Hypertension in the Hypertension in the Athletic Population Athletic Population Matthew Lewullis, DO Matthew Lewullis, DO Mercy Sports Medicine Mercy Sports Medicine Norristown, PA Norristown, PA
Objectives Objectives � Overview of hypertension Overview of hypertension � � Proper blood pressure Proper blood pressure � measurement measurement � Guidelines for athletic Guidelines for athletic � participation participation � Adults Adults � � Children and Adolescents Children and Adolescents � � Medications Medications � � BP measurement on the BP measurement on the � sideline sideline
Prevalence Prevalence � HTN affects approx. 60 HTN affects approx. 60 � million Americans million Americans � Most common medical Most common medical � issue in athletes issue in athletes � Reduce CAD, CVA, Reduce CAD, CVA, � CHF, etc. CHF, etc. � Improved detection, Improved detection, � treatment, and control of treatment, and control of HTN in adults over the HTN in adults over the last 3 decades last 3 decades
Risk Factors Risk Factors � Coronary artery disease Coronary artery disease � � Cerebral vascular Cerebral vascular � accident accident � Congestive heart failure Congestive heart failure � � Atrial fibrillation Atrial fibrillation � � Left ventricular Left ventricular � hypertrophy hypertrophy � Retinal disease Retinal disease � � Kidney disease Kidney disease �
Proper Measurement Proper Measurement � Many factors can influence BP measurement Many factors can influence BP measurement � � bladder distension, room temperature, recent exercise, bladder distension, room temperature, recent exercise, � alcohol or nicotine, arm position, muscle tension, talking, alcohol or nicotine, arm position, muscle tension, talking, background noise, decongestants, caffeine, etc. background noise, decongestants, caffeine, etc. � Ideal to sit for 5 minutes prior to testing Ideal to sit for 5 minutes prior to testing � � Remove clothing, don Remove clothing, don’ ’t roll up the patient t roll up the patient’ ’s shirt s shirt � � Patient comfortable in a chair with back and arm Patient comfortable in a chair with back and arm � supported supported � Middle of cuff at level of right atrium Middle of cuff at level of right atrium � � Middle of sternum Middle of sternum �
Proper Measurement Proper Measurement � Proper cuff: Proper cuff: � � Bladder length Bladder length – – 80% of arm circumference 80% of arm circumference � � Bladder width Bladder width – – 40% of arm circumference 40% of arm circumference � Arm Size Cuff Type Bladder Size Arm Size Cuff Type Bladder Size 22 – – 26 cm 26 cm Small Adult 12 x 22 cm 22 Small Adult 12 x 22 cm 27 – – 34 cm 34 cm Adult 16 x 30 cm 27 Adult 16 x 30 cm 35 – – 44 cm 44 cm Large Adult 16 x 36 cm 35 Large Adult 16 x 36 cm 45 – – 52 cm 52 cm Adult Thigh 16 x 42 cm 45 Adult Thigh 16 x 42 cm
Proper Measurement Proper Measurement � Inflate about 30 mmHg beyond disappearance Inflate about 30 mmHg beyond disappearance � of the radial pulse of the radial pulse � Deflate slowly at about 2 Deflate slowly at about 2- -3 mmHg 3 mmHg � � Appearance of sound is systolic Appearance of sound is systolic � � Disappearance of sound is diastolic Disappearance of sound is diastolic � � Precise BP is usually an average of multiple Precise BP is usually an average of multiple � measurements over weeks or months measurements over weeks or months
Guidelines Guidelines � The Seventh Report of the Joint National Committee The Seventh Report of the Joint National Committee � on Prevention, Detection, Evaluation, and Treatment on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII), August 2004. of High Blood Pressure (JNC VII), August 2004. � The Fourth Report on the Diagnosis, Evaluation, and The Fourth Report on the Diagnosis, Evaluation, and � Treatment of High Blood Pressure in Children and Treatment of High Blood Pressure in Children and Adolescents, September 1996, revised May 2005. Adolescents, September 1996, revised May 2005. � 36th Bethesda Conference: Recommendations for 36th Bethesda Conference: Recommendations for � Determining Eligibility for Competition in Athletes Determining Eligibility for Competition in Athletes with Cardiovascular Abnormalities: Task Force 5: with Cardiovascular Abnormalities: Task Force 5: Systemic Hypertension, 2005. Systemic Hypertension, 2005.
JNC VII JNC VII � Guidelines for adults Guidelines for adults � � No specific indications or recommendations for No specific indications or recommendations for � athletes athletes Category Systolic BP Diastolic BP Category Systolic BP Diastolic BP Normal <120 and <80 Normal <120 and <80 Pre- -hypertension hypertension 120- -139 or 139 or 80- -89 89 Pre 120 80 HTN, Stage I 140- -159 or 159 or 90- -99 99 HTN, Stage I 140 90 HTN, Stage II ≥ 160 or 160 or ≥ 100 100 HTN, Stage II ≥ ≥
JNC VII JNC VII � Pre Pre- -hypertension, Stage I, II hypertension, Stage I, II – – lifestyle modifications lifestyle modifications � � Weight reduction (BMI 18.5 Weight reduction (BMI 18.5- -24.9) 24.9) � � DASH diet DASH diet � � Sodium restriction (2.4g sodium) Sodium restriction (2.4g sodium) � � Aerobic physical activity (>30min/day, most days) Aerobic physical activity (>30min/day, most days) � � Moderation of alcohol consumption Moderation of alcohol consumption � � Men ( Men ( ≤ ≤ 2 drinks/day), Women ( 2 drinks/day), Women ( ≤ ≤ 1 drink/day) 1 drink/day) � � Stage I Stage I – – at least one medication, rec. thiazide type at least one medication, rec. thiazide type � diuretics for most patients (HCTZ, Zaroxolyn, etc.) diuretics for most patients (HCTZ, Zaroxolyn, etc.)
JNC VII JNC VII � Stage II Stage II – – 2 medications for most patients 2 medications for most patients � � CAD and CVA risk doubles for every 20/10 CAD and CVA risk doubles for every 20/10 � increase in BP, starting at 115/75 increase in BP, starting at 115/75 � Most patients require 2 or more medications to Most patients require 2 or more medications to � reach goal reach goal � Evaluation of HTN patient should at least Evaluation of HTN patient should at least � include physical exam, electrocardiography, include physical exam, electrocardiography, urinalysis, kidney function, electrolytes, urinalysis, kidney function, electrolytes, cholesterol to assess for target organ damage cholesterol to assess for target organ damage
Guidelines Guidelines � The Seventh Report of the Joint National Committee The Seventh Report of the Joint National Committee � on Prevention, Detection, Evaluation, and Treatment on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII), August 2004. of High Blood Pressure (JNC VII), August 2004. � The Fourth Report on the Diagnosis, Evaluation, and The Fourth Report on the Diagnosis, Evaluation, and � Treatment of High Blood Pressure in Children and Treatment of High Blood Pressure in Children and Adolescents, September 1996, revised May 2005. Adolescents, September 1996, revised May 2005. � 36th Bethesda Conference: Recommendations for 36th Bethesda Conference: Recommendations for � Determining Eligibility for Competition in Athletes Determining Eligibility for Competition in Athletes with Cardiovascular Abnormalities: Task Force 5: with Cardiovascular Abnormalities: Task Force 5: Systemic Hypertension, 2005. Systemic Hypertension, 2005.
Children and Adolescents Children and Adolescents � Classification stages Classification stages � same as JNC VII same as JNC VII � Based on age, sex, and Based on age, sex, and � percentile of height percentile of height � More emphasis on More emphasis on � detecting target organ detecting target organ damage damage � 3 separate measurements 3 separate measurements � to diagnose HTN to diagnose HTN
Children and Adolescents Children and Adolescents
Children and Adolescents Children and Adolescents Category BP percentile Category BP percentile Normal <90% (SBP and DBP) Normal <90% (SBP and DBP) Pre- -hypertension hypertension 90%- -95% (SBP or DBP) 95% (SBP or DBP) Pre 90% HTN, Stage I 95%- -99%+5 (SBP or DBP) 99%+5 (SBP or DBP) HTN, Stage I 95% HTN, Stage II >99%+5 (SBP or DBP) HTN, Stage II >99%+5 (SBP or DBP)
Children and Adolescents Children and Adolescents � Pre Pre- -hypertension hypertension � � Weight and diet management, introduce physical activity Weight and diet management, introduce physical activity � � Medicate if target organ damage Medicate if target organ damage � � Re Re- -check 6 months check 6 months � � Stage I Stage I � o HTN, � Medicate if symptomatic, target organ damage, 2 Medicate if symptomatic, target organ damage, 2 o HTN, � diabetes, or if fail above diabetes, or if fail above � Re Re- -check every 1 check every 1- -2 weeks 2 weeks � � Stage II Stage II � � Initiate medical therapy Initiate medical therapy �
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