Hypertension in Athletes

Aka: Hypertension in Athletes, Exercise Participation in Hypertensive Patients, Blood Pressure Elevations and Physical Activity

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II. Activity Restrictions

  1. See Hypertension Criteria
  2. No Restriction
    1. High-Normal Blood Pressure
    2. Controlled mild to moderate Hypertension <140/90
  3. Limit to low-intensity dynamic, no isometric sports
    1. Uncontrolled Hypertension (>140/90)
    2. Controlled Hypertension with end organ damage
    3. Controlled Severe Hypertension
  4. No Collision Sports
    1. Secondary Hypertension due to renal cause
  5. References
    1. (1994) J Am Coll Cardiol 24:845-99 [PubMed]

III. General recommendations

  1. Gradual cool down prevents post-exercise Hypotension

IV. Management: Starting Exercise (non-athletes)

  1. Exercise 30-60 minutes >3 times weekly (daily is best)
  2. Choose aerobic Exercise that works large Muscle groups
  3. Progressive Resistance Training
    1. Limit intensity to 40-70% of One Repetition Maximum
    2. Combine with aerobic activity
    3. Use low resistance, but high repetition

V. Management: Banned Antihypertensives for athletes

  1. Thiazide Diuretics (banned by USOC, NCAA)
  2. Beta Blockers
    1. Banned in shooting, archery, diving, ice skating

VI. Medications: Preferred agents in athletes

  1. ACE Inhibitor or Angiotensin Receptor Blocker (ARB)
    1. Effects
      1. Slight decrease in Heart Rate
      2. Increases Stroke Volume
      3. Decreases Systemic Vascular Resistance
    2. Advantages
      1. No effect on Energy Metabolism
      2. No Impairment of aerobic performance
    3. Indications
      1. Good first-line Antihypertensive in athletes
  2. Alpha Adrenergic Antagonist (e.g. Prazosin)
    1. Effects
      1. Decreases Systemic Vascular Resistance
      2. No reflex increase in Heart Rate
      3. No reflex increase in Cardiac Output
    2. Advantages
      1. No effect on Energy Metabolism
      2. No Impairment of aerobic performance
    3. Disadvantages
      1. May be associated with CHF (avoid in age over 55)
  3. Calcium Channel Blockers
    1. Effects
      1. Decreased Systemic Vascular Resistance
      2. Only agent with significant venodilation
    2. Disadvantages
      1. General
        1. Muscle Blood Flow may diminish
        2. Lactate threshold may be reached earlier
      2. Dihydropyridines (e.g. Amlodipine)
        1. Reflex Tachycardia
      3. Nondihydropyridines (e.g. Diltiazem)
        1. Slightly decreased maximum Heart Rate)
        2. Decreased contractility
    3. Advantages
      1. No significant effect on Energy Metabolism
      2. No major Impairment of aerobic performance
    4. Indications
      1. First line agent in black athletes
      2. First line agent in Exercise induced Hypertension

VII. Medications: Less desirable agents in athletes

  1. Cardioselective Beta Blockers
    1. Effects
      1. Decreased Heart Rate
      2. Decreased heart contractility
      3. Increased Systemic Vascular Resistance
    2. Disadvantages: Impacts aerobic performance
      1. Decreased Exercise tolerance
      2. Decreased maximum Heart Rate
      3. Banned in precision sports
      4. May exacerbate Asthma
    3. Indications
      1. Comorbid condition (e.g. Coronary Artery Disease)
      2. Avoid in most athletes
    4. Agents: Labetalol (combined Alpha-Beta Blocker)
      1. Preferred in athletes if Beta Blocker is needed
      2. Less Impairment of muscle Blood Flow
      3. Less Impairment of maximum oxygen uptake
  2. Thiazide Diuretics
    1. Effects
      1. Decreases plasma volume
      2. Decreases Cardiac Output
      3. Decreases Systemic Vascular Resistance
    2. Indications
      1. Second-line agent if salt-sensitive
    3. Disadvantages
      1. Dehydration risk
      2. Banned by USOC and NCAA

VIII. Special Circumstances: Exercise Induced Hypertension

  1. Check Blood Pressure at peak Exercise
  2. Exercise-induced Hypertension: Peak BP > 200/90
  3. Best managed with Dihydropyridines (e.g. Amlodipine)
    1. Only agents that result in significant venodilation

IX. References

  1. Niedfeldt (2002) Am Fam Physician 66(3):445-52 [PubMed]
  2. Swain (1997) Phys Sportsmed 25:47-64 [PubMed]

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