CAREER POST GRADUATE INSTITUTE OF DENTAL SCIENCES AND HOSPITAL

DEPARTMENT OF ORAL MEDICINE & RADIOLOGY

Seminar Topic:" HYPERTENSION"" HYPERTENSION"

Under the guidance of :Dr. Nitin Agarwal (H.O.D)Dr. Nitin Agarwal (H.O.D)Dr. Payal TripathiDr. Payal TripathiDr. Arti SachdevDr. Arti SachdevDr. Vasu SiddharthaDr. Vasu SiddharthaDr. Sudheer ShuklaDr. Sudheer Shukla

Presented by :

Aanshika Aanshika TiwariTiwari

JR-11

Hypertension is the abnormal

elevation of systolic blood

pressure above 140 mmHg or

elevation of diastolic blood

pressure above 90 mm Hg

VIII JNC, 2014

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Hypertension

Systolic BloodPressure (SBP)

Diastolic BloodPressure (DBP)

> 140 mmHg > 90 mmHg

Types of hypertensionTypes of hypertension

• Essential hypertension– 90%

– No underlying cause

• Secondary hypertension– Underlying cause

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Causes of Secondary Hypertension• Renal

– Parenchymal– Vascular– Others

• Endocrine• Miscellaneous• Unknown

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Classification

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Blood Pressure Classification

Normal <120 and <80

Prehypertension 120–139 or 80–89

Stage 1 Hypertension

140–159 or 90–99

Stage 2 Hypertension

>160 or >100

BP Classification

SBP mmHg

DBP mmHg

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INCIDENCE IN INDIA

• 25% of urban population and 10 % of rural population suffer from hypertension

• 70% of all hypertensive patients are stage I hypertension

• 12% of all hypertensive suffer from isolated systolic hypertension

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WHO ARE AT RISK ?

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Hypertension: Predisposing factors

• Advancing Age • Sex (men and postmenopausal women)• Family history of cardiovascular disease• Sedentary life style & psycho-social stress• Smoking ,High cholesterol diet, Low fruit

consumption• Obesity & wt. gain• Co-existing disorders such as diabetes, and

hyperlipidaemia• High intake of alcohol

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Etiology of Primary Hypertension

It is multifactorial High salt intake Heavy alcohol use Obesity Sedentary lifestyle Genetic factors

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Aetiology of Systemic Aetiology of Systemic HypertensionHypertension

A. Renal Renovascular stenosisPolycystic kidney diseaseglomerulonephritis

B. Endocrine • Primary aldosteronism• Cushing’s syndrome• Pheochromocytoma

Acromegaly

• Hypothyroidism &• Hyperparathyroidism

Exogenous hormone • Oral contraceptive • Glucocorticoids

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Others– Coarctation of the aorta– Pregnancy Induced HTN (Pre-eclampsia)– Sleep Apnea Syndrome.

Aetiology of Aetiology of Systemic Systemic HypertensionHypertension

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Clinical manifestations Clinical manifestations

SYMPTOMS DUE TO HYPERTENSION- Headache Dizziness-in morning hours. SYMPTOMS DUE TO TARGET ORGAN

DAMAGE-• 1)CVS-• Dyspnea• Palpitation• Chest pain

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2) KIDNEY-Polyuria,Hematuria,Nocturia

3) CNS- Stroke,Hypertensive encephalopathy, Dizziness

4) Retina- blurred vision

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WHITE COAT HYPERTENSION a syndrome whereby a

patient's feeling of anxiety in a medical environment results in an abnormally high reading when their blood pressure is measured.

20% of mild hypertensive individual may present with whitecoat hypertension

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Why to treat ?

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Diseases Attributable to Diseases Attributable to HypertensionHypertension

HYPERTENSION

Gangrene of the Lower Extremities

Heart Failure

Left Ventricular Hypertrophy Myocardial

InfarctionCoronary Heart

DiseaseAortic

Aneurym

Blindness

Chronic Kidney Failure

Stroke Preeclampsia/Eclampsia

Cerebral Hemorrhage

Hypertensive encephalopathy

Adapted from Dustan HP et al. Arch Intern Med. 1996; 156: 1926-193519

Target Organ Damage Heart

• Left ventricular hypertrophy• Angina or myocardial infarction• Heart failure

Brain• Stroke or transient ischemic attack

Chronic kidney disease Peripheral arterial disease Retinopathy20

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DIAGNOSIS

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Basic investigation in all patient

Physical examination Laboratory investigation- Urine analysis Routine blood chemistries Serum lipid profile Serum sodium and potassium

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Investigation in specific group

Electrocardiography Echocardiography TSH Chest X-ray Serum calcium and phosphate Renal usg

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How to treat ?

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Treatment OverviewTreatment Overview

Goals of therapyLifestyle modificationPharmacologic treatmentFollow up and monitoring

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Goals of Therapy

Reduce Cardiac and renal morbidity and mortality.

Treat BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease.

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Non pharmacological Non pharmacological Treatment of hypertensionTreatment of hypertension

Avoid harmful habits ,smoking ,alcohal

Reduce salt and high fat diets

Loose weight , if obese

Regular exercise

DASHdiet

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Life style modificationsLife style modifications

• Lose weight, if overweight

• Increase physical activity

• Reduce salt intake

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• Stop smoking• Limit alcohol

intake

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Limit intake of foods rich in fats and cholesterol

increase consumption of fruits and vegetables

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Lifestyle ModificationModification Approximate SBP reduction

(range)

Weight reduction 5–20 mmHg / 10 kg weight loss

Adopt DASH eating plan

8–14 mmHg

Dietary sodium reduction

2–8 mmHg

Physical activity 4–9 mmHg

Moderation of alcohol consumption

2–4 mmHg

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DRUG THERAPY

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DiureticsExample: Hydrochlorothiazide• Act by decreasing blood volume and cardiac

output.• Drugs of choice in elderly hypertensivesSide effects-• Hypokalaemia• Hyponatraemia• Hyperlipidaemia• Hyperuricaemia (hence contraindicated in gout)• Hyperglycaemia (hence not safe in diabetes)• Not safe in renal and hepatic insufficiency

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Beta blockers

Example: Atenolol, Metoprolol, nebivolol, • Block 1 receptors on the heart• Block 2 receptors on kidney and inhibit release of

renin• Decrease rate and force of contraction and thus

reduce cardiac output• Drugs of choice in patients with co-existent

coronary heart diseaseSide effects-

• lethargy, impotency, bradycardia

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Calcium channel blockersCalcium channel blockers

Example: Amlodipine• Block entry of calcium through calcium

channels• Cause vasodilation and reduce peripheral

resistance• Drugs of choice in elderly hypertensives and

those with co-existing asthma• Neutral effect on glucose and lipid levels

Side effects Flushing, headache, Pedal edema

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ACE inhibitorsExample: Ramipril, Lisinopril, Enalapril• Inhibit ACE and formation of angiotensin

II and block its effects• Drugs of choice in co-existent diabetes

mellitus, Heart failure

Side effects-dry cough, hypotension, angioedema

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Angiotensin II receptor blockers

Example: Losartan• Block the angiotensin II receptor

and inhibit effects of angiotensin II• Drugs of choice in patients with co-

existing diabetes mellitus

Side effects-safer than ACEI, hypotension,

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Alpha blockers

Example: prazosin

• Block -1 receptors and cause vasodilation

• Reduce peripheral resistance and venous return

Side effects-

Postural hypotension,

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POSTURAL HYPERTENSIONsupine-to-standing BP decrease >20 mmHg systolic or >10 mmHg diastolic.

Management:i. Assessment of consciousnessii. Position patient in supine with feet slightly elevatediii. Assess ABCiv. Initiate definitive care

• Administration of O2• Monitor vital signs

v. Subsequent management after consciousness/medical consultation on delayed recovery

vi. Discharge 40

Choice of antihypertensive drugs in various coexisting conditionscondition drugs

Diabetes mellitus ACE inhibitorARBs

Coronary artery disease Beta blocker,ACE inhibitor

Heart failure ACE inhibitordiuertics

pregnancy Methyldopa

asthma Calcium channel blocker

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ORAL MANIFESTATION

There are no regonized manifestation of HT but antihypertensive drugs can often cause side effects-

Xerostomia Gingival hyperplasia Paresthesia Taste perception alteration

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HYPERTENSIVE CRISISHYPERTENSIVE EMERGENCIES- High BP associated with target organ damage. Requires treatment in ICU with constant monitoring of BPHYPERTENSIVE URGENCIES- High BP but no organ damage. Treatment : -Sodium nitroprusside -Nifedipine -Nitroglycerin -Hydralazine -Labetolol

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Causes of Resistant Hypertension

Improper BP measurement Excess sodium intake Inadequate diuretic therapy Medication

• Inadequate doses• Drug actions and interactions (e.g., (NSAIDs), illicit drugs, sympathomimetics, OCP)• Over-the-counter drugs and some herbal supplements

Excess alcohol intake Identifiable causes of HTN

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HYPERTENSION MANAGEMENT IN DENTISTRY

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GUIDELINES FOR BLOOD PRESSURE (ADULT)

BLOOD PRESSURE (in mm Hg)

ASA CLASSIFICATION

DENTAL THERAPY CONSIDERATION

<140 & <90 I

1) Routine dental management.2) Recheck in 6 months.

140-159 & 90-94 II

1) Recheck BP prior to dental treatment for three consecutive appointments; if all exceed these guidelines , medical consultation is indicated.

2) Routine dental management.3) Stress reduction protocol as

indicated.46

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BLOOD PRESSURE ( in mm Hg)

ASA CLASSIFICATION

DENTAL THERAPY CONSIDERATION

160-199 &/or 95-114 III

1)Recheck blood pressure in 5 minutes.2)If still elevated ,medical consultation before dental therapy.3)Routine dental therapy.4)Stress reduction protocol.

>200 &/or >115 IV

1)Recheck blood pressure in 5 minutes.2)Immediate medical consultation if still elevated.3)No dental therapy, routine or emergency , until elevated BP corrected.4)Emergency dental therapy with drugs5)Refer to hospital if immediate dental therapy indicated.

PRE OPERATIVE MEDICATION & MANAGEMENT

Patient BP should be monitored & controlled within normal.

To antihypertensive patient morning dose of medication prior to surgery must be given.

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INTRA AND POST OPERATIVE MANAGEMANT

1) Blood pressure should be monitored continuously.2)Patient cardiac status also monitored. 3) Antihypertensive must be continued. 4) If the procedure is performed under local anesthesia , the local anesthetic without adrenaline is to be used.

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CONCLUSION• Hypertension is a major cause of morbidity and mortality, and

needs to be treated

• It is an extremely common condition; however it is still under-diagnosed and undertreated

• Hypertension is easy to diagnose and easy to treat

• Aim of the management is to save the target organ from the deleterious effect

• Besides pharmacology we have other choices and one has to be acquainted with that choice

• Life style modification should always be encouraged in all Hypertensive patients

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THANK YOU!

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