Managing Hypertension in Athletes

Hypertension (HTN), or high blood pressure, is the most prevalent cardiovascular disease among athletes. HTN is divided into three classifications. Prehypertension is a bloods pressure over 120/80 but less than 140/90. Stage 1 HTN is a blood pressure of 140/90 to 160/100. Stage 2 HTN is a blood pressure over 160/100.

Prehypertension can usually be managed with life style changes including a low-fat diet, weight loss, and exercise. There are no restrictions for sports participation for athletes with prehypertension.

Stage 1 and 2 HTN usually require medication to control blood pressure in addition to life style modification. There are several classes of medications used to treat HTN. The most common of these are thiazine diuretics, angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), calcium channel blockers (CCB), and Beta blockers.

Thiazine diuretics are often first-line treatment for HTN. However, diuretics are not recommended for endurance and competitive athletes because they contribute to dehydration, electrolyte loss, and heat illnesses.  Beta blockers, such as propranolol, are also not recommended for athletes because they decrease heart rate, cardiac output, and VO2 max. Which decreases performance. Thiazine diuretics and Beta blockers are also banned in competition by some sport specific governing bodies.

ACE inhibitors and ARBs should be first-line medications for reducing blood pressure in athletes. Ace and ARBs may slightly decrease heart rate, increase stoke volume, and decreases systemic vascular resistance. They are the preferred treatment because they have no effect on energy metabolism and do not impair aerobic performance. ACE inhibitors and ARBs should not be used together.

CCBs, such as Amlodipine, are also recommended for HTN management in athletes. They are considered first line therapy for African American athletes and for exercise induced HTN. CCBs decreased systemic vascular resistance. Their disadvantages are that they may diminish muscle blood flow and cause aerobic threshold to be reached earlier. Amlodipine can cause reflex tachycardia and Diltiazem may slightly decrease maximum heart rate and decrease contractility. Advantages of CCBs are that they have no significant effect on energy metabolism and no major impairment of aerobic performance.

There is no restriction in sports participation for athletes with well controlled stage 1 HTN. Athletes with stage 2 HTN or uncontrolled stage 1 HTN should limit sports participation to low-intensity aerobic sports.

Athletes with HTN should be evaluated prior to sports participation. Evaluation should include a thorough history, physical exam, blood chemistry, lipid profile, urinalysis, and a 12- lead ECG.  An echocardiogram or exercise stress test may also be warranted. Lifestyle modification and medication management for athletes with HTN should be closely monitored by a health care provider.   

References

O'Connor, F. G. MD, Meyering, C. D., Patel, R., Oriscello, R. P. (2007). Hypertension, athletes, and thesSports physician: Implications of JNC VII, the fourth report, and the 36th Bethesda conference guidelines. Current Sports Medicine Reports. 6, 80-84

Pelto, H. (2017). Hypertensive medications in competitive athletes. Current Sports Medicine Reports. 16, 45–49. doi: 10.1249/JSR.0000000000000325

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