hypertension

Question 1

Define hypertension

Answer 1

Hypertension is an abnormal elevation in blood pressure, characterized by a systolic blood pressure equal to or greater than 140 mm Hg, and/or a diastolic blood pressure equal to or greater than 90 mm Hg.

Normal blood pressure of 120/80

prehypertension is 120-139 OR diastolic from 80-89

only a physician can make a diagnosis of hypertension and decide on its treatment

hypertension stage 1 (140-159, OR 90-99)
hypertension stage 2 160 or higher OR 100 or higher
hypertensive crisis (emergency care needed) higher than 180 OR higher than 110

Question 2

what is hypertensive organ damage?

Answer 2

Late signs and symptoms of hypertension are related to the involvement of the kidneys, brain, eyes, heart and arteries. This hypertensive target organ damage may result in renal failure, encephalopathy, CNS dysfunction, retinal vessel hemorrhage, congestive heart failure, and peripheral arterial changes.

Question 3

what is hypertensive urgency?

Answer 3

• BP is severely elevated (> 180/110), but there is no associated organ damage.
• Symptoms:
• Severe headache
• Shortness of breath
• Nosebleeds
• Severe anxiety
• Requires readjustment and/or additional dosing of oral medications, but most often does not necessitate hospitalization for rapid blood pressure reduction.

Question 4

what is hypertensive emergency?

Answer 4

• BP reaches levels that are damaging organs.
• Generally occur at blood pressure levels exceeding 180 systolic OR 120 diastolic, but can occur at even lower levels in patients whose blood pressure had not been previously high.
• Consequences may include:
• Stroke
o By damaging & narrowing the blood vessels in the brain, there is lack of oxygen delivered to the brain.
o Signs & symptoms of stroke:
• Severe headache
• Confusion, feeling unsteady, or losing co-ordination.
• Slurring words or having difficulty understanding what people are saying.
• Suddenly losing vision or blurred vision.
• Feeling numb or weak (or being paralysed) on 1 side of the body.
• Loss of consciousness
• Memory loss
• Heart attack
o Blood is not supplied to the cardiac muscle.
o Signs & symptoms of heart attack:
• Chest pain or discomfort (chest pressure, squeezing, fullness or pain, burning or heaviness).
• Discomfort in other areas of the upper body (neck, jaw, shoulder, arms, back).
• Shortness of breath.
• Sweating
• Nausea
• Light-headedness
• Damage to the eyes and kidneys
• Loss of kidney function
• Aortic dissection
• Angina (unstable chest pain)
• Pulmonary edema (fluid backup in the lungs)
• Eclampsia
• If blood pressure reading is systole > 180 or diastole > 110, and the patient is having any symptoms of possible organ damage, should not wait to see if the pressure comes down on its own. Seek emergency medical assistance immediately. Call 9-1-1.

Question 5

what is the etiology of hypertension?

Answer 5

About 90% of patients have no readily identifiable cause for their disease, which is referred to as primary (essential) hypertension. In the remaining 10% of patients, an underlying cause or condition may be indentified, this is secondary hypertension.

possible causes:

• sleep apnea
• drug-induced or drug-related
• chronic kidney disease
• primary aldosteronism
• renovascular disease
• chronic steroid therapy and Cushing syndrome
• Pheochromocytoma
• Coarction of the aorta
• Thyroid or parathyroid disease

Question 6

what are the clinical signs and symtpoms that may be associated with severe, uncontrolled hypertension? Early hypertension? Advanced hypertension?

Answer 6

, such as visual changes, dizziness, spontaneous nosebleeds, and headaches

early - elevated blood pressure readings, narrowing and sclerosis of retinal arterioles, headache, dizziness, tinnitus

advanced - rupture and hemorrhage of retinal arterioles, pailledema, left ventricular hypertrophy, proteinuria, congestive heart failure, angina pectoris, renal failure, dementia, encephalopathy

Question 7

why should someone who is overweight with hypertension be encouraged to lose weight?

Answer 7

• According to a study by Guagnano MT, et al, waist circumference is the most important anthropometric factor associated with the hypertensive risk.
o Males with W > 102cm (40 inches) are 3x more likely to have hypertension than males with W less than 37 inch (94cm) waist.

Females with greater than 88cm (34 inches) is 2x more likely to have hypertension than females with W less than 31 inches (80cm)

Question 8

Goal blood pressures for those taking hypertensive medications? diabetics? greater than 80 years of age?

Answer 8

• His goal should be less than 140/90, since he is taking medications and does not have diabetes.
• In diabetics, the target is less than 130/80.
• In persons greater than 80 years of age, the systolic target is 150 mmHg.

Question 9

Two drugs that together significantly reduce blood pressure than either alone?

Answer 9

Ramipril and Hydlochlorothiazide

Question 10

do dentists have a role in detecting hypertension?

Answer 10

The JNC 7 specifically encourages the active participation of all health care professionals in the detection of hypertension and decide on its treatment. The dentist, however, should detect abnormal blood pressure measurements, which then become the basis for referral to or consutlation with a physician

Question 11

Facts about hypertension

Answer 11

one fourth of the US oopulation has hypertension and it is increasing, attributed to aging of the population and to the epidemic increase in obesity.
Diagnosis and treatment of hypertension were based on diastolic but now on both, isolated systolic hypertension gradually increases with age such athat among patients older than 50 years of age, most prevalent form of hypertension

More than half of americans aged 65 and older have hypertension.

Question 12

what’s primary hypertension? secondary?

Answer 12

about 90% of patients have no readily identifiable causes for their disease, which is referred to as primary (essential) hypertension. In the remianing 10% of patients an underlying cause or condition may be identified; these patients have secondary hypertension.

Question 13

causes of secondary hypertension?

Answer 13

sleep apnea
drug-induced or drug-related
chronic kidney disease
primary aldosteronism
renovascular disease 
chronic steroid therapy and cushing syndrome
pheochromocytoma
coarctation of the aorta
thyroid or parathyroid disease

primary hypertension - older people it could be usually central arterial stiffness and loss of elasticity

Question 14

what is systolic pressure? diastolic?

Answer 14

pressure at the peak of ventricular contraction is systolic pressure.

Diastolic pressure represents the total resting resistance in the arterial system after passage of the pulsating force produced by contraction of the left ventricle.

Question 15

what is white coat hypertension?

Answer 15

About 15% to 20% of patients with untreated stage 1 hypertension have what is called white coat hypertension, which is defined as persistently elevated blood pressur eonly in the presence of a health care worker but not elsewhere.

Question 16

what are categories of drugs to reduce blood pressure?

Answer 16

thiazide diuretics - often first drugs of choice, given either alone or in combination with ACEIs, ARBs, BBs, CCBs depending on the degree of evleation of blood pressure (if lifestyle modifications are ineffective at lowering blood pressure adequately)
angiotensin-converting enzyme inhibitors (ACEIs)
angiotensin receptor blockers (ARBs)
Beta blockers (BBs)
Calcium channel bockers (CCBs)

Question 17

how to manage patients who are hypertensive

Answer 17

1. medical history
2. blood pressure for all new patients and at recall appointments (more frequent if necessary)
3. encourage to go to physician if you suspect they are non-compliant with physician treatments
4. upper level stage 2 blood pressure - leave cuff on arm during appointment and periodically check

Question 18

What’s the primary concern in dental managment of a patient with hypertension?

Answer 18

that during the course of treatment, a sudden, acute elevation in blood pressure might occur, potentially leading to a seriuos outcome such as stroke of MI. This might occure due to the release of endogenous catecholamines in response to stress and anxiety, from injection of exogenous catecholamines in the form of vasoconstrictors in the local anesthetic, or from absorption of a vasoconstrictor from the gingival retration cord. Other concerns include potential drug interactions between the patient’s antihypertensive medications and the drugs used in dental practice, and oral adverse effects that may be caused by antihypertensive medications.

Question 19

The american college of cardiology and the american heart association have jointly published practice guidelines for the perioperative evaluation of patient with cardiovascular disease for whom noncardiac surgery of various types is planned. Determination of risk includes evaluation of three factors which are?

Answer 19

1. the risk imposed by the patient’s cardiovascular disease (see minor, intermediate and major risk factors (pg. 45 textbook))
2. the risk imposed by the surgery or procedure (high, intermediate and low risk (low is nonsurgical dental procedures)) even head and neck surgery is only intermediate and extensive perio surgery is intermediate
3. the risk imposed by the functional reserve or capacity fo the patient.

In summary, patients with blood pressures less than 180/110 mm Hg can undergo any necessary dental treatment, both surgical and nonsurgical, with very little risk of an adverse outcome.

Question 20

At what blood pressure should elective dental care be deferred? what hsould happen after that?

Answer 20

Blood pressure at 180/110 mm Hg or greater (uncontrolled hypertension) a physician referral for evaluation and treatment within 1 week is indicated. Patients with uncontrolled blood pressure associated with symtpoms such as headache, shortness of breath, or chest pain should be referred to a physician for immediate evaluation.

Question 21

What should you do if a patient requires urgent dental care if they are an uncontrolled hypertensive patient?

Answer 21

The patient shoudl be managed in consultation with the physician, and measures such as intraoperative blood pressure monitoring, electrocardiogram monitoring, establishement of an IV line, and sedation may be used.

Question 22

What can you do to reduce stress?

Answer 22

• let them discuss their fears openly
• shorter mornign appointments
• anxiety can be reduced for many patients by oral premedication with a short-acting benzodiazepin such as triazolam, taken 1 hour before the start of the dental appointment.
• nitrous oxide plus oxygen for inhalaation sedation is an excellent intraoperative anxiolytic for use in patients with hypertension.
• because many of the antihypertensive agents tend to produce orthostatic hypotension as a side effet, rapdi changes in chair position during dental treamtnet hsould be avoided. after appointment is over slowly return to upright position.

Question 23

local anesthesia with hypertensive patients?

Answer 23

small doses such as those contained in one or two cartridges of lidocaine with 1:100,000 epinephrine cause minimal physiologic changes.
This is due to a preponderance of action among B2 receptors and a decrease in diastolic pressure; thus, mean arterial pressure is essentially unchange, with onlyh a minimal increase in heart rate.
- use of modest (one or two cartridges of 2% lidocain with 1:100,000 epi) caries little clinical risk in patients with hypertension, the benefits of its use far outweighing any potential problems.
- with uncontrolled you should talk to the physician if there is dental work that is urgent.
- levonordefrin should be avoided
- topical vasoconstrictors generally should not be used for local hemostasis in patients with hypertension. When doing crown and bridge, avoid epinephrine in the gingival retraction cord, instead use somethign else.

Question 24

what about the use of NSAIDs with hypertensive patients?

Answer 24

the efficacy of antihypertensive drugs may be decreased by the prolonged use of nonsteroidal antiinflammatory drugs - an interaction that should be considered if these drugs are used for analgesia, although the use of nonsteroidal antiinflammatory drugs for a few days is of little clinical importance.

Question 25

oral manifestations of hypertensive medication?

Answer 25

• those taking diuretics may report dry mouth
• lichenoid reactions have been reported with thiazides, methyldopa, propranolol, and labetalol.
• ACEIs may cause neutropenia, resulting in delayed healing or gingival bleeding.
• angioedma and a persistent cough may be caused by ACEIs
• calcium channel blockers can cause gingival overgrowth

Question 26

how do beta blockers work ?

Answer 26

Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline. When you take beta blockers, the heart beats more slowly and with less force, thereby reducing blood pressure. Beta blockers also help blood vessels open up to improve blood flow.

Question 27

NSAIDs

Answer 27

The reason why aspirin is distinguished from other NSAIDs (and not included in FDA’s warning) is that it is a selective COX-1 inhibitor; COX-1 plays a role in regulating angiogenesis in endothelial cells, being beneficial from a cardiovascular standpoint. The use of aspirin in the prevention of cardiovascular events is well established.

Various factors may contribute to this association between NSAIDs, heart attack and stroke. For example, all NSAIDs can potentially, and to varying degrees, affect vasoconstriction and sodium excretion, which can lead to hypertension, a risk factor for cerebrovascular events.

COX-2 is one of two similar enzymes that churn out short-lived fats called prostaglandins. The other, COX-1, works in platelets – cells in the blood that stick together in the first stages of clotting. COX-2 is active in the cells that line blood vessels. These enzymes have diverse, potent, and often contrasting effects in the body. For example, low-dose aspirin protects against heart attacks and strokes by blocking COX-1 from forming a prostaglandin called thromboxane A2 in platelets. On the other hand, COX-2 is the more important source of prostaglandins, particularly one called prostocyclin, which causes pain and inflammation.

COX-2 inhibitors are a subclass of nonsteroidal anti-inflammatory drugs (NSAIDs), among the most common drugs consumed on the planet. Older NSAIDs include drugs like Naprosyn, which inhibits mostly COX-1; Advil®, which inhibits COX-1 and COX-2; and Voltaren® and Mobic®, which mostly inhibit COX-2. The newer drugs were developed because targeting COX-2 reduced serious gastrointestinal side effects like bleeding ulcers. However, aggressive direct-to-consumer advertising meant that drugs like Vioxx and Celebrex were taken mostly by patients who had never had the GI problems with the older, cheaper NSAIDs.

Arguments against the proposed mechanism were threefold. First, it was proposed that COX-2 didn’t exist under normal circumstances in the blood-vessel lining and PGI-M came from some other source. The kidneys were suggested as the source by some researchers. Second, even if blood-vessel prostacyclin was blocked, other protective mechanisms, especially formation of nitric oxide (NO) would take over. And third, although NSAIDs elevate blood pressure, it was proposed that this observation was unrelated to COX-2 and treating high blood pressure would deal with the problem.

FitzGerald’s group has now “closed the loop” with its earlier clinical studies and answered these questions in a paper just published in Science Translational Medicine. In it, they confirm that COX-2 is expressed in cells lining blood vessels and that selectively removing it predisposes mice to blood clotting and high blood pressure. These mice, just like humans taking COX-2 inhibitors, also see a fall in PGI-M. What’s more, the Penn group discovered that COX-2 in lining cells controls the expression of eNOS, the enzyme that makes NO in the body. “So, rather than replacing the missing prostacyclin, as others have proposed, NO is lost and amplifies the effects of COX-2 inhibition on the cardiovascular system,” says FitzGerald.