Hypertension Essentials

High blood pressure (hypertension) affects nearly 1 in 2 people worldwide between the ages of 35 and 70 years old.  Hypertension is a leading risk factor for stroke, heart attack, death and disability. Hypertension is often called the silent killer, as there usually aren’t any symptoms until an adverse event occurs. Here are some essential points on hypertension.

How is hypertension defined?

Unless the blood pressure is dangerously high (greater than 210/120) or a patient is having symptoms (a heart attack, stroke or congestive heart failure), hypertension should be diagnosed after two to three measurements about one to two weeks apart.  In Stage I hypertension the blood pressure readings average 140/90 or greater. In Stage II hypertension, the readings average greater than 160/90.

What causes hypertension?

In the vast majority of patients with hypertension, 90%, there is no cause for the high blood pressure. This is called primary or essential hypertension. In approximately 10% of patients, high blood pressure may be secondary to another process and can occur with kidney or adrenal disease, a narrowing of the aorta, sleep apnea or taking medications known to increase blood pressure. Secondary hypertension usually occurs in a patient who has not had previous hypertension and who is very young (under age 35) or very old (over age 70).  These patients should undergo further testing to see if there is a reversible cause for the hypertension.

What is white coat hypertension?

White coat hypertension is defined as a blood pressure greater than 140/90 in a doctor’s office, but normal at home.  White coat hypertension occurs in about 10% of patients.  In patients with white coat hypertension as well as many other patients with essential hypertension, it is important to get accurate blood pressure readings at home, with the patient relaxed, in their own environment.  This may be accomplished in two ways. One is with an ambulatory blood pressure monitor, a device given to a patient in a doctor’s office. The patient wears the monitor for 24 hours, blood pressure readings are taken every hour and averaged, both during the day and at night. The other method is to have a patient take readings with a blood pressure monitor, usually purchased at a local pharmacy. Arm or wrist cuffs are best. For optimal results, patients are advised to sit quietly for 15-20 minutes before taking a reading, the arm should be bared and supported on a table or arm chair, the cuff should be at the level of the heart and they should refrain from coffee or cigarette smoking for at least 30 minutes. If blood pressure readings are still elevated on home readings, then therapy should be initiated.

How do we treat hypertension?

The first line of treatment for hypertension is life style modification.  This includes weight loss (if overweight), limiting the sodium (salt) content in the diet, starting an aerobic exercise program, limiting alcohol consumption and getting the proper amount of sleep. These interventions may lower the blood pressure by 5 to 20 points.  The DASH (Dietary Approaches to Stop Hypertension) diet is recommended for patients with high blood pressure.  The DASH diet is high in fruits, vegetables and low fat diary products and low in saturated and total fats (http://health.usnews.com/best-diet/dash-diet?int=9ff509). The DASH diet has been shown to reduce blood pressure by 11 to 15 points in hypertensive patients.  Once it is felt that medications are necessary to lower the blood pressure, the doctor and the patient must collaborate. All hypertension medications work, but to achieve the proper blood pressure lowering, the patient must be able to tolerate the medications, side effects should be minimal and the regimen must be as simple as possible (the goal is to take medications once or at most twice per day).

What is resistant hypertension?

Resistant hypertension is a blood pressure greater than 140/90 despite taking three different blood pressure medications for more than one month. The most common cause is the patient not taking the medications or not taking them correctly. Other factors which can cause resistant hypertension is taking certain over the counter medications (such as ibuprofen, Advil, Motrin, Aleve, nasal decongestants),  taking steroids or other medications known to raise blood pressure, sleep apnea (stopping breathing during the sleep cycle, not allowing the body to get the proper rest), excess alcohol, or developing one of the secondary causes of hypertension.

What is the goal of hypertension treatment? How low should the blood pressure go? The goal of treating high blood pressure is to reduce the risk for heart attack, congestive heart failure, stroke, kidney damage and death.  In 2014, the Eighth Joint National Committee issued recommendations based on the available medical literature. The goal for blood pressure control was less than 140/90 in patients under 60 years old and less than 150/90 in patients over 60 years old. The higher blood pressure target in older individuals recognized that these patients had a higher risk for complications with increasing medications, such as lightheadedness, dizziness, falls and fractures.  This month, the landmark SPRINT study was presented at the American Heart Association meeting. SPRINT is a trial which enrolled 9300 patients and compared two blood pressure goals, treating to under 140 and treating to under 120. The study was stopped early as the patients who were treated to under 120 had a significantly lower risk for congestive heart failure and cardiac death.  Those treated to under 120 were taking more medications and had a higher risk for low blood pressure, passing out and kidney injury.  While treating blood pressure to under 120 may be the new goal, certain caveats must be considered. The risks and benefits of taking more medications must be weighed on an individual basis. In addition, diabetic patients and patients with prior stroke were excluded from the SPRINT trial. Those patients should still be treated to a blood pressure under 140. Previous studies showed that diabetic patients had no benefit from further blood pressure reduction from 140 to 120. The SPRINT trial has generated a lot of controversy in the medical community. Most hypertension experts believe that the SPRINT trial will change, but not revolutionize, hypertension treatment. They don’t’ believe that the new goal for hypertension treatment should be lowered to 120 for all patients. However, in patients over 50 with a high risk for cardiovascular disease who have no diabetes or stroke, more aggressive blood pressure treatment is warranted.

Go Nuts for the Best Diet

What is the best diet for weight loss? What is the best diet for heart health? Many heart patients are obese and are looking for a good diet to lose weight. Certainly all heart patients would like to follow a diet that would help reduce their risk for further heart problems. What is the data on diets?

There are many different commercial diets available, all of which tout their ability to help people lose weight. There are, however, far fewer rigorous scientific trials studying the various diets.  In an ideal world, the best way to evaluate diets is to study one diet compared to another diet, however this is rarely done. Most diet studies compare patients on a diet to patients not on a diet. In a 2015 review in the Annals of Internal Medicine, the data on eleven weight loss programs were systemically reviewed. The eleven programs were: Weight Watchers, Jenny Craig, Nutrisystem, Health Management Resources (HMR), Medifast, OPTIFAST, Atkins, The Biggest Loser club, eDiets, Lose It!, and SlimFast. There were only 39 randomized, controlled trials available in the medical literature for review and even those had significant shortcomings such as limited duration, high rates of dropout, and poor adherence to the diet programs. It was felt that only two programs, Jenny Craig and Weight Watchers, were able to show weight loss at one year, and their results were only modest at best. Another recent review in the Journal of the American Medical Association showed that all diets produced weight loss at six months and one year compared to no diet at all. Weight loss at six months was greater than at one year, with wide variations (from 22 pounds with Atkins diet to 14 pounds for Jenny Craig). At one year, the variations were minor (from 14 pounds with Jenny Craig to 13 pounds for Weight Watchers). Lastly, the US News and World Report came out with their take on the best diets (http://health.usnews.com/best-diet). They did not use the scientific literature, but based their rankings on a panel of “nationally recognized experts in diet, nutrition and food psychology”.  This method is less rigorous and more prone to opinion and bias. Still, they concurred with the medical literature review ranking Weight Watchers number one and Jenny Craig number three for weight loss.

On the other hand, several diets specifically geared towards heart disease have a solid body of data. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fruits, vegetables, whole grains and low fat dairy products, while low in saturated and total fat content. The DASH diet has been shown to significantly reduce blood pressure in hypertensive patients.  Interestingly, US News and World Report ranked the DASH diet as their number one over all diet for 2015; the fifth year in a row it has been number one.

The Mediterranean diet (http://dietamediterranea.com/en/nutrition/) has become the standard for heart healthy eating, showing reduction in heart disease, stroke, cancer and Alzheimer’s disease and lowering the risk for cardiovascular death. It is a plant-based diet with high intake of olive oil, fruit, nuts, whole grains, moderate intake of fish, poultry and wine and low consumption of red meat and sweets. The Mediterranean diet has not been around for very long. It was first described in the 1950’s in Southern Europe and it is actually a result of post-World War II impoverishment and food restrictions. Despite being born from poverty it is rich in benefits.  It has been studied in primary prevention (preventing patients who do not have heart disease from having a heart attack or stroke) and in secondary prevention (preventing patients who have had heart disease from having another event).  It has been studied in over 100,000 patients. In people who do not have disease, those who follow a Mediterranean diet have a 47% lower risk for developing heart disease. In patients who have had a heart attack, those on the diet lowered their risk of dying from heart disease by 50-70%. The Mediterranean diet isn’t just a diet, but a way of life. In addition to the food content, it is emphasized that the food be savored, that meals be shared with friends and family and daily physical activity be a part of the lifestyle.

Nuts, specifically tree nuts such as walnuts, almonds and hazelnuts, are an integral component of the Mediterranean diet and are high in unsaturated fatty acids, fiber, vitamins and minerals. A recent study of nuts showed that nut consumption of 30 grams (about a handful) per day several times per week decreased the chance of dying from heart disease and cancer. It also lowered the risk for diabetes, obesity, hypertension and inflammatory disease.

So the clear winners are the Mediterranean diet for best overall heart health and the DASH diet for hypertension. Both of these diets are well supported by data and recommendations from the American College of Cardiology. Unfortunately, there is no clear winner for the best diet for weight loss as the data is not as strong.  To find out which weight loss diet is right for you, you must first change the concept of a diet, something you go on and then come off. Instead of going on a diet, you should try to achieve a balanced lifestyle with food consumption that is livable and good for the long term. Therefore the likely answer for the best diet for weight loss is similar to, “What is the best exercise” (Answer, the exercise that you like to do and will stick with).  So pick a diet that suits your tastes best and one that fits your lifestyle and budget. Once you have picked your diet and your exercise regimen, stay with it for the long haul. Just remember to reward yourself with a tasty treat. How about a handful of almonds?

Commotion in the Heart

On a warm spring night, a twelve-year-old pitcher toes the rubber in a Little League baseball game. His team is playing their in-town rivals in an intense game with many friends and family looking on. The batter, one of the best and biggest on the opposing team, awaits the pitch. The count is two balls, one strike; a hitter’s count. The pitcher winds and delivers a fastball down the middle of the plate. There is a loud “ping” followed by a dull thud. The baseball was rocketed by the trampoline effect of the batter’s aluminum bat and it struck the pitcher in the left side of the chest.  Coaches and parents rush to the mound. The pitcher, gets up, dusts himself off, proclaiming he is fine. The adults leave for the sidelines. As the pitcher returns to the rubber, he collapses, in full cardiac arrest.

What happened to this young pitcher?  He is a victim of commotio cordis, “commotion in the heart”. Commotio cordis was first described in 1857 and is defined as a blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. Commotio cordis is the second leading cause of sudden death in young athletes. Sudden cardiac arrest can occur in young athletes if a projectile, such as a baseball, strikes the chest at just the right time in the heart cycle. The projectile’s energy is transmitted to the heart, disrupting the normal heart rhythm, causing sudden cardiac arrest and collapse of the athlete. The vulnerable period for a projectile striking the heart is only about 10 to 15 milliseconds long and represents one percent of the total heart cycle. Children and young adolescents are at greatest risk for commotio cordis because they have compliant chest walls that transmit the energy of the projectile to the heart.  Commotio cordis most commonly occurs in youth baseball, but it can also happen in lacrosse, hockey, football and soccer. It can also happen during boxing or karate after a blow to the chest or after a collision between sports participants.

The treatment for commotio cordis is prompt defibrillation, an electric shock to the heart that restores the heart to normal rhythm. The shock is usually provided by an Automatic External Defibrillator (AED), a small portable device that is brought to the victim’s side. Unless the arrhythmia is treated promptly, commotio cordis is almost always fatal.  The sooner the patient is shocked, the greater the chance of surviving. Fifty percent of victims of sudden cardiac arrest survive if shocked within two to three minutes, but only ten percent will live if the shock is more than ten minutes from the time of collapse.  Timing is everything and having an AED as close as possible to potential victims can be life saving.

In recent years AEDs have become widespread.  AEDs have been used by bystanders to treat sudden cardiac arrest in airports, schools, casinos, stadiums, businesses, fitness centers and many other venues where there are large public gatherings.  With the recognition of sudden cardiac arrest in young athletes and after cases of commotio cordis have been reported, AEDs are now being placed in youth sporting facilities.  Community organizations and businesses are encouraged to buy an AED for the area’s sports venues.  An AED is not very expensive, typically costing about $1000, and the cost is equal to buying an outfield sign for three to five years.

Does Your Heart Pine For the Mountains?

While planning a trip to the Andes Mountains, I wondered about the effects of high altitudes on the heart.  Are high mountain elevations bad for the heart? Are there beneficial effects to the heart and exercise fitness for those living at high elevations?

With ascension to higher elevations, a variety of illnesses can occur, including acute altitude sickness, high altitude pulmonary edema (HAPE, fluid in the lungs, similar to congestive heart failure) and high altitude cerebral edema (HACE, swelling of the brain). High altitude is defined as 4,900 to 11,500 feet (for example: Mount Washington, White Mountains, New Hampshire), very high altitude is 11,500 to 18,000 feet (ex, Pikes Peak, Rocky Mountains, Colorado) and extremely high altitude is greater than 18,000 feet (ex, Mount McKinley, Alaska).  As altitude increases the available amount of oxygen progressively decreases until the "death zone" is reached at about 26,000 feet (for example at the summit of Mount Everest). In the death zone, the amount of oxygen is so low that life is not sustainable without the use of supplemental oxygen through oxygen tanks. In the body, the oxygen we breathe in is bound to hemoglobin, a compound found in red blood cells. The oxygen bound to hemoglobin is carried by the blood throughout the body and released for use.  At sea level, oxygen optimally saturates the hemoglobin. At high altitudes, the oxygen saturation of hemoglobin drops significantly, and the body feels "oxygen deprived". This would be similar to being trapped in a smoke filled room and not having enough oxygen to breathe. The body compensates for the lack of oxygen by increasing the breathing rate (hyperventilating), increasing the heart beat, increasing the amount of blood the heart pumps, producing more red blood cells and shunting blood away from nonessential functions (for example digestion is more difficult at high altitudes).

With rapid ascension from sea level to high elevations, acute altitude sickness may occur, especially for heights above 8000 feet. Symptoms include headache, nausea, vomiting, weakness, dizziness, swelling of the hands or feet, and shortness of breath with exertion. Acute altitude sickness symptoms are usually temporary and improve with hydration and as the person "gets used to" the elevation, a process called altitude acclimatization. Ascending slowly is the best way to prevent altitude sickness. Altitude acclimatization is routinely used by mountain climbers and includes ascending about 1000- 2000 feet at a time (once above 8000 feet) for several days and allowing the body to acclimatize to the lower levels of oxygen at the higher elevation. Once the body has adjusted to the new elevation, the process is repeated at progressively higher altitudes. For a climber attempting to reach the summit of Mount Everest, acclimatization can take several weeks.  In addition to acclimatization, other prophylactic measures include aspirin, ibuprofen or acetazolamide (a diuretic). 

High altitude pulmonary edema (HAPE) develops after two or more days at altitudes greater than 9000 feet. The risk increases with higher altitudes and faster ascent.  If left untreated, HAPE is fatal in 50% of cases. The symptoms include shortness of breath with exertion, dry cough, gurgling in the chest and pink frothy mucous. Despite symptoms similar to congestive heart failure from a weakened heart muscle, HAPE occurs due to high pressure in the lungs with leaking of fluid from the small vessels in the lungs into the lung tissue. Since the mechanism is different, it is treated differently than conventional congestive heart failure. Diuretics are not used, but oxygen and medications that reduce the pressure in the lungs are given. Immediate descent to lower altitudes is lifesaving. There appears to be a continuum from acute mountain sickness to HAPE to HACE and precautions to avoid acute mountain sickness reduce the risk of the more serious HAPE and HACE.

Patients with established heart disease need to be cautious at high elevations. Angina, chest pain due to heart artery disease, can worsen at altitude due to the increased demands on the heart. If a coronary stent is being planned, this should be done prior to travel. Patients with stable coronary artery disease and little or no angina with exertion at sea level can likely tolerate elevations to 8000 or 9000 feet.  Patients with congestive heart failure, unstable chest pain, pre-existing high pressure in the lungs or unstable rhythm diseases should not ascend to greater than 6000 feet. 

Can living at a high altitude be beneficial? Why do so many endurance athletes come from the mountainous countries of Kenya, Ethiopia, Uganda or countries in the Andes and Himalaya mountains? Why is the United States Olympic training facility located in the Rockies in Colorado Springs? The same effects the body goes through while acclimatizing to high altitudes occur in people who live at high elevations full time. Some of these effects are quite beneficial for heart performance and endurance athletics. For instance, the amount of blood the heart pumps with each beat is greater in those living at high attitudes. In addition, the body manufactures additional red blood cells to carry more oxygen (this is similar to “blood doping”, the method of cheating Lance Armstrong was accused of during his Tour de France wins).  Both of these adaptations have the same effect, to increase the amount of oxygen available to exercising muscles. So living at high elevations can give an edge in athletic performance.  However, training at high altitudes offsets these beneficial effects, essentially negating them, as athletes cannot train with same intensity at elevation that they can at sea level. That is why athletes, “live high and train low”; they live at elevation and do their training a lower attitudes.

So if you are lucky enough to live at a high elevation, start training at sea level; you could become an Olympic star. If you are visiting the mountains, take precautions and enjoy the views.

Alcohol and the Heart

Can a drink a day keep the cardiologist away? Does alcohol decrease the risk for heart attack and cardiac death or is it harmful to the heart?

Before tackling this question, some definitions are in order. Moderate drinking is defined as two or less drinks per day for men and one or less for women.  A drink is 12 ounces of regular beer or 5 ounces of wine or 1.5 ounces of spirits.

In large studies looking at alcohol and cardiac mortality there appears to be a J shaped curve. Patients with moderate alcohol consumption were at the bottom of the curve (the lowest mortality) with 16% reduction in deaths for men and 12% reduction for women compared to nondrinkers. Nondrinkers had an intermediate mortality rate. Patients with heavy alcohol use, greater than 4 drinks per day, had the highest mortality. The possible heart protective effect of alcohol was even given a name, “the French Paradox”, based on the observation that people in France have low levels of heart disease despite diets high in saturated fat.  In 1991, 60 Minutes aired a show on the paradox, and it was suggested that the high French intake of alcohol, particularly red wine, was responsible for the effect and the lower cardiac mortality. After the show, red wine consumption in the US increased by 44%.

How does alcohol decrease cardiac disease?  While the answer to this question is still not known, it had been theorized that resveratrol, an antioxidant found in the skin of grapes, was the mechanism. Resveratrol, which is found in red wine, is purported to have anti-inflammatory properties and to increase longevity. However, it has been found that the amount of resveratrol in wine is rather low and cannot explain any protective benefits.  Alcohol itself, it seems, may provide benefit by increasing HDL (“good cholesterol”) and decreasing inflammation.  Alcohol, especially after meals, increases insulin sensitivity and sugar metabolism, keeping weight down and diabetes risk low.  On the other hand, heavy alcohol consumption can cause liver disease and cancer as well as having adverse effects on the heart, such as hypertension (elevated blood pressure), atrial fibrillation (an irregular rhythm from the upper chambers of the heart), congestive heart failure and stroke.

Alcohol is a well-known heart toxin. In patients who drink and are susceptible, alcohol can weaken the heart muscle (a condition called cardiomyopathy), decreasing the heart’s pumping ability and causing congestive heart failure, with fluid filling up in the lungs and leading to shortness of breath.  If the heart’s ability to pump blood continues to worsen, the body is deprived of oxygen, several organ systems fail (for example the kidneys stop working) and death follows. In extreme cases, alcoholic cardiomyopathy can lead to heart transplantation. Fortunately abstaining from alcohol once the diagnosis is made can lead to recovery of the function of the heart muscle.  The amount of alcohol needed to cause cardiomyopathy is not known. Women need lower amounts than men and the same consumption in one person may cause no adverse effect while in another person it may cause heart failure. Alcohol is implicated in atrial fibrillation as well. Atrial fibrillation is dangerous in that it can lead to heart failure or blood clots and stroke. Drinking less than 2 drinks per day was not associated with an increased risk for atrial fibrillation. However, for those who drink more than two per day, the risk of atrial fibrillation increases 8% for each drink above two. The more alcohol consumed, the greater the risk for atrial fibrillation. In addition, binge drinking can lead to atrial fibrillation, a phenomenon termed “Holiday Heart Syndrome”  (due to excess consumption of alcohol on weekends or on holidays).  Lastly, for some people, even moderate alcohol consumption can be dangerous, including patients on blood thinners or those with uncontrolled high blood pressure.

Clearly, alcohol is a double-edged sword and the scientific community is still split over whether it is beneficial or not.  There are several factors to keep in mind regarding the data on alcohol’s cardiac protective effects. In almost all of the studies, patients are asked about their alcohol consumption rather than having it measured. This certainly can lead to inaccurate data, as many people will not be truthful about their alcohol use.  It is not known whether moderate drinking is truly protective or whether it is a marker of a healthy lifestyle (moderate drinkers tend to have better over all health, watch a better diet and exercise more than heavy drinkers).  It had been thought that wine was better than other types drinks, however, it seems that the type of alcoholic beverage is less important than the amount and pattern of usage.  In addition, more recent data has shown that the death rates between moderate drinkers and nondrinkers are not that different. In fact, it has been suggested that no amount of alcohol is safe for the heart.

What then is the recommendation for alcohol use? No health agency or major medical group recommends drinking for health purposes. The American Heart Association suggests that if you don’t drink, then don’t start. If you choose to drink alcohol, do so in moderation, without binge drinking. Further, if your moderate drinking is wine with meals, then the benefit seems to be the greatest.