Hypertension, Athletes and the Sports Physician: Implications of JNC VII, The Fourth Report, and the 36th Bethesda Conference Guidelines

1
Hypertension, Athletes and the Sports Physician
Implications of JNC VII, The Fourth Report, and
the 36th Bethesda Conference Guidelines

• Francis G. OConnor, MD, MPH
• Medical Director, USUHS Consortium for Health
• and Military Performance (CHAMP)
• Uniformed Services University of the Health
  Sciences

2
Objectives

• Outline key changes and additions to
• JNC VII
• The Fourth Report
• The 36th Bethesda Report
• Discuss clinical implications for the sports
  clinician.

3
National Heart, Lung, and Blood
InstituteNational High Blood Pressure Education
Program
The Seventh Report of the Joint National
Committee onPrevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC 7)
Chobanian AV, Bakris GL, Black HR et al The
seventh report of the Joint National Committee on
prevention, detection, evaluation, and treatment
of High blood pressure the JNC 7 report. JAMA
20032892560-72.
4
Why a New JNC Report?

• Publication of many new studies.
• Need for a new, clear, and concise guideline
  useful for clinicians.
• Need to simplify the classification of BP.

5
Background

• HTN prevalence 50 million people in the United
  States.
• The BP relationship to risk of CVD is continuous,
  consistent, and independent of other risk
  factors.
• Each increment of 20/10 mmHg doubles the risk of
  CVD across the entire BP range starting from
  115/75 mmHg.
• Prehypertension signals the need for increased
  education to reduce BP in order to prevent
  hypertension.

Hypertension is the most common cardiovascular
disease encountered in the athletic population.
6
Background
Benefits of Lowering BP
Average Reduction Stroke incidence 3540
Myocardial infarction 2025 Heart
failure 50
7
Trends in awareness, treatment, and control of
high blood pressure in adults ages 1874,
Adapted from JNC VII.
National Health and Nutrition Examination Survey, Percent National Health and Nutrition Examination Survey, Percent National Health and Nutrition Examination Survey, Percent National Health and Nutrition Examination Survey, Percent
II 197680 II (Phase 1) 198891 II (Phase 2) 199194 19992000
Awareness 51 73 68 70
Treatment 31 55 54 59
Control 10 29 27 34
8
JNC VII Blood Pressure Classification
BP Classification SBP mmHg DBP mmHg
Normal lt120 and lt80
Prehypertension 120139 or 8089
Stage 1 Hypertension 140159 or 9099
Stage 2 Hypertension gt160 or gt100
High Normal of JNC VI replaced by Prehypertension.
Four Stages of Hypertension in JNC VI
consolidated to Two Stages.
9
Key Messages

• For persons over age 50, SBP is a more important
  than DBP as CVD risk factor.
• Starting at 115/75 mmHg, CVD risk doubles with
  each increment of 20/10 mmHg throughout the BP
  range.
• Persons who are normotensive at age 55 have a 90
  lifetime risk for developing HTN.
• Those with SBP 120139 mmHg or DBP 8089 mmHg
  should be considered prehypertensive who require
  health-promoting lifestyle modifications to
  prevent CVD.

10
Key Messages

• Thiazide-type diuretics should be initial drug
  therapy for most, either alone or combined with
  other drug classes.
• Certain high-risk conditions are compelling
  indications for other drug classes.
• Most patients will require two or more
  antihypertensive drugs to achieve goal BP.
• If BP is gt20/10 mmHg above goal, initiate therapy
  with two agents, one usually should be a
  thiazide-type diuretic.

11
Key Messages

• The most effective therapy prescribed by the
  careful clinician will control HTN only if
  patients are motivated.
• Motivation improves when patients have positive
  experiences with, and trust in, the clinician.
• Empathy builds trust and is a potent motivator.
• The responsible physicians judgment remains
  paramount.

12
Implications for the Sports Physician

• Diagnosis
• Evaluation of the hypertensive recommends the
  following 12 lead electrocardiography
  urinalysis blood glucose and hematocrit serum
  potassium, creatinine and calcium and a
  lipoprotein profile.
• Evaluation
• While echocardiography is recognized in JNC VII
  as more sensitive than electrocardiography for
  detecting left ventricular hypertrophy, there is
  no specific recommendation mandating screening
  echocardiography.

13
Implications for the Sports Physician

• Treatment
• JNC VII specifically addresses compelling
  indications for pharmacologic intervention heart
  failure post myocardial infarction high
  coronary disease risk diabetes chronic kidney
  disease and recurrent stroke prevention.
• In addition, other special situations e.g.
  minorities, are identified with suggested
  treatment strategies.
• Specific comments into recommendations for
  athletes, however, do not appear in JNC VII.

AMSSM should be a member of the writing group for
JNC VIII.
14
The Fourth Report on the Diagnosis,
Evaluation, and Treatment of High Blood Pressure
in Children and Adolescents

• National High Blood Pressure Education Program
  Working Group on High Blood Pressure in Children
  and Adolescents. Pediatrics 2004 114 Suppl
  555-76.

15
Why a Fourth Report?

• Updates 1996 standard reflects literature from
  1997 to 2004.
• The Fourth Report BP standards based on sex, age
  and height are more accurate and utilize data
  from the 1999-2000 National Health and Nutrition
  Examination Survey (NHANES) and new height
  percentile data from the CDC growth charts.
• Hypertension for athletes under 18 years old is
  also classified as prehypertension, Stage 1, and
  Stage 2 hypertension to mirror the current
  recommendations for adults.
• Enhanced focus on detection of early target organ
  damage.

16
Implications for the Sports Physician

• Diagnosis
• A diagnosis requires at least three measurements.
• 90 to 95 was high-normal, now prehypertension
• 95 to 99 plus 5mmHg is Stage I Greater than
  99 plus 5 mmHg is Stage II.
• The plus 5mmHg is new from 1996.
• Ambulatory blood pressure monitoring recognized
  as useful in white coat hypertension.

17
Implications for the Sports Physician

• Evaluation
• All children and adolescents diagnosed with
  hypertension require a careful history and
  physical examination as well as further
  evaluation for a secondary etiology as clinically
  indicated.
• Renal US for all children with sustained BP gt 95
• To evaluate for target organ disease
• Echocardiogram, as well as a retinal examination,
  is currently recommended for all patients with a
  BP gt 95th percentile.

18
Implications for the Sports Physician

• Treatment/Clearance
• Similar to adults, any child athlete with Stage 2
  hypertension should be restricted from
  participation until adequate control is obtained.
  
• Children with identified target organ disease
  should have participation recommendations based
  upon the nature of their target organ disease.
• Note that the Current PPE monograph is based upon
  the 1996 Report
• Athletes pick up an extra 5mmHg for clearance for
  sport.

19
36th Bethesda Conference Recommendations
for Determining Eligibility for Competition in
Athletes with Cardiovascular Abnormalities Task
Force 5 Systemic Hypertension.

• Kaplan NM, Gidding SS, Pickering TG, et al
  Journal of the American College of Cardiology
  2005, 45 (8)1346-8.

20
Why a 36th Conference?

• Ten year Update.
• Publication of many new studies.
• New interventions.

21
36th Bethesda Conference Guidelines

• Recommendations for Determining Eligibility for
  Competition in Athletes with Cardiovascular
  Abnormalities 26th Bethesda Report
• Congenital heart disease
• Acquired valvular heart disease
• Hypertrophic cardiomyopathy, myocarditis, and
  other myopericardial diseases and mitral valve
  prolapse
• Systemic hypertension
• Coronary artery disease
• Arrhythmias

22
36th Bethesda Conference Guidelines

• Recommendations for Determining Eligibility for
  Competition in Athletes with Cardiovascular
  Abnormalities 2005
• 12 Distinct Task Force Reports

• Preparticipation Screening
• Congenital Heart Disease
• Valvular Heart Disease
• Cardiomyopathies
• Hypertension
• Arrhythmias
• Sports Classification
• Drugs
• AEDs
• Commotio Cordis
• Legal

23
Implications for the Sports Physician

• Treatment/ Clearance
• Note that the Current PPE monograph is based upon
  the 26th Bethesda Conference Report.

24
Implications for the Sports Physician

• 26th versus 36th
• Little variation is noted between the
  classification tables from the two conferences
  except for the addition of triathlon (IIIC),
  snowboarding (IIIB), and skateboarding (IIIB)
  the combination of single and doubles tennis into
  tennis (IC) the change of fencing from IIB to
  IB and the absence of Australian rules football
  (IIC).

25
Task Force 5 Systemic Hypertension 36th Bethesda Conference Recommendations Task Force 5 Systemic Hypertension 36th Bethesda Conference Recommendations
1 Before individuals commence training for competitive athletics, they should undergo careful assessment of BP and those with initially high levels (above 140/90 mm Hg) should have out-of-office measurements to exclude isolated office white-coat hypertension. Those with pre-hypertension (120/80 mm Hg up to 139/89 mm Hg) should be encouraged to modify lifestyle but should not be restricted from physical activity. Those with sustained hypertension should have echocardiography. Left ventricular hypertrophy (LVH) beyond that seen with athletes heart should limit participation until BP is normalized by appropriate drug therapy.
2 The presence of Stage 1 hypertension in the absence of target organ damage including LVH or concomitant heart disease should not limit the eligibility of any competitive sport. Once having begun a training program, the hypertensive athlete should have BP remeasured every two to four months (or more frequently, if indicated) to monitor the impact of exercise.
3 Athletes with more severe hypertension (stage 2), even without evidence of target organ damage such as LVH, should be restricted, particularly from high static sports (classes IIIA to IIIC), until their hypertension is controlled by either lifestyle modification or drug therapy.
4 All drugs being taken must be registered with appropriate governing bodies to obtain therapeutic exemption.
5 When hypertension coexists with another cardiovascular disease, eligibility for participation in competitive athletics is usually based on the type and severity of the associated condition.
Table 1 36th Bethesda Conference Recommendations

26
Implications for the Sports Physician

• Evaluation
• Those athletes with stage 1 hypertension should
  have a blood chemistry (glucose, creatinine/GFR,
  electrolytes, lipid profile), hematocrit,
  urinalysis and electrocardiogram.
• If an athlete has stage 2 hypertension, abnormal
  results, or a possible secondary cause then
  referral for therapy plus additional study
  including echocardiography is recommended.
• Clearance
• Currently an athlete listed as severe
  hypertension (stage 2) has a blood pressure
  reading than 160/100 on two occasions and should
  be restricted from competition until the pressure
  is controlled.
• Using the 26th Conference guidelines, a similar
  reading of 160/100 on three occasions would be
  classified as Moderate (stage 2) and would result
  in no restrictions for the athlete.

27
Key Websites

• National Heart Lung and Blood Institute
• http//www.nhlbi.nih.gov/
• Clinical Practice Guidelines
• JNC VII
• The 4th Report
• American College of Cardiology
• http//www.acc.org
• Consensus Conference Reports
• 36th Bethesda Conference Report

28
Conclusion

• "After teaching over 500 residents and medical
  students the principles of sports medicine, and
  having the honor of training 14 incredibly
  competent primary care sports medicine fellows, I
  have begun to realize just how important this
  area truly is. I have always felt that you really
  did not have to know the difference between a
  basketball and a baseball your patients surely
  will. More and more of our general population
  continue interests in sports beyond youth in many
  forms of recreational activity. We must all
  become 'team physicians' of sort to those
  recreational exercises we call our patients."

David O. Hough