The 2017 ACC/AHA guidelines (see Whelton PK, et al.) 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:
Adapted from Whelton PK, et al.
|2017 Hypertension Classification|
|Normal||<120 mmHg||and||<80 mmHg|
|Elevated||120-129 mmHg||and||<80 mmHg|
|Stage 1||130-139 mmHg||or||80-89 mmHg|
|Stage 2||≥140 mmHg||or||≥90 mmHg|
An hypertensive urgency is an hypertensive crisis situation without progressive target organ dysfunction, such as pulmonary edema, cardiac ischemia, neurologic deficits, or acute renal failure.
Systolic blood pressure >180 mmHg or diastolic blood pressure >110 -120 mmHg without associated organ damage.
- Signs and symptoms may include:
- severe headache
- shortness of breath
- nosebleed (epistaxis)
- mounting anxiety
- adjustment of medications
- medical evaluation
⚠️ Stop all dental treatment. Hypertensive urgencies may be associated with adverse acute events.
An hypertensive emergency is characterized by evidence of impending or progressive target organ dysfunction.
Systolic blood pressure usually >180 mmHg or diastolic blood pressure >120 mmHg, or at lower levels in persons without a history of high blood pressure, and is associated with organ damage.
- Comorbidities may include:
- Immediate care is required, especially if symptoms of organ damage may be present. These include:
- chest pain
- shortness of breath
- back pain
- change in vision
- difficulty speaking
⚠️ Stop all dental treatment. Hypertensive emergencies are associated with adverse acute events.
The longer a patient has been suffering from high blood pressure, the higher the risk of developing target organ diseases (see below).
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
- post-myocardial 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.
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.
- Heart – left ventricular hypertrophy, angina/prior MI, prior coronary vascularization, CHF.
- Brain – stroke / transient ischemic attack.
- Kidney – chronic kidney disease.
- Eye – retinopathy.
- Arteries – peripheral arterial disease (PAD).
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.
Signs and symptoms that may develop when BP is uncontrolled include:
- retinal hemorrhage
- occipital headache
- failing vision
- weakness and paresthesia of the extremities
- renal failure.
- Medical Disorders
- Oral Health Care Considerations
- Medical Emergencies
- Classifications and Definitions
- Brouwers S, et al. Arterial Hypertension. Lancet 2021; 398: 249–261.
- Casey DE, et al. 2019 AHA/ACC Clinical Performance and Quality Measures for Adults With High Blood Pressure. A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circ Cardiovasc Qual Outcomes. 2019;12:e000057.
- Go AS, et al. An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. Hypertension. 2014;63(4):878-85.
- Miller CS, et al. 2017 Hypertension guidelines. JADA. 2018;149(4):229-31.
- Ovbiagele B, et al. Level of systolic blood pressure within the normal range and risk of recurrent stroke. JAMA 2011;306(19):2137-2144.
- Unger T, et al. 2020 International Society of Hypertension global hypertension practice guidelines. J Hypertension. 2020; 75: 1334–1357.
- Whelton PK, et al. 2017 - ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary—a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):e13-e115.
- Williams B, et al. 2018 practice guidelines for the management of arterial hypertension of the European society of cardiology and the European society of hypertension ESC/ESH task force for the management of arterial hypertension. Eur Heart J 2018; 39: 3021–3104.