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Hypertension The Silent Killer

Hypertension The Silent Killer. HYPERTENSION. Is ... “the level of blood pressure at which the benefits of action (i.e. Therapeutic intervention) exceed those of Inaction.”. HYPERTENSION. Is a medical term for elevated blood pressure Definition: SBP>or =140 mm Hg DBP > or =90 mm Hg

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Hypertension The Silent Killer

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  1. Hypertension The Silent Killer

  2. HYPERTENSION • Is ... “the level of blood pressure at which the benefits of action (i.e. Therapeutic intervention) exceed those of Inaction.”

  3. HYPERTENSION • Is a medical term for elevated blood pressure • Definition: SBP>or =140 mm Hg DBP > or =90 mm Hg • Can also occur in children and adults but more common among people >50 years old • Prevalence. 20% - 30 % • In 90- 95%, the cause is unknown • Most of the time patient is asymptomatic • Remains the significant cause of morbidity and mortality in the world. • Heart Attacks (Myocardial Infarction) - 3.4% • Stroke – 11.5% • Kidney Damage – 53%

  4. Epidemiology • Who- over 972 millions adults (1 in 3 adults) • What- high blood pressure • Where- all over the world • When- typically over the age of 50 • Why- family history, being overweight, having high sodium intake

  5. HYPERTENSION : Types • Most common cardiovascular disease in the World • Primary (Essential)- No pre-existing cause • Unknown etiology • 80-90% of all cases • Treatment mainly symptomatic • Secondary- Known etiology a. Kidney Disease b. Thyroid Disease c. Adrenal Disease • Treat to eliminate cause of the disease • Office or White Coat Hypertension – increased in BP associated with the stress of physician office visits. - may affect as 50% of hypertensive patients.

  6. .

  7. Causes Genetics- family history Weight- obesity Diet- too much sodium intake Diabetes Stress Smoke/Alcohol Effects Why?

  8. Controllable Obesity Eating too much salt Alcohol Lack of exercise Stress Uncontrollable Race Heredity Age FACTORS CONTRIBUTING TO HIGH BLOOD PRESSURE

  9. Resistant Hypertension • Blood pressure that cannot be reduced below 140/90 mmHg ( below 160 mmHg for ISH) in patients who are complying with adequate triple drug regimens in appropriate dosage. • 50%-75% of people being treated for hypertension, target BP is not achieved

  10. Causes of Resistant Hypertension • Improper blood pressure measurement • Volume overload and pseudotolerance • Excessive sodium intake • Volume retention secondary to kidney disease • Inadequate diuretic therapy • Drug-induced • Non-compliance • Inadequate doses • Inappropriate drug combinations • Obesity • Ethanol • Tobacco

  11. Assessing Cause and Incidence of Resistant Blood Pressure • Inaccurate BP Measurement • White Coat Hypertension • Disease Progression • Suboptimal Treatment • Non-Compliance with prescribed therapy • Antagonizing Substances • Coexisting Conditions • Secondary Hypertension

  12. Causes of Isolated Systolic Hypertension • Aging (increased aortic rigidity) • Increased cardiac output– Thyrotoxicosis –Anemia – Aortic insufficiency

  13. Patient Evaluation • Medical History, • Physical Examination, • Routine Laboratory Tests, • Other diagnostic procedures. • Assess presence of acute or rapidly progressive target organ damage • Reveal identifiable causes of hypertension • Assess the patient’s lifestyle and identify other cardiovascular risk factors

  14. HYPERTENSION PRESENTATION • Usually asymptomatic • It doesn’t refer to being tense, nervous or hyperactive • The only way to find out is to have it checked • A single reading showing high BP doesn’t mean you're hypertensive, but it is a sign that you need to watch carefully

  15. Symptoms & Signs • Often people , are unaware • Mild Headache • Blurring of Vision • Dizziness/ Sweating • Palpitation • Chest pain • Difficulty of Breathing

  16. Measurement of Blood Pressure

  17. Physical Examination • Mercury sphygmomanometer – gold standard device • Brachial artery • Korotkoff technique • Korotkoff Phase l (clear sounds) - record systolic blood pressure • Korotkoff Phase V (sound disappear) - record diastolic pressure • Korotkoff Phase IV (muffling) - record diastolic pressure (children) • Cuff size - small overestimate Bp • - Bladder approx. 80% of the circumference of the arm • Seated Bp reading after 5 min of rest • Caffeine – 30-60 mins • Smoking – 15 – 30 mins • Exogenous stimulants – phenylephdrine, nasal decongestants eye drops – secondary hypertension

  18. What does high BP does to your body? • It increases the heart’s workload, causing it to enlarge and weaken over time • It must pump harder and the arteries carry blood moving under greater pressure • The elasticity or stretchiness in the arteries decreases • As the heart struggles to pump harder the muscle wall can grow larger • A constantly elevated BP hastens the formation of plaque or fatty deposits within the blood vessel which causes atherosclerosis

  19. Hypertension • Therefore there is risk of stroke, congestive heart failure, kidney failure and heart attack • Those with uncontrolled BP are: • 1. 3x more likely to developed coronary artery disease • 2. 6x more likely to developed CHF • 3. 7x more likely to developed stroke

  20. Hypertension Affects Target Organs Hypertension Renovascular disease Renal failure Angina pectoris Unstable angina Myocardial infarction Sudden death Heart failure TIA Ischemic stroke Hemorrhagic stroke Claudication Aneurysm Critical limb ischemia

  21. Increased Death from MI and CHF Clinical Impact of Hypertension Hypertension The 2nd leading cause of new cases of end stage renal disease 2-4 fold increase in strokes Contributes to visual loss in people with diabetes

  22. Congestive heart failure Cerebral hemorrhage Renal failure Retinopathy Dissecting aneurysm Hypertensive crisis Coronary artery disease Angina pectoris Myocardial infarction 2° renovascular hypertension Peripheral vascular insufficiency Cerebral thrombosis - stroke Clinical disorders resulting fromhypertension and atherosclerosis Hypertension Atherosclerosis

  23. Risk factors for cardiovascular complications in hypertensive subjects Obesity Salt intake Previous cardiovascular disease Family history of cardiovascular disease Age Sex Race Hyperlipoproteinemia Diabetes mellitus Cigarette smoking

  24. DIAGNOSTIC WORK-UP OF HYPERTENSION • Assess risk factors and co-morbidities • Reveal identifiable causes of hypertension (Sleep apnea, Drug-induced related, Chronic kidney disease, Primay aldosteronism, Thyroid diseases, Cushing.s syndome) • Assess presence of target organ damage • Conduct History and Physical Examination • Obtain Lab test • Complete Blood Count (CBC) • Urinalysis • Chest X-Ray • Lipid Profile (Total Cholesterol/ Triglycerides/LDL/HDL) • Other Blood Chemistry (ALT/AST/BUN/Creatinine/Uric Acid) Obtain ECG and other workups

  25. TREATMENT OF HYPERTENSIONGoals of Therapy • Reduction of cardiovascular and renal morbidity and mortality. • Treating SBP and DBP to targets that are <140/90 mmHg is associated with a decrease in CVD complications • Hypertension and Diabetes or Renal disease, the BP goal is <130/80 • To decrease: • Cerebrovascular Accidents 35-40% • Coronary events20-25% • Heart failure50% • Progression of renal disease • Progression to severe hypertension • All cause mortality

  26. Factors to Consider in Treating Hypertension • Repeat readings • R/O : Secondary causes • Estimate CV risk status • Co-morbid conditions • Lifestyle changes • Drugs

  27. TREATMENT OF HYPERTENSION Non-pharmacological Pharmacotherapy • Restriction of salt intake • Reduction of body weight •  cardiac output (ß-blockers, Ca2+ channel blockers) •  plasma volume (diuretics) •  peripheral vascular resistance (vasodilators) MAP = CO X TPR

  28. Treatment : Non Pharmacological • Maintain a healthy body weight- lose weight if needed, obesity causes the heart to work harder • Eat a well balanced diet including fresh fruits and vegetables and low fat dairy product. Avoid eating high fat high cholesterol foods which promote atherosclerosis. Reduce sodium in your diet because it leads to water retention and increase heart workload. • Exercise regularly • Stop smoking

  29. Lifestyle Modification Recommendations

  30. Pharmacologic Therapy Consider: • Severity of BP • End organ damage, including LVH • Presence of other conditions or risk factors: DM, CHD, smoking, LDL • 50% of patients controlled with one drug; another 30% with two; • The vast majority of patients with diabetes require two or more drugs

  31. "Individualized Care" • Risk factors considered • Non-pharmacological therapy tried first • Monotherapy is instituted • Considerations for choice of initial monotherapy: • Renin status • Coexisting cardiovascular conditions • Other conditions

  32. Treatment : Pharmacological • Medication is often necessary to control BP • It is imperative to follow your physician’s instruction in taking your medications • Take your medicine daily as prescribed and never stop it unless instructed

  33. Threshold for Initiation of Treatment and Target Values

  34. Diuretics Thiazide Loop diuretics Aldosterone antagonists K-sparing Adrenergic inhibitors Peripheral agents Central (α-agonists) alpha -blockers* beta-blockers Alpha+beta-blockers Direct Vasodilators* Calcium channel blockers Dihydropyridine Non dihydropyridine ACE-inhibitors Angiotensin-II blockers Drugs for Hypertension * Usually not monotherapy

  35. JNC VII: Management of Hypertension by Blood Pressure Classification

  36. COMPELLING INDICATIONS FOR INDIVIDUAL DRUG CLASSES Key: THIAZ=thiazide diuretic, ACEI=angiotensin converting enzyme inhibitor, ARB=angiotensin receptor blocker, BB=beta blocker, CCB=calcium channel blocker, ALDO ANT= aldosterone antagonist

  37. Dental treatment and hypertension

  38. Hypertension in Dentistry • Patients have to be treated with care • Risks of heart failure/ heart attack • Patients must be monitored continuously • Many patients with hypertension also have metabolic syndrome, which is likely to develop periodontal disease due to an increase in build up of calculus around the gums • Common health issues can disrupt not only overall dietary health, but also dental health

  39. Hypertension in Dentistry • The risk of providing dental treatment to patients with hypertension is low • LA containing epinephrine can be used with little risk in dental patients with hypertension • For patients taking a nonselective beta blocker, use epinephrine cautiously (max. of 2 carpules of 1:100,000 epi) • Gingival hyperplasia is common in patients taking a calcium channel blocker • Elective dental treatment should be deferred in patients with a blood pressure ≥180/110 (uncontrolled blood pressure)

  40. Implications for Dentistry • Care in use of vasoconstrictors (e.g. supersensitivity to catecholamines with guanethidine) • Orthostatic hypotention (common to all antihypertensive drugs) • Judicious use of CNS depressants (esp. with centrally-acting antihypertensive drugs) • Salivary inhibition (xerostomia common with centrally-acting antihypertensive drugs) • NSAIDs (decrease action of captopril, spironolactone, furosemide) • Gingival hyperplasia (with long-term use of Ca2+channel blockers)

  41. Summary Points • Hypertension is defined as a sustained blood pressure ≥140/90 • Any level of hypertension is associated with an increased risk of cardiovascular disease • Hypertension remains an asymptomatic disease for long periods of time • Many patients with hypertension are unaware of their disease • Many patients with hypertension are noncompliant with medication and thus are not well controlled • Elevated blood pressure cannot be cured, it can only be controlled • and its effects can be prevented or reduced- if it is treated and controlled early.

  42. Hypertensive Crisis • Hypertensive Urgency - Increased in diastolic blood pressure >120 – 130 mmHg - No End-Organ Damage - Lowers down BP within 24 hours • Hypertensive Emergency - Systolic Bp exceeding 210 mmHg and diastolic BP > 130 mmHg - With End-Organ Damage (e.g.: Acute M.I., ICH, Unstable Angina and Hypertensive Encephalopathy) - Requires immediate BP reduction within an hour (IV medications)

  43. What is the primary reason for hypertensive emergencies • Renovascular Disease • Pheochromocytoma • Non-adherence to anti-hypertensive medication • Hyperaldosteronism • Erythropoeitin

  44. Clinical Presentation • Variable • Mean Systolic BP 210 + 32 • Mean Diastolic BP 130 + 15 • Frequency of signs and symptoms • Chest Pain 27% • Dyspnea 22% • Neuro defect 21% • Interestingly…. • Headache was only 3% and epistaxis was 0%

  45. Threshold BP There is no specific BP where hypertensive emergencies occur But, organ dysfunction is rare with diastolic BPs < 130 mm Hg Rate of increase may be more important Hence, encephalopathy will occur at lower BPs in pregnancy and in children

  46. Hypertensive Emergency CNS - encephalopathy, intracranial hemorrhage, Grade 3-4 retinopathy Heart - CHF, MI, angina Kidneys - acute kidney injury, microscopic hematuria Vasculature -aortic dissection, eclampsia

  47. Initial Evaluation • Focused history • History of hypertension? • How well is hypertension controlled? • What antihypertensives? • Adherence to antihypertensive regimen? • Last dose of antihypertensive? • Social History • Recreational Drugs • Amphetamines • Cocaine • Phencyclidine

  48. Initial Evaluation • Confirm BP in both arms • Use appropriate sized BP cuff • Cuff that is too small • BP cuffs that are too small falsely elevate BP measurements in obese patients • Assess for end-organ damage • Vascular Disease • Assess pulses in all extremities • Auscultate over renal arteries for bruits • Cardiopulmonary • Listen for rales (CHF) • Murmurs or gallops

  49. Initial Evaluation • Neurologic Exam • Hypertensive Encephalopathy - mental status changes, nausea, vomiting, seizures • Lateralizing signs uncommon and suggest cerebrovascular accident • Retinal Exam • Lost art • Keith-Wagener-Barker Classification • ECG • LVH, look for signs of ischemia, injury, infarct • Renal Function Tests (urine included) • Elevated BUN, Creatinine, proteinuria, hematuria • CBC • CXR - pulmonary edema, aortic arch, cardiac enlargement

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