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Concerns

Is your high blood pressure controlled or uncontrolled?

Hypertensive urgency

Hypertensive emergency

For how long have you had high blood pressure?

What medications are you taking?

Have you been diagnosed with any target organ disease?

Do you have any signs or symptoms of high blood pressure?

Is your high blood pressure controlled or uncontrolled?

The 2017 ACC/AHA guidelines recommend establishing blood pressure (BP) levels on the basis of the average of 2 to 3 readings on at least 2 different occasions, classifying BP into 4 categories:

BP Category Systolic BP

mm Hg

Diastolic BP

mm Hg

Normal <120 and <80
Elevated 120-129 and <80
Hypertension
Stage 1 130-139 or 80-89
Stage 2 >140 or >90
Hypertensive crisis >180 and/or >120

The new guidelines do not change our approach to the question “At what level of BP is treatment unsafe for the patient?” The 2017 ACC/AHA guidelines still state that uncontrolled BP is classified as a minor risk condition with respect to surgical procedures and outcomes; thus, most dentistry is considered safe up to these levels. However, practitioners should be aware that the ACC/AHA 2007 guidelines include a statement that BP should be brought under control before any surgery is performed, and because most dental procedures are elective, the general recommendation remains intact to defer care at BP of 180/120 mm Hg or higher. Also, it is unclear whether more intensive therapeutic interventions may result in a change in the frequency of drug interactions and adverse effects, including hypotensive episodes, during dental care.

Hypertensive crisis

Systolic blood pressure >180 mm Hg or diastolic blood pressure >100 mm Hg without associated organ damage. Signs and symptoms may include:

  • severe headache
  • shortness of breath
  • nosebleed (epistaxis)
  • mounting anxiety

Treatment

  • adjustment of medications
  • medical evaluation
Alert!

Hypertensive emergencies are associated with adverse acute events.

Hypertensive emergency

Systolic blood pressure usually >180 mm Hg or diastolic blood pressure>120 mm Hg, or at lower levels in persons without a history of high blood pressure, and is associated with organ damage. Comorbidities may include:

  • aortic dissection
  • kidney damage, with or without loss of kidney function
  • damage to the eyes
  • pulmonary edema
  • eclampsia

Treatment

  • Immediate care is required, especially if symptoms of organ damage may be present. These include: – chest pain – shortness of breath – back pain – numbness/weakness – change in vision – difficulty speaking
Alert!

Hypertensive emergencies are associated with adverse acute events.

For how long have you had high blood pressure?

The longer a patient has been suffering from high blood pressure, the higher the risk of developing target organ diseases (see below).

What medications are you taking?

Blood pressure medications can be divided into several different classes. Recommendations from JNC 8 suggest initiating treatment with the following classes of medications – ACEI (angiotensin-converting enzyme inhibitor), ARB (angiotensin receptor blocker),  CCB (calcium channel blockers) or thiazide-type diuretics. The use of a β-blocker was not recommended for initial therapy. There are 3 treatment strategies for antihypertensive drug therapy: A. Start one drug, titrate to maximum dose, and then add a second drug. B. Start one drug and then add a second drug before achieving maximum dose of the initial drug. C. Begin with 2 drugs at the same time. A thiazide diuretic is the preferred medication in the absence of compelling complications, such as heart failure, ischemic heart disease, chronic kidney disease, and recurrent stroke, or those conditions commonly associated with hypertension, including diabetes and high coronary disease risk. Different pharmacological regimens may suggest different comorbidities:

  • heart failure: Diuretic, beta-blocker, ACE inhibitor, ARB, aldosterone antagonist
  • postmyocardial infarction: beta-blocker, ACE inhibitor, aldosterone antagonist
  • high coronary disease risk: diuretic, beta-blocker, ACE inhibitor, CCB
  • diabetes: diuretic, beta-blocker, ACE inhibitor, ARB, CCB
  • chronic kidney disease: ACE inhibitor, ARB
  • recurrent stroke prevention: diuretic, ACE inhibitor

Side effects of these medications may include sublingual edema, oral dryness and gingival overgrowth . Be aware that chronic use of non-steroidal anti-inflammatory drugs may increase the risk of cardiovascular events in elderly patients with hypertension.

Have you been diagnosed with any target organ disease?

Over time,continued high blood pressure will cause damage to certain organs in the body. These are the “target organs” which may develop target organ disease or damage.

A systolic blood pressure >150 mm Hg may predispose a patient with a recent (within 120 days) non-cardio-embolic ischemic stroke to a recurrent stroke.

Do you have any signs or symptoms of high blood pressure?

Signs and symptoms that may develop when BP is uncontrolled include:

  • retinal hemorrhage
  • papilledema
  • hematuria
  • proteinuria
  • occipital headache
  • failing vision
  • tinnitus
  • dizziness
  • weakness and paresthesia of the extremities
  • CHF
  • angina
  • renal failure.

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