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Hypertensive Medications in Competitive Athletes

Pelto, Henry MD

doi: 10.1249/JSR.0000000000000325
General Medical Conditions: Section Articles
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Hypertension is the most common cardiovascular disease in athletes. It is an important cause of long-term morbidity and mortality, even in a fit, athletic population. Management options to reduce these long-term risks exist that have minimal impact on athletic performance. Identification and management of underlying lifestyle factors and diseases that may lead to secondary hypertension is critical. These include substance abuse, medications, and underlying medical conditions. After evaluation and management of these issues, medications can be used to reduce blood pressure. In the athletic population, first-line medication treatment should include ACE inhibitors, angiotensin II receptor blockers (ARB), and calcium channel blockers (CCB). The response to treatment should be followed closely to ensure adequate blood pressure control. Athletic participation in sports with high dynamic load should be limited in individuals with stage 2 hypertension or stage 1 hypertension with evidence of end organ damage.

Department of Family Medicine, University of Washington, Seattle, WA

Address for correspondence: Henry Pelto, MD, Department of Family Medicine, University of Washington, Box 354060, Seattle, WA 98195; E-mail: pelto@uw.edu.

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Introduction

Hypertension is the most common cardiovascular disease in the general population, as well as in athletes (25). Significant long-term morbidity and mortality are well-established consequences of uncontrolled hypertension (18,36). While exercise is frequently thought of as a primary treatment for high blood pressure, athletes do not have lower, and may in fact have higher, rates of hypertension than the general population (7). The large majority of patients with elevated blood pressure on preparticipation examination (PPE) will eventually develop hypertension (37). Evidence suggests that many with normal blood pressure during the PPE may have masked hypertension (6). This stresses the importance of initial screening and annual repeat blood pressure measurements in athletes.

A diagnosis of hypertension can be made after two elevated blood pressure measurements taken at unique time points. The degree of hypertension is delineated into two stages. In adults, stage 1 hypertension is defined as systolic blood pressure (SBP) ≥140 mm Hg and/or diastolic blood pressure (DBP) ≥90 mm Hg and stage 2 hypertension as SBP ≥160 mm Hg and/or DBP ≥100 mm Hg. The definition of hypertension in children and adolescents varies based on age and body size. SBP or DBP between the 95th and 99th percentile plus 5 mm Hg based on age and height defines stage 1 hypertension and SBP or DBP >99th percentile plus 5 mm Hg defines stage 2 hypertension (4). Tables with normative data based on large, population-based studies are available (28). Hypertension should be diagnosed if SBP ≥140 mm Hg and/or DBP ≥90 mm Hg in adolescents regardless of age or body size (4). Care should be taken to measure blood pressure appropriately, particularly in the preparticipation setting when evaluation may be done in a mass screening format. The patient should be seated quietly for 5 to 10 min before measurement with use of an appropriately sized blood pressure cuff. One of the most common reasons for falsely elevated blood pressure is the use of a cuff that is too small.

The common occurrence of “white-coat” hypertension is important in athletes during the PPE given the stress and anxiety often associated with this encounter. In this setting, consideration should be given to ambulatory blood pressure monitoring (blood pressure measurement via automated device every 20 to 60 min over a 24-h period) when elevated blood pressure is identified on initial screening.

Isolated, or spurious, systolic hypertension is another common finding in athletes (20). This finding is far more common in men and in those with higher body mass index. The long-term implications of this finding are not entirely clear. It appears that this group represents an intermediate risk category between normotensive and hypertensive groups. The risk of developing true hypertension in the future also is increased in these individuals (29).

When evaluating an athlete with elevated blood pressure, several historical findings should be taken into consideration. These include family history, dietary history, alcohol and illicit drug use, and medication use. Several subcategories of these warrant particular attention in athletes (Table 1). Many ergogenic aids including anabolic steroids are known to cause elevated blood pressure. Alcohol, frequently used among young athletes, also can lead to elevated blood pressure. High dietary sodium intake also should be addressed when discussing elevated blood pressure with athletes. Screening for these issues with appropriate intervention, if positive, should be undertaken before initiation of medication management, particularly in those with prehypertension (SBP, 120–139 mm Hg; DBP, 80–90 mm Hg).

Table 1

Table 1

Certain medical conditions may lead to secondary hypertension and should be considered in otherwise healthy, young, particularly adolescent, athletes. Renal, endocrine, vascular, and neurologic conditions can lead to elevated blood pressure (Table 1). High blood pressure during screening might be the presenting sign of these diseases. A careful history should be taken to evaluate for other signs and symptoms that may suggest a primary cause for hypertension, such as excessive sweating, palpitations, chest pain, headaches, and urinary changes. Stage 2 (SBP ≥160/DBP ≥100), isolated diastolic, and nocturnal hypertension are all more likely to indicate secondary hypertension (15,16). When elevated blood pressure is present, and confirmed on follow-up, providers should consider further evaluation including renal function, electrolytes, complete blood count, urinalysis, renal ultrasound, electrocardiogram, and echocardiogram.

There are many classes of antihypertensive medications that can be used to effectively lower blood pressure. Large consensus guidelines exist to help providers determine the appropriate medication to use for a particular patient (11,21). Specific factors that should be considered in the athlete population are: age, comorbid medical conditions, medications and supplements, sport type, as well as nutritional and hydration status. Additional consideration should be given to the status of any chosen medication on the World Antidoping Agency (WADA) banned substance list (1). Medications may be on this list due to direct performance enhancing effects or ability to cover up the presence of other ergogenic aids. While a therapeutic exemption can be completed with minimal effort, other agents may be used without risk of a positive test.

The following sections discuss the most common antihypertensive drug classes: angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARB), β-blockers, calcium channel blockers (CCB), and thiazide diuretics. The mechanism of action, unique features in specific populations, use in the athletic population, and common specific medications and dosing within each class will be reviewed.

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Thiazide Diuretics

Thiazide diuretics have long been a mainstay of the initial management of hypertension in adults (Figure). This class of medications blocks the sodium-chloride channel in the distal tubule of the kidney. Thiazide diuretics have been cited as a possible first-line treatment for hypertension (21). This is a change from previous recommendations for use of thiazide diuretics as first-line monotherapy in all but special populations (11). This recommendation change was largely based on the fact that in reviewed clinical trials, thiazide diuretics achieved similar outcomes in all areas evaluated, other than in heart failure, where they are superior. In athletes, several factors should be taken into consideration when initiating diuretic therapy. First, urinary loss of potassium may lead to hypokalemia, putting athletes at risk of muscle cramping or rhabdomyolysis. This is particularly true in hot environments or events that tend to raise core body temperature over a prolonged period. Special caution should be taken using this class of medication in athletes prone to heat related illness (e.g., those with sickle cell trait). Another consideration in athletes is the fact that diuretics are listed on the WADA banned substance list (1). This is primarily due to the fact that they can be used to dilute urine and obscure the urinary concentration of other banned substances. Diuretics also can be used for accelerated weight loss for sports in which weight criteria are used to determine qualification for participation (e.g., horse racing and wrestling). Based on previous data, thiazide diuretics appear to have minimal effect on V˙O2max or rating of perceived exertion in exercising individuals (5,35). If diuretics are used as an antihypertensive medication in athletes, consider initiation of therapy with hydrochlorothiazide (HCTZ) at 25 mg PO daily (Table 2). Chlorthalidone (12.5 mg daily by mouth) also can be considered. It has a longer mechanism of action (24 h vs 12 h for HCTZ), greater potency, and most clinical trials that have evaluated the efficacy of thiazide diuretics have used chlorthalidone (9,14,26). Importantly, for the athletic population, the risk of hypokalemia is increased with chlorthalidone (17). Given current guideline recommendations and risks of use unique to the athletic population, thiazide diuretics are not recommended as first-line antihypertensive therapy in athletes.

Figure

Figure

Table 2

Table 2

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Calcium Channel Blockers

Calcium channel blockers act by inhibiting voltage-gated calcium channels in cardiac and vascular muscle to decrease cardiac contractility and relax vascular smooth muscle. This has the combined effect of decreasing cardiac output and peripheral vascular resistance, which leads to a decrease in blood pressure. One large clinical trial showed the superiority of CCB as first-line therapy for black patients (26). This is based largely on a 51% increase in the risk of stroke in the black population with ACE-I monotherapy compared with CCB. Additionally, ACE inhibitors were less effective at lowering blood pressure when compared with CCB as initial therapy in black patients with hypertension (26). Several subclasses of calcium channel blockers exist. Amlodipine (dihydropyridine-type) and long-acting diltiazem are less cardioselective than other CCB leading to minimal impact on cardiovascular performance (34) and have lower rates of side effects, such as headache, flushing, dizziness, and fatigue. An initial dose of amlodipine 2.5 mg once daily or diltiazem extended release 120 mg once daily are recommended for this class of medications (Table 2).

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ACE Inhibitors and ARB

Both of these medication classes have strong efficacy in lowering blood pressure values and are generally well tolerated. ACE inhibitors and ARB medications decrease blood pressure through the renin-angiotensin system. This system affects blood pressure through the production of angiotensin II which stimulates the release of aldosterone from the adrenal cortex. Angiotensin II also is a potent vasoconstrictor. Aldosterone increases renal reabsorption of sodium and water effectively increasing circulating blood volume and increasing blood pressure. ACE inhibitors block the enzyme responsible for converting angiotensin I to angiotensin II, ultimately producing a vasodilatory effect. ARB block the receptor for type 1 angiotensin II. This leads to vasodilation, decreased aldosterone release, and decreased renal reabsorption of sodium and water, leading to lower blood pressure. A study recently found ACE inhibitors have been shown to lower blood pressure more effectively than the other major antihypertensive medication classes (13). This study looked at a relatively young patient population (22–51 yr) and showed a significant reduction in systolic and DBP when compared with CCB, β-blockers and thiazide diuretics. The mechanism of action of ACE inhibitors and ARB suggests that they will have similar blood pressure lowering effects and indeed a systematic review comparing the two classes showed a similar efficacy for ACE inhibitors and ARB. In the athletic population with significant past cardiovascular disease, ACE inhibitors should be considered first-line therapy. Especially, patients with past myocardial infarction. Initial treatment with an ACE inhibitor in athletes with diabetes or chronic kidney disease and high blood pressure also is recommended. Both of these medication classes have minimal impact on cardiovascular performance measures (8,10,12). Use of ARB avoids the most common side effect of ACE inhibitors, dry cough, which can effect up to 10% of individuals taking an ACE-I (31).

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β-Blockers

β-blockers lower blood pressure through the modulation of the sympathetic nervous system. There are two primary types of β-blockers, β1 and β2. β1 receptors exist primarily in the heart, and medications that target these are termed cardioselective. Blockade of these receptors regulates the response of the body primarily in the exertional (fight or flight) state. Specifically, β receptor blockade in cardiac tissue, decreases heart rate and blood pressure through chronotropic and ionotropic effects. Additionally, nonselective β-blockers inhibit the renin-angiotensin system, further decreasing blood pressure. β-blockers are not among the first-line medications in the treatment of hypertension (21). There are significant considerations specific to β-blockers in the athlete population. First, β-blockers are negative ionotropic agents that reduce heart rate and stroke volume during exercise. This may lead to a profound effect on exertional activity. Several studies have shown that V˙O2max values and submaximal exercise capacity are decreased by β-blocker treatment in individual patients (3,19,33). Additionally, rate of perceived exertion (RPE) during exercise is increased in patients taking β-blockers (32,33). All β-blockers share these effects, although they appear to be less pronounced in nonselective β-blockers when compared with those that are β1-selective (2,22,23). Second, in certain sports (e.g., shooting, golf, and diving) which require increased concentration and fine motor control, β-blockers can be used as an ergogenic aid to improve performance. To this end, β-blockers are listed on the WADA banned substance list (1). Based on this information, β-blockers are generally not recommended for use in the athletic population.

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Other Medication Classes

There are other antihypertensive medication classes used as non–first-line agents in the general population. These include α-blockers and centrally acting agents. The side effect profiles of these medications limit their use in the athletic population.

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Sports Participation in Athletes With Hypertension

Recommendations for participation in specific athletic activities may need to be altered for patients with hypertension (27). No participation restrictions are necessary for individuals with blood pressure <140/90 mm Hg. As noted above, laboratory and imaging evaluation is recommended in any athlete diagnosed with hypertension. Stage 1 hypertension without end organ damage should not limit participation. With stage 2 hypertension or if there is any evidence of end organ damage, including left ventricular wall thickening, in those with stage 1 hypertension, participation should be restricted. Resistance (static) exercise raises both systolic and DBP acutely. Aerobic (dynamic) exercise raises SBP more gradually (30). In those who warrant restriction from participation, particular attention should be paid to limiting static exercise (class IIIA-C), such as skiing, body building, gymnastics, field events, cycling, boxing, and rowing (24). In adults, restriction from other sports should be considered in this population, whereas blood pressure management is implemented and improvement in control noted. In youth athletes with stage 2 hypertension or stage 1 hypertension with end organ damage, participation in class IIIA-C activities should be restricted until their blood pressure is normalized (28). Monitoring for improved blood pressure control in those diagnosed with hypertension should continue regardless of sport participation status.

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Follow-Up

Response to both lifestyle and medication management of hypertension should be followed closely for both side effects and blood pressure response to treatment. Changing medication class should be considered if any adverse effects are experienced by the athlete. A determination regarding response to treatment should be made approximately one month after medication initiation. If an adequate response to treatment has not been achieved, medication dosage increase or addition of a second medication is recommended (21).

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Conclusion

Hypertension is the most common cardiovascular disease in athletes, and the most common medical condition diagnosed on the PPE. Care should be taken to appropriately diagnose hypertension including appropriate blood pressure measurement and with multiple measurements over time and consideration of ambulatory blood pressure monitoring. Many factors, particularly in the athletic population, may lead to secondary elevated blood pressure including ergogenic aids, illicit drugs and alcohol and underling medical conditions. These should be screened for and evaluated appropriately when an elevated blood pressure is found. When medication is deemed appropriate for the treatment of hypertension, several classes of medications can be considered in athletes. ARB and ACE inhibitors should be considered as first-line therapy for most athletes. Calcium channel blockers should be considered in older athletes and black athletes. Due to side effect profiles, impact of athletic performance and status on banned substance lists, thiazide diuretics and β-blockers should be considered as second-line agents for specific populations or if additional medications are needed to achieve adequate blood pressure control. Participation should be restricted, particularly from sports with high static load in athletes with stage 2 hypertension or stage 1 hypertension with evidence of end organ damage.

The author declares no conflict of interest and does not have any financial disclosures.

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