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Home , Diuretic, History of hypertension, Thiazide

PRACTICAL THERAPEUTICS

Managing in Athletes and Physically Active Patients MARK W. NIEDFELDT, M.D., Medical College of Wisconsin, Milwaukee, Wisconsin

Athletes and other physically active patients should be screened for hypertension and given appropriate if needed. Mild hypertension should be treated with non- O A patient informa- pharmacologic measures for six months. If pressure control is adequate, lifestyle tion handout on high and modifications are continued. If control is inadequate, low-dose therapy with an exercise, written by angiotensin-converting enzyme inhibitor or a channel blocker may be started. A the author of this may be used as first-line treatment for hypertension in casually active article, is provided patients; however, diuretic therapy is less desirable in high-intensity or endurance ath- on page 457. letes because of the risk of or . If beta blockade is needed, a combined alpha- may be the best choice. When the target blood pressure is achieved, long-term follow-up care and management should be emphasized. If excellent control is maintained for six to 12 months, may be reduced or withdrawn in a small number of patients. If the target blood pressure is not achieved, the medication dosage may be adjusted, or a second medication, usually a diuretic, may be added. Physicians need to be aware of the effects of various on exercise tolerance and the rules for participation established by sports regulatory bodies (Am Fam Physi- cian 2002;66:445-52,457-8. Copyright© 2002 American Academy of Family Physicians.)

Members of various thletes and other physically 30 years of age and 20 to 25 percent of adults family practice depart- active patients are usually 30 to 60 years of age.3 Almost 80 percent of ments develop articles thought to be free of cardiovas- adolescents found to have a blood pressure for “Practical Therapeu- tics.” This article is one cular disease and hypertension above 142/92 mm Hg during a presports- in a series coordinated because of their apparently participation physical examination eventually by the Department of Ahigh level of fitness. Indeed, the overall preva- develop chronically elevated blood pressure.4 Family and Community lence of high blood pressure in these groups is All athletes and physically active patients at the Med- approximately 50 percent lower than in the should be screened for hypertension. If the ical College of Wiscon- 1 sin, Milwaukee. Guest general population. However, the risk of condition is diagnosed, appropriate treatment editors of the series are hypertension is increased in some athletes and should be started to reduce the risk of mor- Linda N. Meurer, M.D., physically active patients, including blacks, the bidity and mortality associated with cardio- M.P.H., and Douglas elderly, persons who are obese, and those with vascular disease.5 Bower, M.D. , renal disease, or a family . Wheelchair athletes with spinal Hypertension Classification cord injuries may also have hypertension and Secondary Hypertension because of loss of autonomic control of blood The sixth report of the National Com- pressure.2 mittee on Prevention, Detection, Evaluation, Hypertension often begins in early adult- and Treatment of High Blood Pressure hood. It becomes more prevalent with increas- emphasizes the progressive nature of hyper- ing age, affecting 5 to 10 percent of adults 20 to tension and divides blood pressure into six classes (Table 1).5 Most athletes and physically active patients with hypertension fall into The risk of hypertension is increased in some athletes and stage 1 or 2. Secondary hypertension develops in fewer physically active patients, including blacks, the elderly, per- than 5 percent of athletes and physically active sons who are obese, and those with diabetes, renal disease, patients.6 It tends to occur in younger or a family history of hypertension. patients, adult patients with rapid onset of severe hypertension, and patients with hyper-

AUGUST 1, 2002 / VOLUME 66, NUMBER 3 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 445 TABLE 1 Clinical Evaluation Classification of Blood Pressure* In athletes and other physically active patients with hypertension, the history should Systolic Diastolic focus on behaviors that may affect blood pres- blood pressure blood pressure sure, such as a high intake of and satu- Class (mm Hg) (mm Hg) rated fats (e.g., in processed and “fast” foods) Optimal <120 <80 and the use of alcohol, drugs (specifically, stim- Normal <130 <85 ulants taken before competitions, or ), High normal 130 to 139 85 to 89 tobacco, or anabolic steroids (Table 2).5,7-9 Many Hypertension over-the-counter medications, including non- Stage 1 140 to 159 90 to 99 steroidal anti-inflammatory (NSAIDs), Stage 2 160 to 179 100 to 109 , diet pills, and , can also Stage 3 ≥180 ≥110 cause blood pressure to rise. Patients should also be questioned about *—If the systolic blood pressure and the diastolic blood pressure fall into different classes, the higher the use of herbs and dietary supplements, class should be used. with special attention given to substances pur- Adapted with permission from The sixth report of ported to increase energy or control weight. the Joint National Committee on Prevention, Detec- These supplements often contain “natural” tion, Evaluation, and Treatment of High Blood Pres- substances such as guanara, ma huang, and sure. Arch Intern Med 1997;157:2413-46. ephedra, which are . Stress levels should be evaluated. Chronic environmental or social stress may result in higher levels of circulating catecholamines tension that responds poorly to routine thera- and chronic neurogenic activation of the sym- pies. The most common cause of secondary pathetic , which can contribute hypertension is vascular or parenchymal renal to hypertension.8 disease.6 The clinical evaluation should include Hypertension can also occur secondary to proper measurement of blood pressure7 and estrogen in oral contraceptive pills, which are laboratory tests directed at excluding causes of commonly taken by female athletes. This sec- secondary hypertension or identifying end- ondary hypertension generally develops soon organ damage. Studies should include an elec- after they start taking the pills. About 5 per- trocardiogram, a , uri- cent of all women who take oral contraceptive nalysis, and measurements of sodium, pills develop hypertension over a five-year , blood nitrogen, creatinine, period.7 fasting , and total, low-density lipopro- tein (LDL), and high-density lipoprotein (HDL) cholesterol levels. Other studies and The Author further evaluation may be performed if a sec- ondary cause of hypertension is suspected. MARK W. NIEDFELDT, M.D., is assistant professor of family and community medicine and orthopedic surgery and associate director of the sports medicine fellowship pro- gram at the Medical College of Wisconsin, Milwaukee. Dr. Niedfeldt graduated from Treatment the Medical College of Wisconsin, where he also completed a family practice residency NONPHARMACOLOGIC THERAPY and sports medicine fellowship. Compared with the general population, Address correspondence to Mark W. Niedfeldt, M.D., Departments of Family and athletes and other physically active patients Community Medicine and Orthopaedic Surgery, Medical College of Wisconsin, 2320 N. Lake Dr., Milwaukee, WI 53211 (e-mail: [email protected]). Reprints are not avail- are often more motivated to comply with able from the author. nonpharmacologic interventions, because

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TABLE 2 High dietary potassium intake may improve blood pressure Risk Factors for Hypertension in Athletes control, especially in endurance athletes, who may tend to and Other Physically Active Patients be hypokalemic.

High sodium intake Excessive consumption (binge drinking) Illicit use (e.g., cocaine) be especially sensitive to the effects of dietary use sodium.9 use (e.g., in supplements taken to enhance energy or control weight) Potatoes and bananas, as well as many other High stress levels fruits, contain significant amounts of potas- Male gender sium. These foods should be included in the Race (blacks affected more often than whites diet of athletes and other physically active by about a 2-to-1 ratio, and Asians affected patients. High dietary potassium intake may the least) provide some protection against high blood Family history of hypertension or cardiac disease pressure or may improve blood pressure con- in men over 55 years of age and women over 10 65 years of age trol. A high-potassium diet is especially Diabetes mellitus or glucose intolerance important in endurance athletes, who may 5 Smoking or chewing tobacco tend to be hypokalemic. Calcium or supplementation for the sole purpose of improving blood pres- Information from references 5, 7, 8, and 9. sure control is not routinely recommended in physically active patients.5 Weight Loss. Losing just 4.5 kg (10 lb) can reduce blood pressure in overweight patients these measures have virtually no side effects. who have hypertension.11 Loss of this much Although lifestyle modifications cannot elim- weight also seems to enhance the blood pres- inate the need for ther- sure–lowering effects of many medications.12 apy in all patients, dietary and behavioral The weight reduction plan should include changes may reduce the amount of medica- foods that are high in fiber and low in satu- tion needed and, thus, the possibility of side rated fats.13 effects. Dietary and lifestyle changes may Lifestyle Changes. Excessive alcohol use can include decreasing sodium intake, increasing decrease the effectiveness of antihypertensive potassium intake, losing weight, decreasing drug therapy. Adults should limit alcohol alcohol consumption, avoiding stimulant use, intake to the equivalent of two beers per day. applying relaxation techniques, and perform- Women and lighter weight persons should ing aerobic exercise. consume no more than the equivalent of one Dietary Changes. A reduction in sodium beer per day.5 intake can lead to a decrease in blood pres- Some athletes routinely use biofeedback, sure.5 In particular, patients should be advised muscle relaxation techniques, meditation, yoga, to reduce their intake of processed foods such and stress management techniques. These stress as luncheon meat and fast foods. Processed reduction tools may have value as adjunctive foods provide 75 percent of the sodium rec- therapy in patients with hypertension. ommended for the typical American diet.9 Regular aerobic exercise adequate to achieve These foods are particularly common in the moderate fitness can lower blood pressure, diets of adolescent athletes. Blacks, older per- enhance weight loss, and reduce mortality.14 sons, and those with diabetes mellitus seem to The effects of exercise on hypertension are

AUGUST 1, 2002 / VOLUME 66, NUMBER 3 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 447 even more dramatic in patients with hyper- cians and patients also need to be aware that the tension secondary to renal dysfunction. U.S. Olympic Committee (USOC) and the Recommendations on exercise and sports National Collegiate Athletic Association participation for patients with hypertension (NCAA) have banned the use of some antihy- are provided in Table 3.15 pertensive medications.16-18 The effects of anti- hypertensive drug classes are summarized in PHARMACOLOGIC THERAPY Table 4.5,6,16-21 Athletes and other physically active patients . Both thiazide and loop diuretics need to monitor medication effects, because decrease plasma volume, cardiac output, and some antihypertensive drugs may have an vascular resistance.20 The thiazide diuretics adverse influence on exercise tolerance. Other have less pronounced effects. drugs, including NSAIDs, may decrease the Thiazide diuretics are often recommended action of antihypertensive medications, includ- as initial therapy in patients with hyperten- ing diuretics, beta blockers, and angiotensin- sion. In several randomized, controlled trials converting enzyme (ACE) inhibitors.16 Physi- (conducted primarily in the elderly),22-28 these agents have been associated with decreases in both mortality and morbidity. TABLE 3 Thiazide diuretics are useful as second-line Exercise and Sports Participation in Athletes therapy in -sensitive athletes and physically and Other Physically Active Persons with Hypertension active patients with hypertension.5 These agents should be given in a low dosage and, in Exercise some patients, combined with a potassium- The recommended mode, frequency, duration, and intensity of exercise are sparing agent. Thiazide diuretics are inexpen- generally the same as those for persons without hypertension. sive and a good choice in patients who exercise Sports participation only casually, in physically active elderly Blood pressure should be controlled before resumption of participation in patients, and in black patients. Possible side vigorous sports, because both dynamic and isometric exercise can cause effects include hypovolemia, orthostatic remarkable increases in blood pressure. , and urinary loss of potassium Recommendations on exercise restrictions and magnesium. These side effects can lead to High-normal blood pressure No restrictions muscle , , and rhabdomy- Controlled mild to moderate No restrictions on dynamic exercise; olysis in patients who are exercising intensely hypertension (<140/90 mm Hg) possible limit on isometric training or or competing in warm weather. sports in some patients The side effects associated with thiazide Uncontrolled hypertension Limited to low-intensity dynamic exercise; diuretics are magnified with the more potent (>140/90 mm Hg) avoid isometric sports. loop diuretics. Consequently, loop diuretics are Controlled hypertension with Limited to low-intensity dynamic exercise; inappropriate for use in the treatment of end-organ damage avoid isometric sports. hypertension in athletes and other physically Severe hypertension with no Limited to low-intensity dynamic exercise, active patients. These agents have also been end-organ involvement with participation only if blood pressure shown to cause short-term increases in plasma is under adequate control. cholesterol, glucose, and levels.21 Secondary hypertension of Limited to low-intensity dynamic exercise; Sports regulatory bodies have banned the renal origin avoid “collision” sports that could lead to damage. use of all diuretics. These agents cannot be used by elite athletes who are required to 16-18 Information from 26th Bethesda Conference: recommendations for determining undergo drug testing. eligibility for competition in athletes with cardiovascular abnormalities. January ACE Inhibitors. These agents block the con- 6-7, 1994. J Am Coll Cardiol 1994;24:845-99. version of angiotensin I to angiotensin II, which is a potent vasoconstrictor and a source

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of sodium retention.19 ACE inhibitors are associated with a slight decrease in rate, Athletes who take beta blockers perceive greater exertion an increase in volume, and a decrease in during exercise, which may affect adherence to the 20 total peripheral resistance. prescribed medication regimen. ACE inhibitors have been shown to have beneficial effects in patients with , systolic dysfunction or nephropathy. They reverse ventricular hypertrophy and micro- decrease systemic vascular resistance, with no albuminuria, with preservation of renal func- reflex increase in heart rate or cardiac output. tion. In exercise, ACE inhibitors have no A first-dose hypotensive effect can occur, major effects on energy and cause especially in the elderly. no impairment of maximum oxygen uptake. Alpha blockers cause no major changes in In general, these drugs have no deleterious energy metabolism during exercise, and max- effects on training or competition.20 imum oxygen uptake is preserved. Therefore, The major side effect of ACE inhibitors is a these agents have no major effects on training dry, nonproductive cough. Because there have or sports performance.20 Alpha blockers have been anecdotal reports of postural hypoten- been used in athletes with diabetes mellitus sion after intense exercise in patients taking who have hypertension and hypercholes- ACE inhibitors, an adequate cool-down terolemia, because they do not exacerbate period is recommended. these conditions.7 ACE inhibitors are excellent for treating The arm of the ongoing Anti- mild to moderate hypertension. They are hypertensives and Lipid-Lowering Treatment often the first-line agents for the treatment of to Prevent Heart Attack Trial (ALLHAT)29 was high blood pressure in physically active discontinued because of an increased inci- patients, especially those with diabetes.5 Their dence of congestive heart failure, compared effectiveness may be improved by adding a with use of a diuretic. The ALLHAT findings thiazide in a low dosage, with the drugs taken should be taken into consideration, especially separately or in combination. in athletes older than 55 years. The potassium-sparing effect of ACE Centrally acting alpha agonists have no inhibitors may be increased when these agents major effects on training or sports perfor- are taken concomitantly with NSAIDs.19 Use mance.19 Because of their side effects, however, of ACE inhibitors is contraindicated in preg- these agents are rarely used. These effects may nancy. Therefore, patients of childbearing age include mild to moderate drowsiness, dry should use some form of contraception if they mouth, and impotence. Rebound hypertension are taking an ACE inhibitor. can occur with the abrupt discontinuation of Angiotensin-II receptor blockers produce orally administered (Catapres).7 similar effects as ACE inhibitors. However, Beta Blockers. Noncardioselective beta because of their action at the receptor level, blockers significantly decrease contractility of they do not cause a dry cough. Currently, insuf- the heart and decrease heart rate. Systemic ficient data are available to document whether vascular resistance is increased, especially in angiotensin-II receptor blockers have cardiac the muscle and skin. Because these drugs and renal protective effects. Therefore, these inhibit lipolysis and glycogenolysis, hypo- agents are generally recommended only for glycemia may occur after intense exercise. In patients who cannot tolerate ACE inhibitors.5 addition, athletes who take beta blockers per-

Alpha Blockers. The alpha1-receptor antago- ceive greater exertion during exercise, which nists competitively block postsynaptic alpha1 may affect adherence to the prescribed med- arteriolar smooth muscle receptors. They ication regimen.20 An increased total choles-

AUGUST 1, 2002 / VOLUME 66, NUMBER 3 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 449 TABLE 4 Summary of Pharmacologic Treatment for Hypertension in Athletes and Other Physically Active Patients

Stroke Cardiac Vascular Plasma Effects on Heart rate volume output resistance volume training

Thiazide diuretics* No effect Decrease Decrease Decrease Significant No effect or decrease decrease in endurance

ACE inhibitors† Slight increase Increase Increase Decrease No effect No effect

Alpha blockers No effect No effect No effect Decrease No effect No effect

Beta blockers Significant No effect Significant Increase No effect Significant decrease decrease decrease

Calcium channel Decrease, No effect or No effect or Decrease No effect or No effect blockers increase, or decrease decrease increase no effect

CHF = congestive heart failure; USOC = U.S. Olympic Committee; NCAA = National Collegiate Athletic Association; ACE = angiotensin-converting enzyme; BPH = benign prostatic hyperplasia. *—Loop diuretics are inappropriate for the treatment of hypertension in competitive athletes and other physically active patients.

terol level and a decreased HDL cholesterol cular resistance, but less impairment of mus- level may also be noted.7 cle blood flow and maximum oxygen uptake. Although cardioselective beta blockers have If beta blockade is necessary, a combined fewer side effects than noncardioselective alpha-beta blocker may be the best choice.21 agents, they also impair cardiac output and The USOC has banned the use of beta maximum oxygen uptake, particularly in ath- blockers in athletes participating in precision letes. Cardioselective beta blockers should not events such as archery, shooting, diving, and be used in athletes and other physically active ice skating.16-18 patients unless there is an underlying condi- Blockers. These drugs tion (e.g., coronary artery disease) that inhibit calcium slow-channel conduction, requires their use.20 thereby reducing the calcium concentration in When combined alpha-beta blockers are vascular smooth muscle cells, which results in used, the beta effects are greater than the alpha decreased systemic vascular resistance with effects. There is a decrease in the systemic vas- generalized .19 Calcium channel

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Patients in whom drug Patients in whom drug Side effects class is recommended class should be avoided Banned status

Hypovolemia, , and urinary loss Elderly patients, black patients, Endurance athletes, Use banned by of potassium and magnesium, which can lead to muscle patients with CHF collegiate athletes USOC and cramps, arrhythmias, and in patients NCAA exercising intensely or competing in warm weather Dry, nonproductive cough (angiotensin I blockers) Patients with diabetes mellitus, Female patients who None renal insufficiency, CHF, are not using asthma, or contraception

First-dose hypotensive effect with alpha1 blockers, Patients with hyperlipidemia May want to avoid None especially in elderly patients or BPH in men older than Centrally acting agents may cause drowsiness, dry 55 years mouth, and impotence; rebound hypertension can occur with abrupt discontinuation of clonidine (Catapres). Increase in perceived exertion levels, impairment of Patients with coronary Patients with asthma, Use banned in cardiac output and maximum oxygen uptake, artery disease endurance athletes, precision sports earlier and lactate threshold, possible collegiate athletes (i.e., shooting, exacerbation of exercise-induced bronchospasm archery, diving, or asthma ice skating) Nondihydropyridines (e.g., [Calan], Patients with asthma, None None [Cardizem]) can cause heart rate suppression and black patients minor impairment of maximum heart rate, decreased left ventricular contractility, and . Dihyrdopyridines (e.g., [Norvasc], [Procardia]) can cause reflex , fluid retention, and vascular headaches.

†—Because of insufficient data documenting cardiac and renal protective effects, angiotensin-II receptor blockers are generally recom- mended only in patients who cannot tolerate ACE inhibitors. Angiotensin-II receptor blockers do not cause dry, nonproductive cough. Information from references 5, 6, and 16 through 21.

blockers are effective in reversing ventricular served.20 There is a potential for competitive hypertrophy. “steal” of muscle blood flow (because of Dihydropyridines such as amlodipine vasodilatation) and earlier onset of the lactate (Norvasc) and nifedipine (Procardia) can threshold.30 However, calcium channel block- cause reflex tachycardia, fluid retention (pedal ers, especially the dihydropyridines, are gener- ), and vascular headaches. Nondihy- ally well tolerated and effective in physically dropyridines such as verapamil (Calan) and active patients. They are often used as first- diltiazem (Cardizem) can cause heart rate line agents in black athletes.5 suppression, minor impairment of maximal heart rate, decreased left ventricular contrac- The author thanks Larry Duenk, M.D., Department of tility, and constipation.5 Family and Community Medicine, Medical College of Wisconsin, Milwaukee, for reviewing the manuscript. Calcium channel blockers have no major effects on energy metabolism during exercise, The author indicates that he does not have any con- and maximum oxygen uptake is generally pre- flicts of interest. Sources of funding: none reported.

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