Managing High Blood Pressure in Active People

Even though athletes and other people who exercise regularly have lower incidence of high blood pressure (hypertension) than those who are less active, they should still get regular check-ups for hypertension and pay special attention to the impact of medications that may be prescribed to treat it.

That's the advice of Mark W. Niedfeldt, MD, Medical College of Wisconsin Associate Professor of Family and Community Medicine. "The instance of hypertension overall is on the rise, but what we find with people who exercise on a regular basis is that their blood pressure tends to be a little bit lower," said Dr. Niedfeldt. "Regular exercise tends to keep them out of that hypertensive range. The other thing that we know increases hypertension is obesity, and people who are physically active tend to have lower levels of obesity.

"And people who exercise often have lower blood pressure because of their lifestyle in general. People who take the time to exercise are more likely to watch the fatty foods in their diet, to watch their salt, and do some of the other things that help keep their blood pressure lower."

Still, high blood pressure does occur in people who are active. While the overall prevalence of hypertension in athletes and regular exercisers is approximately 50% lower than in the general population, according to Dr. Niedfeldt's article "Managing Hypertension in Athletes and Physically Active Patients" (American Family Physician, August 1, 2002), physical activity alone by no means guarantees normal blood pressure. Because hypertension is a leading indicator of increased risk for heart disease, stroke and other health problems, early intervention is helpful to athletes and non-athletes alike.

Drugs Can Affect Performance
Blood pressure is a measurement of the amount of force blood applies to the walls of arteries, which carry the blood from the heart throughout the body. Hypertension occurs when extra pressure exerted by the blood onto the arterial walls is strong enough to create a dangerous condition.

We use two numbers to measure blood pressure (e.g., 120/80). The first number in a blood pressure reading is the amount of "systolic" pressure when the heart pumps blood into the arteries. The second number is the "diastolic" pressure within the arteries when the heart has relaxed between pumping actions.

A systolic reading of between 120 and 139 is now regarded as prehypertensive; a reading of 140 or more is considered high. Diastolic pressure ranging from 80 to 89 is now classified as prehypertensive, and a reading above 90 is considered high. Both numbers are important, but for people who are 50 or older, systolic pressure is a stronger predictor of hypertension-related complications.

Dietary and other lifestyle modifications are usually the first treatment option for hypertension, Dr. Niedfeldt said. A wide variety of medications are available to lower blood pressure and are most often prescribed after lifestyle changes have been tried but haven't been effective enough. The side effects of these drugs can be different in physically active people, sometimes in ways that make it impossible to continue to engage in sports or workouts at the same level as before the medication was taken.

"The one major class of medications used for blood pressure are the diuretics," said Dr. Niedfeldt. "Those, for the elderly, have been shown to decrease morbidity and mortality, and I think for the casual exerciser they're not a big deal because they can use these diuretics safely. But I wouldn't use them in somebody who is doing two-a-day summer football workouts in ninety-degree heat, or in endurance athletes, for example, because that could be a problem.

"Probably the medications we use the most with athletes are the ACE inhibitors, similarly the angiotensin receptor blockers, because they don't tend to have an effect on exercise tolerance (capacity to exercise to one's full ability). For example, a beta-blocker can be an excellent anti-hypertension medication, which has been shown to be very useful in certain kinds of heart failure and heart attack. However, it reduces the rise in your heart rate that normally occurs with exercise. That can cause a lot of problems."

Level of Exercise is a Consideration
The level of a person's exercise regimen needs to be taken into account when determining which blood pressure medication to use, Dr. Niedfeldt said. A "high performance" athlete may experience problems that don't come into play for someone who simply walks vigorously several times a week.

"I recently saw a patient who was a triathlete and she had been placed on a beta-blocker," said Dr. Niedfeldt. "She told me 'I can't even run, I can't do anything, if I exercise for more than five minutes I'm out of breath, I feel terrible.' A beta-blocker may be okay for someone who is just walking - I have a number of patients who take beta-blockers and are active and walk and exercise and they do just fine, but they're not exercising at a higher level.

"Most of the medications for hypertension are going to be fine, even for the casual walker, but if you take someone who even goes up to running over walking, they may notice a change from the beta-blocker. With diuretics you worry about dehydration or potassium getting low, especially in endurance athletes, whereas with others you don't have that concern. The side effect profile is very low."

Sports organizations such as professional leagues, the Olympics, and high school and college associations have banned certain blood pressure medications and dietary supplements, in some cases because they are dangerous when used by athletes and in some cases because they enhance performance artificially to the degree that they give users a competitive edge.

Dr. Niedfeldt recalled the much-publicized case of Hank Gathers, a college basketball player who collapsed and died of heart failure during a game. "He was on a beta-blocker for a heart condition, but went off it because in his case the beta-blocker impaired his performance. There are conditions where we need to use certain drugs, but the athlete's level of activity must be adjusted accordingly."

Tips for Athletes and Others
"We have some people who are strength athletes who don't do anything aerobic, and they still can be hypertensive," said Dr. Niedfeldt. "They potentially can add a little bit more aerobic exercise and bring their blood pressure down a little bit. Another thing I look for is what a person may be taking as far as supplements, because a number of supplements can increase blood pressure.

"Ephedra, for example, has gotten a lot of press lately, and it definitely can increase blood pressure. In 2002, somewhere in the neighborhood of $1.2 billion was spent on ephedra-based products in the US, and about three billion doses were taken. So I always ask about stimulants, dietary supplements, fat burners, metabolism aids, whatever they may be called, when I see someone who's exercising and I'm screening them and see that their blood pressure is high. Anabolic steroids are known to elevate blood pressure, so there's potential for the same with some of the other pro-hormone supplements."

Dr. Niedfeldt stressed that a diet with less salt and fatty foods, and avoiding tobacco and caffeine, can help lower blood pressure no matter what one's level of exercise. Foods that are high in potassium, such as potatoes, bananas and other fruits are also helpful.

Maintaining an appropriate body weight is another very useful tool in managing hypertension. Fast walking, bicycling, running and other aerobic activity also help, as do stress-reducing relaxation techniques including meditation and deep breathing exercises.

For athletes and others who adhere to fairly rigorous exercise routines, Dr. Niedfeldt recommended good communication with physicians as to the level of athletics they enjoy and immediate reporting of any unusual symptoms that may arise if hypertension medication is used.

Dan Ullrich
HealthLink Contributing Writer

For more information on this topic, see the HealthLink articles Advice for the Aging Athlete and Revised Blood Pressure Guidelines Put Millions in New Category.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.