In a previous blog post, I talked about the general problem of high blood pressure, or “hypertension.” Today, I thought I’d focus our discussion about hypertension specifically on the issues that athletes face.
Here at the blog, we’ve talked about many UNcommon cardiovascular problems that athletes might confront. But hypertension is different. In fact, high blood pressure is the MOST COMMON cardiovascular problem discovered in athletes. If you don’t have this problem, you almost certainly know fellow athletes who do. And if you don’t have high blood pressure now, you might develop high blood pressure as you age. So….this is a problem worth knowing about.
First, some definitions….and we’re talking about adults here….
The NORMAL blood pressure is 160/100.
Benefits of Exercise
Randomized clinical trials have shown that physical activity is associated with a decrease in the blood pressure for all patient groups: those who have a normal blood pressure at the outset, those with high normal blood pressure or “pre-hypertension,” and those with high blood pressure. Regular and moderate aerobic exercise can reduce the blood pressure by up to 10 mm Hg. Similarly, moderate intensity resistance training (using light weights and high number of reps) can reduce the blood pressure by 3-6 mm Hg.
Regular exercise provides a real benefit. Among the physically active, the risk of developing hypertension is 50% less than for the inactive population. Nonetheless, there will be individuals who DO develop hypertension despite engaging in a regular exercise program. Those at particular risk include: African-Americans, the elderly, the obese, those with diabetes, and those with chronic kidney disease.
Evaluation of the Blood Pressure in Athletes
I’ve talked several times here at the blog about how important it is for athletes to have a physician. The BP should be checked at every visit. For student athletes, the BP should be checked at a pre-participation physical examination. It is important to remember that the BP varies over time. No single measurement should govern treatment decisions. If the BP is elevated at the doctor’s office, it may be wise to re-check the blood pressure in a more relaxed setting such as the home. You may need to work with your physician on how best to do this.
Some behaviors are known to be associated with elevated BP: increased sodium (salt) intake, tobacco use (any form), various over-the-counter medications (cold remedies, decongestants, “diet pills”), ergogenic aids (caffeine, Sudafed, cocaine, human growth hormone (HGH), anabolic steroids), various prescription medications (particularly non-steroidal anti-inflammatory drugs such as Motrin and oral contraceptives), and various dietary supplements.
Treatment of Hypertension in the Athlete
The first approach to treatment will involve “non-pharmacologic” therapy–treatment WITHOUT medications. Since we know the list of “bad” behaviors (noted above), our first efforts should be to eliminate these. We should also note that regular physical activity is helpful in this regard….but if you’re reading here, you’re probably already an athlete. Other useful measures include: ensuring adequate potassium intake (particularly for endurance athletes) and a variety of relaxation techniques (meditation, yoga, Tai Chi, etc.).
If medications are needed to control an athlete’s hypertension, several broad categories of medications are available. Each category has its own benefits and drawbacks. Anything I say here is a simplification, and there is an art and science to the selection of blood pressure medications for a patient. You will need to work carefully with your physician to choose an approach that WORKS FOR YOU.
1. ACE (angiotensin converting enzyme) inhibitors. Examples include: Altace, Zestril, lisinopril, enalapril. May be the drug of choice for athletes. There are few side effects if they are used in individuals who do not have kidney disease. Athletes taking ACE inhibitors may experience a sudden decrease in the BP just after a workout (potentially leading to blackout or syncope), so they should be aware of this possibility and have a cool-down period at the end of each workout.
2. Calcium channel blockers. Examples include: Norvasc, Calan, Isoptin, Cardizem. These medications are also useful in the athlete. They do not lead to a decrease in exercise capacity. They can lead to a decrease in the heart rate and contractility (strength) of the left ventricle (heart’s main pumping chamber), but this is compensated for by an increase in the stroke volume (the amount of blood the heart ejects with each heartbeat).
3. ARB’s (antiotensin receptor blockers). Examples include: Avapro, Atacand, Cozaar. These medications are similar to the ACE inhibitors. Again, they have a favorable side effect profile.
4. Central alpha-agonists. Examples include: Catapres, Tenex. These medications are not generally useful for the athlete. Side effects include: fatigue, orthostatic hypotension (decrease in the BP related to body position), and fluid and electrolyte imbalances.
5. Diuretics. Examples include: hydrochlorothiazide (HCTZ), Lasix. These should generally be avoided in the athlete. There is an increased risk of heat-related illness, impaired exercise capacity, cramps, and even arrhythmias. In hot weather, these medications may lead to unacceptably high losses of magnesium and potassium.
6. Beta-blockers. Examples include: Inderal, Lopressor, Toprol, Labetalol, Coreg. This is another category of drugs that should generally be avoided in the athlete. They lead to a significant reduction in maximum exercise capacity along with decreased cardiac output and VO2 max. They are also associated with increased perception of exertion and impaired temperature regulation.
Participation Recommendations for Athletes with Hypertension
Prudent recommendations for athletes with hypertension are summarized nicely in a report from the 36th Bethesda Conference on Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities. For athletes with high normal blood pressure or mild hypertension, there should be no restrictions to exercise or sports participation. The blood pressure should be checked every 2-4 months. For athletes with moderate or severe hypertension, activities should be restricted until the blood pressure is controlled.
The World Anti-Doping Agency (WADA) publishes a listing of medications or other substances that are banned for use by athletes during competition. Athletes should be aware of the ramifications (for their particular sport and circumstance) if they choose, along with their physician, to use medications which are included on the banned list.