avoided with adrenalin. - When the patient does not present good blood pressure control, it is best to refer him or her to the physician in order to ensure adequate control before dental treatment. - In the case of emergency dental visits, treatment should be conservative, with the use of analgesics and antibiotics. - Surgery is to be avoided until adequate blood pressure control has been secured.

ARTERIAL HYPERTENSION Dental management Certain nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, indomethacin or the naproxen, can interact with antihypertensive drugs (beta-blockers, diuretics), thereby lowering their antihypertensive action. Normally more than five days of treatment with both types of drugs are required for interactions to manifest; as a result, NSAIDs should not be prescribed for longer than this five-day period. - Avoid NSAID because of their renal effects which cause retention of sodium and water that lead to raise in the blood pressure.