CC
A 40-year-old African American male presents to the office with a referral for extraction of third molars because of periodontal disease. (Essential hypertension is most commonly diagnosed during the third to fifth decades of life, has a higher prevalence in African American males, and is more resistant to therapy in African Americans.)
HPI
The patient complains of a 2-week history of bilateral mandibular third molar looseness. Triage of the patient reveals that his blood pressure is elevated, which he attributes to anxiety. (Emerging evidence indicates that anxiety may be an independent risk factor for incident hypertension.) He states that he has never seen a primary care physician and denies any history of hypertension. He denies headache, dizziness, blurred vision, chest pain, lower extremity edema, and shortness of breath (signs of potential end-organ damage commonly seen inhypertensive emergency).
PMHX/PDHX/medications/allergies/SH/FH
The patient describes himself as “healthy as a horse” (hypertension is an asymptomatic disease) but physically out of shape because of a lack of exercise. He does not take any medications currently. He smokes one pack of cigarettes daily and has consumed four alcoholic beverages daily for the past 10 years. (Smoking, consumption of alcohol, and a sedentary lifestyle increase the risk of hypertension and coronary artery disease [CAD].) He is single, and his typical diet consists of fast foods (a diet high in sodium, saturated fat, and simple sugars). His family history is significant for the sudden death of his father at age 44 years from a heart attack. (A family history of myocardial infarction [MI] is significant when the paternal age is less than 45 years and the maternal age is less than 55 years.) His father also was known to had diabetes for the last 6 years. (Family history of diabetes and CAD are nonpreventable risk factors; but obesity, smoking, and excessive alcohol consumption are preventable risk factors for cardiovascular disease.)
Examination
General. The patient is awake, alert, and oriented; calm and cooperative; and follows commands well. He appears to be in no apparent distress. He weighs 240 lb and is 5 feet, 7 inches tall (a body mass index of 37.6 kg/m 2 , consistent with class II obesity).
Vital signs. His sitting blood pressure is 185/104 mm Hg in the right arm and 181/101 mm Hg in the left arm (although an inter-arm blood pressure difference of about 10 mm Hg may be normal, a greater difference may be consistent with aortic dissection or subclavian stenosis). His other vitals consist of a heart rate of 80 bpm, a respiratory rate of 16 breaths per minute, a temperature of 37.4°C measured on the forehead, and a visual analog scale score for pain of 0 out of 10 (In 1995, Dr. James Campbell urged the American Pain Society to treat pain as the “fifth vital sign” (P5VS)—pain may cause an acute increase in blood pressure.)
Maxillofacial. No facial edema, erythema, or induration is found. Neck examination is benign, with no evidence of masses or lymphadenopathy. The jugular venous distension is undetectable. (A jugular venous pressure >3 cm or a measured central venous pressure >8 is consistent with right ventricular failure. The most common cause of right ventricular failure is left ventricular failure.)
Intraoral. Examination is consistent with mobile lower third molars with an 8-mm periodontal probing depth.
Cardiovascular. No carotid, femoral, or renal bruits are present (these are indicative of peripheral vascular disease). The apical impulse is palpated at the fifth intercostal space and the midclavicular line (normal position). It is enlarged at 4 cm (normal is 2–3 cm), sustained, and strong in intensity (indicative of ventricular hypertrophy). On auscultation, in addition to S1 (first heart sound) and S2 (second heart sound), there is a S4 gallop (a pathologic heart sound during the late diastolic period produced by the atrium pushing on an inelastic myocardium) just before S1. (In comparison, an S3 sound may be auscultated in patients with congestive heart failure [CHF], secondary to uncontrolled hypertension. An S3 is heard shortly after an S2). The rhythm is regular (irregularly irregular rhythm can be due to atrial fibrillation caused by hypertension). There is no murmur or rub on auscultation. Peripheral pulses are bounding, with rapid upstroke and 2+ intensity, and synchronous with appropriate amplitude. (A delayed femoral pulse, compared with the radial pulse, is consistent with coarctation, a congenital cause of hypertension.)
Pulmonary. The chest is clear on auscultation bilaterally. There are no crackles or wheezing. (Cardiogenic wheeze is produced by pulmonary edema in acute CHF.)
Abdomen. The patient is obese and has no evidence of surgical scars or striae (present in hypercortisolism secondary to adrenal tumor, pituitary tumor, or paraneoplastic syndromes). Bowel sounds are present on auscultation. The abdomen is soft and nontender to palpation. The kidneys are nonpalpable. (Individuals with enlarged kidneys, as seen in polycystic kidney disease, may present with hypertension.) The liver is 10 cm at the midclavicular line (normal, 10–12 cm). The aorta is not palpable and is not enlarged. (If it were enlarged, this would be suggestive of an acute abdominal aneurysm.) No abdominal bruit was auscultated. (An upper abdominal bruit with a diastolic component that lateralizes to either side should raise suspicion for renal artery stenosis.)
Imaging
The panoramic radiograph is the study of choice when evaluating third molars. In the current patient, there is evidence of bone loss surrounding the roots of mandibular third molars. In the setting of controlled hypertension, no additional radiographs are required for minor surgical procedures. On evaluation of hypertensive urgency or emergency in the emergency department (ED), additional studies are required and may include a chest radiograph (to evaluate for cardiogenic pulmonary edema and cardiomegaly), electrocardiogram (ECG) (to rule out acute MI), and head computed tomography (to rule out intracerebral hemorrhage). Depending on the clinical history and findings, a preoperative ECG may be warranted for patients undergoing general anesthesia who have risk factors for cardiovascular disease (hypertension, diabetes, smoking, hypercholesterolemia, and age older than 45 years in males and older than 55 years in females).
Labs
Laboratory studies are obtained based on the patient’s medical history. For a patient with essential hypertension who presents for minor surgical procedures, no laboratory studies are indicated. Several laboratory parameters may be measured by the primary care physician or measured preoperatively to detect secondary causes of hypertension. A basic metabolic panel is obtained to assess plasma sodium (rennin-producing tumors, renal disease), potassium (renal or adrenal disease), and creatinine (renal disease). Thyroid-stimulating hormone is often ordered to rule out hypertension secondary to hyperthyroidism or other thyroid disorders. Routine workup of the newly diagnosed hypertension also includes an estimated glomerular filtration rate, a lipid panel, urinalysis (including urine albumin–to–creatinine ratio), and an ECG. Other tests to consider are urine vanillylmandelic acid (pheochromocytoma) and serum cortisol, which may find the potential causes of secondary hypertension. An astute clinician uses the patient’s history and physical examination to develop a differential diagnosis. Radiographic, laboratory, and other tests are used to assess the validity of specific diagnoses.
Assessment
Chronic severe localized periodontitis complicated by elevated blood pressure.
The diagnosis of hypertension requires additional blood pressure readings. If these readings are confirmed in subsequent evaluations, the patient is classified as having stage II hypertension. The correct diagnosis of blood pressure includes having two elevated reads in two visits 2 weeks apart. However, based on the 2021 Updated Evidence Report and Systematic Review for the US Preventive Services Task Force on Screening for Hypertension in Adults, the office-based blood pressure screening has major accuracy limitations, including misdiagnosis. Alternatively, patients use home blood pressure monitoring devices, which relies on their correct use of the device. Exercise, alcohol, caffeine, amphetamines, and other similar chemicals distort the true baseline blood pressure of the patient, and they should be instructed to avoid these before their measurements. A dental visit is often the first time a suspicion of hypertension is raised.==++
According to the eighth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-8), a normal systolic blood pressure is below 120 mm Hg, and a normal diastolic blood pressure is below 80 mm Hg. A patient with normal blood pressure meets both these criteria. The blood pressure may be considered normal, elevated, stage I, or stage II. Beyond stage II hypertension, the patient may experience hypertensive urgency or emergency. JNC 8 bundles hypertensive urgency and emergency under the term crisis , with end-organ damage being the differentiating factor ( Table 111.1 ). The effects on the end organs, such as the heart, brain, kidney, and eyes, are in a linear relationship.
| Blood Pressure | Systolic (mm Hg) | Diastolic (mm Hg) | Management |
|---|---|---|---|
| Normal | <120 | <80 | LSM, follow-up every year |
| Elevated | <140 | <90 | LSM, follow-up every 6 months |
| Stage I | <160 | <100 | LSM, medications, follow-up every month until titrated |
| Stage II | ≥160 | ≥100 | LSM, two medications, follow-up every month until titrated |
| Urgency | ≥180 | ≥110 | IV medications, refer to ED |
| Emergency | ≥180 + EOD | ≥110 + EOD | Gtt medications, ICU |
Treatment
Management of a patient with hypertension begins with an accurate diagnosis. Blood pressure is determined by cardiac output (stroke volume × heart rate) and total peripheral resistance. It is measured with the patient in a sitting position with the arm at the level of the heart. Patients should avoid smoking and caffeine 30 minutes and 1 hour, respectively, before a blood pressure reading is taken. Note that a large cuff produces an erroneously low reading, and a small cuff produces an erroneously high reading. The blood pressure can be measured in both arms. A difference greater than 10 mm Hg may be suggestive of aortic dissection. The most common site for measurement of blood pressure is the brachial artery. The cuff is applied to the arm. It is tightened as the radial pulse is palpated, and the pressure is raised until it is 30 mm Hg above where the radial pulse disappears. This technique ensures that an auscultatory gap (a period of silence as the blood pressure cuff pressure decreases) does not result in an erroneously low reading. As discussed earlier, measurements are repeated two or three times in different settings before the diagnosis of hypertension is made.
The confirmation of diagnosis should be followed by further evaluation to determine the duration of hypertension, the presence and extent of target-organ damage through physical and laboratory workup, and the 10-year atherosclerotic cardiovascular disease risk. Treatment options are recommended based on the stage of hypertension. In general, however, all the management strategies include lifestyle modification. Decreasing salt intake, Dietary Approaches to Stop Hypertension (DASH), increased intake of citrus fruits, decreasing alcohol intake to one standard drink per day for females and two for males, a minimum of 30 minutes of exercise per day, and weight loss to a target body mass index below 25 are the most important items in lifestyle modification. Several medications are available for the management of hypertension ( Table 111.2 ).
| Classes | Examples | Mechanism of Action | Indications | Contraindications | Side Effects |
|---|---|---|---|---|---|
| A CE inhibitors |
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Convert angiotensin I to angiotensin II in the lungs |
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| A RBs |
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Block the angiotensin II receptors in the heart, blood vessels, kidney, adrenal cortex, lungs, and brain |
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| A lpha-blockers |
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Selectively block α 1 receptors |
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| B eta-blockers |
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Either nonselective or selective; whereas nonselective beta-blockers display both β 1 and β 2 antagonism, most of the other commonly used beta-blockers are β 1 -selective, also known as cardioselective |
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| C CBs |
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The main class of CCB used for the treatment of hypertension is the dihydropyridines, which are used to reduce systemic vascular resistance and arterial pressure; nondihydropyridines are selective to the myocardium to varying degrees and may be used in the treatment of patients with angina |
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| D iuretics |
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Help reduce fluid buildup in the body |
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