Hypertension, or high blood pressure, is a major risk factor for stroke and heart attacks. It is usually asymptomatic and requires regular screening. The document defines hypertension as a blood pressure reading over 140/90 mmHg. It classifies hypertension into stages and discusses essential (primary) hypertension, which makes up 95% of cases, versus secondary hypertension, which has an identifiable underlying cause such as kidney, heart, endocrine or neurological diseases. The document explores causes of essential hypertension like salt overload, activation of the renin-angiotensin-aldosterone system, and sympathetic nervous system activation. It also examines various secondary causes of hypertension.

1. HYPERTENSION
Dr Lamya Abd Alkarem
MRCP(UK) Member Of Royal
Colleges Of Physicians
London, Glasgow & Edinburgh

2. Introduction
● Hypertension is a major risk factor for stroke and MI.
● It is usually asymptomatic
● Regular screening (eg 3-yrly) is a vital primary care task.
● It causes ~50% of all vascular deaths (8≈106/yr).
● Most preventable deaths are in areas without universal screening

3. Why ?
● Hypertension is a common disease encountered in
dental setting.
● Its wide spreading, terrible consequences, and life-
long treatment require an attentive approach by
dentists.
● Hypertension management in dental office includes
disease recognition and correct measurement,
knowledge of its treatment and oral adverse effects,
and risk assessment for dental treatment.
● Dentist role in screening undiagnosed and
undertreated hypertension is very important since
this may lead to improved monitoring and treatment.

4. Definition
● Blood pressure has a skewed normal distribution
within the population, and risk is continuously
related to blood pressure, so it is impossible to
define ‘hypertension’.
● Therefore, the practical definition of hypertension is
'the level of blood pressure at which the benefits of
treatment outweigh the costs and hazards'.
● Assess BP over a period of time (don’t rely on a
single reading).
● The ‘observation’ period depends on the BP and the
presence of other risk factors or end-organ damage.

5. Definition
● Blood pressure is necessary to perfuse the organs
of the body with blood, so is vital to the sustainment
of life.
● The normal blood pressure (BP) is 120 mmHg
systolic and 80 mmHg diastolic.
● Hypertension describes the state of chronically
raised blood pressure
● commonly defined as a BP in excess of 140/90
mmHg;
● about 20% of the population are, by this measure,
hypertensive.

6. Whom to treat
● All with BP ≥160/100mmHg (sustained(
● For those ≥140/90, the decision depends on the risk of coronary
events, presence of diabetes or end-organ damage.
● The recent HYVET study(The Hypertension in the Very Elderly Trial )
showed that there is even substantial benefit in treating the over-80s

7. ● The category of prehypertension, which is defined
as SBP of 120 to 139mmHg and DBP of 80 to
89mmHg .
● Patients with prehypertension are at increased
risk of developing hypertension, those with blood
pressure values 130–139/80–89mmHg have a
two times greater risk of developing hypertension
than those with lower values
● Hypertension is a highly prevalent cardiovascular
disease, which affects over 1 billion people
worldwide

8. ● Although more than 70% of hypertensive patients are aware of the disease,
❖ only 23–49% are treated,
❖ and fewer (20%) achieving control .
● Hypertension prevalence varies by age, race,
education
● Overall the prevalence of hypertension appears to
be around 30–45% of the general population, with a
steep increase with ageing
● A permanent high blood pressure (BP) affects
blood vessels in the kidneys, heart, and brain

9. ● increasing the incidence of renal and cardiac coronary heart disease and
stroke.
● Hypertension was called the “silent killer” because it often affects target
organs (kidney, heart, brain, eyes) before the appearance of clinical
symptoms

10. Classification Of Hypertension
Classification SBP
(mmHg)
DBP (mmHg)
Normal <120 < 80
Prehypertension 120- 139 80- 89
Stage I hypertension 140- 159 90- 99
Stage II hypertension ≥160 ≥100
Isolated systolic hypertension ≥140 <90

11. Classification
1- Isolated systolic hypertension (ISH)
● The most common form of hypertension in
the UK—affects >50% of the over-60s,
● Results from stiffening of the large arteries
(arteriosclerosis).
● It is not benign: doubles risk of MI, triples risk
of CVA.
● Treatment reduces this excess risk and is as, if
not more, effective than treating moderate
hypertension in middle-aged patients.

12. Classification
2- Malignant’ or accelerated phase hypertension:
● Refers to a rapid rise in BP leading to vascular
damage (pathological hallmark is fibrinoid
necrosis).
● Usually there is severe hypertension (eg systolic
>200, diastolic>130mmHg) + bilateral retinal
haemorrhages and exudates;
● papilloedema may or may not be present.
● Symptoms are common, eg headache ―

13. Classification
3- Essential hypertension (primary, cause unknown).
● ~95% of cases.
4- Secondary hypertension ~5% of cases.

14. Essential hypertension
● Three important causes of primary hypertension are :
1. salt/volume overload
2. activation of the reninangiotensin aldosterone system (RAAS)
3. Activation of the sympathetic nervous system

15. 1- Salt/volume overload
● Salt (sodium chloride) overload/volume overload is
one of the common causes of hypertension.
● Essential hypertension has been associated with
high sodium intake in a variety of scientific models,
clinical studies and trials
● it is certified that decreasing the sodium intake
ameliorates this effect [40, 41].
● High sodium intake
❖ increases blood pressure by expanding
intravascular volume
❖ may have direct neurohormonal effects on the
cardiovascular system

16. 2- The “Renin Angiotensin Aldosterone System”
(RAAS)
● (RAAS) hormonal axis also contributes to
hypertension in many patients
● Renin, a hormone synthesized and released by
the kidney in response to intravascular volume
depletion and hyperkalemia,
● It promotes the conversion of angiotensinogen
(produced by the liver) to angiotensin I
● Angiotensin I converted to angiotensin II by the
angiotensin-converting enzyme (ACE) in the lung

17. the RAAS system
● One mechanism of increasing blood pressure by angiotensin II is
❖ increasing renal sodium reabsorption,
❖ producing vasoconstriction
❖ and activating the sympathetic nervous system

18. the RAAS system
● Another mechanism is Angiotensin II also
increases the production and secretion of
aldosterone from the adrenal cortex, and
● Aldosterone increases renal sodium
reabsorption
● Thus, the RAAS system increases blood
pressure through increasing renal sodium
reabsorption (which leads to intravascular
volume expansion) and vasoconstriction.

20. Essential (Primary) hypertension
3- Activation of the sympathetic nervous system (SNS)
● It contributes to the development, maintenance, and progression of
hypertension

21. Secondary Hypertension
● Hypertension with an organic cause, well established the following:
i. Renal
ii. Cardiac
iii. Endocrine
iv. Neurological
v. Others

22. Secondary Hypertension
(i) renal: (parenchyma or renal vascular)
❖ chronic pyelonephritis
❖ acute and chronic glomerulonephritis
❖ polycystic kidney disease,
❖ renal vascular stenosis or renal infarction,
❖ other severe kidney disease (arteriolar nephrosclerosis), renin-secreting
tumors

23. Renal causes
❖ Renal artery stenosis
● is a narrowing of one or more of the renal arteries
● leads to reduced blood flow to the affected kidney
and hypertension.
● A renal bruit may be heard over the affected kidney.
❖ Polycystic kidney disease
● is a group of genetic diseases characterized by
bilateral cystic enlargement of the kidneys.
● It presents with hypertension, chronic renal failure or
abdominal masses.

24. Renal causes
❖ Chronic renal failure
● Chronic renal failure, particularly
glomerulonephritis,
● is characterized by hypertension, due to impaired
glomerular filtration.

25. ii-Cardiac causes
❖ Coarctation of the aorta
● is a congenital narrowing in the aorta, most
commonly just distal to the origin of the left
subclavian artery.
● Blood pressure is raised proximal to the
narrowing, but may be normal or low distal to the
narrowing.
● Associated features include
● weak femoral pulses, radiofemoral delay and a
systolic murmur heard loudest over the site of the
coarctation.

26. Aortic valve incompetence Coarctation of the Aorta

27. Cardiac
❖ Aortic incompetence
● Clinical features such as an early diastolic murmur heard best in the
aortic area
● wide pulse pressure
● heart failure, may be seen.

28. Secondary Hypertension
(iii) endocrine:
● oral contraceptives
● adrenal hyperfunction
❖ Cushing’s syndrome,
❖ primary aldosteronism,
❖ congenital or hereditary adrenogenital syndrome
● pheochromocytoma, myxedema, acromegaly, thyroid and parathyroid
hyper function

29. Endocrine causes
❖ Cushing’s syndrome
● Cushing’s syndrome results from the overproduction of
glucocorticoids (mainly cortisol) by the adrenal cortex
● stimulated either by a pituitary adenoma, an adrenal
adenoma, or ectopic ACTH (adrenocorticotrophic
hormone) secretion from a tumour.
● Excess glucocorticoids may produce
❖ hypertension,
❖ centripetal fat distribution,
❖ moon facies,
❖ hirsutism, acne and proximal muscle wasting.

30. Endocrine causes
❖ Conn’s syndrome
● Conn’s syndrome results from the overproduction of
mineralocorticoids (mainly aldosterone) by the adrenal cortex,
● normally caused by an adrenal adenoma.
● Excess aldosterone leads to sodium and water retention via its effect
on the kidney, which causes hypertension

31. Endocrine causes
❖ Phaeochromocytoma
● Phaeochromocytoma is a neoplasm of the adrenal medulla,
● which leads to the overproduction of catecholamines.
● Patients often experience paroxysmal palpitations and anxiety.

32. Endocrine causes
● Congenital adrenal hyperplasia (CAH)
● It is a group of autosomal recessive disorders characterized by impaired
cortisol synthesis.
● It results from the deficiency of one of the five enzymes required for the
synthesis of cortisol in the adrenal cortex leading to hypertension via
excess formation of the mineralocorticoid 11-deoxycorticosterone.

35. Secondary Hypertension
(iv) neurological:
● psychogenic “diencephalic syndrome,”
● polyneuritis
● (acute porphyria, lead poisoning),
● increased intracranial pressure;

36. Secondary Hypertension
(v) others:
● Increased intravascular volume (transfusion excessive polycythemia vera)
● Polyarteritis
● Hypercalcemia
● Drugs (corticosteroids, cyclosporine)
● Sleep apnea
● Pregnancy toxemia,
● Acute intermittent porphyria.