Hypertension for newbies

1. HYPERTENSION
• HYPERTENSION is defined as having
• Systolic blood pressure more than 140 mmHg
• Diastolic blood pressure more than 90 mmHg
• Or as having to use antihypertensive
medication.

2. CLASSIFICATION OF BLOOD PRESSURE
Systolic blood
pressure
Diastolic blood
pressure
Normal < 120 <90
Prehypertension 120-139 80-89
Stage 1.
Hypertension
140-159 90-99
Stage 2.
Hypertension
>160 >100

3. Major Cardiovascular Risk Factors
• Hypertension
• Age (>55 ♂; > 65 ♀)
• Diabetes mellitus
• Elevated LDL (or total) cholesterol or low HDL cholesterol
• Estimated GFR < 60 mL/min
• Family history of premature CVD (men<age 55 or women
aged <65)
• Microalbuminuria
• Obesity (BMI >30; weight in kilograms ÷height in meters
squared)
• Physical inactivity
• Tobacco usage, particularly cigarettes

4. Causes of Hypertension
• 95%: cause undetermined (essential
hypertension)
• 5%: identifiable and potentially correctable
causes of hypertension
• Chronic kidney disease
• Coarctation of the aorta
• Adrenal disorders
• Drugs like long use of steroid and cyclosporins
• Thyroid or parathyroid disease
• Sleep apnea

5. Target Organ Damage
• Heart
• Left ventricular hypertrophy
• Angina/prior MI
• Prior coronary revascularization
• Heart failure
• Brain
• Stroke or TIA
• Dementia
• Chronic kidney disease
• Peripheral arterial disease
• Retinopathy

6. Lifestyle Modifications
• Weight loss if overweight
• Adopt DASH eating plan; fruits,vegetables,
low fat dairy, reduced cholesterol
• Sodium intake(<2.4 g/day)
• Regular aerobic physical activity
• Limit alcohol intake (< 1-2 drinks/day)
• Stop smoking

7. DRUGS IN HYPERTENSION
• Diuretics
• Thiazides (Diuril,hydrochlorthiazide, HCTZ)
• Loop Diuretics (Lasix)
• K-Sparing Diuretics(Midamor, Dyrenium)
• Beta blocker
• acebutol
• atenolol
• metoprolol
• labetalol
• nadolol
• pindolol
• propanolol
• Sotalol timolol

8. • ACE inhibitors
• Captopril
• Enalapril
• Moexipril
• Perindopril
• Quinipril
• Ramipril
• Angiotensin Receptor Blockers
• Losartan
• Olmesartan
• Valsartan

9. • Calcium channel blockers
• Diltiazem
• Nicardipine
• Nifedipine
• Alpha 1 blocker
• Prazosin
• Alpha 2 agonist centrally acting
• clonidine

10. CLINICAL CONSIDERATION
• Good patient rapport
• Minimize waiting time
• Short, morning appointments
• Ensure physical comfort
• If anxious or fearful:
• Oral sedation ( night before and/or 1 hourbefore appt)
with pre, intra, & post-op vital signs and use of pulse
oximeter
• sedation intra-operatively
• “Painless” injection technique (use topical, slow
administration, ensure adequate anesthesia)
• Post-op pain control

11. SEDATIVES (ORAL)
• Barbiturates
• Phenobarbitone (long acting )
• Butobarbitone (short acting )
• Thiopentone ( ultra short )
• Benzodiazepines
• Hypnotics
• Diazepam
• Flurazepam
• Alprazolam

12. • Antianxiety
• Diazepam
• Alprazolam
• Chlorazepam
• Lorazepam
• Anticonvulsants
• Diazepam
• Lorazepam
• Clonazepam
• clobazam

13. • Non benzodiazepine hypnotics
• Zopiclone
• Zolpidem
• zaleplon

14. LOCAL ANAESTHESIA
Effect of local anaesthesia on cardio vascular system.
MINIMAL TO MODERATE OVER DOSE 1.8 – 5.0µg/ml of lidocane in blood level
SIGNS SYMPTOMS
Talkativeness , apprehension, excitability Lightheadedness, restlessness
Slurred speech, generalised stutter
leading to muscular twitching and tremor.
Nervousness, dizziness
Euphoria, dysarthria, nystagmus, Sensation of twitching before actual
twitching is observed.
Sweating, vomiting Metallic taste
Failure to follow commands Visual disturbance
Elevated blood pressure Auditory disturbance
Elevated heart rate Drowsiness and disorientation
Elevated respiratory rate Loss of consciousness

15. • LA blood levels and their actions
• 1.8-5 ml
• Antidysrhythemic actions
• 5-10 ml
• Peripheral vasodilation
• 10 ml
• Intensive myocardial depression.

16. • Moderate to high dose levels:
• Tonic clonic seizure activity followed by:
• Genralised central nervous system depression
• Depressed blood pressure, heart rate and
respiratory rate.

17. • In hypertension
• Local anaesthetics with epinephrine concentration of
1: 200,000 or 1: 100,000
• Without epinephrine may be used for short
procedures.
• Or mepivicane 3%
• Prilocane 4%
• La is administered slowly.
• Under no circumstances should the rate of drug
deposition be less than 60 seconds for 1.8ml cartridge.

18. • Vasoconstrictors increase the duration of
anaesthesia and reduce systemic toxicity by
delaying their absorption.
• It is always advisable to consult the patient’s
cardiologist before commencing treatment.
• Cardiac patients will require shorter
appointments.

19. Hypertension is not diagnosed on single
elevated BP recording.
Classification is usually based on average value
of two or more BP readings at two or more
appointments.
The higher value of either the systolic or
diastolic pressure determines the patient’s
classification.

20. • Dental office plays a vital role in detection of
hypertension.
• In early hypertension the patient may be
asymptomatic.
• The first visit includes BP readings spaced at
least 10 mins apart.
• Before patient is sent to physician reading
should be >180mmHg systolic or 100mmHg
for diastolic.

21. • Record BP at each visit of the patient.
• Any procedure should not be performed until
accurate BP measurements and histories have
not been taken.
• Time of day should also be recorded since BP
varies significantly throughout the day.
• Dental treatment for hypertensive patient is
safe as long as stress is minimised.

22. • Many physicians are unaware of dental
procedures, therefore a dentist must explain
• Current medical status
• Medications
• Surgical treatment plan
• Patient management
• Estimated degree of stress
• Length of procedures
• Other complexity

23. • BP generally increases around awakening and
peaks at midmorning.
• Lower BP levels occur in the afternoon.
• Therefore afternoon BP appointments must
be preferred.

24. • No routine periodontal treatment should be
given who is hypertensive and not under
medications.
• Surgical field should be limited as excessive
bleeding occurs in hypertensive patients.
• It is important to minimise pain by providing
profound anaesthesia to avoid an increase in
endogenous epinephrine secretion.

25. • The benefit of small dose of epinephrine used in
dentistry over weights potential for
hemodynamic compromise.
• The smallest possible dose of epinephrine should
be used.
• Intra ligamentary injections are contraindicated
as hemodynamic changes are similar to
intravenous.
• Conscious sedation can also be used in severe
anxiety
• DRUGS : fentanyl, morphine, meperidine

26. epinephrine
Á-1 adrenergic
receptors, producing
vasoconstriction
Β-2 receptors, causing
vasodilation of skeletal
muscle arterioles.
stimulates

27. Epinephrine should be used cautiously !!
ß- blocker
ß- 1
cardiac
receptor
(selective)
ß- 2
peripheral
receptor
(non
selective)
Stimulates heart
blocks

28. FUNCTIONS OF EPINEPHRINE
• Adrenaline increases oxygen consumption and
carbon dioxide removal.
• Increases glycogenesis in liver and muscles.
• Increases blood coagulation time.
• Increases RBC count in blood by contracting
smooth muscles and releases RBCs from spleen.
• Increases heart rate.
• Excitability of cardiac muscles.

29. • Noradrenaline causes constriction of blood
vessels ( so it is called GENERAL
VASOCONSTRICTOR ) and increases total
peripheral resistance.
• Adrenaline also causes constriction of blood
vessels but dilatation of blood vessels in
skeletal muscles through Beta 2 receptor, so
total peripheral resistance is decreased by
adrenaline.

30. • Adrenaline increases systolic blood pressure.
• Noradrenaline increases diastolic pressure.
• Former has action on heart muscles and later
has action on skeletal muscles.
• Diastolic pressure is decreased by reducing
total peripheral resistance.

31. • Adrenaline increases rate n force of
respiration.
• Increases sweating.
• Causes fatigue of skeletal muscles.
CNS
• adrenaline secretion increases during FLIGHT
FIGHT AND FRIGHT conditions.

32. • When the patient is taking non selective B-
blocker (propanolol and nadolol ) may cause
ELEVATED BLOOD PRESSURE.
• Reflex bradycardia by vagus nerve and
baroreceptors will result
• Leading to vascular perfussion and death.

33. • Some side effects of antihypertensive
medications are….
• POSTURAL HYPOTENSION
• Which can be minimised by slow postural
changes and frequent movements in dental
chair.
• Others- depression, nausea, vomiting,
frequent micturation, xerostomia, gingival
over growth and sedation.

34. Emergency treatment for hypertensive
patients in dental office.
• Management of severe local anaesthetic
overdose with slow or rapid onset.
• 1. position patient supine with legs elevated
slightly.
• 2. assess and perform BLS as needed.
• 3. administer O2 and moniter vital signs.
• 4. perform venipuncture and anticonvulsant
(diazepam, midazolam )
• 5. consult physician.

35. NITROGLYCERIN
• Decreases coronary artery resistance
• Increases coronary blood flow
• Vascular dilation
• Decreases cardiac output
• Dose- 0.3- 0.6 mg
• In dental office the use of spray is preferred over
tablets due to instability of tablets.
• 1 or 2 metered sprays are recommended
sublingually with no more than 3 dose within 15
mins.