ΥΠΕΡΤΑΣΗ ΣΤΟΥΣ

ΑΘΛΗΤΕΣ

Ανδρέας ΠιτταράςΚαρδιολόγος - Hypertension Specialist ESH

Ass. Prof. George Washington University USAΥπερτασικό ιατρείο Ασκληπιείο Βούλας

MEDITON

Disclosure of Relationships

Over the past 12 months

No relationships to disclose

on this lecture

A. Pittaras

Physical exercise is known to lower BP

and reduce cardiovascular risk

through a wide range of mechanisms.

Effects of Exercise/Physical Activity

• Antihypertensive

• Anti-atherogenic

• Anti-arrhythmic

• Lipid Metabolism

• CHO Metabolism

• LVH Regression

• Cardiac Function

• Endothelial Function

• Weight Control

• Bone Density

• Reduces Stress

• Increases Energy

• Induces Deep Sleep

• Improves Brain Function

• Free & Safe

• No Side-effects

Effects of Exercise/Physical Activity

• Lower risk of all-cause

mortality

• Lower risk of CVD

mortality

• Lower risk of CVD

(including stroke)

• Lower BP & risk of HTN

• Lower risk of T2DM

• Lower risk of adverse

lipid profile

• Lower risk cancers of the

bladder breast colon,

endometrium esophagus

kidney lung stomach

• Improved cognition

• Reduced risk dementia

• Improved quality of life

• Reduced anxiety

• Reduced risk depression

• Improved sleep

• Slowed-reduced weight gain

• Weight loss

• Prevention of weight regain

• Improved bone health

• Improved physical function

• Lower risk falls- injuries

older

JAMA

Nov 2018

Endothelial function

Coronary flow reserve

Tolerance of myocardial ischaemia

Myocardial capillary density

Ventricular fibrillation thresholds

Arterial blood pressure

Arterial stiffness

CV benefits of regular endurance training

EXERCISE

OBESITY

HTN

DYSLIPIDEMIADIABETES

CAD AFib

CKD

P.F.Kokkinos, A. Pittaras., et al. Cardiology Clinics 2001;19(3):507-516

Kokkinos P, Pittaras A., et al. New Eng J Med 1995;333:1462-7

P.Kokkinos, M. Doumas, A.Pittaras, A. Manolis et. Al. Hypertension 2009

Faselis C., Doumas M, Pittaras A, Kokkinos P. Hypertension 2014

P.Kokkinos, M. Doumas,A. Pittaras, Α. Manolis Am. J. of Hypertension 2009

P. Kokkinos, M. Doumas, A. Pittaras, A. Manolis , Blood Pressure 2009

A.Pittaras, M. Doumas, P. Kokkinos et. al. Top Scoring Abstract AHA & ACC Meeting

C. Faselis, A. Pittaras, P. Kokkinos et al Mayo Clin Proc. 2016

Kokkinos P. Pittaras A. et al. Diabetes Care 2009 32:623-28

A. Pittaras, C. Faselis, P. Kokkinos et al Am J Cardiol. 2013

Kokkinos P, Pittaras A., et al. Circulation 2008

Narayan P, Doumas M, Pittaras A, Kokkinos PF. Am J Cardiol. 2017

Lovic D, Narayan P, Pittaras A, Faselis C, Doumas M, Kokkinos P. J Clin Hypertens 2017

HTN IN ATHLETES

• HTN is the most prevalent CVD among athletes

and physically active subjects.

• The management of HTN in athletes can differ

from standard approaches, primarily due to the

potential side effects of some medications that

may impair training and performance.

“ATHLETS”

• Competitive athletes:

-Scholastic (high school)

-Club

-Collegiate

• Professional

• Recreational athletes

• Exercise for fitness and health

Hypertension in athletes: epidemiology

...the overall prevalence of high BP in athletes

is approximately 50% lower than in the general

population…

Fagard RH , Cardiol Clin 2007

HTN IN ATHLETS

• There was no evidence that BP was lower in athletes

than in controls.

• A number of studies showed a higher BP in athletes.

• The prevalence of HTN in athletes could not be

determined reliably because of different definitions of

HTN and poorly standardised methods of BP

measurement.

• A positive linear association between high BP and

LVH was observed in athletes, but confounding

factors may have played a role.

• Future studies should be designed to determine more

precisely the prevalence, determinants and

prognostic significance of HTN in athletes.

51 studies: 138.390 Athletes. H. Berge BMJ 2015

51 studies: 138 390 athletes. H. Berge BMJ 2015

Prevalence of HTN in athletes. H. Berge BMJ 2015

Prevalence of HTN in athletes. H. Berge BMJ 2015

Prevalence of HTN in athletes. H. Berge BMJ 2015

• HTN was defined in 11 different ways in the 25 studies.

• The most often used criteria for HTN ranged from SBP

≥140 or DBP ≥90 mm Hg to BP>140/90 mm Hg.

• The lowest cut-off value for HTN was BP ≥130/85 mm Hg

and the highest cut-off value was ≥160/95 mm Hg.

• 3 studies used medication to define HTN.

• One accepted self-reported HTN

• One only included participants with BP≤120/80 mm Hg.

• The prevalence of HTN was lower in studies that were

restricted to athletes within the age range 18–40 years

• 6 studies excluded patients with high BP>140/90mm Hg.

Prevalence of HTN in Athletes studies

Method of BP measurement in athletes Ι

• Some descriptions of measurement methods in 21 studies

• BP was measured in the sitting position in 10 studies and in a

supine position in 6 studies.

• At least 5 min of rest prior to BP recordings was required in 11

studies, while only 4 informed about time from physical activity

to BP measurement.

• Athletes abstained from caffeine and/or smoking prior to BP

recordings in 2 studies, and no studies informed about the

physical environment where the BP measurements took place.

• Only 8 studies reported whether an appropriate cuff size was

used. In the 8 studies using a ‘standard’ mercury

sphygmomanometer, the method of measurement performance

was reported in 3 studies.

• Only the 3 studies that used an automated BP device reported

the device type and manufacturer.

Method of BP measurement in athletes ΙΙ

• A single measurement in 5 studies, but repeated in 3 of

these if BP was high. The lowest of these values was

registered in 2 studies, and the highest in one.

• BP was recorded 2 and 3 times in 6 and 4 studies,

respectively, and there was a significant difference in

SBP between one and two BP recordings (127±4.7 vs

118±4.0mm Hg, p<0.05).

• Choice of arm for measurement was presented in 5

studies and no study measured BP in both arms.

• 3 studies recommended repeated BP recordings on a

separate occasion if the BP was elevated.

• Only 1 study referred athletes with elevated office BP to

ambulatory BP measurement.

Children and adolescents

• Age-adjusted tables baseupon gender and height percentile

Power sport athletes

• Measurement of forearm circumference

Appropriately sized cuff

• Good luck finding one…

Establishing BP levels in young athletes or in power sports (boxing, wrestling, weight

lifting) athletes is not so simple…

Establish BP levels in Athletes

• 410 football players at the annual preventive check (age

16±4 years)

• 41 athletes out of 410 (10%) were detected as having

elevated SBP or DBP in the first measurement.

• 18 athletes out of 410 (4.4%) had BP above the accepted

normal levels after two or more BP measurements

• Only 2 athletes had elevated 24h-ABPM values!

• Be careful (as usual) in diagnosing hypertension before

starting treatments / restrain the activity of an athlete!

Kouidi E et al, Am J Hypert 1999

Screening for Secondary Causes

• Prevalence of 2nd HTN in athletes is expected to be the

same as in the general population.

• Certain special situations must also be considered.

• Wheelchair athletes with spinal cord injuries above T6

level may have severe episodic HTN in the case of self-

induced autonomic dysreflexia (commonly known as

boosting), which is a massive sympathetic discharge

induced by nociceptive stimuli, improving performance

time by 10% in elite wheelchair marathon racers during

simulated racing.

Drug-induced HTN in Athletes

• NSAIDs

• Oral contraceptive pills (commonly taken by female

athletes)

• Herbal and dietary supplements used to increase energy or

control weight, containing “natural” substances such as

Guarana, Ma huang, and Ephedra, which are stimulants.

• Performance-enhancing drugs, such as Androgen-anabolic

steroids, Growth hormone, Erythropoietin, or Stimulants

such as Amphetamines, Caffeine, Ephedrine and

Pseudoephedrine and Cocaine have negative

cardiovascular effects, including HTN.

• Doping substances, impair both lipid and glucose

homeostasis, may favor in direct prothrombotic effect

(erythropoietin), in vasospasm (cocaine) or arrhythmias

(cocaine and other stimulants).

Assessment of TOD in Athlets

• Urinalysis, including microalbuminuria, is among routine

laboratory investigations to be performed in HTNsive pts.

• In athletes false positive results are likely, since exercise-

induced proteinuria, a benign and reversible

phenomenon, may occur if vigorous physical activity is

performed in the 24 h before the test.

• Echocardiography and ETT (with ECG and BP

monitoring), which are not always included in evaluation

of the HTNsive pt, are warranted as routine tests in the

HTNsive athlete

Lovic D, Pittaras A, Faselis C, Doumas M, Kokkinos P. J Clin Hypertens 2017

Predominant Changes in Heart with Aerobic Training

Volume Load Increases

Diastolic Stress Increases

Chamber Size Increases

Eccentric LVH

• Inhaling and breath holding while engaging in

the actual lifting of a weight (i.e., Valsalva

maneuver) can result in extremely high BP

responses, dizziness and even fainting,

especially in hypertensive individuals.

• Thus, such practice must be avoided during

resistance training.

WEIGHT LIFTING

BP up to 345/245 mm

Hg have been recorded

during heavy lifts.

• Activation of central

sympathetic drive

• Size of muscle mass

• Intrathoracic and

intraabdominal

pressure associated

with Valsalva.

McDougall JD, et al. J Appl

Physiol ‘85 58:758-90

McDougall JD, et al. J Appl

Physiol ‘92 73:1590-97

Palatini et al. J Hypertension

1989 7(6)S72-S-73

Predominant Changes in Heart with Resistance/Anaerobic Training

Pressure Load Increases

Systolic Stress Increases

Wall Thickness Increases

Concentric LVH

10

20

30

40

50

60

70

80

90

100

<5 5 6 7 8 9 10 12 14 18 22

Schematic Representation of Exercise-

Related Health Benefits

Threshold

>16-22 METs

Athletes/

Marathoner, etc

Plateau

%

13-16 METs

Highly Active

METS

Most of these health

benefits are realized at

relatively low levels

of physical activity

Differential effect of prolonged intense exercise on RV & LV volumes.

Duration-dependent effect of endurance events on right ventricular EF.

hs-cTnT concentrations before, immediately after, and 24 and 72 hours after marathon

Mayo Clin Proc. 2012 Jun; 87(6): 587–595.

Proposed pathogenesis of cardiomyopathy in endurance athletes

long-term sustained vigorous aerobic ET increases the prevalence of AFib

Characteristics of endurance exercise speculated to promote AF

N. John Bosomworth et al Can Fam Physician 2015;61:1061-70

STUDIES IN ATHLETES

Potential association between dose of endurance sports and CV events

Lancet. 2011;378(9798):1244–1253

Relationship between dose of physical activity and

reduction in all-cause mortality. The mortality benefits of exercise appear with even small amounts of daily

exercise and peak at 50 to 60 minutes of vigorous exercise per day.

Nonpharmacological Treatment

• All HTNsives have to adhere to lifestyle changes.

• In athletes with grade 1–2 HTN at low/moderate added CVR,

it is possible to delay the initiation of treatment by several

weeks, in order to assess the efficacy of lifestyle changes.

• Athletes are often more motivated to comply with

nonpharmacological interventions.

• Reduction of high sodium, and increase foods rich in K+

(endurance athletes may tend to be hypokalemic).

• Weight loss for overweight athletes, under specialist

supervision.

• BP-raising substances, (NSAIDs etc).

• In patients with 2nd HTN, clinical evaluation for sports

participation is preferably postponed to after removal of the

cause of hypertension.

2007 , 2009, 2013, 2018 ESH/ESC GuidelinesCombinations between Some Classes of Antihypertensive Drugs

Thiazide diuretics

ACE-i

CCBs

ARBs

• Pronounced antihypertensive effect

• CV protection

• Optimal tolerability

• Antihypertensive drugs such as beta blockers and diuretics impair

the ability to regulate body temperature during exercise in hot and/or

humid environments and provoke hypoglycemia.

• People using these medications should be educated on the

signs/symptoms, adequate hydration, proper clothing, the optimal

times of the day, decreasing time and intensity during periods of

increased heat or humidity, and methods to prevent hypoglycemia.

• In addition, beta blockers can alter submaximal and maximal exercise

capacity, particularly in those without myocardial ischemia.

• Because antihypertensive agents such as alpha blockers, CCBs, and

vasodilators may provoke hypotensive episodes after abrupt

cessation of activity, extending the cool-down period is generally

recommended.

• In athletes two further aspects should be considered:

- Some drugs are considered doping substances and are banned

by several sports associations

- Others have a negative effect on exercise performance.

• RAAS blockers and dihydropiridine CCBs appear to be the first

choice antihypertensive agents particularly in endurance athletes,

since they have no major effects on energy metabolism or

cardiovascular adaptation to exercise.

• RAAS blockers are contraindicated in female athletes during the

reproductive age.

• α-blockers and centrally acting α-agonists can be used in association

as second- or third-choice drugs.

Pharmacological Treatment

• Diuretics usually not recommended, favoring the excretion or dilution

of illegal substances, rapid weight loss, in weight-related categories

(boxing),so they are considered doping substances in several sports.

• Diuretics impair exercise performance and capacity in the first weeks

of treatment, and appears to be restored during long-term treatment.

• Loop diuretics can also precipitate hypovolemia, orthostatic

hypotension, and electrolyte imbalance (loss of potassium,

magnesium), in pts exercising intensely or in warm weather.

• Diuretics are contraindicated in elite athletes requiring drug testing.

• As second- or third-choice drugs and at low dosage in physically

active patients with HTN and salt-sensitive HTNsive athletes (blacks).

• Potassium-sparing diuretics avoid electrolyte disturbances.

Pharmacological Treatment: Diuretics

• β-blockers are prohibited in certain competitive sports (shooting, ski

jumping, archery, diving) due to their antitremor and anxiolytic effect.

• β-blockers affect sports performance in endurance athletes, as a

consequence of their negative ino- and chrono-tropic effect and

impairment of muscle blood flow, thus increasing the perception of

greater exertion during exercise.

• Inhibition of lipolysis and glycogenolysis could impair energy

metabolism.

• β-blockers should be used in athletes only when it is mandatory, as in

the presence of coronary artery disease, rather than merely for their

antihypertensive effect.

• For mandatory cases, a combined α-β blocker may be the best choice,

since they are expected to provide a lesser impairment of muscle

blood flow and of maximum oxygen uptake.

Pharmacological Treatment: β-blockers

• Diuretics and beta blockers are not ideal drugs for

athletes in sports with high aerobic demands.

• If these are the optimal therapy, and are not

banned by the sport's governing body, consider

carefully the time doses.

• It is best to take diuretics at least 7-8 hours prior.

• Be aware of the risks of hypoK and hypoNa.

• Beta blockers is best to take them at least 3-4

hours prior to competition.

• It is unknown what if any adjustments are needed

for extreme endurance events (eg, marathon,

ironman). Take any new medication for at least

one week prior to any competitive event.

Athletes with exaggerated BP response to ETT

• Normal or Increased resting BP.

• This issue is particularly complex.

• No widely accepted definition of exertional HTN:

- Cut off the 90°–95° percentile

- Fixed number

- Peak values

- 3 min ETT

- BP in the recovery period or at a chosen heart rate

- Peak SBP >210 mmHg for men and >190 mmHg for women.

• Possible negative prognostic role (±) independently of resting BP.

• Such rises should not be a reason to restrict physical activity.

• Those Athletes are more prone to develop HTN.

• Reasonable to recommend to regularly check BP, either at home

or in a clinical setting, in order to promptly intervene if

hypertension develops.

Sports eligibility depends on the pt’s risk profile

CONCLUSION

• Incidence of HTN is low in athletes, but it can be more

frequent with advancing age

• It is important to exclude the intake of substances which

can increase BP values (and CV risk!!)

• Diagnostic procedures must include echocardiography

and exercise testing

• Sport activity can be permitted depending on the presence

of well controlled BP values and low CV risk

• Althoug compelling indications do not exist, preferred

pharmacological treatment should be based on RAS-

blockers and/or calcium antagonists

• While endurance sports reduce CV events, power sports

increase the risk of coronary artery disease