Athletes with Hypertension, Hyperlipidemia and Other Medical Risks

1
Athletes with Hypertension, Hyperlipidemia and
Other Medical Risks

• Karl B. Fields, MD
• Chief of Family Medicine Program
• Director of Sports Medicine Fellowship
• Moses Cone Hospital, Greensboro, NC
• 2007

2
Hypertension

• Systemic hypertension is the most common
  cardiovascular disease in the world
• Also most common found in athletes
• Prevalence may be as much as 25 in adults
• Populations at higher risk
• Men
• Older individuals
• Asian and African- Americans

3
Mortality Decline 1972-94

• CVA 60
• 50 to 66 fall in women due to lower BP
• CHD 53
• Since 1993 these rates have leveled and actually
  increased slightly
• 1999/2000 HBP patients 70 aware, 59 treated,
  34 in control (JNC VII)

4
Classification of Hypertension

• Normal lt120 and lt80
• PreHypertension 120 - 139 and lt80 -89
• Stage 1 Hypertension 140 159 and 90 99
• Stage 2 Hypertension 160 and gt and 100 and gt
• Pearl 1 Systolic BP gt 140 much more important
  risk in individuals gt 50 yo
• Pearl 2 Risk of CVD beginning at 115/75 doubles
  for each increment of 20/10
• JNC VII

5
Pediatric/ Adolescent HBP Equivalent to 95 Age
and Height

• Age 1 gt102-105 or gt57-59
• Age 6 gt111-115 or gt73-75
• Age 12 gt123-125 or gt80-82
• Age 17 females gt129-130 or gt 84-85
• Age 17 males gt136-138 or gt 87-88
• JNC VI and VII

6
Hemodynamic Changes with HTN

• Normotensive individuals decrease their TPR as
  their CO increases
• Prehypertensives show less drop in TPR
• Mild HTN show normal CO but no change in TPR
• Moderate HTN begin to show decrease in CO and
  actual increase in TPR
• Severe HTN develop overt cardiac dysfunction and
  even CHF

7
CARDIA STUDY EXERCISE BP IN YOUNG ADULTS

• Male and Female Subjects n 5115
• Age range 18 to 30
• 534 hypertensive at onset excluded
• 687 subjects (18) had exaggerated BP
• e.g. Systolic BP gt 210 in men or 190 in women
• 1.7 times more likely to have hypertension at 5
  year followup
• AJH vol 7 234-241 1994

8
Hypertensive Response to Exercise A Risk Factor
for CVD?

• Framingham data show that DBP response gt 95
  predicted HTN as did poor SBP response in
  recovery for men
• BP gt 210 on ETT had a strong association with LVH
  in normotensive men (64 vs 6) Gottdiener JS
  Brown J Zoltick J Fletcher RD Ann Intern Med
  1990 Feb 1112(3)161-6.
• CV mortality 2x higher in men with BP gt 200 on 6
  min bike protocol at 16 yrs.
• Biggest problem with this data is poor
  reproducibility
• Nevertheless, High exercise BP and poor BP
  recovery may be markers of CVD

9
HTN Causes End Organ Damage

• Hypertensive persons have increased relative risk
  ratios of 2.0 to 4.0 for
• Coronary artery disease
• CVA
• Peripheral artery disease
• Cardiac failure

10
HBP as a Risk Factor for MI

• HBP increases risk of MI and sudden death
  proportionate to degree of severity
• 35 of ASCVD events are secondary to HBP
• 35 OF MI in men and 45 in women with HBP are
  unrecognized MIs Framingham data - Kannel/
  JAMA 96
• Logarithmic increase with multiple risk factors

11
Evaluation of HBP

• Generally few symptoms or signs except abdominal
  adiposity
• Majority of hypertension in women and much of the
  early onset in men can be attributed to excess
  body fat Framingham data
• Careful measurement and standard workup for all
  new patients with HBP
• Exclude secondary causes

12
Exercise in the Hypertensive Athlete Concerns??

• Isometric exercise results in dramatic BP
  increase
• Aerobic exercise may increase BP by 50
• Will increased CV demand of exercise cause an
  increase in HTN complications
• SV, CO and HR all increase with workload
• HR reaches up to max. levels, and SV increases up
  to 24
• CO approx 2.5 times resting level

13
Dynamic Exercise Long Term Effects on BP

• Resting BPs decrease with consistent aerobic
  exercise training
• Avg. reduction of 11mmHg (systolic) and 9mmHg
  (diastolic)
• Changes cardiac architecture/ Eccentric
  Hypertrophy with both increase in LV wall
  thickness and lumen size
• This LV hypertrophy reverses to baseline after as
  little as 2 wks of detraining
• Intensity seems more important than frequency in
  that even 2 sessions totally 60 to 90 mins per
  week of greater 50 of VO2 Max maintains BP
• Ishikawa-Takata K Ohta T Tanaka H Am J
  Hypertens 2003 Aug16(8)629-33.

14
Aerobic Exercise for Lowering BP Strong
Evidence!

• Metaanalysis reviewed 121 trials and included 54
  (2419 patients)
• Whelton SP Chin A Xin X He J Ann Intern Med
  2002 Apr 2136(7)493-503.
• SBP decreased in 44 of 53 trials
• DBP decreased in 42 of 50 trials
• Lowered pressures in both normotensive and
  hypertensive patients with a greater effect in
  African-Americans and Asians
• Hart, CJSM, 2002
• Genes that control endothelial nitric oxide
  synthetase may relate to which individuals lower
  BP with exercise
• Kimura Hypertension 2003

15
Static Exercise and BP Control

• Isometric exercise can see 1.5 to 2.5 increases
  in BP
• Much of increase is due to increased TPR and HR
• Levels gt 300mm HG recorded in weightlifters (
  Valsalva maneuver?)
• McDougall ,et al.
• No evidence that these marked BP elevations pose
  long-term risks

16
Static Exercise Effect on BP

• Cases suggest that concentric LVH may result from
  repetitive static exercise
• Case reports of subarachnoid hemorrhage in
  weightlifters raised concerns
• Typically, though, static exercise causes minimal
  change in SV, diastolic function or cardiac
  architecture
• Cardiac morphologic changes may be more prevalent
  in African-American athletes genes?
• General consensus is that most static exercise is
  beneficial

17
Static Exercise Benefits BP Evidence Moderate

• Consistent static exercise may decreases BP
• Isometric hand grip exercise 3x weekly lowered
  SBP after 10 weeks
• Taylor, et al MSSE, 2003
• Current ACSM recommendations are to balance
  static with dynamic training in HBP patients
  (circuit training)
• 3 sessions totaling 45 minutes aerobic exercise
  per week will counterbalance negative effects

18
Environmental Risks for Hypertensive Athletes

• Exercising in heat
• Hypertensive athletes are unable to shunt blood
  to skin as effectively as the normotensive
• Greater free-water loss
• Hyperkalemia
• Question Increased risk of rhabdomyolysis
• Medications may worsen heat tolerance with
  diuretics and beta blockers requiring caution

19
Risks for Older Hypertensive Athletes

• Athletes gt35 have increased risk for CAD and may
  need additional tests
• Exercise tolerance testing
• Systolic gt225-240 warrants further attention
• Rise in diastolic BP may indicate elevated TPR
• Failure of BP to fall by 3 mins post ETT - CAD?
• Failure of HR to fall gt 12 beats/min - CAD?
• Echocardiogram

20
Treatment Strategies

• Hypertensive athletes should be adequately
  treated before return to intense activity
• BP should be rechecked during season and
  monitored during training
• Clearance will depend on sport and level of
  hypertension and end organ damage

21
Treatment Strategies

• Stage 1 hypertension
• Allowed to play if no evidence of end organ
  damage, including heart disease
• Stage 2 hypertension
• Restricted from play until BP is controlled
  (especially in sports with large isometric
  component)
• Hypertension with complications
• Participation based on severity of associated
  conditions Bethesda Guidelines

22
Non-Pharmacologic Treatment The First Step

• Aerobic exercise 4 - 9 mm Hg drop
• 30 minute sessions most days
• Weight loss 5 20 mm drop per 10kg decline
• Combination of exercise and weight loss lowered
  BP by average of 12.5/7.9 mm Hg
• Avoidance of certain medications, illicit drugs
• Moderation of alcohol 2 4 mm Hg drop
• Stopping smoking
• JNC VII

23
DASH Diet

• Rich in fruits, vegetables and low-fat dairy
• Low in total and saturated fats
• High in fiber, Ca, K, and Mg
• Based on 2000 calories led to lower BP
• Dash diet lowered SBP 5.5
• DBP 3.0
• Bacon, et al. Sports Medicine 2004
• see http//dash.bwh.harvard.edu

24
Pharmacologic Treatment of Athletes

• ACE inhibitors are most commonly used drugs in
  athletes because of low side-effect profile/ ARBs
  for patients who develop cough
• Calcium antagonists are reasonable choice
• All 3 drugs work on peripheral resistance
• Beta blockers, diuretics for comorbid illness
• Rarely use alpha blockers or central agents
• ALLHAT trial very favorable to diuretics in
  individuals 55 and older

25
Summary HBP

• Athletes merit careful evaluation for HBP
• Stricter BP control needed in active patients
  with known chronic disease - DM, renal disease,
  etc.
• Earlier diagnosis and control indicated in
  African-American individuals
• Average BP readings much higher
• NSAIDs interfere with ACE, beta-blockers and
  diuretics
• ACSM currently lists exercise as the cornerstone
  therapy for prevention, treatment and control of
  HBP ACSM 2004 position statement

26
Exercise and Hyperlipidemia

• Aerobic exercise has beneficial effects on lipid
  profiles
• Total cholesterol and LDL decrease only slightly
  (lt10)
• Major increases in HDL
• Major decreases in Triglycerides

27
Runners/ Sedentary MalesWilliams, et al. 1986

• Total Chol 191
• TG 71
• HDL 65
• LDL 147
• BMI 22.6
• avg. age was 46

• Total Chol 217
• TG 123
• HDL 50
• LDL 161
• BMI 25

28
HDL levels of Athletes Improve with Exercise
Strong Evidence

• Women endurance athletes averaged 65 to 80
• Men endurance athletes 55 to 70
• Men power athletes 35 to 50
• analysis of 32 cross sectional studies by Haskell
• Meta-analysis of 19 trials suggest exercise
  increases HDL on avg 11 regardless of weight
  loss
• Kelley GA Kelley KS Atherosclerosis. 2006
  Jan184(1)207-15.  

29
Frequency and Intensity of Exercise Affect Lipid
Profiles

• All exercise groups affect VLDL, TG and increase
  the size of LDL particles
• High quantity and intensity exercise has the
  greatest impact on HDL, particle size and LDL
  effects
• These occur with minimal change in weight
• Kraus, et al. N Engl J Med 2002 Nov
  7347(19)1483-92
• Amount and frequency of exercise have greater
  effect than intensity

30
Graded Exercise Lipidsfrom UpToDate 2007
31
Lipid Profile Responses

• Men and women show different response to diet and
  exercise
• Men have greater increase in HDL and decrease in
  TG
• Women need both diet and exercise for favorable
  effect on TG and HDL
• Genetic variants seem to influence these
  responses with APO E related to TG and APO A to
  HDL

32
Possible Mechanisms for Lipid Changes with
Aerobic Exercise

• Increases in cardiac and skeletal muscle
  lipoprotein lipase activity
• Changes in hepatic lipase activity
• Increased fitness decreases abdominal fat stores
  even if without weight loss
• Selective effects on tissue lipolysis
• Exercise may stimulate abdominal lipolysis
  preferentially

33
Potential Benefits of Exercise in Preventing
Chronic Disease

• Type 2 DM
• Metabolic Syndrome
• Colon Cancer and possibly other cancers
• Coronary Heart Disease
• Perhaps 1/3 of deaths from these could be
  reversed by ending sedentary life style in this
  population (Est. 200,000)
• Lifestyle benefit may outweigh mortality

34
Exercise and DM 2 Prevention

• Meta-analysis of 10 prospective cohort studies
• Regular, moderate physical activity lowers risk,
  including brisk walking
• RR 0.69 versus sedentary
• Effect is independent of BMI

35
Breast Cancer and Exercise

• Breast cancer risk declined to 0.82 in vigorous
  exercise group (7hr vs 1hr per week)
• Postmenopausal women with moderate exercise had
  same decrease risk 18
• California teachers had a lower risk (20) with
  vigorous exercise but only in ER negative tumors

36
Can Exercise lower Risk of Other Cancers?

• Colon cancer is decreased by about 50 in the
  most vigorous exercise group based on
  meta-analysis
• Colditz GA Cannuscio CC Frazier AL Cancer
  Causes Control 1997 8(4)649-67.
• Decrease prostate cancer risks of 30 reported
  for patients on low fat diet and exercise program
• Possible decrease in uterine and ovarian cancers
• Possible effect of exercise on fat stores and
  hormonal storage

37
Exercise and Immunity

• Immune system is suppressed with too much
  exercise intensity
• Immune system seems stimulated by moderate
  exercise
• Immune system is suppressed by sedentary life
  style
• J point hypothesis of immunity and exercise

38
The Athlete with Medical Problems

• In general athletes can continue to compete with
  most medical conditions
• Exercise improves most cardiac risk factors and
  lowers risk of developing Type 2 DM and Metabolic
  syndrome
• Exercise may lessen risk of specific cancers
• Intense exercise may pose cardiac and immune
  system risks which suggests that training must
  stress moderation to gain maximal benefits