5. Physical Examination/Personal History: Do You Have or Have You Ever Been Told You Have Hypertention?
The goal in measuring blood pressure during the PPE is to reduce the risk of an acute cardiac event during exercise such as an aortic disruption or a cerebral vascular event and to identify athletes in need of further evaluation and possible treatment.
Blood pressure in children increases with age and height. Percentile values are available at http://www.nhlbi.nih.gov/guidelines/hypertension/child_tbl.htm. Children with values >95th percentile are considered to have hypertension, and those between the 90th and 95th percentile are considered to have prehypertension. For children older than 14 years, the 90th percentile is generally exceeded with a systolic blood pressure (SBP) >130 mm Hg or a diastolic blood pressure (DBP) >80 mm Hg. Hypertension in adults requires SBP and DBP values greater than 140 and 90 mm Hg, respectively. Individuals meeting these criteria on screening should undergo further evaluation.
Blood pressure measurements should be made using measurement guidelines (5) (Table) Athletes with normal blood pressure should have their blood pressure measured at every health care encounter. Adults with values of SBP between 120 and 139 mm Hg and of DBP between 80 and 89 mm Hg should be reevaluated in a year.
Secondary hypertension is ultimately found in approximately 5% of athletes and physically active individuals (7). The possibility of secondary hypertension should be considered when the history or physical examination raises this possibility and when hypertension is severe, occurs in younger athletes, has a sudden onset, and is not controlled by the usual drug regimen.
The history examination should determine whether the athlete uses any over-the-counter (OTC) medications or supplements that could increase blood pressure. These include OTC cold and sinus remedies that contain sympathomimetic agents, nonsteroidal medications frequently used by athlete for pain management, excessive alcohol consumption, or the use of cocaine, amphetamines, anabolic steroids, or selective androgen receptor modulators (8).
The physical examination should seek to identify secondary causes of hypertension. This should include inspection for the buffalo hump and moon facies of Cushing syndrome and signs of hyperthyroidism, auscultation for abdominal and flank vascular bruits, and simultaneous palpation of the radial and femoral arterial pulse to exclude a radial femoral pulse delay. In adolescents and adults, a radial femoral pulse delay is a better sign of coarctation than absence of the femoral pulse (9). A wide pulse pressure and primarily systolic hypertension should prompt a search for aortic insufficiency.
Laboratory testing also is designed to detect secondary causes of hypertension and should include a thyroid-stimulating hormone level to detect hyperthyroidism, electrolytes to look for the hypokalemia associated with aldosterone excess, a serum calcium level to detect hyperparathyroidism, measures of renal function, and a urinalysis. A low pretreatment potassium level or rapid decrease in potassium with diuretic therapy suggests hyperaldosteronism. Adrenal hyperplasia without adenoma is a variant of hyperaldosteronism that often occurs in patients with difficult-to-treat hypertension and responds well to aldosterone antagonists.
TREATMENT OF ATHLETES WITH HYPERTENSION
Treatment should be aimed at the underlying cause. Physical activity, low-sodium diets, and alcohol restriction can reduce blood pressure in some athletes. Both sodium restriction and alcohol restriction should be tried before initiating drug therapy. Most individuals with carefully diagnosed hypertension will require medication therapy, and approximately two-thirds of patients require more than one agent. We often initiate therapy with a low-dose diuretic followed by either an ACE-I or ARB alone or in combination in non-Blacks (10). Initial treatment in Blacks is either a thiazide-type diuretic or a calcium channel-blocker alone or in combination (10,11).
SPECIAL CONSIDERATIONS IN ATHLETES
Diuretics increase the urinary loss of potassium, and hypokalemia can cause muscle cramps and rhabdomyolysis, especially in athletes exercising in hot environments. Nevertheless, we frequently use low-dose diuretics as initial therapy, especially in Blacks since Black athletes are more sensitive to sodium than their White counterparts. We avoid higher doses except in athletes with large body mass and hold the diuretics several days before athletic events that are associated with high sweating rates and loss of body fluid. We often combine diuretics with ACE-I or ARB that prevent hypokalemia produced by diuretics alone. Athletes have used diuretics to dilute the urine, thereby decreasing the concentration of banned ergogenic medications. Diuretics also can be used to “make weight” in sports with weight classes such as wrestling and boxing. Consequently, diuretic use is prohibited by the World Anti-Doping Agency (12).
Our second choice for blood pressure control in athletes is either an ACE-I or an ARB because there are theoretical reasons to believe that ACE inhibitors can improve athletic performance and they reduce potassium loss from the diuretic. The most challenging side effect of ACE inhibitor is a dry cough in approximately 10% of patients. ARB can be used in patients who develop a cough (4).
A variety of other agents is available including calcium channel blockers. Avoid beta-blocking agents because they impair aerobic performance and their use is banned for athletes participating in precision events (12). These prohibitions exist because beta-blockade slows the heart rate and allows more time between pulse movement to fire a steadier shot in shooting and archery.
Athletes treated for hypertension should be seen frequently until their blood pressure is controlled. Patients on diuretics or agents that affect the renin-angiotensin system should have periodic measurements of their serum potassium and creatinine levels. Follow-up visits can be at 3- to 6-month intervals once the BP is at target and stable (4).
Seven of 28 high school football players undergoing a team screening provided free by a local physician were referred for hypertension evaluation. None of the athletes had hypertension when their blood pressure was measured using a mercury sphygmomanometer. Subsequent discussion with the physician revealed that he had used an inappropriately small cuff. All seven athletes were linemen.
Key Point: An undersized cuff on a muscular arm produces spuriously elevated blood pressures.
A 17-year-old high school senior who had recently relocated to Connecticut from northern Maine was referred for hypertension detected during an Air Force physical screening. Upon examination, his blood pressure was 184/105 mm Hg in each arm. His cardiovascular examination result was normal, and he had palpable femoral pulses bilaterally, but there was a clear discrepancy between the timing of his radial and femoral pulses. His chest x-ray showed extensive rib notching consistent with aortic coarctation and collateral vessel development. He was referred for surgical repair.
Key Point: Femoral pulses are often present in adolescents with previously undetected aortic coarctation because the femoral pulse is well supplied by collaterals. Adolescents and young adults with hypertension should be examined for a radial-femoral pulse delay.
An 18-year-old high school football defensive lineman was referred for a screening blood pressure of 188/68 mm Hg in each arm. His cardiac examination revealed a 3/6 diastolic murmur over his sternum. His echocardiogram results showed moderate aortic insufficiency. His hypertension was treated with an ARB and was cured.
Key Point: Aortic insufficiency produces systolic hypertension and wide pulse pressure. It is often hard to hear, so aortic insufficiency should be excluded in all athletes with systolic hypertension and wide pulse pressure.
1. 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.
2. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA
. 2014; 311: 507–20.
3. Pickering TG. Measurement of blood pressure in and out of the office. J. Clin. Hypertens. (Greenwich)
. 2005; 7: 123–9.
4. World Anti-Doping Agency. The 2013 Prohibited List International Standard. 2013.
Irfan M. Asif, MD
Vice Chair Research & Academics
Director, Sports Medicine Fellowship
Department of Family Medicine
Greenville Health System/University of South Carolina Greenville
William Roberts, MD, MS
Professor, Family Medicine
1414 Maryland Avenue E
St. Paul, MN 55106
Michael Frederickson, MD
Professor, Stanford University
V. F. Froelicher, MD (111C)
Professor of Medicine, Stanford University
Palo Alto VA Medical Center, 650-493-5000 x 64605
3801 Miranda Avenue, Building 100, Room E2-441
Palo Alto, CA 94304-1207
Francis G. O’Connor, COL, MC, USA
Professor and Chair, Military and Emergency Medicine
Medical Director, Consortium for Health and Military Performance
Uniformed Services University of the Health Sciences
Aaron L. Baggish, MD, FACC
Cardiovascular Performance Program
Massachusetts General Hospital
Meagan M. Wasfy, MD
Sports Medicine Fellow
Cardiovascular Performance Program
Massachusetts General Hospital
Ricardo Stein, MD
Jeffrey S. Kutcher, MD
Director, Michigan NeuroSport
Department of Neurology
University of Michigan
Aswathnarayan R. Manandhi, MD
Cardiology Division, Hartford Hospital
Paul D. Thompson, MD, FACC
Chief of Cardiology, Hartford Hospital
Abhimanyu (Manu) Uberoi, MD
Cardiology Fellow, Cedars Sinai Medical Center
Benjamin D. Levine, MD
Director, Institute for Exercise and Environmental Medicine
S. Finley Ewing Jr. Chair for Wellness at Texas Health Presbyterian Dallas
Harry S. Moss Heart Chair for Cardiovascular Research
Professor of Medicine and Cardiology
Distinguished Professorship in Exercise Science
University of Texas Southwestern Medical Center at Dallas
Chad Asplund, MD, MPH, FACSM
Medical Director, Student Health Services and Sports Medicine
Associate Professor, Family Medicine
Georgia Regents University
Team Physician Georgia Regents University, Paine College, Augusta Greenjackets
Jonathan Myers, PhD
Palo Alto VA Medical Center
David Liang, MD
Director, Stanford Marfan’s Clinic
Marco Perez, MD
Stanford CV Genomics
Rick Dewey, MD
Cardiology Fellow and Genomics Program Researcher
Michael J. Khadavi, MD
PM&R Resident, Sportsmedicine Program Stanford
George K. Lui, MD, FACC
Medical Director, The Adult Congenital Heart Program at Stanford
Stanford Hospital & Clinics and Lucile Packard Children’s Hospital
Clinical Assistant Professor of Medicine
Division of Cardiovascular Medicine
Stanford University School of Medicine
Jon-Emile Stuart Kenny, MD
Stephen Ruoss, MD
Professor of Medicine, Pulmonary and Critical Care
Stanford University Medical Center