The Hypertensive Athlete

General Principles

  • An estimated 108 million Americans over the age of 18 years have hypertension (HTN).

  • HTN is the most common cardiovascular condition observed in competitive athletes.

  • Athletes are usually considered to be free from cardiovascular disease because of their apparent high level of fitness.

    • The overall incidence of HTN in athletes is approximately 50% less than that in the general population.

  • HTN begins in young adulthood; incidence increases with age

    • Almost 80% of adolescents with an elevated blood pressure (BP) (>142/92 mmHg) during preparticipation physical examinations have HTN.

Definition and Staging of Hypertension (2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APHA/ASH/ASPC/NMA/PCNA Guideline)

  • Normal BP: Systolic <120 mmHg and diastolic <80 mmHg

  • Elevated BP: Systolic 120–129 mmHg and diastolic <80 mmHg

  • HTN:

    • Stage 1: Systolic 130–139 mmHg or diastolic 80–89 mmHg

    • Stage 2: Systolic ≥140 mmHg or diastolic ≥90 mmHg

  • If there is a disparity in category between systolic and diastolic pressures, the higher value determines stage ( Table 36.1 )

    Table 36.1
    Classification of Hypertension
    Systolic (mmHg) Diastolic (mmHg)
    Normal <120 <80
    Elevated blood pressure 120–129 <80
    Hypertension: Stage 1 130–139 80–89
    Hypertension: Stage 2 ≥140 ≥90
    Classification of blood pressure (BP) for adults aged ≥18 years. The classification is based on the mean of two or more appropriately measured seated BP readings on each of three or more office visits. In contrast with the classification provided in the JNC 7 report, a new category designated “elevated blood pressure” is combined with stage 1 hypertension to replace the prehypertension category. All blood pressures over 140 mmHg systolic or 90 mmHg diastolic are considered stage 2 hypertension. If there is a disparity in category between the systolic and diastolic pressures, the higher value determines the stage.
    Whelton PK, Carey RM, Aronow WS, 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: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol . 2018;71(19):2199–2269. Erratum in: J Am Coll Cardiol . 2018;71(19):2273–2275, Table 6 , Page 2209.

  • Stage 1: systolic 130–139 mmHg or diastolic 80–89 mmHg

    • Associated with increased cardiac output (CO), which primarily increases systolic BP, along with “normal” vascular total peripheral resistance (TPR)

    • TPR is normal compared with resting levels in normotensives but inappropriately high when CO is elevated.

      • In nonhypertensive patient, TPR falls to compensate for rise in CO, thereby maintaining normal BP.

      • Lack of decrease in TPR is result of impaired baroreceptor function.

      • Baroreceptors are “reset” to maintain elevated rather than normal BP over time.

    • People with stage 1 HTN are hypersensitive to catecholamine secretion and mental stress and have a hyperkinetic circulatory state.

  • Stage 2:

    • Systolic BP 140–159 mmHg and diastolic BP 90–99 mmHg

      • Increased heart rate (HR) and CO and decreased TPR

      • Decreased arterial lumen and disturbed autoregulation of peripheral blood flow

  • Systolic BP >160 mmHg and diastolic BP >100 mmHg

    • Normal HR and CO; increased TPR

      • Increased afterload leads to left ventricular hypertrophy (LVH) and increased diastolic BP. Severe and/or uncontrolled HTN may lead to development of diastolic dysfunction and congestive heart failure (CHF).

      • CO can no longer increase in response to exercise or other physiologic demands.

      • Loss of contractility and CHF may develop.

  • Most active individuals with HTN will fall into stage 1 or lower stage 2 (<160 mmHg/<100 mmHg).

  • Those with comorbidities, such as diabetes or renal disease, should be treated at stage 1 levels.

  • Values for pediatric athletes under age 13 are adjusted for age, gender, and height ( Table 36.2 ).

    Table 36.2
    2017 American Academy of Pediatrics Updated Definitions for Pediatric Blood Pressure Categories
    For Children Aged 1 to <13 Years For Children Aged ≥13 Years
    Normal BP Systolic and diastolic BP <90th percentile Systolic BP <120 and diastolic BP <80 mmHg
    Elevated BP Systolic and diastolic BP ≥90th percentile to <95th percentile or 120/80 mmHg to <95th percentile (whichever is lower) Systolic BP 120–129 and diastolic BP <80 mmHg
    Stage 1 HTN Systolic and diastolic BP ≥95th percentile to <95th percentile + 12 mmHg or 130/80—139/89 mmHg (whichever is lower) 130/80–139/89 mmHg
    Stage 2 HTN Systolic and diastolic BP ≥95th percentile + 12 mmHg or ≥140/90 mmHg (whichever is lower) ≥140/90 mmHg
    Flynn JT, Kaelber DC, Baker-Smith CM, et al; Subcommittee on Screening and Management of High Blood Pressure in Children. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics . 2017;140(3):e20171904, Table 3 . Erratum in: Pediatrics . 2017; Erratum in: Pediatrics . 2018;142(3).

  • Higher stages are associated with a higher risk of nonfatal and fatal cardiovascular disease in addition to progressive renal disease ( Fig. 36.1 ).

    Figure 36.1, Hypertension as a risk factor for cardiovascular disease.

Clinical Pathophysiology of Hypertension

Primary Hypertension

  • Ninety-five percent of cases

  • Abnormal neuroreflexes and sympathetic control of peripheral resistance

  • Abnormal renal and metabolic control of vascular volume and compliance

    • Abnormal local smooth muscle and endothelial control of vascular resistance

    • Sustained increases in systemic vascular resistance (SVR)

Secondary Hypertension

  • Five percent of cases

  • Younger patients or adults with rapid onset of HTN and no prior history of HTN

  • BP is often poorly responsive to routine therapy.

Causes ( Fig. 36.2 )

  • Renal (most common)

    • Renovascular disease

      • Increased renin stimulates conversion of angiotensin I to angiotensin II, which is a vasoconstrictor, in addition to release of aldosterone

      • Renal retention of sodium and water

      • Fibromuscular dysplasia in younger patients and atherosclerosis in older patients

    • Renal parenchymal disease

      • Inability of damaged kidneys to excrete sodium and water

    Figure 36.2, Causes of hypertension.

  • Endocrine

    • Adrenal

      • Pheochromocytoma

      • Cushing syndrome

      • Primary aldosteronism

    • Thyroid

      • Hyperthyroidism

      • Hypothyroidism

    • Acromegaly

    • Hyperparathyroidism

  • Other

    • Coarctation of the aorta

    • Obstructive sleep apnea

Risk Factors For Hypertension

  • Age

    • Five to ten percent in adults aged 20–30 years

    • Twenty to thirty-five percent in middle-aged adults

    • More than 50% in adults aged over 60 years

    • Residual lifetime risk of 90%

  • Genetic factors

    • Males more than females

    • African Americans more than Caucasians (2:1); Asians lowest risk

    • Family history (HTN twice as common if either parent has HTN)

  • Metabolic factors

    • Obesity

    • Glucose intolerance

    • Endocrine disorders (see “Causes”)

  • Stress

    • Environmental

    • Social

    • Leads to chronic neurogenic activation of the sympathetic nervous system

  • Behavioral factors

    • High sodium intake

    • Excessive alcohol consumption

    • Drug abuse (see later)

  • Medications

    • Oral contraceptive pills (OCPs); 5% will develop HTN over 5 years

    • Nonsteroidal anti-inflammatory drugs (NSAIDs), particularly chronic use

    • Antidepressants, including tricyclic antidepressants, selective serotonin reuptake inhibitors, and monoamine oxidase inhibitors

    • Corticosteroids, including both glucocorticoids and mineralocorticoids

    • Decongestants, such as phenylephrine and pseudoephedrine

    • Some weight-loss medications

    • Attention-deficit/hyperactivity disorder (ADHD) medications such as methylphenidate and amphetamines

    • Illicit drug use

      • Recreational: cocaine, methamphetamines or tobacco (chew)

      • Ergogenic: stimulants, erythropoietin, human growth hormone, or anabolic steroids

Diagnosis of Hypertension

Resting Blood Pressure

  • Diagnosis of HTN can be confirmed by serial (at least three) office-based BP measurements with a mean of ≥130/≥80 mmHg spaced over a period of weeks to months (see Table 36.1 ).

    • Should be confirmed with home BP monitoring or ambulatory blood pressure monitoring (ABPM) if possible.

  • In children and early adolescents, HTN is defined as average systolic or diastolic BP ≥95th percentile for age, gender, and height, measured on three separate occasions. Adolescents over age 13 use the same measurements as adults (see Table 36.2 ).

Environment During Measurement

  • Measurement of BP should be performed in a standard measurement situation, preferably a quiet area.

  • Avoid exercise and caffeine for >30 minutes before measurement.

  • Let the athlete sit in a chair with back supported and feet flat on the floor for a few minutes if possible.

  • Choose the appropriate-size BP cuff. Many athletes will need a large cuff, and a thigh cuff should be available for very large athletes.

    • BP cuff’s inflatable bag should cover approximately 80% of arm’s circumference.

    • BP may be overestimated if the BP cuff is too small, whereas BP may be underestimated if the BP cuff is too big.

  • Avoid rapid deflation of the cuff.

  • Repeat BP measurements if elevated.

    • In younger athletes, if BP in arm is elevated, obtain BP measurement in leg to assess for aortic coarctation.

“White Coat” Hypertension and Other Stress Phenomena

  • Anxiety provoked by medical examination or other sources of mental stress can lead to artificially elevated BP, known as “white coat” HTN.

  • Average of several readings is a better estimate of true BP.

  • If initial BP is high, have athlete rest for 5 minutes and repeat BP measurement.

  • If BP remains elevated, check BP at least once per week for at least two additional visits.

  • Averaged daily BP is a better predictor of later end-organ damage than random office BP.

  • Twenty-four-hour ABPM may more accurately assess BP in people with variable readings in the office or at home but can be difficult and expensive.

  • Home BP monitoring correlates well with ABPM.

  • Athletes/exercisers can take their own BP, but must be well trained in measurement of BP.

  • Emphasize importance of accurate readings.

Clinical Evaluation

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