Dental professional update: Blood pressure guidelines changed

In November 2017, the American Heart Association (AHA) and American College of Cardiology (ACC) released a new clinical practice guideline on hypertension. In December 2017, the American Dental Association (ADA) reported the AHA and ACC updates. The guidelines, in a nutshell, state that normal blood pressure is under 120/80 mm Hg. Previously, normal was under 140/90 mm Hg. The categories of prehypertension, hypertension stage 1, and hypertension stage 2 have also changed.

In this article, I would like to provide a summary and highlight of the new guidelines, while discovering what the changes mean to the dental professional. But let’s start with the basics and review what hypertension is.

What hypertension is and what the numbers mean

High blood pressure is a common condition in which the long-term force of the blood against the artery walls is high.(1) Hypertension (high blood pressure) ­­affects 1 of 3 adults or about 75 million people in the United States.(2) This condition is related to the increase risk for heart disease and stroke, two of the leading causes of death in the United States.(3) High blood pressure is called the “silent killer” because it often has no warning signs or symptoms, and many people do not know they have it.

The blood pressure is measured with two numbers:(4)

• Systolic blood pressure (the upper number) — indicates how much pressure your blood is exerting against the artery walls when the heart beats.
• Diastolic blood pressure (the lower number) — indicates how much pressure your blood is exerting against the artery walls while the heart is resting between beats.
• A reading of 117/76 mm Hg is read as “117 over 76 millimeters of mercury.”

New categories of blood pressure in adults

The first table represents the categories from the new guideline, and the second table represents the categories from the older guideline.

As you can see, the threshold to become diagnosed with hypertension has been lowered. Here are the more significant takeaways:

• The category of prehypertension has disappeared. This is replaced by the category of elevated blood pressure. But also note that the numbers are different.
• Both the systolic and diastolic numbers have changed to a lower level.
• People with readings of 130 as systolic or 80 as diastolic now are considered to have high blood pressure. High blood pressure used to be defined as 140/90 mmHg
  
• A patient will be diagnosed to have hypertension stage 1 if the systolic (top number) blood pressure is above 130/80 mm Hg. Those numbers previously indicated prehypertension level.
• A patient will be diagnosed to have hypertension stage 2 if the blood pressure is over 140/90 mm Hg. Those numbers previously corresponded to the category of hypertension stage 1.

The guidelines also point out that individuals with systolic and diastolic blood pressure that fall into two different categories should be designated to the higher category.

To fully understand the new guidelines, please refer to the original documents (Click here to be redirected to the American Heart Association website where you can download the executive summary).

Let’s look at an example.

Q. The patient’s blood pressure reading on the right arm is at 129/79 mm Hg. According to the new guidelines, the patient’s blood pressure belongs to which of the following categories?

A. Normal

B. Elevated

C. Hypertension stage 1

D. Hypertension stage 2

E. Prehypertension

If we were to follow the older guidelines, blood pressure of 129/79 mm Hg falls in the range of prehypertension (systolic 120-139 mm Hg or diastolic 80-89 mm Hg). According to the newer guidelines, the same number is considered to be elevated blood pressure (systolic 120-129 mm Hg and diastolic under 80 mm Hg).

Answer: B. Elevated

New recommendations for taking blood pressure

On page 23 of the executive summary, you can find the Checklist for Accurate Measurement of BP (5) (click here to view the executive summary from the AHA website). I would like to present some items that may need more attention from dental professionals.

• At the first visit, record blood pressure in both arms. Use the arm that gives the higher reading for subsequent readings.
• Separate repeated measurements by 1-2 min.
• Provide patients the blood pressure readings both verbally and in writing.
• Allow patients to rest for five minutes prior to measuring their blood pressure.
• Average at least two readings over two visits (a determination of whether a person has hypertension should not be made from a single blood pressure measurement).
• If the reading is above 130/80 mm Hg on the first visit, patients should follow up with their primary health care provider.

Implications for patients, dental professionals, and students

The new guidelines do not provide any specific instructions for the dental professionals. However, the new changes can impact some aspects of the dental appointment.

• More patients are going to be diagnosed with hypertension (46 percent of U.S. adults are identified as having high blood pressure, compared with 32 percent under the previous definition.) (6)
• Consequently, the dental professional may see drugs that treat hypertension more frequently. It will become important to understand the side effects of the most common hypertension drugs. For example, calcium channel blockers such as amlodipine can cause gingival hyperplasia.
• Educate the patient about the new guidelines as they may not be aware of the new changes and refer them to a physician if necessary.
• The dental professional will play an even more important role in screening for hypertension as patients may visit the dental office more often than they visit the medical office. According to the 2014 study published by the ADA, screening for diabetes, high blood pressure and high cholesterol in the dental office could save the health care system up to $102.6 million each year. (7)

I hope that this article helped you understand the new blood pressure guidelines. It is important for us, dental professionals to be updated to provide the best care for the patient, as we are, health care providers. Please go to the link shared above to see the full guidelines and have a copy in your office. Our profession is only as strong as the educated professionals that tirelessly care for patients!

References:

1. Mayo Clinic Staff. Mayo Clinic, Mayo Foundation for Medical Education and Research. High Blood Pressure (Hypertension). https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/symptoms-causes/syc-20373410, Published September 09, 2016. Accessed December 13, 2017.
2. Merai R, Siegel C, Rakotz M, Basch P, Wright J, Wong B; DHSc., Thorpe P. CDC Grand Rounds: A Public Health Approach to Detect and Control Hypertension. MMWR Morb Mortal Wkly Rep. 2016 Nov 18;65(45):1261-1264
3. Yoon SS, Fryar CD, Carroll MD. Hypertension Prevalence and Control Among Adults: United States, 2011-2014. NCHS data brief, no 220. Hyattsville, MD: National Center for Health Statistics; 2015.
4. American Heart Association, Inc. Understanding Blood Pressure Readings. American Heart Association. http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/KnowYourNumbers/Understanding-Blood-Pressure-Readings_UCM_301764_Article.jsp#.Wi86hkqnHLY Updated: December 5, 2017. Accessed December 13, 2017
5. 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. 2017 High Blood Pressure Clinical Practice Guideline: Executive Summary. 2017, 70 (6): 23. doi: https://doi.org/10.1161/HYP.0000000000000066
6. Burger,D. New Guideline On Hypertension Lowers Threshold. American Dental Association. http://www.ada.org/en/publications/ada-news/2017-archive/november/new-guideline-on-hypertension-lowers-threshold Published December 2017. Accessed December 13, 2017
7. Burger,D. New Guideline On Hypertension Lowers Threshold. American Dental Association. http://www.ada.org/en/publications/ada-news/2017-archive/november/new-guideline-on-hypertension-lowers-threshold Published December 2017. Accessed December 13, 2017