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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. HYPERTENSION : Types • 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.

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  6. Causes Genetics- family history Age Weight- obesity Diet- too much sodium intake Diabetes Stress Smoke/Alcohol Lack of exercise Effects Why?

  7. 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

  8. 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

  9. 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

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

  11. 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

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

  13. 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

  14. What does high BP does to your body? • 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

  15. 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

  16. 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

  17. 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

  18. 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

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

  20. Treatment : Non Pharmacological • Maintain a healthy body weight- lose weight if needed, • 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

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

  22. Threshold for Initiation of Treatment and Target Values

  23. 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

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

  25. 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

  26. 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 • Common health issues can disrupt not only overall dietary health, but also dental health • Care in use of vasoconstrictors • Orthostatic hypotention (common to all antihypertensive drugs)

  27. 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)

  28. Dental treatment and hypertension

  29. 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)

  30. 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%

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

  32. 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

  33. 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

  34. 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

  35. Management Elevated BP without target organ damage Hypertensive urgency Oral meds Goal - gradual reduction of BP over 24 - 48 hours Elevated BP with target organ damage Hypertensive emergency Parenteral meds Goal - Reduce diastolic BP by 10-15% or to 110 mm Hg over a period of 30 - 60 minutes

  36. Acute Post Operative Hypertension Frequent in post-operative state (20-75%) Hyper-responsiveness to surgical trauma Increased stress hormones? Activation of RAA? Also hypothermia, hypoxia, carbon dioxide retention, bladder distention Prevention Safe to give antihypertensives pre-op Hold diuretics Treatment - BP thresholds vary Control pain and anxiety While NPO use nicardipine, esmolol or labetolol Resume oral medications when possible

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