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Dental Management of Patients with Hypertension and

Cardiac Complications from Hypertensive Heart Diseases

Authors: Juhee Kim, Angela DeBartolo, DDS, and Analia Veitz-Keenan, DDS

Introduction Complications of hypertensive heart diseases frequently seen
Hypertension is a major risk factor of cardiovascular disease and in dental clinic
is currently ranked as the leading contributor to global disabili-
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ty-adjusted life-years. According to the recent National Center for Atrial fibrillation
Health Statistics (NCHS) data brief, the prevalence of hyperten-
sion in adults aged 18 and over in the United States was 45.4%, Being the most frequently encountered arrhythmia, atrial fibrilla-
and increased with age. The prevalence of hypertension was lower tion (AF) is a multifactorial disease in which the heart beats irreg-
in 18 to 29-year-old adults at 22.4%, which increased to 54.5% ularly due to abnormal conduction. The irregular heartbeat starts
in 40-59 years of age and to 74.5% in adults at 60 years old or from the upper chambers of the heart and, if such a condition is
older. Along with its high prevalence, hypertension is also a ma- left untreated, will lead to heart failure, decreased quality of life,
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jor source of financial burden both worldwide and in the United and even death. Along with its high morbidity and mortality rate,
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States. It accounts for about 10% of global healthcare expenditures the recurrence rate of AF is also high being about 40 to 50%.
and about 15.1% of total hospital costs in the United States. 3,4 The symptoms of AF include but not limited to palpitations, short-
ness of breath, chest pain, fatigue, and malaise. However, since
In addition to its high prevalence and financial burden, hyperten- AF is often asymptomatic, it is imperative that clinicians review
sion often leads to serious consequences and causes cardiac com- patient’s medical history and underlying conditions, particularly
plications such as atrial fibrillation, coronary artery disease, valvu- hypertension, thoroughly. Treatment of AF often involves heart
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lar disease, ischemic heart disease, arrhythmia, and others. Thus, rate and rhythm control through regimens such as antiarrhythmic
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it is imperative to understand the current burden of hypertension medications and electrical devices (i.e pacemaker), and anticoag-
and hypertension-related cardiac and other systemic complications ulation medications.
to manage hypertensive patients with appropriate strategies.
Coronary artery disease
Despite its high prevalence, about 37.3% of patients in the United
States still have undiagnosed hypertension. As dental practitioners Coronary artery disease (CAD) is the most common cause of
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often see patients on a regular basis, it would be beneficial if they death worldwide and is the most common type of heart disease
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would operate as the frontline to monitor patients’ blood pressure in the United States. CAD occurs when the coronary artery gets
(Table 1), assess their need for medical consultation, and ultimate- narrowed or blocked by buildup of plaque, which is made of cho-
ly help prevent potential systemic complications of hypertension. lesterol deposits in the walls of the coronary arteries. The partial
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Furthermore, it is incumbent on all oral healthcare providers to be obstruction of the coronary arteries will reduce the blood supply
aware of appropriate management strategies. In managing patients
with hypertension and hypertension-related cardiac complications, to the heart and ultimately lead to ischemic heart disease, which
understanding the potential side effects and interactions of antihy- would be further discussed in the next section. Although the symp-
pertensive, anticoagulant, and antiplatelet agents, and the potential toms of CAD involve chest pain, fatigue, malaise, dizziness, and
risk of using local anesthesia with epinephrine are all of grave nausea, it is usually asymptomatic and unnoticed by patients un-
importance. Thus, dental practitioners can aid in not only prevent- til they have a heart attack. Thus, it is critical to review patients’
ing systemic complications of hypertension, but also provide the risk factors for CAD regularly such as hypertension. Treatment of
most appropriate treatment to patients with hypertension and hy- CAD often includes anti-cholesterol, antihypertensive, anticoagu-
pertension-related cardiac complications, and ultimately promote lant, and antiplatelet medications.
patient-centered care.
Procedural treatment methods include balloon angioplasty and
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Therefore, the purpose of this paper is to: 1) provide a review of stenting, and coronary bypass graft (CABG) surgery.
the four complications from hypertensive heart disease frequently
seen in dental clinics - atrial fibrillation, coronary artery disease, Ischemic heart disease
ischemic heart disease, and valvular disease, 2) inform the reader
of the appropriate dental management of patients with hyperten- As aforementioned, CAD leads to ischemic heart disease and the two
sion and such complications, and 3) ultimately ensure that patients terms are interchangeable. Ischemic heart disease is a condition in
with such conditions receive proper attention and management. which blood and oxygen supply is limited or blocked due to plaque
buildup or narrowing of blood vessels. If the blood and oxygen sup-
Blood Pressure Systolic Diastolic ply to the heart is completely blocked, necrosis of heart muscle cells
takes place and leads to myocardial infarction, which is also known
Category pressure pressure as a heart attack. The treatment regimens and procedural methods
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(mmHg) (mmHg)
Normal 120 and 80 for ischemic heart disease are similar to those of CAD.
Elevated 120-129 and 80 Valvular heart disease
Stage 1 130-139 or 80-89 Valvular heart disease is a condition in which a valve in the heart
Hypertension does not function properly due to either congenital or acquired
cause. With malfunctioning heart valves, the heart is not able to
Stage 2 140 or 90 regulate the blood flow properly. Valvular heart disease is often
Hypertension asymptomatic until it progresses to an advanced stage, and its
Table 1. Updated Blood Pressure Categories by the American College of symptoms usually include shortness of breath, chest pain, fatigue,
Cardiology/American Heart Association (ACC/AHA) in 2017. 7,8 malaise, fever, arrhythmia, and dizziness. According to the CDC,
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