1st International course in Sports Cardiology
“Sports Cardiology in practice”
Friday 28th of August 2015
St George’s University,
London, UK
Managing the athlete with
hypertension
Mats Börjesson
Professor, MD, FESC
Swedish School of Sport and Health Sciences
And Karolinska University Hospital,
Stockholm, Sweden.
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
A Registered Branch of the ESC
Athletes with hypertension
•  The relation of physical activity and
hypertension
•  The scope of the problem (prevalence?)
•  The investigation of an increased BP in
athletes
•  Managing the athlete with manifest
hypertension
References
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Definition of hypertension
•  Arterial hypertension is defined as having a:
-resting systolic blood pressure ≥ 140
mmHg and/or
-a diastolic blood pressure ≥ 90 mmHg
•  The measuring must be undertaken as a
standardized procedure
•  The BP must be repeatedly high
(Guidelines for Management of arterial hypertension: The Task Force for the management
Of aretrial hyoertension of the ESH and ESC. J Hypertens 2013;31:1281-357).
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Hypertension-major risk factor for CAD
•  (
Incidence: 4.40/100 000
Person years
US Kings County.
Meyer L, Circulation 2012
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Relation of physical activity to BP
•  Meta-analysis (20 RCT, n=837)
all with hypertension
•  Evidence by GRADE
•  Best evidence for aerobic activity (+++)
12/ 5 mmH, and isometric training (++),
resistance training lower evidence (+)
•  Medium/high intensity
•  40-60 minutes/ session
•  ≥3 times week, for 8-37 weeks
(Borjesson et al 2015, www.fyss.se)
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
The prevalence in athletes?
19% of
football
players
7% of
soccer
players
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
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Varying prevalence of hypertension (0-45%)
Poor methodology of studies, limiting factor
No evidence for a lower BP in athletes
A positive association between BP level and
increased LV mass/LV hypertrophy was found
•  Prognostic significance?
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Risks in the long run?
Fig: Leischik R, F1000Research 2014;3:105.
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Relation to exercise capacity?
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Older athletes more common
•  ”Master athletes”: Defined as >35 years of age (40),
may be significantly older
•  Organized form of competitive sports, specifically
designed for
older athletes (over 50 sports:
running, cycling, skiing..)
”..unique psychological and physiological
stresses that competition places on such
athletes, particularly those with cardiovascular
disease” : AHA 2001
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Athletes older and less fit…
Med Sci Sports Exerc. 2012 May;44(5):894-9
.Performance trends and cardiac biomarkers
in a 30-km cross-country race,
1993-2007.Aagaard P, Sahlén A,
Braunschweig F.
*n=124 608 runners of Lidingöloppet, 30-km race, 1993-2007
* Biggest increase in participation among older men and women
•  Mean running times increased in all finishing quartiles
•  Mean running time associated with basal NT-pro-BNP
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Even more relevant in older athletes
N=87 runners, 42+/-8 years, Berne 10-mile race
Ambulatory BP on normotensives, without known CHD
33/87= 33% had masked hypertension
This was associated with decreased diastolic function and higher
LV mass/volume ratio, but not to systolic function.
2-fold risk of masked HT, if an office BP of ≥120/80 (grey zone)
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Ambulatory BP in athletes with true office BP ≥120/80?
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
young
competitive
athletes
ESC screening
recommendations
family and personal history, physical
examination,12-lead ECG
negative
findings
positive
findings
no evidence of
cardiovascular
disease
eligibility
for competition
further examinations
(echo, stress test, 24-h Holter,
cardiac MRI, angio/EMB, EPS)
diagnosis of
cardiovascular
disease
Corrado et al,
Eur Heart J 2005
management according to
Section of Sports Cardiology established protocols
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
How to measure BP
•  Standard sphygomanometer
used, adjusted to arm size
•  Resting state!
•  Sitting position
•  Both arms (and one leg, if first time)
•  ≥140/90
•  Repeat measurements necessary for
diagnosis
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Management of isolated (office) BPñ
•  Consider the circumstances
-true rest?
-white coat hypertension?
-adequate equipment?
•  Re-assess the blood pressure, over the coming
weeks
•  Consider ambulatory BP, if borderline BP
(≥120/80), especially in middle-aged athletes
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Exclude secondary hypertension
•  Only 5% in total, but (relatively) more common
in the young
•  Palpation of femoral pulses (CA)
•  Ausculatation of renal arteries
•  Electrolytes & kidney function
•  Hormonal (Cushing, Conn, pheocromocytome)
•  Consider medications/drugs/doping
(AAS, epo, efedrine, cocaine, NSAID)
(Fagard EJCPR 2005; Pope JE Arch Int Med 1993)
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Discrepancy of BP between arms and legs
•  BP in the legs- normally 5-10 mmHg higher than
in the arms.
•  If BP >20 mmHg higher in the arms…
suspect coarctatio aortae
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Anabolic steroids and blood pressure
Related to
sodium
retention?
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Exaggerated BP response during exercise
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May be revealed at exercise-test (treadmill/bike)
Defined as (at least) >250 mmHg
Is seen in all hypertensives
Is associated with increased risk of developing
later hypertension, in normotensives
•  Thus, finding of exaggerated BP response during
activity, lead to follow-up of BP (like pregnancy)
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Management of confirmed hypertension
Fagard et al, EJCPR 2005
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
1.Risk stratification
Depending on the 1. severity of blood pressure, 2. other risk factors and
3. any target organ damage (TOD) on heart, kidney or eyes
=TOTAL RISK is the key
(Fagard et al EJCPR 2005)
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Rule out target organ damage
•  Ophtalmological evaluation (retinopathy?)
•  Kidney tests
creatinine increased?
micro-albuminuria?
•  Cardiac evaluation
ECG (LVH?)
echocardiography (LVH?)
ultrasound (arterial thickening, plaques?)
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Treatment options
Those with low-moderate added risk, should be given lifestyle advice
(and medications if these measures fail)
Those with high-very high risk, should be treated
promptly with anti-hypertensive medication
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Sports and anti-hypertensive medications
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Beta-blockers (lower max HR) (lower VO2max) DOPING LIST (selected)
Diuretics (risk of dehyration) (lower VO2max) DOPING LIST (all)
ACE-inhibitors/ARBs (dehydration, diarrhea, BP during exerc)
Calcium channel blockers (excessive BP response post-exerc)
Thus, at present the different vasodilators (ACE/
ARBs) are first-line treatment in hypertensive
athletes
Refs: Gordon NF, Hypertensin, Human Kin 1997; Kokkinos P, JACC 2006; Nashar K,
Am J Hypertens 2004; L Vanhees, J Hypertens 2000; Fagard EJCPR 2005)
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Lifestyle recommendations
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Regular aerobic exercise
Moderate salt restriction
Increased fruit intake, decrease saturated fat
Moderate alcohol consumption
No smoking
Control of body weight
•  What about competitive sports?
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Competitive sports eligibility
•  BP >200/115- Treat BP- sports contraindicated.
•  Well controlled BP, in athletes with no added risk
factors and no TOD: no contraindications
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Follow-up
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Regular BP-controls (yearly)
Additional risk factors
TOD?
Adjustment of medications?
Lifestyle advice continuous
Re-review of sports eligibility
Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu
Thank you!
On behalf of the Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
A Registered Branch of the ESC
Interested in Sports Cardiology?
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Section of Sports Cardiology
European Association for Cardiovascular Prevention & Rehabilitation (EACPR)
www.sportscardiology.eu