Hypertension

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Hypertension and Athletes
And...

• Anthony Beutler, MD
• Uniformed Services University

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Actual Quotes from Sports Medicine Patients

• I wan all dem kids to do what I do, to look up
  to me. I wan all the kids to copulate me.
• --Andre Dawson
• Chicago Cubs

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Objectives

• Review of Hypertension JNC VII
• Hypertension in Athletes
• Diagnosis Workup
• Treatment
• Risks
• Using Exercise to Treat Hypertension
• Current Literature Review

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Review of HTN JNC VIIStuff You Know

• Most common cardiovascular condition in
  competitive athletes
• 50 million adult Americans have hypertension
• Almost 32 are unaware
• Only 54 are being treated
• Nearly 3/4 of adult Americans with HTN are not
  controlling their BP below 140/90 mm Hg

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Percentage of U.S. Adults Ever Told They Have
Hypertension
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Review of HTN JNC VIIStuff You Knew
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Review of HTN JNC VIIWhats New in JNC VII

• below 120
• 80
• 121 139
• 80 89
• 140 159
• 90 99
• over 160
• 100

• Normal Blood Pressure
• PreHypertension
• Stage I Hypertension
• Stage II Hypertension

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Review of HTN JNC VIIMessages from JNC VII

• In adults over 50, systolic or diastolic blood
  pressure more important?
• Beginning at 115/75, CVD risk doubles for
  every
• Use 2 or more agents for
• A 55 yo normotensive pt has a ______ lifetime
  risk of developing HTN.

Systolic 20 10 over 160/100,
DM, CKD 90
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Actual Quotes from Sports Medicine Patients

• I want to rush for 1,000 or 1,500 yards,
  whichever comes first
• --George Rogers
• Your Washington Redskins

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Objectives

• Review of Hypertension JNC VII
• Hypertension in Athletes
• Diagnosis Workup
• Treatment
• Risks
• Using Exercise to Treat Hypertension
• Current Literature Review

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HTN in Athletes Diagnosis WorkupHow to
Measure

• Patient seated, arm supported at heart level
• Rested for minimum of 5 minutes
• No tobacco or caffeine within 30 minutes
• Average of 2 or more readings separated by 2
  minutes
• Appropriate cuff size

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HTN in Athletes Diagnosis and WorkupChildren
and Adolescents

• Children and adolescents
• Age-adjusted tables based upon gender and height
  percentile
• Rule of 3s
• Three different measurements on three different
  days
• Appropriately sized cuff
• Good luck finding one

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The Labels Change
Values Stay the Same
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HTN in Athletes Diagnosis and WorkupWork-up

• History
• Family History, Drugs, and Sx of Secondary HTN
• Exam
• Lab
• CBC, electrolytes, fasting glucose, lipid, BUN/Cr
• Rads
• EKG, CXR, Echo?

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HTN in Athletes TreatmentNon-Pharmacologic

• Control Weight
• 10 lbs 15/10
• Diet
• Na
• K
• Ca2
• Caffeine
• ETOH
• Exercise

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HTN in Athletes TreatmentDASH Diet

• Diet rich in
• fruits and vegetables (8-10 servings/d)
• low-fat dairy products (2.7 servings/d)
• reduced saturated and total fat
• All Comers demonstrated average i 5.5/3.0 mmhg
• Among HTN individuals, BP i 11.4/5.5 mmhg

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HTN in Athletes TreatmentPharmacologic
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Drugs in
Hypertensive Athletes
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Dr. Beutler Surveyed Himself 100 Times Top 3
Answers on the Board
A 21 yo All American Football Lineman has HTN.
What drug do you put him on?
ss
S
I
Ca Chan (Dihydr)
B
P
Ace Inhibitor
ARB
B-Blocker
Diuretic or Alpha Block
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HTN in Athletes RisksRisks for HTN Athletes

• RR of CV Events
• Increased 2.0 4.0
• Depending on BMI
• RR of Heat Illness
• Increased 2.0 5.0
• HTN Athletes have decreased variation in TPR
• Decreased ability to shunt blood to skin during
  high temperature exercise

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HTN in Athletes RisksClear to Play

• Stages 1 and 2 hypertension, in the absence of
  target organ damage or concomitant heart disease,
  should not limit eligibility for any competitive
  sport
• Stage 3 hypertension - should be restricted from
  participating, particularly from high static
  sports, until their hypertension is adequately
  controlled and they are without evidence of
  target organ damage

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HTN in Athletes RisksClear to Play JNC VII

• BP gt 99th percentile No Go until BP Controlled
• When hypertension coexists with other
  cardiovascular diseases, eligibility for athletic
  participation is based upon the type and severity
  of the coexistent disease process

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HTN in Athletes RisksClear to Play 36th
Bethesda

• 1. All Athletes have BP monitored (avoid white
  coat)
• a. Prehypertension modify lifestyle and
  participate
• b. Any Sustained HTN echo limit participation
  until BP normal with meds
• 2. Stage 1
• W/o end organ damage no limit, check BP q2 mo
• W/ end organ damage (LVH) see 1b
• 3. Stage 2
• W/ or w/o EOD restrict, esp high static sports,
  until BP nl

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HTN in Athletes RisksClear to Play 36th
Bethesda

• All Drugs must be registered with governing
  bodies
• If HTN and other disease, base clearance on
  demands of other disease

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Objectives

• Review of Hypertension JNC VII
• Hypertension in Athletes
• Diagnosis Workup
• Treatment
• Risks
• Using Exercise to Treat Hypertension
• Current Literature Review

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HTN in Athletes Exercise to Treat HTNStatic vs
Dynamic Exercise
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New York City
E XERC I S E
D Y N A M I C
Marathon
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HTN in Athletes Exercise to Treat HTNDynamic
Exercise

• Decrease in resting blood pressures
• 11/9 mmHg
• Moderate intensity exercise (55 - 70 max heart
  rate) appears most beneficial
• Beyond 70 blood pressure may actually increase!
• Precise mechanism not completely delineated
• Eccentric Hypertrophy
• Decreased Arteriole Stiffness

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HTN in Athletes Exercise to Treat HTNDynamic
Exercise

• Use It or LOOSE It
• All beneficial effects lost after 2 months of
  deconditioning

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Actual Quotes from Sports Medicine Patients

• Coach treats us like men. He lets us wear
  earrings.
• --Torrin Polk
• Houston Texans

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Static exercise
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HTN in Athletes Exercise to Treat HTNStatic
Exercise

• Multiple studies show decrease in resting BP
  after 4-8 weeks of resistance training
• BP changes typically 2-3 points less than dynamic
  exercise studies
• More improvement with lower weight, higher rep
  (15 rep max)
• And with proper technique, avoiding valsalva
• Classically described concern with static
  exercise

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Arterial Blood Pressure Response to Heavy
Resistance Exercise

• MacDougall, JD, Tuxen, D, et al. Journal of
  Applied Physiology. 198558(3)785-790.

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HTN in Athletes Exercise to Treat
HTNMacDougall Study

• Left brachial a-line
• Performed
• single-arm curls and overhead presses
• Single and double-leg seated leg presses
• Recorded highest absolute pressure of 480/350 mm
  Hg!!!

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HTN in Athletes Exercise to Treat HTNSafety of
Weighlifting

• Despite elevations in blood pressure, weight
  lifting remains safe sport
• Very few reported instances where elevations
  known to cause injury
• Isolated reports of subarachnoid hemorrhage and
  brain stem ischemia
• Hypertensive patients have traditionally been
  advised to avoid resistance training
• Studies No h risk of stroke or MI

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Actual Quotes from Sports Medicine Patients

• Nobody in football should be called a genius. A
  genius is someone like Norman Einstein
• --Joe Theismann
• Your Washington Redskins

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Objectives

• Review of Hypertension JNC VII
• Hypertension in Athletes
• Diagnosis Workup
• Treatment
• Risks
• Using Exercise to Treat Hypertension
• Current Literature Review

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HTN in Athletes Current Literature ReviewACSM
Position Stand Mar 2004

• Exercise remains a cornerstone therapy for the
  primary prevention, treatment, and control of
  HTN. The optimal training frequency, intensity,
  time, and type (FITT) need to be better defined
  to optimize the BP lowering capacities of
  exercise, particularly in children, women, older
  adults, and certain ethnic groups.

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HTN in Athletes Current Literature ReviewACSM
Position Stand Mar 2004

• Based upon the current evidence, the following
  exercise prescription is recommended for those
  with high BP Frequency on most, preferably all,
  days of the week. Intensity moderate-intensity
  (40-lt60 VO2R). Time gt or 30 min of continuous
  or accumulated physical activity per day. Type
  primarily endurance physical activity
  supplemented by resistance exercise.

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HTN in Athletes Current Literature ReviewSome
Hick in Greensboro vs The Godfather

• Hypertension in the athlete. Sachtleben T,
  Fields KB.
• Curr Sports Med Rep. 2003 Apr2(2)79-83.
• Hypertension, Athletes, and the Sports
  Physician. OConnor F, Meyering C, Patel R,
  Oriscello R
• Curr Sports Med Rep. 2007 680-84.

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HTN in Athletes Current Literature
ReviewEffect of Athletic Participation on Golden
Years

• Use of medications and dietary supplements in
  later years among male former top-level athletes
• Kujala UM, Sarna S, Kaprio J.
• Arch Intern Med. 2003 May 12163(9)1064-8
• Who
• Male athletes (N 2026) represent Finland in
  internatl events
• 1401 control subjects classified healthy at age
  of 20 years
• Represented Finland 1920 through 1965

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HTN in Athletes Current Literature
ReviewEffect of Athletic Participation on Golden
Years

• Rates of Rxs for HTN, CHF drugs examined
• Results
• Use of CHF Drugs - 0.61 (Hazard Ratio)
• Use of CAD Drugs - 0.72
• Use of Asthma Drugs - 0.47
• Among Endurance Athletes
• Use of HTN Drugs 0.73
• Use of DM Drugs 0.38
• No difference between Power Athletes Controls

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HTN in Athletes Current Literature
ReviewEffect of Athletic Participation on Golden
Years

• Athletes had Lower Usage of
• NSAIDs
• Antacids
• Higher usage of
• Vitamins A, C, E
• Selenium
• Fe

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HTN in Athletes Current Literature ReviewYour
Very Own College

• Managing hypertension in athletes and physically
  active patients
• Niedfeldt MW
• Am Fam Physician. 2002 Aug 166(3)445-52

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Actual Quotes from Sports Medicine Teachers

• You guys line up alphabetically by height. You
  guys pair up in groups of three, and then line up
  in a circle.
• --Bill Peterson
• Florida State Football Coach

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Objectives

• Review of Hypertension JNC VII
• Hypertension in Athletes
• Diagnosis Workup
• Treatment
• Risks
• Using Exercise to Treat Hypertension
• Current Literature Review

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With Love to Papa Jarvis.
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The Long Short of It
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Pharmacologic Treatment

• Diuretics
• Beta-blockers
• ACE-inhibitors
• Angiotensin II receptor blockers
• Ca channel blockers
• Central alpha-receptor agonists
• Alpha-1 blockers

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Diuretics

• Have been shown to improve long-term morbidity
  and mortality
• Must caution athlete about potential for volume
  depletion, dehydration, and hypokalemia
• May be accentuated by exercise
• Remain good choice for the low-level,
  non-competitive weekend athlete
• Not a good choice for the endurance athlete
• Banned by both the IOC and NCAA

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Beta-blockers

• Exert their influence via negative inotropic and
  chronotropic effects
• i max heart rate, myocardial contractility,
  cardiac output, O2 consumption, and VO2max
• i myocardial contractility and rate g increased
  diastole and thus h coronary perfusion
• Excellent choice for patient with CHD
• Many will be able to mount h level of exertion
  while on beta-blockers

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Beta-blockers

• Probably drug of choice for non-endurance athlete
  and those with CHD
• Not a good choice for the endurance athlete
• Banned by the IOC and NCAA for certain sporting
  events

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Central alpha-receptor agonists

• Act in the CNS to block sympathetic stimulation
  and thereby inhibit increases in vascular tone
• No known specific negative effects upon exercise
• Frequently cause fatigue, drowsiness, dry mouth,
  and post-exercise hypotension
• Rebound hypertension in the forgetful or
  noncompliant patient
• Are effective medications with minimal negative
  influences upon exercise
• Limited by sedative side effects

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Alpha-1 receptor blockers

• Decrease vascular contractility and TPR by
  blocking the alpha-1 receptors in smooth muscle
• Resultant arterial vasodilatation frequently
  causes orthostatic hypotension and 1st dose
  syncope
• Conflicting evidence about their effect on
  exercise
• Good choice for most active patients ? for elite
  level excellent choice for older patient with BPH

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Angiotensin-converting enzyme (ACE) inhibitors

• Block conversion of angiotensin I to angiotensin
  II
• Angiotensin II -- potent vasoconstrictor
• h arterial pressure by direct vasoconstriction of
  arterioles
• Stimulates secretion of aldosterone by adrenal
  cortex g induces fluid retention
• Inhibits renal excretion of Na and H2O

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Angiotensin-converting enzyme (ACE) inhibitors

• Well tolerated
• 10 - 15 of patients experience cough
• Has been associated with angioedema and
  anaphylaxis
• ? Increased risk of exercise-induced anaphylaxis
• Increase in buildup of bradykinins
• Teratogenic

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Angiotensin-converting enzyme (ACE) inhibitors

• Excellent choice for most active patients - many
  would say, the drug of choice in the
  hypertensive athlete
• Especially for those with diabetes
• Elderly and blacks do not respond as well
• Probably due to low renin states

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Angiotensin-II receptor blockers

• Also act upon renin-angiotensin-aldosterone
  system by blocking angiotensin II at receptor
  level
• Inhibit vasoconstrictor effects of angiotensin II
  as well as the increase in bradykinins
• So far have appeared to have all the beneficial
  effects of ACE inhibitors without usual side
  effects
• No definitive studies but appear to be similar
  to ACE inhibitors in efficacy and side effect
  profile

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Calcium channel blockers

• Decrease vascular smooth muscle contractility by
  inhibiting influx of Ca ions
• Have negative inotropic and chronotropic effects
  upon myocardium
• 3 classes with slightly different
  pharmacodynamics
• Phenylalkylamines (verapamil)
• Benzothiazepines (diltiazem)
• Dihydropyridines (nifedipine, amlodipine -
  Norvasc, felodipine - Plendil)

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Calcium channel blockers

• Phenylalkylamines (verapamil)
• Causes less vasodilatation, but has greater
  negative inotropic and chronotropic effects
• Benzothiazepines (diltiazem)
• Lesser effects upon arterial tree and myocardium
• Dihydropyridines (nifedipine, amlodipine -
  Norvasc, felodipine - Plendil)
• Almost exclusively affect arterial tree causing
  vasodilatation no inotropic or chronotropic
  effects

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Calcium channel blockers

• No studies demonstrating negative effects upon
  exercise
• Long-acting Ca-blockers (particularly the
  dihydropyridines) are excellent choice for active
  pt
• Short-acting formulations - trash can
• Verapamil, and to lesser extent diltiazem, are
  avoided in active pt, due to their negative
  inotropic and chronotropic effects