Hypertension final
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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
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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
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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
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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
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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
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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.
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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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