Risk Analysis of Oral Treatment in Hypertensive Patients Under ECG Monitoring: A Single-Center Retrospective Observational Study

doi:10.21203/rs.3.rs-4997351/v1

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Research Article

Risk Analysis of Oral Treatment in Hypertensive Patients Under ECG Monitoring: A Single-Center Retrospective Observational Study

https://doi.org/10.21203/rs.3.rs-4997351/v1

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Objectives

This study investigates intraoperative cardiovascular risks in hypertensive patients undergoing oral treatment, focusing on predictive factors for intraoperative hypertension and ECG abnormalities.

Materials and Methods

We retrospectively analyzed patients monitored with ECG during oral procedures. Blood pressure and heart rate were recorded at four key time points. We examined patients requiring antihypertensive intervention and those with new-onset intraoperative ECG abnormalities to identify predictive factors.

Results

Among 1,492 patients (1,511 records), 166 cases (10.99%) required antihypertensive medication. Preoperative systolic blood pressure (OR: 1.146, P < 0.001) and surgical suturing (OR: 2.271, P = 0.034) were significant predictors. Additionally, 625 records (41.36%) noted new-onset ECG abnormalities, with significant associations to age (OR = 1.033, P < 0.001), preoperative systolic blood pressure (OR = 1.021, P < 0.001), cerebrovascular disease (OR = 1.490, P = 0.005), and arrhythmia (OR = 1.020, P = 0.017).

Conclusions

The risk of cardiovascular complications during oral treatment in hypertensive patients is influenced by factors such as age, preoperative systolic blood pressure, comorbidities like cerebrovascular disease and arrhythmia, and the requirement for surgical suturing. Close monitoring and management of these factors are crucial for reducing intraoperative risks.

Clinical Relevance:

This study offers insights for better cardiovascular risk management in hypertensive patients during oral treatment.

Hypertension

Oral Surgery

Cardiovascular Risk

Electrocardiographic Monitoring

Oral health is a crucial aspect of overall well-being, impacting various organs and systems and consequently affecting an individual’s quality of life. With the aging population, oral health, particularly among older people, is receiving increased attention[1; 2]. As per 2021 data, the number of individuals aged 60 and above in China has reached 264.0 million, accounting for 18.70% of the total population[3]. Aging not only results in a greater need for oral treatment but also leads to a decline in patient’s physical conditions, complicating their systemic health and increasing the risks associated with oral treatments[4; 5].

Hypertension is one of the most prevalent chronic diseases, especially among older individuals[6]. According to the 2018 guidelines from the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH), hypertension is defined as blood pressure levels ≥ 140/90 mmHg based on repeated office measurements or out-of-office measurements of ambulatory or home blood pressure, if feasible[7]. As of 2019, at least 1.2 billion people globally are affected by hypertension[8], and in China, approximately 24.7% of the population had been diagnosed with hypertension by 2018[9].

Hypertensive patients face a significantly increased risk of various cardiovascular events[10]. In hypertensive patients undergoing dental treatment, the use of anesthetics and direct surgical stimuli often result in greater intraoperative blood pressure instability. Additionally, hypertensive patients frequently present with other systemic diseases. Consequently, compared to normotensive patients, hypertensive patients undergoing non-cardiac surgery have a higher baseline cardiovascular risk and a significantly higher incidence of cardiovascular disease. Intraoperative bleeding is also commonly observed in these patients[11; 12]. It is vital to acknowledge the complexities of performing invasive dental procedures on hypertensive patients. A thorough assessment of patients’ blood pressure before treatment and maintaining it within a safe range during the procedure are essential[13; 14].

Currently, no specific risk assessment protocol exists for dental treatment in hypertensive patients. Abnormal intraoperative blood pressure and electrocardiogram (ECG) readings may indicate higher treatment risks. The 2014 ACC/AHA guidelines classify dental treatments as low-risk procedures with general management recommendations, suggesting that perioperative blood pressure should be maintained below 180 mmHg systolic or 110 mmHg diastolic[15; 16]. Patients with systolic blood pressure exceeding 180 mmHg face significantly higher risks of various cardiac diseases[13]. Even when a patient's systolic blood pressure is less than 180 mmHg, it is necessary to monitor potential blood pressure changes to prevent emergencies[11]. Besides blood pressure monitoring, continuous ECG monitoring is a critical component of surgical procedures. Continuous ECG monitoring is essential for diagnosing various cardiac rhythm disorders[17]. Hypertensive patients have a higher likelihood of concomitant cardiac rhythm disorders, and abnormal ECG findings can further indicate an increased surgical risk[18]. In the context of dental treatments, Lu et al. studied the risk of tooth extraction in elderly patients with cardiovascular diseases, finding that advanced age and comorbidities increase surgical risk and recommending dynamic ECG monitoring during treatment[14]. Li et al. identified that age, gender, systemic diseases, and the number of teeth extracted significantly impact cardiovascular responses during tooth extractions [19].

Clinically, a preoperative screening protocol is needed to identify high-risk hypertensive patients and enable preventive measures against potential intraoperative complications. Based on this premise, our study investigates the changes in heart rate, blood pressure, and ECG in hypertensive patients (primarily elderly) undergoing invasive dental treatments, analyzing preoperative characteristics that may influence treatment risks.

This study retrospectively reviewed hypertensive patients who underwent dental treatments under ECG monitoring in our hospital. We collected data on heart rate, blood pressure, ECG results, and patient information, such as age, gender, and medical history, to identify characteristics of patients who experienced abnormal blood pressure changes and new ECG abnormalities during the procedure. The aim is to analyze cardiovascular risk factors that may affect hypertensive patients undergoing dental treatments.

2.1 Study Design

This retrospective observational study was conducted by collecting blood pressure (BP) and continuous electrocardiogram (ECG) monitoring data from hypertensive patients during oral treatment. Blood pressure fluctuations and electrocardiographic abnormalities during the treatment process were assessed to identify risk factors influencing the cardiovascular response. This study was approved by the Ethics Committee of the Peking University School of Stomatology (PKUSSIRB-202385014).

2.2 Patient Selection

This retrospective study collected 3,312 consultation records from the electrocardiographic monitoring clinic of Peking University School of Stomatology in 2022. The medical records of these patients were analyzed, and a total of 1,511 consultation records from 1,492 hypertensive patients were included in the analysis. Due to the relative independence of each dental treatment, it was assumed that 19 repeated consultation records were independent and included in the study. These patients had been evaluated by our maxillofacial surgeons and were advised to undergo dental treatment under ECG monitoring.

The primary criterion for evaluation was systolic blood pressure at the time of consultation. If the preoperative systolic blood pressure was higher than 160 mmHg or if the patient had other complex systemic diseases, such as diabetes, heart disease, or cerebrovascular disease, treatment under ECG monitoring was recommended. The dental procedures performed on these patients included tooth extraction, biopsy, and pulpectomy, with tooth extraction being the most common.

Before undergoing dental procedures under ECG monitoring, patients underwent an electrocardiogram, and a cardiologist conducted a medical history review and physical examination. Blood pressure and ECG were dynamically monitored and recorded throughout the treatment process. Inclusion criteria for the subjects were: (1) a confirmed diagnosis of hypertension based on patient medical history and medication history; (2) at least one dental treatment procedure performed under ECG monitoring with complete medical records. Exclusion criteria included fewer than three recorded intraoperative heart rate and blood pressure readings (mainly due to the short duration of the surgical procedure, with insufficient data for analysis under the condition of 10-minute interval recording).

2.3 Data collection

The monitoring data were obtained from the cardiologist’s continuous ECG and blood pressure records, which included information such as the patient’s medical history, blood pressure, and heart rate upon room entry, as well as intraoperative continuous ECG and blood pressure monitoring data (with blood pressure measured at 5–10 minute intervals during surgery). The flowchart illustrating the monitoring process in the ECG clinic is presented in Fig. 1. The data also encompassed intraoperative changes in heart rate and rhythm, along with blood pressure management measures—specifically, the use of antihypertensive medications and their dosages. This study relied on the cardiologist’s records of perioperative blood pressure interventions and intraoperative ECG abnormalities, as patients exhibiting these conditions were considered to be at higher cardiovascular risk.

Intraoperative interventions included: (1) administering oral antihypertensive medications to patients with systolic blood pressure exceeding 180 mmHg during surgery; (2) administering oral antihypertensive medications to patients whose systolic blood pressure remained above 170 mmHg after at least two intraoperative measurements. Intraoperative newly recorded ECG abnormalities refer to those not detected in the preoperative ECG but appearing during intraoperative ECG monitoring.

2.4 Independent variables of the study

The independent variables in this study were categorized into three groups. The first group included basic patient information such as gender, age, and systemic comorbidities (e.g., heart disease, diabetes, cerebrovascular disease). The second group comprised examination results at the time of consultation, including blood pressure, heart rate, and electrocardiogram (ECG) results taken preoperatively and at the start of the operation. The third group assessed the difficulty of dental treatment procedures, primarily including the number of teeth extracted (if the procedure was a tooth extraction), whether dental high-speed turbine handpieces were used, and whether surgical incision and suturing were required.

When analyzing potential influencing factors for blood pressure and heart rate fluctuations preoperatively and at the start of operation, only independent variables related to essential patient information were included. For intraoperative blood pressure and heart rate fluctuation analysis, the initial blood pressure and heart rate values were added to the first group of independent variables. For analyzing intraoperative hypertension requiring medication intervention and new ECG abnormalities, all three groups of independent variables were included. Systemic comorbidities were further subdivided into categories such as coronary heart disease, arrhythmias, whether a cardiac stent was implanted, whether anticoagulant drugs were used, whether statins were used, and the presence of diabetes or cerebrovascular disease to enhance the accuracy of the analysis.

2.5 Risk Analysis

The risk assessment will be approached from two key perspectives: comparing patients who required intraoperative antihypertensive interventions with those who did not, and comparing patients who developed new ECG abnormalities during surgery with those who did not. Univariate and multivariate analyses will be conducted to identify factors that may contribute to elevated blood pressure necessitating medication or the occurrence of new ECG abnormalities. ROC curves will be generated to establish cut-off points for continuous variables, which will then be categorized. The sensitivity and specificity of each indicator will be assessed to determine their effectiveness in predicting the likelihood of intraoperative blood pressure management or the development of new ECG abnormalities. The ultimate objective is to identify patient characteristics that can reliably predict the likelihood of these intraoperative events. The risk analysis process is shown in Fig. 2.

2.6 Statistical Analysis

Statistical analysis was conducted using SPSS version 27.0. Due to the large sample size and normal distribution of the data, continuous variables were described as mean ± standard deviation, and categorical variables were expressed as ratios or proportions. Analysis of variance (ANOVA) was used to compare the means among multiple groups. The t-test was used to compare the means between the two groups. Logistic regression analysis was employed to identify risk factors for high-risk populations, using the enter method for model inclusion. The diagnostic significance of factors was evaluated using the receiver operating characteristic (ROC) curve. A P-value of less than 0.05 was considered statistically significant.

3.1 Demographic Characteristics

3.1.1 Gender

Among all 1,492 hypertensive patients attending the ECG monitoring clinic, there were 781 females (52.35%) and 711 males (47.65%).

3.1.2 Age

The average age of the 1,492 patients was 73.74 ± 11.71 years, with the oldest being 99 years old and the youngest 27 years old. According to the WHO definition, patients aged 60 and above are considered elderly. In this study, 1,316 patients (88.20%) were elderly, 148 patients (9.93%) were middle-aged (45–59 years), and 28 patients (1.88%) were young adults (16–44 years).

3.1.3 Other Systemic Chronic Diseases

Among the 1,492 hypertensive patients included in the analysis, 934 (62.67%) had other systemic chronic diseases. The primary systemic chronic diseases were heart disease, hyperglycemia, and cerebrovascular disease, as illustrated in Fig. 3.

Of these, 751 patients (50.34%) had heart diseases, with 68 patients (4.68%) having multiple heart conditions. The prevalence of heart disease is detailed in Table 1, with coronary heart disease being the most commonly associated condition.

3.1.4 Types of Surgical Treatments

Out of the 1,511 consultations, 1,343 (88.88%) were for tooth extractions. Other treatments included 78 biopsies, 66 pulpectomies, 13 bone spur removal surgeries, five implant surgeries, two laser treatments, and one each of cyst curettage, caries removal, and joint cavity irrigation. Among all procedures, 15.75% of patients underwent suturing, 11.98% had incisions made with a scalpel, and only 40 procedures (2.65%) utilized a dental high-speed turbine handpiece.

The demographic characteristics are summarized in Table 1.

Table 1

Demographic Characteristics of Study Participants
Characteristic			Number N = 1492	%
Age		Mean (SD)	73.74 ± 11.71
Age		Range	27–99
Gender	Male		711	47.65%
Gender	Female		781	52.35%
Other Systemic Chronic Diseases, n = 934
Coronary heart disease			346	46.07%
Arrhythmia			266	35.42%
- Increased heart rate			214	28.50%
- Decreased heart rate			52	6.92%
Atrial fibrillation			185	24.63%
Rheumatic heart valve disease			10	1.33%
Cardiomyopathy			8	1.07%
Congenital heart disease			6	0.80%
Degenerative valvular heart disease			1	0.13%
Types of Surgical Treatments, n = 1511
Tooth extractions			1343	88.88%
Biopies			78	5.16%
Pulpectomies			66	4.37%
Bone spur removal surgeries			13	0.86%
Implant surgeries			5	0.33%
Laser treatments			2	0.13%
Other treatments			4	0.26%
Sutures			238	15.75%
Incisions			181	11.98%
High-speed turbine handpiece			40	2.65
SBP: Systolic blood pressure; DBP: Diastolic blood pressure; : P<0.05;༚P<0.01༛**༚P<0.001

3.2 Blood pressure and heart rate values

3.2.1 Blood Pressure and Heart Rate Data Preoperatively and at the Start of Operation

Before the surgery officially began, all patients had their blood pressure and heart rate measured at least twice. From a gender perspective, the preoperative systolic blood pressure and heart rate of female patients were significantly higher than those of male patients. In comparison, the diastolic blood pressure was significantly lower in female patients. The median age of the patients was 75 years. Patients were divided into groups based on whether they were older or younger than 75 years. Patients older than 75 years had higher systolic blood pressure, lower diastolic blood pressure, increased pulse pressure difference, and slower heart rate. Patients with heart disease had lower systolic blood pressure, diastolic blood pressure, and heart rate compared to those without heart disease. Patients with cerebrovascular disease and diabetes had significantly lower diastolic blood pressure than those without these conditions. Additional results are shown in Table 2.

3.2.2 Intraoperative Maximum Blood Pressure and Heart Rate Data

During surgery, blood pressure and heart rate were measured at 10-minute intervals. The highest systolic blood pressure for each patient was used for analysis. Intraoperatively, female patients had higher systolic blood pressure and heart rate, and lower diastolic blood pressure compared to male patients, consistent with preoperative data. Patients over 75 years old had higher systolic blood pressure, lower diastolic blood pressure, and more significant pulse pressure differences.

Hypertensive patients with heart disease monitored by ECG showed lower blood pressure and heart rate compared to other patients. Diabetic patients had lower diastolic blood pressure, and those with cerebrovascular disease had both lower diastolic blood pressure and heart rate. No significant differences were found in other data. Additional results are shown in Table 2.

Table 2

Preoperative, at the start of operation, and intraoperative maximum blood pressure and heart rate measurement results(x̄±s). N = 1511.
		Preoperative BP and HR
		SBP(mmHg)	DBP(mmHg)	HR		SBP(mmHg)		DBP(mmHg)		HR		SBP(mmHg)		DBP(mmHg)		HR
Average		141.25 ± 19.36	71.51 ± 12.20		75.31 ± 12.80		142.66 ± 16.99		71.93 ± 11.31		76.96 ± 12.98		145.57 ± 17.96		72.94 ± 11.32		78.52 ± 13.19
Sex
Male	140.47 ± 17.61		73.27 ± 11.25		75.44 ± 12.12		138.17 ± 19.80		72.87 ± 12.21		73.87 ± 12.24		142.97 ± 18.24		74.40 ± 11.25		77.06 ± 12.38
Female	144.65 ± 16.16***		70.71 ± 11.24***		78.34 ± 13.57***		144.05 ± 18.52***		70.27 ± 12.06***		76.62 ± 13.17***		147.93 ± 17.39***		71.61 ± 11.24***		79.86 ± 13.77***
Age
[27,75)	138.25 ± 19.6		75.21 ± 12.25		76.93 ± 13.17		140.30 ± 17.20		75.43 ± 11.01		78.37 ± 13.26		143.23 ± 18.07		76.21 ± 10.97		80.05 ± 13.30
[75,99)	144.03 ± 18.68***		68.06 ± 11.09***		73.80 ± 12.27***		144.86 ± 16.50***		68.67 ± 10.60***		75.64 ± 12.57***		147.75 ± 17.60***		69.88 ± 10.79***		77.11 ± 12.95***
Cardiac disease
Yes	138.88 ± 17.03		70.65 ± 10.51		73.33 ± 11.23		136.59 ± 18.23		69.69 ± 11.27		71.53 ± 11.24		141.77 ± 17.13		71.80 ± 10.47		74.81 ± 11.26
No	144.51 ± 16.67***		72.55 ± 11.64**		78.73 ± 13.40***		143.52 ± 19.50***		72.40 ± 12.54***		77.15 ± 13.11***		147.43 ± 18.07***		73.49 ± 11.69**		80.34 ± 13.69***
Diabetes mellitus
Yes		142.17 ± 17.46	70.11 ± 10.69		77.77 ± 13.72		139.40 ± 20.13		69.34 ± 11.64		75.93 ± 13.43		144.83 ± 18.34		71.44 ± 11.61		79.17 ± 13.71
No		142.88 ± 16.77	72.75 ± 11.50***		76.59 ± 12.61		142.08 ± 18.95*		72.49 ± 12.33***		75.02 ± 12.50		145.91 ± 17.79		73.62 ± 11.13***		78.23 ± 12.95
Cerebrovascular disease
Yes		142.70 ± 16.79	69.88 ± 10.26		75.59 ± 11.18		140.21 ± 19.52		69.14 ± 10.88		73.75 ± 11.18		145.92 ± 16.78		71.24 ± 11.32		76.74 ± 11.11
No		142.65 ± 17.04	72.45 ± 11.51***		77.30 ± 13.38*		141.51 ± 19.32		72.11 ± 12.44***		75.70 ± 13.16**		145.48 ± 18.26		73.37 ± 11.29**		78.98 ± 13.64**

3.2.3 Intraoperative Blood Pressure and Heart Rate Fluctuations

From the 1,511 consultation records, intraoperative blood pressure and heart rate measurements were extracted to calculate the difference between their highest and lowest values. The average intraoperative systolic blood pressure fluctuation for all patients was 14.95 mmHg, the average diastolic blood pressure fluctuation was 8.32 mmHg, and the average heart rate fluctuation was 6.00 beats per minute.

Analysis showed no statistically significant correlation between patient gender and intraoperative blood pressure or heart rate fluctuations. Patients were divided into two age groups: 75 years and older, and younger than 75. No statistically significant differences in blood pressure and heart rate fluctuations were observed between these two groups.

Using the 2023 hypertension classification standard, patients were grouped based on their preoperative systolic blood pressure, with 160 mmHg as the cutoff for grades I and II hypertension. Patients with preoperative systolic blood pressure ≥ 160 mmHg had more significant intraoperative blood pressure and heart rate fluctuations. Patients with heart disease had smaller intraoperative systolic blood pressure and heart rate fluctuations. In contrast, diabetes or cerebrovascular disease did not significantly affect intraoperative blood pressure and heart rate fluctuations. Specific data are shown in Table 3.

Table 3

Fluctuations in blood pressure and heart rate occur during surgery (x̄±s). N = 1511.
	Intraoperative Fluctuation Values
	SBP(mmHg)	DBP(mmHg)	HR
Sex
Male	14.40 ± 13.37	8.03 ± 8.36	5.84 ± 7.76
Female	15.46 ± 13.06	8.57 ± 7.90	6.14 ± 7.86
Age
[27,75)	15.02 ± 13.59	8.17 ± 8.13	6.32 ± 7.68
[75,99)	14.89 ± 12.82	8.46 ± 8.11	5.67 ± 7.93
Preoperative SBP
<160	14.22 ± 11.36	7.98 ± 7.42	7.57 ± 8.04
≥ 160	18.72 ± 19.80***	10.02 ± 10.91**	5.69 ± 7.73***
At the start of the operation’s SBP
<160	13.71 ± 11.50	7.96 ± 7.73	5.70 ± 8.48
≥ 160	23.00 ± 19.39***	10.59 ± 10.02***	7.98 ± 7.66***
Cardiac disease
Yes	13.82 ± 12.68	8.12 ± 8.50	5.44 ± 6.50
No	15.51 ± 13.44*	8.41 ± 7.93	6.27 ± 8.37*
Diabetes mellitus
Yes	14.99 ± 12.93	8.05 ± 7.48	5.74 ± 8.99
No	14.94 ± 13.35	8.44 ± 8.40	6.12 ± 7.21
Cerebrovascular disease
Yes	16.13 ± 18.51	8.49 ± 10.26	5.34 ± 6.34
No	14.65 ± 11.48	8.27 ± 7.49	6.17 ± 8.14

3.3 Risk analysis

3.3.1 Blood pressure and heart rate indicators

Among the 1,511 consultation records, 164 patients were assessed as high-risk by the internist and required medication intervention. After temporary oral medication control, these surgeries were completed. Two cases were deemed extremely high-risk and were terminated. Thus, 166 (10.52%) consultation records were included in the medication intervention group for analysis.

Of the patients who received intraoperative medication, 83.73% used nitroglycerin, with doses ranging from 0.3 to 2 mg. A few patients used captopril, metoprolol, or a combination of nitroglycerin and captopril, depending on their condition. A detailed summary is available in Table 4.

Table 4

Intervention during surgery. N = 166.
Type	Number
Nitroglycerin	139(83.73%)
Captopril	10(6.02%)
Captopril + Nitroglycerin	8(4.82%)
Metoprolol	7(4.22%)
Surgical abortion	2(1.20%)
Total	166(100%)

Univariate analysis indicated that patient gender and various comorbidities, as well as whether a cardiac stent was implanted, influenced the need for intraoperative medication intervention. Female patients (t=-2.364, P = 0.019), patients without coronary heart disease (t = 3.617, P < 0.001), without arrhythmias (t = 2.750, P = 0.006), and without cerebrovascular disease (t = 2.469, P = 0.014) were more likely to need intraoperative blood pressure intervention. Patients without a cardiac stent (t = 2.562, P = 0.011), not taking anticoagulants (t = 4.439, P < 0.001), and not on statins (t = 4.477, P < 0.001) were also more likely to need intraoperative blood pressure intervention. Higher systolic blood pressure (t=-23.895, P < 0.001) and heart rate (t=-3.667, P < 0.001) preoperatively, and higher systolic blood pressure (t=-13.203, P < 0.001) and heart rate (t=-3.496, P < 0.001) at the start of the operation were associated with a greater likelihood of requiring intraoperative blood pressure intervention. Patients needing surgical suturing (t = 2.529, P = 0.012) were also more likely to require intraoperative blood pressure intervention. Refer to Table 5 for detailed information.

Table 5

Univariate analysis of the intervention group. N = 1511.
				P-value
Sex
Male (Ref)	655(90.97%)	65(9.03%)	-2.364	0.0 19*
Female	690(87.23%)	101(12.77%)		0.0 19*
Age	73.70 ± 11.57	74.01 ± 12.75	-0.326	0.745
Coronary heart disease
Yes	460(92.74%)	36(7.26%)	3.617	<0.001***
No	885(87.19%)	130(12.81%)		<0.001***
Arrhythmia
Yes	264(92.96%)	20(7.04%)	2.750	0.006**
No	1081(88.10%)	146(11.90%)		0.006**
Heart stent
Yes	316(92.40%)	26(7.60%)	2.562	0.011*
No	1029(88.02%)	140(11.98%)
Anticoagulant
Yes	827(91.99%)	72(8.01%)	4.439	<0.001***
No	518(84.64%)	94(15.36%)
Statins
Yes	626(92.74%)	49(7.26%)	4.477	<0.001***
No	719(86.00%)	117(14.00%)
Cerebrovascular disease
Yes	283(92.48%)	23(7.52%)	2.469	0.014*
No	1062(88.13%)	143(11.87%)
Diabetes
Yes	424(89.83%)	48(10.17%)	0.684	0.494
No	921(88.64%)	118(11.36%)
Preoperative SBP	137.97 ± 12.21	167.78 ± 14.90	-23.895	<0.001***
Preoperative HR	74.82 ± 12.42	79.27 ± 15.02	-3.667	<0.001***
At the start of the operation’s SBP	140.74 ± 16.10	158.22 ± 16.03	-13.203	<0.001***
At the start of the operation’s HR	76.48 ± 12.54	80.87 ± 15.58	-3.496	<0.001***
Number of tooth extractions per time	1.51 ± 1.00	1.57 ± 1.38	-0.579	0.564
Dental high-speed turbine handpieces
Yes	34(85.00%)	6(15.00%)	-0.822	0.411
No	1311(89.12%)	160(10.88%)
Surgical incision
Yes	155(85.64%	26(14.36%)	-1.398	0.164
No	1190(89.47%)	140(10.53%)
Surgical suture
Yes	199(83.61%)	39(16.39%)	2.529	0.012*
No	1146(90.02%)	127(9.98%)

To avoid missing potential influencing factors, all variables from the univariate analysis were included in the logistic regression model. After controlling for confounding factors, it was found that higher systolic blood pressure preoperatively (OR = 1.146, P < 0.001), higher systolic blood pressure (OR = 1.026, P = 0.005), and higher heart rate (OR = 1.068, P = 0.002) at the start of the operation increased the likelihood of requiring medication intervention. The need for suturing also indicated a higher likelihood of requiring intraoperative medication intervention (OR = 2.271, P = 0.034). Comorbidities such as heart disease, cerebrovascular disease, and diabetes were not statistically significantly related to the need for intraoperative medication intervention. Detailed information is presented in Table 6.

Table 6

Multivariate analysis of the blood pressure intervention group. N = 1511.
	OR	OR 95%Low	OR 95%High	P-value
Sex	1.097	0.696	1.729	0.689
Age	0.982	0.962	1.002	0.073
Coronary heart disease	0.772	0.343	1.740	0.532
Arrhythmia	1.177	0.636	2.179	0.605
Heart stent	0.858	0.370	1.990	0.721
Anticoagulant	1.068	0.624	1.828	0.811
Statins	1.291	0.693	2.406	0.420
Cerebrovascular disease	1.328	0.733	2.405	0.350
Diabetes	0.814	0.510	1.299	0.388
Preoperative SBP	1.146	1.122	1.170	<0.001***
Preoperative HR	0.962	0.922	1.003	0.069
At the start of the operation’s SBP	1.026	1.008	1.044	0.005**
At the start of the operation’s HR	1.068	1.024	1.113	0.002**
Number of tooth extractions per time	1.024	0.837	1.252	0.820
Dental high-speed turbine handpieces	0.732	0.215	2.487	0.617
Surgical incision	1.341	0.542	3.317	0.525
Surgical suture	2.271	1.064	4.848	0.034*

ROC curves were plotted for the continuous variables identified. Systolic blood pressure preoperatively, systolic blood pressure at the start of the operation, and heart rate at the start of the operation could estimate the need for intraoperative medication intervention. The first measured systolic blood pressure preoperatively had the highest predictive efficiency. Using 158.5 mmHg as the threshold for systolic blood pressure preoperatively yielded the highest Youden index, at 0.69. With this cutoff, the sensitivity was 79.52%, and the specificity was 89.67%. Using 155.5 mmHg as the threshold for systolic blood pressure at the start of the operation yielded a Youden index of 0.43. With this cutoff, the sensitivity was 59.64%, and the specificity was 78.54%. For detailed information on the ROC curves, see Table 7 and Fig. 4.

Table 7

The area under the curve of preoperative SBP, at the start of the operation’s SBP and HR.
	The area under the curve	P value
Preoperative SBP	0.91	<0.001***
At the start of the operation’s SBP	0.79	<0.001***
At the start of the operation’s HR	0.58	<0.001***

The sensitivity and specificity of these indicators were calculated based on the optimal ROC curve thresholds (AUC > 0.60). Using only systolic blood pressure preoperatively as a judgment indicator, the sensitivity was 79.52%, and the specificity was 89.67%. Using only systolic blood pressure at the start of the operation, the sensitivity was 59.64%, and the specificity was 78.54%. The indicator of surgical suturing had reasonable specificity (85.20%) but poor sensitivity (23.49%). When both systolic blood pressure preoperatively and at the start of the operation were used in combination, the combined specificity reached 94.28%, and the combined sensitivity was 87.95%, with a specificity of 79.18% and a Youden index of 0.67. The summary of the sensitivity and specificity of each indicator is presented in Table 8.

Table 8

Evaluation of SBP (preoperative and at the start of operation) and the need for suturing in predicting intraoperative intervention
	Sensitivity	Specificity	Positive Predictive Value	Negative Predictive Value	Youden’s J Statistic
Preoperative SBP(158.5mmHg)	79.52%	89.67%	48.71%	97.26%	0.69
At the start of the operation’s SBP(155.5mmHg)	59.64%	78.54%	31.23%	94.39%	0.38
Surgical suture	23.49%	85.20%	16.39%	90.02%	0.09
Preoperative SBP and at the start of the operation’s SBP	51.20%	94.28%	49.63%	93.93%	0.45
Preoperative SBP or at the start of the operation’s SBP	87.95%	79.18%	29.58%	98.07%	0.67
Preoperative SBP and surgical suture	18.07%	98.59%	61.22%	90.70%	0.17
Preoperative SBP or surgical suture	84.94%	76.28%	30.65%	97.62%	0.61
At the start of the operation’s SBP and surgical suture	13.25%	97.47%	39.29%	90.10%	0.11
At the start of the operation’s SBP or surgical suture	69.88%	71.52%	23.25%	95.06%	0.41

In clinical applications, sensitivity should be prioritized to ensure patient safety. Referring to the Youden index, a combination of systolic blood pressure preoperatively and at the start of the operation should be used to identify high-risk patients early. Blood pressure should be measured once preoperatively and once before the procedure begins. Patients with systolic blood pressure ≥ 159 mmHg preoperatively or ≥ 156 mmHg at the start of the operation should be prepared with antihypertensive medication and closely monitored for intraoperative blood pressure changes. In our hospital’s analyzed population, patients screened using this method had relatively safe treatments, with 98.07% maintaining stable intraoperative blood pressure without requiring temporary oral medication intervention.

3.3.2 ECG abnormality indicators

Among the 1,511 consultation records in this study, 625 cases (41.36%) showed new ECG abnormalities detected by continuous monitoring during surgery. The most common abnormalities were ventricular and supraventricular premature contractions, accounting for 97.76% of the new ECG findings. Only 25 cases involved frequent premature contractions (13 ventricular and 12 supraventricular), with 6 cases exhibiting both ventricular and supraventricular premature contractions, and 1 case showing both ventricular premature contractions and supraventricular tachycardia. The summary of abnormal ECG findings is presented in Table 9.

Table 9

Types of abnormal cardiac rhythms
Type N = 625		n(%)
Ventricular premature contraction	335(53.60%)
-Frequent premature ventricular contractions	13(2.08%)
Premature atrial contraction	245 (39.20%)
-Frequent premature atrial contraction	12(1.92%)
Ventricular premature contraction + Premature atrial contraction	6(0.96%)
Sinus arrhythmia	7(1.12%)
Atrioventricular conduction block	4(0.64%)
Supraventricular tachycardia	2(0.32%)
Ventricular premature contraction + Supraventricular tachycardia	1(0.16%)

Univariate analysis indicated that patient age, presence of coronary heart disease, cerebrovascular disease, use of anticoagulants, use of statins, preoperative systolic blood pressure, and systolic blood pressure at the start of the operation were statistically correlated with the occurrence of new intraoperative ECG abnormalities. The results of the univariate analysis are presented in Table 10. Patients without coronary heart disease (t = 2.262, P = 0.024), without cerebrovascular disease (t = 2.323, P = 0.020), not using anticoagulants (t = 2.107, P = 0.035), and not using statins (t = 2.660, P = 0.008) were more likely to experience abnormal ECG results during surgery. Additionally, older patients (t=-5.580, P < 0.001) and those with higher preoperative systolic blood pressure (t=-9.712, P < 0.001) and systolic blood pressure at the start of the operation (t=-8.631, P < 0.001) were more likely to experience intraoperative ECG abnormalities.

Table 10

Univariate analysis of abnormal electrocardiogram group. N = 1511
	Normal Electrocardiogram group	Abnormal electrocardiogram group	t	P-value
Sex
Male	428(59.44%)	292(40.56%)	-0.608	0.543
Female	458(57.90%)	333(42.10%)		0.543
Age	72.34 ± 11.97	75.69 ± 11.04	-5.580	<0.001***
Coronary heart disease
Yes	311(62.70%)	185(37.30%)	2.262	0.024*
No	575(56.65%)	440(43.35%)		0.024*
Arrhythmia
Yes	181(63.73%)	103(36.27%)	1.964	0.050
No	705(57.46%)	522(42.54%)		0.050
Heart stent
Yes	215(62.87%)	127(37.13%)	1.826	0.068
No	671(57.40%)	498(42.60%)
Anticoagulant
Yes	547(60.85%)	352(39.15%)	2.107	0.035*
No	339(55.39%)	273(44.61%)
Statins
Yes	421(62.37%)	254(37.63%)	2.660	0.008**
No	465(55.62%)	371(44.38%)
Cerebrovascular disease
Yes	197(64.38%)	109(35.62%)	2.323	0.020*
No	689(57.18%)	516(42.82%)
Diabetes
Yes	294(62.29%)	178(37.71%)	1.958	0.050
No	592(56.98%)	447(43.02%)
PreoperativeSBP	137.22 ± 17.71	146.95 ± 20.17	-9.712	<0.001***
Preoperative HR	75.51 ± 13.22	75.02 ± 12.19	0.732	0.464
At the start of the operation’s SBP	139.57 ± 16.29	147.05 ± 17.01	-8.631	<0.001***
At the start of the operation’s HR	77.13 ± 13.34	76.71 ± 12.45	0.622	0.534
Number of tooth extractions per time	1.50 ± 0.99	1.56 ± 1.13	-1.068	0.286
Dental high-speed turbine handpieces
Yes	22(55.00%)	18(45.00%)	-0.437	0.636
No	864(58.42%)	607(41.26%)
Surgical incision
Yes	109(60.22%)	72(39.78%)	0.461	0.645
No	777(58.42%)	553(41.58%)
Surgical suture
Yes	143(60.08%)	95(39.92%)	-0.494	0.622
No	743(58.37%)	530(41.63%)

All variables from the univariate analysis were included in the logistic regression model. The results of the multivariate analysis are summarized in Table 11. Patient age (OR = 1.033, P < 0.001), preoperative arrhythmia (OR = 1.020, P = 0.017), presence of cerebrovascular disease (OR = 1.490, P = 0.005), and preoperative systolic blood pressure (OR = 1.021, P < 0.001) were statistically correlated with new intraoperative ECG abnormalities.

Table 11

Multivariate analysis of abnormal electrocardiogram group
	OR	OR 95%Low	OR 95%High
Sex	1.163	0.927	1.458	0.192
Age	1.022	1.012	1.033	<0.001***
Coronary heart disease	1.151	0.784	1.689	0.472
Arrhythmia	1.436	1.068	1.931	0.017**
Heart stent	1.020	0.696	1.497	0.918
Anticoagulant	0.894	0.681	1.172	0.417
Statins	1.114	0.831	1.493	0.472
Diabetes	1.146	0.906	1.450	0.255
Cerebrovascular disease	1.490	1.129	1.967	0.005**
Preoperative SBP	1.021	1.012	1.030	<0.001***
Preoperative HR	0.991	0.968	1.013	0.415
At the start of the operation’s SBP	1.008	0.998	1.018	0.111
At the start of the operation’s HR	1.003	0.981	1.026	0.763
Number of tooth extractions per time	1.031	0.926	1.147	0.581
Dental high-speed turbine handpieces	0.772	0.390	1.531	0.459
Surgical incision	1.042	0.637	1.704	0.869
Surgical suture	1.053	0.690	1.606	0.812

ROC curves were plotted for the continuous variables identified, with preoperative systolic blood pressure remaining the most efficient predictor. For more details on the ROC curves, please refer to Table 12 and Fig. 5. Patient age also showed some predictive significance. The areas under the curves for preoperative systolic blood pressure and age were 0.64 and 0.58, respectively, indicating low diagnostic accuracy. The highest Youden index for preoperative systolic blood pressure was 0.20 at 145.5 mmHg, with a sensitivity of 53.60% and specificity of 66.82%. With the previous cutoff of 158.5 mmHg for intraoperative intervention, the Youden index was 0.19, with a sensitivity of 28.96% and a specificity of 89.84%. Compared to the 145.5 mmHg cutoff, the 158.5 mmHg threshold had significantly higher specificity and better-screened patients with relatively stable treatment processes. Therefore, the 158.5 mmHg threshold was adopted for diagnosis in this study.

Table 12

The area under the curve of preoperative SBP and age
	The area under the curve	P value
Preoperative SBP	0.64	<0.001***
Age	0.58	<0.001***

Using preoperative systolic blood pressure with a threshold of 158.5 mmHg and adding the indicators of cerebrovascular disease and preoperative arrhythmia, the sensitivity, specificity, positive predictive value, negative predictive value, and Youden index were calculated. The results are presented in Table 13. These indicators showed slightly lower sensitivity but higher specificity. Notably, using preoperative systolic blood pressure as the standard, the sensitivity was 28.96%, and the specificity was 89.84%. When preoperative systolic blood pressure was below 158.5 mmHg, there was a 64.19% probability of no new intraoperative ECG abnormalities. Above this value, there was a 66.79% probability of new intraoperative ECG abnormalities. Referring to the Youden index, preoperative systolic blood pressure alone was the standard that had the highest Youden index of 0.19 for identifying patients likely to develop ECG abnormalities.

Table 13

Assessment of preoperative SBP, SBP at the start of the operation, and the need for suturing in predicting abnormal intraoperative ECGs
	Sensitivity	Specificity	Positive Predictive Value	Negative Predictive Value	Youden’s J Statistic
Preoperative SBP(158.5mmHg)	28.96%	89.84%	66.79%	64.19%	0.19
Arrhythmia	16.48%	79.57%	35.71%	57.43%	-0.04
Cerebrovascular disease	17.44%	77.77%	35.62%	57.18%	-0.05
Preoperative SBP(158.5mmHg)or arrhythmia	40.32%	72.01%	50.40%	63.11%	0.12
Preoperative SBP(158.5mmHg)and arrhythmia	3.84%	98.53%	64.86%	59.23%	0.02
Cerebrovascular disease or preoperative SBP(158.5mmHg)	42.24%	69.53%	49.44%	63.05%	0.12
Cerebrovascular disease and preoperative SBP(158.5mmHg)	4.16%	98.08%	60.47%	40.80%	0.02
Cerebrovascular disease or arrhythmia	29.92%	62.98%	36.31%	56.02%	-0.07
Cerebrovascular disease and arrhythmia	2.72%	95.49%	29.82%	58.18%	-0.02

3.3.3 Preliminary Risk Assessment Process

Based on the above findings, a combined application of systolic blood pressure preoperatively and systolic blood pressure at the start of the operation can better predict potential intraoperative abnormalities. The preliminary risk assessment plan is as follows: When both blood pressure measurements are below the standard values, the surgical procedure is relatively safe, with only a 1.93% likelihood of requiring intraoperative intervention for high blood pressure and a 34.71% likelihood of abnormal ECG results during surgery. As abnormal indicators appear, the probability of these two risk outcomes gradually increases, reaching a maximum of 49.63% for requiring intraoperative intervention and 74.07% for new ECG abnormalities during surgery. The preliminary risk assessment process is illustrated in Fig. 6.

4.1 The Significance of Blood Pressure and ECG Monitoring

Hypertension is one of the most common chronic diseases among elderly patients. In China, the prevalence of hypertension is high, and blood pressure control remains suboptimal[20]. Hypertensive patients are the primary group receiving ECG-monitored dental treatments at our hospital. In this study, 45.22% of the 3,312 ECG monitoring outpatient records involved patients with hypertension, with an average preoperative systolic blood pressure of 141.24 mmHg. Adequate blood pressure control in hypertensive patients can significantly reduce the incidence of related cardiovascular diseases. Blood pressure may further increase during dental procedures, making monitoring essential for high-risk hypertensive patients[21; 22; 23]. Studies suggest that systolic blood pressure is significantly correlated with long-term prognosis and that even short-term fluctuations in blood pressure can increase the risk of cardiovascular events[24]. Based on existing evidence, surgeries for patients with systolic blood pressure ≥ 180 mmHg/diastolic blood pressure ≥ 110 mmHg should be postponed until blood pressure is stabilized, except in emergencies[25]. Therefore, in this study, intraoperative blood pressure was capped at 180 mmHg. If intraoperative blood pressure reached or exceeded 180 mmHg or multiple measurements were not less than 170 mmHg, temporary medication was administered to control blood pressure. Treatment continued once blood pressure was effectively controlled and rescheduled if control was ineffective. Heart rate is closely related to blood pressure, and hypertensive patients often have higher heart rates[26]. Elevated heart rates also impact all-cause mortality risk[27], influencing antihypertensive strategies[28]. Thus, heart rate was recorded during the analysis of this study.

As early as the 1960s, scholars reported using ECG monitoring during tooth extractions and observed tachycardia and other abnormal ECG findings[29]. Blinder et al. compared ECG changes before and after tooth extractions, noting that tachycardia was the most common abnormality during extractions, especially with vasoconstrictor-containing anesthetics[30]. Existing studies have not found life-threatening arrhythmias in dental patients, indicating that the overall risk of dental treatment is relatively low[29; 30; 31; 32]. The most common ECG abnormality observed in this study was premature contractions, which can occur in regular patients, with a 24-hour ECG monitoring incidence of 40–75%[33]. Research shows that asymptomatic ventricular premature beats in regular patients do not significantly affect long-term prognosis [34]. Still, in hypertensive patients with potential heart disease, ventricular premature beats are associated with increased overall mortality[35; 36]. ECG rhythm monitoring is essential for hypertensive patients during surgery [14]; thus, this study recorded patients’ ECG rhythm changes.

4.2 The Impact of Gender and Age on Blood Pressure and Heart Rhythm

Results showed that preoperative blood pressure levels were related to factors such as gender, age, and comorbidities. In this study, preoperative systolic blood pressure was significantly higher in female patients than in male patients. In comparison, diastolic blood pressure was lower, pulse pressure was higher, and heart rate was faster in females. A retrospective study showed similar results, suggesting that older female patients require more effort to control blood pressure [37]. During dental procedures, factors like mental stress, surgical stimulation, and anesthesia can further increase blood pressure. Female patients’ intraoperative blood pressure was also significantly higher than that of male patients. Li et al. measured patients’ blood pressure during tooth extractions and similarly found that female patients generally had higher intraoperative blood pressure than male patients [19]. Preoperative and postoperative blood pressure fluctuations were slightly higher in female patients, but there was no significant difference in blood pressure fluctuations between genders.

Although intraoperative systolic blood pressure was generally slightly higher in female patients, the likelihood of requiring temporary medication for intraoperative high blood pressure and the probability of new intraoperative ECG abnormalities were similar to those of male patients. According to Nathan et al., the overall risk of coronary events in hypertensive female patients is even lower than in male patients[38]. Existing evidence shows no significant correlation between intraoperative medication use and new ECG abnormalities with gender, indicating similar probabilities of these intraoperative events for both male and female patients, with no evidence suggesting that gender affects surgical risk.

Generally, the higher the patient’s age and systolic blood pressure, the greater the risk of related cardiovascular diseases[6]. In this study, patients were grouped by median age of 75. Patients aged 75 and above had significantly higher systolic blood pressure and lower diastolic blood pressure, but there was no significant correlation between age and intraoperative blood pressure fluctuations. The likelihood of requiring intraoperative antihypertensive medication was similar for elderly and general hypertensive patients, indicating that age is not an independent factor in determining the need for temporary intraoperative antihypertensive measures. Regarding ECG monitoring, each year of age increases the probability of ECG abnormalities by approximately 2.4%. These findings suggest that although severe intraoperative hypertension is less common in elderly patients, the likelihood of abnormal cardiac rhythms is higher. Elderly patients have declining physical functions, making them more susceptible to severe diseases from minor disturbances [8]. Therefore, more attention should be paid to changes in cardiac rhythm during surgery for elderly patients.

4.3 The Impact of Systemic Diseases on Blood Pressure and Heart Rhythm

Heart disease is the most common comorbidity with hypertension. Approximately half of the hypertensive patients in this study also had heart diseases. Patients with heart disease generally had lower blood pressure and heart rates, possibly due to stricter blood pressure control strategies [25], and many heart disease medications also have antihypertensive effects.

Regarding diabetes comorbidity, all patients included in this study had controlled blood sugar, with a maximum fasting blood glucose requirement of less than 10.0 mmol/L and a glycated hemoglobin percentage requirement of less than 8.5%. This study found no significant correlation between diabetes and severe intraoperative hypertension, nor between diabetes and abnormal ECG rhythms.

Patients with cerebrovascular diseases had lower diastolic blood pressure than other patients but were approximately 1.47 times more likely to experience intraoperative ECG abnormalities. Numerous pieces of evidence show a close association between hypertension and cerebrovascular diseases. Lowering blood pressure significantly benefits patients with cerebrovascular diseases[39; 40]. Patients with a history of cerebrovascular disease are more likely to experience arrhythmias [41], consistent with this study’s findings, indicating the need for timely attention to intraoperative ECG abnormalities in these patients.

Hypertensive patients often require antiplatelet or anticoagulant medications for comorbid cardiovascular diseases, and those with elevated blood lipids need statins. This study found no significant impact of these medications on intraoperative blood pressure and heart rhythm.

4.4 The Effects of Surgical Procedures on Blood Pressure and Heart Rhythm

This study primarily included patients undergoing tooth extractions in the ECG monitoring clinic, accounting for 88.82%. Surgical treatment difficulty was evaluated using indicators such as the number of teeth extracted, whether incisions or sutures were needed, and the use of dental high-speed turbine handpieces. Only the need for suturing was significantly related to temporary intraoperative antihypertensive medication. Generally, suturing is considered for more extensive surgical wounds, commonly in extractions, alveolar ridge contouring, and biopsies, indicating that patients with more extensive surgical wounds are more likely to require antihypertensive medication during the surgery. Preoperative identification of patients likely needing suturing requires closer monitoring of intraoperative blood pressure. It is noteworthy that suturing is also a standard hemostasis method, possibly due to higher blood pressure and increased bleeding, prompting temporary suturing during surgery. This aspect cannot be distinguished from patients needing suturing preoperatively due to more extensive wounds, potentially affecting study conclusions. Other treatment difficulty indicators showed no significant correlation with intraoperative blood pressure and heart rhythm abnormalities. Another study found that patients extracting two or more teeth had faster heart rates than those extracting one tooth, but there was no significant difference in blood pressure[19]. Blood pressure and ECG monitoring show no conclusive evidence that factors like the number of teeth extracted or procedure types significantly affect treatment risk beyond surgical suturing.

4.5 Cardiovascular Risk Prediction

In this study, patients with systolic blood pressure ≥ 159 mmHg preoperatively were more likely to require medication intervention for high blood pressure and new ECG abnormalities, warranting close attention and recommending ECG-monitored dental treatment for timely intervention. A 2018 study reached similar conclusions, showing that preoperative blood pressure effectively predicts overall blood pressure levels, with patients having preoperative systolic blood pressure ≥ 160 mmHg being 94.6% likely to have poor blood pressure control[42]. Preoperative blood pressure measurement is significant for predicting non-cardiac surgery risk[43]. During clinical procedures, to minimize observational errors, at least two sets of blood pressure and heart rate values are measured before surgery. Analysis showed that at the start of the operation’s blood pressure and heart rate were slightly higher than preoperative values, making systolic blood pressure at the start of operation a meaningful predictor of intraoperative high blood pressure requiring temporary medication control. Patients with systolic blood pressure ≥ 156 mmHg at the start of the operation are more likely to need intraoperative antihypertensive medication. Combining systolic blood pressure indicators preoperatively and at the start of the operation yields the best diagnostic efficiency for early assessment of intraoperative blood pressure and ECG abnormalities.

This study included a large sample size and analyzed high-risk patients undergoing dental treatment with cardiovascular risk events from several aspects, including blood pressure, heart rate, and electrocardiographic monitoring. The analysis focused on potential influencing factors for abnormal blood pressure and electrocardiographic findings. Severe adverse events during dental treatment in hypertensive patients were rare, indicating an overall safe procedure. The most effective predictor of intraoperative cardiac abnormalities was systolic blood pressure operatively. Patients with a preoperative systolic blood pressure of 159 mmHg or higher require special attention to blood pressure and electrocardiographic changes during surgery. At the start of operation’s blood pressure (with a threshold of 156 mmHg) and high preoperative heart rate, high blood preoperatively, and patients requiring surgical suturing due to large surgical wounds were more likely to experience severe intraoperative hypertension, possibly necessitating temporary antihypertensive medication. Patients with arrhythmias, cerebrovascular diseases, advanced age, or high systolic blood pressure preoperatively need closer monitoring for potential abnormal electrocardiographic findings. The combined use of preoperative and systolic blood pressure at the start of the operation indicators can preliminarily screen patients who may require temporary oral medication for hypertension control during surgery and may experience heart rhythm abnormalities.

This study, being retrospective, has certain limitations. It only provides perioperative heart rate and blood pressure data for patients, lacking long-term follow-up on patient prognosis. Additionally, it lacks tracking reports on other objective indicators or complications, such as bleeding, infection, and poor healing. The dental treatments discussed mainly involved tooth extractions, with fewer cases of other procedures. Moreover, antihypertensive measures include not only pharmacological control but also intraoperative physical methods such as verbal and manual soothing and temporarily halting surgical procedures to alleviate patient anxiety and stabilize blood pressure, which were not reflected in the analysis.

Patients with well-controlled hypertension undergoing dental treatment generally face lower overall risk. This study shows that patients with high systolic blood pressure preoperatively, high systolic blood pressure at the start of operation, and fast heart rates are more likely to experience intraoperative blood pressure exceeding 180 mmHg, possibly requiring temporary intraoperative antihypertensive medication. Patients with pre-existing arrhythmias or cerebrovascular disease, older patients, or those with higher systolic blood pressure preoperatively need closer monitoring for intraoperative ECG changes. In clinical practice, it is advisable to measure systolic blood pressure at least twice after patient admission and before the start of the surgical procedure, using 159 mmHg and 156 mmHg as thresholds to identify potentially high-risk patients early.

Conflict of Interest

The authors declare that the research was conducted without any commercial or financial relationships that could potentially create a conflict of interest.

Ethical Approval

This study was approved by the Ethics Committee of the Peking University School of Stomatology (PKUSSIRB-202385014).

Informed Consent

Not Applicable. This study is a retrospective study, and the informed consent requirement was waived by the Institutional Review Board.

Funding

This work was supported by grants from Clinical Research Foundation of Peking University School and Hospital of Stomatology (PKUSS-2023CRF205).

Author Contribution

Y.Y. and W.W. wrote the main manuscript text. X.X. and Y.J. designed the experimental protocol and provided writing guidance. C.L. and J.L. contributed to data collection and analysis. All authors reviewed the manuscript.

Acknowledgement

We gratefully acknowledge the support from the Clinical Research Foundation of Peking University School and Hospital of Stomatology.

Data Availability

The data supporting the findings of this study are included within the manuscript.

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Risk Analysis of Oral Treatment in Hypertensive Patients Under ECG Monitoring: A Single-Center Retrospective Observational Study

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Version 1

Abstract

Objectives

Materials and Methods

Results

Conclusions

Clinical Relevance:

Figures

1 Introduction

2 Materials and methods

2.1 Study Design

2.2 Patient Selection

2.3 Data collection

2.4 Independent variables of the study

2.5 Risk Analysis

2.6 Statistical Analysis

3 Result

3.1 Demographic Characteristics

3.1.1 Gender

3.1.2 Age

3.1.3 Other Systemic Chronic Diseases

3.1.4 Types of Surgical Treatments

3.2 Blood pressure and heart rate values

3.2.1 Blood Pressure and Heart Rate Data Preoperatively and at the Start of Operation

3.2.2 Intraoperative Maximum Blood Pressure and Heart Rate Data

3.2.3 Intraoperative Blood Pressure and Heart Rate Fluctuations

3.3 Risk analysis

3.3.1 Blood pressure and heart rate indicators

3.3.2 ECG abnormality indicators

3.3.3 Preliminary Risk Assessment Process

4 DISCUSSION

4.1 The Significance of Blood Pressure and ECG Monitoring

4.2 The Impact of Gender and Age on Blood Pressure and Heart Rhythm

4.3 The Impact of Systemic Diseases on Blood Pressure and Heart Rhythm

4.4 The Effects of Surgical Procedures on Blood Pressure and Heart Rhythm

4.5 Cardiovascular Risk Prediction

5 Conclusion

Declarations

Conflict of Interest

Funding

Author Contribution

Acknowledgement

Data Availability

References

Additional Declarations

Status:

Version 1