hypertension, athletes and the sports physician

Hypertension, Athletes and the Sports Physician:Hypertension, Athletes and the Sports Physician: Implications of JNC VII, The Fourth Report, and Implications of JNC VII, The Fourth Report, and

the 36th Bethesda Conference Guidelinesthe 36th Bethesda Conference Guidelines

Francis G. O’Connor, MD, MPHFrancis G. O’Connor, MD, MPHMedical Director, USUHS Consortium for Health Medical Director, USUHS Consortium for Health

and Military Performance (CHAMP)and Military Performance (CHAMP)Uniformed Services University of the Health SciencesUniformed Services University of the Health Sciences

ObjectivesObjectives

Outline key changes and Outline key changes and additions to:additions to:– JNC VIIJNC VII– The Fourth ReportThe Fourth Report– The 36The 36thth Bethesda Report Bethesda Report

Discuss clinical Discuss clinical implications for the implications for the sports clinician.sports clinician.

U.S. Department of Health and Human

Services

National Institutes of Health

National Heart, Lung, and Blood Institute

The Seventh Report of the The Seventh Report of the Joint National Committee onJoint National Committee on

Prevention, Detection, Prevention, Detection, Evaluation, and Treatment of Evaluation, and Treatment of High Blood Pressure (JNC 7)High Blood Pressure (JNC 7)

National Heart, Lung, and Blood InstituteNational High Blood Pressure Education Program

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 2003;289:2560-72.

Why a New JNC Report?Why a New JNC Report?

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

BackgroundBackground

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 Hypertension is the most common cardiovascular disease encountered in cardiovascular disease encountered in

the athletic population.the athletic population.

BackgroundBackground

Benefits of Lowering BP

Average % Reduction

Stroke incidence 35–40%

Myocardial infarction 20–25%

Heart failure 50%

34272910Control

59545531Treatment

70687351Awareness

1999–2000

II(Phase 2)1991–94

II(Phase 1)1988–91

II1976–80

National Health and Nutrition Examination Survey, Percent

Trends in awareness, treatment, and control of high blood pressure in adults ages 18–74, Adapted from JNC VII.

JNC VII Blood Pressure Classification

<80 and <120Normal

80–89or120–139Prehypertension

90–99or140–159Stage 1 Hypertension

>100or>160Stage 2 Hypertension

DBP mmHgSBP mmHgBP Classification

High Normal of JNC VI replaced by Prehypertension.High Normal of JNC VI replaced by Prehypertension.

Four Stages of Hypertension in JNC VI consolidated to Four Stages of Hypertension in JNC VI consolidated to Two Stages.Two Stages.

Key MessagesKey Messages

For persons over age 50, SBP is a For persons over age 50, SBP is a more important than DBP as CVD more important than DBP as CVD risk factor.risk factor.Starting at 115/75 mmHg, CVD Starting at 115/75 mmHg, CVD risk doubles with each increment risk doubles with each increment of 20/10 mmHg throughout the of 20/10 mmHg throughout the BP range. BP range. Persons who are normotensive at Persons who are normotensive at age 55 have a 90% lifetime risk age 55 have a 90% lifetime risk for developing HTN.for developing HTN.Those with SBP 120–139 mmHg Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be or DBP 80–89 mmHg should be considered prehypertensive who considered prehypertensive who require health-promoting lifestyle require health-promoting lifestyle modifications to prevent CVD.modifications to prevent CVD.


Thiazide-type diuretics should Thiazide-type diuretics should be initial drug therapy for be initial drug therapy for most, either alone or most, either alone or combined with other drug combined with other drug classes. classes. Certain high-risk conditions Certain high-risk conditions are compelling indications for are compelling indications for other drug classes.other drug classes.Most patients will require two Most patients will require two or more antihypertensive or more antihypertensive drugs to achieve goal BP.drugs to achieve goal BP.If BP is >20/10 mmHg above If BP is >20/10 mmHg above goal, initiate therapy with two goal, initiate therapy with two agents, one usually should be agents, one usually should be a thiazide-type diuretic.a thiazide-type diuretic.


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

Implications for the Sports PhysicianImplications for the Sports Physician

Diagnosis:Diagnosis:– Evaluation of the hypertensive Evaluation of the hypertensive

recommends the following: 12 recommends the following: 12 lead electrocardiography; lead electrocardiography; urinalysis; blood glucose and urinalysis; blood glucose and hematocrit; serum potassium, hematocrit; serum potassium, creatinine and calcium; and a creatinine and calcium; and a lipoprotein profile.lipoprotein profile.

Evaluation:Evaluation:– While echocardiography is While echocardiography is

recognized in JNC VII as more recognized in JNC VII as more sensitive than sensitive than electrocardiography for detecting electrocardiography for detecting left ventricular hypertrophy, left ventricular hypertrophy, there there is no specific recommendationis no specific recommendation mandating screening mandating screening echocardiography. echocardiography.


Treatment:Treatment:– JNC VII specifically addresses JNC VII specifically addresses

compelling indications for compelling indications for pharmacologic intervention: heart pharmacologic intervention: heart failure; post myocardial infarction; failure; post myocardial infarction; high coronary disease risk; high coronary disease risk; diabetes; chronic kidney disease; diabetes; chronic kidney disease; and recurrent stroke prevention. and recurrent stroke prevention.

– In addition, other special situations In addition, other special situations e.g. minorities, are identified with e.g. minorities, are identified with suggested treatment strategies. suggested treatment strategies.

– Specific comments into Specific comments into recommendations for athletes, recommendations for athletes, however, do not appear in JNC VII.however, do not appear in JNC VII.

AMSSM should be a member of the writing group for AMSSM should be a member of the writing group for JNC VIII.JNC VIII.

The Fourth Report on the The Fourth Report on the Diagnosis, Evaluation, and Diagnosis, Evaluation, and

Treatment of High Blood Pressure Treatment of High Blood Pressure in Children and Adolescentsin Children and Adolescents

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

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


Diagnosis:Diagnosis:– A diagnosis requires at least A diagnosis requires at least

three measurements.three measurements.– 90 to 95% was high-normal, 90 to 95% was high-normal,

now prehypertension;now prehypertension;– 95% to 99% plus 5mmHg is 95% to 99% plus 5mmHg is

Stage I; Greater than 99% plus Stage I; Greater than 99% plus 5 mmHg is Stage II.5 mmHg is Stage II.

The plus 5mmHg is new from The plus 5mmHg is new from 1996.1996.

– Ambulatory blood pressure Ambulatory blood pressure monitoringmonitoring recognized as useful recognized as useful in “white” coat hypertension.in “white” coat hypertension.


EvaluationEvaluation::– All children and adolescents All children and adolescents

diagnosed with hypertension diagnosed with hypertension require a careful history and require a careful history and physical examination as well as physical examination as well as further evaluation for a further evaluation for a secondary etiology as clinically secondary etiology as clinically indicated. indicated.

Renal US for all children with Renal US for all children with sustained BP > 95%sustained BP > 95%

– To evaluate for target organ To evaluate for target organ disease:disease:

Echocardiogram, as well as a Echocardiogram, as well as a retinal examination, is retinal examination, is currently recommendedcurrently recommended for all for all patients with a BP patients with a BP >> 95th 95th percentile. percentile.


Treatment/Clearance:Treatment/Clearance:– Similar to adults, any child Similar to adults, any child

athlete with Stage 2 athlete with Stage 2 hypertension hypertension should be should be restricted from participation restricted from participation until adequate control is until adequate control is obtained. obtained.

– Children with identified target Children with identified target organ disease should have organ disease should have participation recommendations participation recommendations based upon the nature of their based upon the nature of their target organ disease.target organ disease.

– Note that the Current PPE Note that the Current PPE monograph is based upon the monograph is based upon the 1996 Report:1996 Report:

Athletes pick up an extra Athletes pick up an extra 5mmHg for clearance for sport.5mmHg for clearance for sport.

http://books.mcgraw-hill.com/cgi-bin/pbg/0071446362?mv_session_id=rkqWE2jS&mv_pc=361&sectioncode=

36th Bethesda Conference: 36th Bethesda Conference: Recommendations for Determining Recommendations for Determining

Eligibility for Competition in Athletes with Eligibility for Competition in Athletes with Cardiovascular Abnormalities: Cardiovascular Abnormalities:

Task Force 5: Systemic Hypertension.Task Force 5: Systemic Hypertension.

Kaplan NM, Gidding SS, Pickering TG, et Kaplan NM, Gidding SS, Pickering TG, et al: Journal of the American College of al: Journal of the American College of

Cardiology 2005, 45 (8):1346-8.Cardiology 2005, 45 (8):1346-8.

Why a 36Why a 36thth Conference? Conference?

Ten year Update.Ten year Update.

Publication of many Publication of many new studies.new studies.

New interventions.New interventions.

3636thth Bethesda Conference Bethesda Conference GuidelinesGuidelines

Recommendations for Recommendations for Determining Eligibility for Determining Eligibility for Competition in Athletes with Competition in Athletes with Cardiovascular Abnormalities Cardiovascular Abnormalities 2626thth Bethesda Report Bethesda Report

Congenital heart diseaseCongenital heart diseaseAcquired valvular heart diseaseAcquired valvular heart diseaseHypertrophic cardiomyopathy, Hypertrophic cardiomyopathy, myocarditis, and other myocarditis, and other myopericardial diseases and myopericardial diseases and mitral valve prolapsemitral valve prolapseSystemic hypertensionSystemic hypertensionCoronary artery diseaseCoronary artery diseaseArrhythmiasArrhythmias

3636thth Bethesda Conference Guidelines Bethesda Conference Guidelines

Recommendations for Recommendations for Determining Eligibility for Determining Eligibility for Competition in Athletes with Competition in Athletes with Cardiovascular Abnormalities Cardiovascular Abnormalities 20052005– 12 Distinct Task Force Reports12 Distinct Task Force Reports

Preparticipation Preparticipation ScreeningScreening

Congenital Heart Congenital Heart DiseaseDisease

Valvular Heart DiseaseValvular Heart Disease

CardiomyopathiesCardiomyopathies

HypertensionHypertension

ArrhythmiasArrhythmias

Sports ClassificationSports Classification

DrugsDrugs

AEDsAEDs

Commotio CordisCommotio Cordis

LegalLegal


Treatment/ Treatment/ Clearance:Clearance:– Note that the Note that the

Current PPE Current PPE monograph is monograph is based upon the based upon the 2626thth Bethesda Bethesda Conference Report.Conference Report.

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Implications for Implications for the Sports the Sports PhysicianPhysician

2626thth versus 36 versus 36thth

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

Table 1: 36th Bethesda Conference Recommendations

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.

5

All drugs being taken must be registered with appropriate governing bodies to obtain therapeutic exemption.

4

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.

3

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.

2

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 “athlete’s heart” should limit participation until BP is normalized by appropriate drug therapy.

1

Task Force 5 : Systemic Hypertension36th Bethesda Conference Recommendations


Evaluation:Evaluation:– Those athletes with stage 1 hypertension should have a Those athletes with stage 1 hypertension should have a

blood chemistry (glucose, creatinine/GFR, electrolytes, blood chemistry (glucose, creatinine/GFR, electrolytes, lipid profile), hematocrit, urinalysis and lipid profile), hematocrit, urinalysis and electrocardiogram.electrocardiogram.

– If an athlete has stage 2 hypertensionIf an athlete has stage 2 hypertension, abnormal , abnormal results, or a possible secondary cause then referral for results, or a possible secondary cause then referral for therapy plus additional study therapy plus additional study including including echocardiographyechocardiography is recommended. is recommended.

Clearance:Clearance:– Currently an athlete listed as severe hypertension (stage Currently an athlete listed as severe hypertension (stage

2) has a blood pressure reading than 160/100 on two 2) has a blood pressure reading than 160/100 on two occasions and should be restricted from competition occasions and should be restricted from competition until the pressure is controlled. until the pressure is controlled.

– Using the 26th Conference guidelines, a similar reading Using the 26th Conference guidelines, a similar reading of 160/100 on three occasions would be classified as of 160/100 on three occasions would be classified as Moderate (stage 2) and would result in no restrictions Moderate (stage 2) and would result in no restrictions for the athlete. for the athlete.

Key WebsitesKey Websites

National Heart Lung and National Heart Lung and Blood InstituteBlood Institute– http://www.nhlbi.nih.gov/http://www.nhlbi.nih.gov/

Clinical Practice GuidelinesClinical Practice Guidelines– JNC VIIJNC VII– The 4The 4thth Report Report

American College of American College of CardiologyCardiology– http://www.acc.orghttp://www.acc.org

Consensus Conference ReportsConsensus Conference Reports – 3636thth Bethesda Conference Report Bethesda Conference Report

http://www.nhlbi.nih.gov/

http://www.acc.org/

ConclusionConclusion

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

David O. Hough

hypertension, athletes and the sports physician

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