hypertension

Hypertension(silent killer ).(د ضياء الحمداني )2013/11/4

Hypertension is persistent abnormal elevation in arterial pressure on repeated measurement (> 140 /90 mmHg) that can be fatal if sustained and untreated. . although there is transient elevation of blood pressure during exercise, anxiety this is a normal response and should not be regarded as hypertension.another transient elevation of blood pressure called white coat phenomena in which there is transient rise in blood pressure particularly when measured by a physician in the medical center,while it will be normal when measured at home this condition can be identify by using ambulatory blood pressure monitoring( automated devices used at home) during which monitoring blood pressure at home reveal reading close to the real level. and as many as 20% of patients with apparent hypertension in the clinic may have a normal BP when it is recorded at home. The risk of cardiovascular disease in these patients is less than that in patients with sustained hypertension but greater than that in normotensive subjects. lowering blood pressure of hypertensive patients to the level considered “normal” blood pressure can result in decreased adverse vascular events such as stroke and myocardial infarction (MI) The Seventh Report of the Joint National Committee (JNC 7) provide classification of hypertension.
Classification of Blood Pressure in Adults
Category
Systolic BP (mmHg)
Diastolic BP (mmHg)
BP
Optimal
< 120
< 80
Normal
< 130
85
prehypertensionl
130-139
85-89

Stage I

140-159
90-99
Stage II
>160
>100
Isolated systolic hypertension
Grade 1
140-159
< 90
Grade 2
≥ 160
< 90
hypertension is typically characterized by an elevation in both diastolic and systolic pressures while Isolated diastolic hypertension, defined as a systolic pressure <140 and a diastolic pressure ≥90, but Isolated systolic hypertension is defined as a systolic pressure ≥140 and a diastolic blood pressure <90 .The prevalence of high blood pressure increases with aging, such that more than half of all Americans aged 65 and older have hypertension. the diastolic blood pressure rises until around age 50 and then levels off or falls, but Isolated systolic hypertension gradually increases with age , it is the most prevalent form of hypertension among patients over the age of 50. In one study, isolated systolic hypertension was identified in 87% of inadequately controlled patients older than 60 years of age and constitutes an important risk factor for cardiovascular disease. While Isolated diastolic hypertension is most commonly seen before age 50 and consider as a more potent cardiovascular risk factor than is systolic blood pressure until age 50. According to National Health study data for the period 1999 to 2000, at least 65 million adults in the United States have high blood pressure (HBP) . The number of people with High BP who are aware of their condition about 5o% and the percentage of those receiving treatment for High BP is 59%. The percentage of patients taking medication whose blood pressure is controlled to <140/90 about 34% In other word 50% of patients with High BP remain unaware of their disease, 40% of patients with High BP are not being treated, and more than 60% of hypertensive patients are taking medications but are not being adequately controlled. . with increased awareness and treatment of hypertension significant decline in mortality from coronary heart disease (50%) and from stroke (57%), has been noticed.
How to measure blood pressure


Measure sitting BP routinely.
Remove tight clothing from the arm
Support the arm at the level of the heart
Use a cuff of appropriate size (the bladder must encompass > two-thirds of the arm) .
Palpate redial artery inflate the cuff 20 mmHg above the level at which the redial artery disappear.
Lower the pressure slowly (2 mmHg per second) .
Auscultate the brachial artery The first sound appear consider the systolic blood pressure while disappearance of sounds measure diastolic BP.
Take two measurements at each visit
Etiology:
About 90% of patients have no identifiable cause for their disease, which is referred to as primary, or idiopathic hypertension. For the remaining 10% of patients, an underlying cause or condition may be identified; for these patients, the term secondary hypertension is applied. The most common cause of secondary hypertension is renal parenchymal disease, followed by renovascular disease and various adrenal disorders.
Causes of secondary hypertension

Renal disease include:

Renal vascular disease (renal artery stenosis).
Parenchymal renal disease, particularly glomerulonephritis.
Polycystic kidney disease.

Endocrine disease

Phaeochromocytoma
Cushing's syndrome
Primary hyperaldosteronism (Conn's syndrome)
Glucocorticoid-suppressible hyperaldosteronism
Hyperparathyroidism
Acromegaly
Primary hypothyroidism
Thyrotoxicosis
Congenital adrenal hyperplasia.and other .


Coarctation of the aorta,.
Pregnancy (pre-eclampsia)
Alcohol .
Obesity.

Drugs
e.g. Oral contraceptives containing oestrogens, anabolic steroids, corticosteroids, NSAIDs, carbenoxolone, sympathomimetic agents

Complication of hypertension. Hypertension may adversely effect brain,retina,heart ,kidney and blood vessels. heart causing left ventricular hypertrophy,heart failure,angina and infarction through acceleration of atherosclerosis and arrhythmia (atrial fibrillation is a common arrhythmia in hypertensive patient). retina patient with long standing hypertension may show retinal changes that can be identify by ophthalmoscopic examination these changes include artriolar thickening,constriction of the vein, ischemia or hemorrhage of the retina even pallipoedema. Kidney involvement result in renal failure.CNS complication include transient ischemic attack stroke either due to intracerebral hemorrhage or cerebral infarction with various neurological deficit (hemiplgia,cranial nerves lesion hemi anesthesia. while vessels complication cause intermittent claudication.
Clinical features:
hypertension may remain an asymptomatic disease for many years, and discover incidentally(silent killer) ,while other may have a symptoms like headache, tinnitus, and dizziness. These symptoms are not specific for hypertension and may be seen as well in normotensive individuals.other may present with symptoms and signs due to complications of hypertension (congestive heart failure. Renal involvement can result in hematuria, proteinuria, and renal failure. Persons with hypertension may report fatigue and coldness in the legs that result from peripheral arterial patient with secondary hypertension, additional signs or symptoms may be present due to associated with underlying disease (Cushing syndrome ,acromeglay ,,etc)
investigation of all patients

Urinalysis for blood, protein and glucose

Blood urea, electrolytes and creatinine.
Blood glucose
Serum lipid profile.
12-lead ECG (left ventricular hypertrophy, coronary artery disease).
investigation of selected patients

Chest X-ray: to detect cardiomegaly, heart failure, coarctation of the aorta

Ambulatory BP recording: to assess borderline or 'white coat' hypertension
Echocardiogram: to detect or quantify left ventricular hypertrophy
Renal ultrasound: to detect possible renal disease
Renal angiography: to detect or confirm presence of renal artery stenosis
Urinary catecholamines: to detect possible phaeochromocytoma
Urinary cortisol and dexamethasone suppression test: to detect possible Cushing's syndrome
Plasma renin activity and aldosterone: to detect possible primary aldosteronism
Treatment


The treatment goal for most patients with hypertension is to reduce blood pressure to <140/90 mm Hg. However, for hypertensive patients with diabetes or kidney disease, the goal is <130/80 mm Hg. In clinical trials, antihypertensive therapy resulted in an average reduction in stroke incidence of 40%; MI, 25%; and heart failure, >50%. thats why that all people with hypertension—stages 1 and 2—should be treated.
Treatment include:
life style modification.
drug therapy:

Lifestyle Modifications include • Weight loss • using DASH (Dietary Approaches to Stop Hypertension) Diet • Fruits • Vegetables• Low-fat dairy products • Reduce cholesterol • Reduce sodium to <2.4 g/day• Regular aerobic physical activity on most days (30 minutes of brisk walking) • no alcohol.
Drug therapy (ABCD). Many drugs are currently available to treat hypertension .A for , Angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs) ACE inhibitor like captopril,enalipril, pindopril,ramipril,lisinopril..angiotensin converting enzyme receptor blocker like losaratn valsartan candasertan,telmisertan .B for Beta blockers (BBs) B blocker like atenolol,labetelol,metoprolol,bisoprolol while C for Calcium channel blockers (CCBs) calcium channel blocker like deltiazem, nefidipne, amoldipine, verapamil. ..and D for Diuretic Diuretic include thiazide,hydrocholothiazide,chlorothalidone aldactone.frusimide,. Other drugs that are less frequently used include alpha blockers, central alpha agonists and direct vasodilators hydralazine minoxidil. the choice of drug based on age, level of blood pressure,associated comorbidity..
For stage 1 hypertension, single- drug therapy may be effective; however, for stage 2 hypertension, two-drug combinations are recommended. Additional drugs may be added as needed. Most people require more than one drug to effectively lower their blood pressure. The presence of certain comorbid conditions such as heart failure, post MI, diabetes, or kidney disease may be a compelling reason to select specific drugs or classes of drugs that have been found beneficial in clinical trials.

DENTAL MANAGEMENT

The dental health professional can play a significant role in the detection and control of hypertension and may be the first one who detect a patient with an elevated blood pressure . The first task of the dentist is to identify patients with hypertension, both diagnosed and undiagnosed. Through a medical history and blood pressure measurement. including the diagnosis of hypertension, type of antihypertensive drugs, compliance of the patient, the presence of symptoms associated with complicated hypertension should be obtained. such as congestive heart failure, cerebrovascular disease, MI, renal disease, peripheral vascular disease. These problems should be identified as well because they may necessitate modification of the dental management plan. In addition to a medical history, all patients should undergo blood pressure measurement and Blood pressure measurements should be routinely performed for all new patients. for noncompliant or inadequately treated ,abnormally elevated blood pressure should also be encouraged to see his or her physician to evaluate his or her condition. In summary, patients with blood pressure less than 180/110 can undergo any necessary dental treatment, both surgical and nonsurgical, with very little risk of an adverse outcome. For patients found to have asymptomatic blood pressure ≥180/110 mm Hg (uncontrolled hypertension), elective dental care should be deferred and the patient referred to a physician as soon as possible for evaluation and treatment. In patients with uncontrolled or severe hypertension, the need for urgent dental treatment (pain, infection, or bleeding) may necessitate treatment. In this instance, the patient should be managed in consultation with the physician, and measures such as intraoperative blood pressure. Patients with elevated blood pressure with symptoms such as headache, shortness of breath, chest pain, nosebleeds, or severe anxiety (severe hypertension) may require more urgent medical attention. Once it has been determined that the hypertensive patient can be safely treated, a management plan should be developed For all patients, the dentist should make every effort to reduce as much as possible the stress and anxiety associated with dental treatment. Patients should be encouraged to express and discuss their fears, concerns, and questions about dental treatment.
• Stress/anxiety reduction achieved by: Short, morning appointments • use of premedication with sedative/anxiolytic • Consider intraoperative use of nitrous oxide/oxygen • Obtain excellent local anesthesia; use epinephrine in modest amounts • Cautious use of epinephrine in local anesthetic in patients taking non-selective b-beta blockers or Avoid the use of epinephrine-impregnated gingival retraction cord Consider periodic intraoperative BP monitoring for patients with upper level stage 2 hypertension; terminate appointment if BP rises above 179/109 • Slow position changes to prevent orthostatic hypotension . Stress management is important for patients with hypertension to lessen the chances of endogenous release of catecholamines during the appointment .Long or stressful appointments are best avoided. Short morning appointments seem best tolerated. If the patient becomes anxious or apprehensive during the appointment, the appointment may be terminated and rescheduled for another day. Anxiety can be reduced for many patients by oral premedication with a short-acting benzodiazepine such as triazolam . An effective approach is to prescribe a dose at bedtime the night before and another dose 1 hour before the dental appointment.