Hypertension in the Hypertension in the Athletic Population - - PowerPoint PPT Presentation
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
Overview of hypertension
Proper blood pressure measurement measurement
Guidelines for athletic participation participation
Adults
Children and Adolescents
Medications
BP measurement on the sideline sideline
HTN affects approx. 60 million Americans million Americans
Most common medical issue in athletes issue in athletes
Reduce CAD, CVA, CHF, etc. CHF, etc.
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
Coronary artery disease
Cerebral vascular accident accident
Congestive heart failure
Atrial fibrillation
Left ventricular hypertrophy hypertrophy
Retinal disease
Kidney disease
Many factors can influence BP measurement
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
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 supported supported
Middle of cuff at level of right atrium
Middle of sternum
Proper cuff:
Bladder length – – 80% of arm circumference 80% of arm circumference
Bladder width – – 40% of arm circumference 40% of arm circumference
16 x 42 cm 16 x 42 cm Adult Thigh Adult Thigh 45 45 – – 52 cm 52 cm 16 x 36 cm 16 x 36 cm Large Adult Large Adult 35 35 – – 44 cm 44 cm 16 x 30 cm 16 x 30 cm Adult Adult 27 27 – – 34 cm 34 cm 12 x 22 cm 12 x 22 cm Small Adult Small Adult 22 22 – – 26 cm 26 cm Bladder Size Bladder Size Cuff Type Cuff Type Arm Size Arm Size
The Seventh Report of the Joint National Committee
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 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.
≥ ≥100 100 ≥ ≥160 or 160 or HTN, Stage II HTN, Stage II 90 90-
99 140 140-
159 or HTN, Stage I HTN, Stage I 80 80-
89 120 120-
139 or Pre Pre-
hypertension <80 <80 <120 and <120 and Normal Normal Diastolic BP Diastolic BP Systolic BP Systolic BP Category Category
Pre-
hypertension, Stage I, II – – lifestyle modifications lifestyle modifications
Weight reduction (BMI 18.5-
24.9)
DASH diet
Sodium restriction (2.4g sodium)
Aerobic physical activity (>30min/day, most days)
Moderation of alcohol consumption
Men (≤ ≤2 drinks/day), Women ( 2 drinks/day), Women (≤ ≤1 drink/day) 1 drink/day)
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.)
The Seventh Report of the Joint National Committee
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 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.
Classification stages same as JNC VII same as JNC VII
Based on age, sex, and percentile of height percentile of height
More emphasis on detecting target organ detecting target organ damage damage
3 separate measurements to diagnose HTN to diagnose HTN
>99%+5 (SBP or DBP) >99%+5 (SBP or DBP) HTN, Stage II HTN, Stage II 95% 95%-
99%+5 (SBP or DBP) HTN, Stage I HTN, Stage I 90% 90%-
95% (SBP or DBP) Pre Pre-
hypertension <90% (SBP and DBP) <90% (SBP and DBP) Normal Normal BP percentile BP percentile Category Category
Pre-
hypertension
Weight and diet management, introduce physical activity
Medicate if target organ damage
Re-
check 6 months
Stage I
Medicate if symptomatic, target organ damage, 2o
HTN, diabetes, or if fail above diabetes, or if fail above
Re-
check every 1-
2 weeks
Stage II
Initiate medical therapy
History, physical, BUN, creatinine, electrolytes, urinalysis, CBC, and urine culture urinalysis, CBC, and urine culture
Renal ultrasound
Echocardiogram
Retinal exam
Ambulatory BP monitoring if suspected “ “white white-
coat HTN HTN” ”
Clearance
Competitive sports participation should be restricted
target organ damage, until BP is normalized. target organ damage, until BP is normalized.
Recommend regular aerobic physical activity (30– –60 60 minutes of moderate physical activity on most days) minutes of moderate physical activity on most days) and limitation of sedentary activities to less than 2 and limitation of sedentary activities to less than 2 hours per day hours per day
With the exception of power lifting, resistance training is beneficial. is beneficial.
The Seventh Report of the Joint National Committee
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 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.
When hypertension coexists with another cardiovascular disease, When hypertension coexists with another cardiovascular disease, eligibility for participation in eligibility for participation in competitive athletics is usually based on the type and severity competitive athletics is usually based on the type and severity of the associated condition.
All drugs being taken must be registered with appropriate govern All drugs being taken must be registered with appropriate governing bodies to obtain a therapeutic ing bodies to obtain a therapeutic exemption. exemption.
Athletes with more severe hypertension (stage 2), even without e Athletes with more severe hypertension (stage 2), even without evidence of target organ damage such as vidence of target organ damage such as LVH, should be restricted, particularly from high static sports LVH, should be restricted, particularly from high static sports (classes IIIA to IIIC), until their (classes IIIA to IIIC), until their hypertension is controlled by either lifestyle modification or d hypertension is controlled by either lifestyle modification or drug therapy. rug therapy.
The presence of stage 1 hypertension in the absence of target or The presence of stage 1 hypertension in the absence of target organ damage including LVH or gan damage including LVH or concomitant heart disease should not limit the eligibility for a concomitant heart disease should not limit the eligibility for any competitive sport. Once having begun a ny competitive sport. Once having begun a training program, the hypertensive athlete should have BP remeas training program, the hypertensive athlete should have BP remeasured every two to four months (or ured every two to four months (or more frequently, if indicated) to monitor the impact of exercise more frequently, if indicated) to monitor the impact of exercise. .
Before individuals commence training for competitive athletics, Before individuals commence training for competitive athletics, they should undergo careful assessment they should undergo careful assessment
should have out-
measurements to exclude isolated office measurements to exclude isolated office “ “white white-
coat” ” hypertension. Those with pre
hypertension (120/80 mm Hg up to 139/89 mm Hg) should be encouraged to modify (120/80 mm Hg up to 139/89 mm Hg) should be encouraged to modify lifestyle but should not be lifestyle but should not be restricted from physical activity. Those with sustained hyperte restricted from physical activity. Those with sustained hypertension should have echocardiography. Left nsion should have echocardiography. Left ventricular hypertrophy (LVH) beyond that seen with ventricular hypertrophy (LVH) beyond that seen with “ “athlete athlete’ ’s heart s heart” ” should limit participation until BP should limit participation until BP is normalized by appropriate drug therapy. is normalized by appropriate drug therapy.
36 36th
th Bethesda Conference
Bethesda Conference Task Force 5: Systemic Hypertension Task Force 5: Systemic Hypertension
th Bethesda Conference
Untreated hypertension in
athletes may be accompanied by some limitation in exercise performance.
Tobacco, excess alcohol,
sympathomimetics, cocaine, ephedra, androgens, steroids, growth hormone, NSAIDs, and excessive sodium intake may all increase BP.
rd Edition
Based on 1996 information for children and adolescents children and adolescents
Based on 26th
th Bethesda Conference
Bethesda Conference
Sums up recommendations for athletes of all age groups at time of athletes of all age groups at time of preparticipation examination preparticipation examination
rd Edition
Restrict from play if:
Adult with stage II
Child with >99%
Concern that target organ damage exists exists
Secondary cause of HTN is suspected
Otherwise, may clear to participate while being further evaluated while being further evaluated
Lifestyle modifications All antihypertensive drugs may limit exercise capacity. Most patients require at least 2 medications for control Beta-blockers (metoprolol, atenolol)
Decrease HR and heart contractility
Banned in shooting, archery, diving, etc.
ACE Inhibitors (lisinopril, enalapril)
Electrolyte imbalance, cough
Diuretics (HCTZ, furosemide)
Electrolyte imbalance, dehydration
Banned in USOC and NCAA
Alpha blockers (terazosin, clonidine) clonidine)
Orthostatic hypotension
ARBs (losartan, olmesartan)
Cough, electrolyte imbalance
Nondihydropyridine Calcium Calcium-
channel blockers
(diltiazem, verapamil) can lower HR lower HR
Dihydropyridine CCBs (amlodipine, isradipine ) (amlodipine, isradipine )
Swelling, dizziness
Check BP and HR supine, then check BP and HR standing at 1 minute and 3 minutes standing at 1 minute and 3 minutes
Hypovolemia if:
SBP decreases ≥ ≥20mmHg, DBP decreases 20mmHg, DBP decreases ≥ ≥10 mmHg, or 10 mmHg, or HR increases HR increases ≥ ≥10 bpm 10 bpm
Useful for syncope, possible internal bleeding, dehydration, medication related dehydration, medication related
Kaplan NM, Gidding SS, Pickering TG, et al: 36th Bethesda Conference: Recommendations for Determining Eligibility for Conference: Recommendations for Determining Eligibility for Competition in Athletes with Cardiovascular Abnormalities: Competition in Athletes with Cardiovascular Abnormalities: Task Force 5: Systemic Hypertension. Journal of the American Task Force 5: Systemic Hypertension. Journal of the American College of Cardiology 2005, 45 (8):1346 College of Cardiology 2005, 45 (8):1346-
8.
Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, Jones DW, Kurtz T, Sheps SG, Roccella EJ. Recommendations Jones DW, Kurtz T, Sheps SG, Roccella EJ. Recommendations for blood pressure measurement in humans and experimental for blood pressure measurement in humans and experimental animals: Part 1: blood pressure measurement in humans: a animals: Part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of statement for professionals from the Subcommittee of Professional and Public Education of the AHA Council on HBP. Professional and Public Education of the AHA Council on HBP. Circulation Circulation 2005 Feb 8;111(5):697 2005 Feb 8;111(5):697-
716.
American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Medical Society for Sports Medicine, American Osteopathic Academy of Sports Medicine, American Osteopathic Academy of Sports
O’ ’Connor MD, F. Hypertension, Athletes and the Connor MD, F. Hypertension, Athletes and the Sports Physician: Sports Physician: Implications of JNC VII, The Fourth Implications of JNC VII, The Fourth Report, and the 36th Bethesda Conference Guidelines. Report, and the 36th Bethesda Conference Guidelines. AMSSM, Albuquerque, NM, 2007. AMSSM, Albuquerque, NM, 2007.