Patient-specific Risk Factors for MACE

Uncontrolled systemic hypertension

The presence of certain cardiovascular conditions or diseases are risk factors for the occurrence of MACE in association with a noncardiac surgical procedure and are categorized as major, intermediate, and minor. Uncontrolled systemic HTN (BP ≥180/110mmHg) is a minor risk factor for MACE in association with noncardiac surgical procedures.19 Other minor risk factors for MACE in association with a noncardiac surgical procedure are: advanced age (>70 years), abnormal ECG (LV hypertrophy, left bundle branch block, ST-T abnormalities), and rhythm other than sinus.

In general, the patient with HTN of < 180/110 will tolerate the delivery of any routine dental care. However, HTN is a risk factor for stroke and an awareness of the patient’s elevated BP should lead to a higher suspicion of coronary artery disease. The ACC/AHA recommends HTN be brought under control prior the delivery of surgical care.

Severely Elevated Blood Pressure

Patients with uncontrolled systemic HTN are at increased risk for the development of severely elevated BP.21,22 Severely elevated BP is defined as SBP >180 mmHg or DBP >110 mmHg.23 The mechanisms that lead to severely elevated BP (which tends to develop gradually over days, weeks, or months) appear to be related to a failure of normal autoregulatory function and an increase in systemic vascular resistance.

For patients with severely elevated BP, dental care should be deferred, and the patient should be referred for medical assessment and management. The patient who is symptomatic or has evidence of target-organ damage (Table 4), should be transported by EMS to an intensive care unit within one to two hours for immediate treatment and observation. While awaiting transport, supportive measures should be undertaken, but the BP should not be acutely lowered. Normal tissue perfusion in the brain, heart, and kidneys is tightly regulated within a certain range of mean arterial pressure (MAP), despite fluctuations in systemic BP.24 Abruptly decreasing the MAP can lead to a significant drop in cerebral blood flow and, thus, cerebral ischemia.23,24 Patients with severely elevated BP who are asymptomatic and without evidence of target organ damage should be medically evaluated within seven days of presentation.23

Table 4. Potential Signs and Symptoms of Severely Elevated Hypertension.
Symptoms and Signs First Response
  • Restlessness
  • Flushed face
  • Headache, dizziness, tinnitus
  • Visual disturbances
  • Dyspnea
    • Pulmonary edema or congestive heart failure
  • SBP >180 mmHg and/or DBP < 120 mmHg
  • A “hammering” pulse
  • Altered mental state
  • Chest pain
    • Myocardial ischemia, infarction, or aortic dissection
  • Seizure
    • Hypertensive encephalopathy
  • Elevate head
  • Administer oxygen
    • 6 L/min by nasal cannula
  • Activate Emergency Medical Services
    • Rapid transport
  • Monitor vital signs
    • Blood pressure, pulse rate and character