Clinical Services 3331 Disease Management Clinic 505-844-HBES (4237) [email protected] Blood Pressure Linda Macdonald, M.D. October 9, 2007 Coronado Thunderbirds

Clinical Services 3331Disease Management Clinic

505-844-HBES (4237)[email protected]

Blood Pressure

Linda Macdonald, M.D.

October 9, 2007

Coronado Thunderbirds



Blood Pressure

• The pressure in the arterial blood vessels results from:– flow of blood from the heart– resistance of the arterial blood vessel walls

• The higher the blood pressure, the harder the heart has to pump in order to supply the body with blood

Blood Pressure



Blood Pressure

• The first (top) number is the systolic blood pressure (SBP) and indicates the pressure in the artery when the heart is actively pumping blood

• The second (bottom) number is the diastolic blood pressure (DBP) and indicates the pressure in the artery when the heart is resting between beats



Measuring Blood Pressure



Measuring Blood Pressure

• Blood pressure is measured in the sitting position after at least 5 minutes of rest

• The blood pressure cuff should be the correct size and should not be placed over clothing

• At least two blood pressure measurements should be made and blood pressure categorized based on the average



Blood Pressure Categories

Category Systolic BP Diastolic BP

Normal blood pressure Less than 120 Less than 80

Pre-hypertension 120 to 139 80 to 89

Stage 1 hypertension 140 to 159 90 to 99

Stage 2 hypertension 160 or higher 100 or higher



Blood Pressure & Aging

• There is an age-related increase in blood pressure due to: – Increased arterial wall tension– Increased peripheral resistance– Increased arterial stiffness

• This is not benign: The blood pressure categories are not adjusted upwards to compensate for aging



Why Do We Worry About High Blood

Pressure?



Framingham Heart Study

Objective:

“…identify the common factors or characteristics that contribute to cardiovascular disease by following its development over a long period of time in a large group of participants who had not yet developed overt symptoms of cardiovascular disease or suffered a heart attack or stroke.”



Framingham Heart Study: Risks of Hypertension

• Cardiac disease– Heart attack and heart failure

• Cerebrovascular disease– Stroke

• Peripheral vascular disease– Circulation in the extremities

• Microvascular disease– Kidney and eye disease



Benefits of Blood Pressure Control

• Blood pressure control can reduce the risk of heart attack by 20% to 25%

• Blood pressure control can reduce the risk of heart failure by more than 50%

• Blood pressure control can reduce the risk of stroke by 35% to 40%

• A 10mmHg drop in SBP lowers the risk of death from stroke by 50-60% and the risk of death from heart attack by 40-50%



Blood Pressure Control



Lowering Blood Pressure

• Lifestyle modification– Smoking cessation– Increased physical activity– Limitation of alcohol intake– Maintenance of a healthy body weight– Diet comprised of healthy foods

• Pharmacotherapy (medications)



Lifestyle Modification

Modification Recommendation Approximate drop in SBP

Weight reduction Maintain normal body weight 5-10 mmHg/

10kg weight loss

DASH eating plan Rich in fruits, vegetables, low fat dairy; reduced saturated & total fat

8-14 mmHg

Less dietary sodium

No more than 2.4 g sodium/day 2-8 mmHg

Physical activity Aerobic activity for 30 minutes at least 5 days/week

4-9 mmHg

Alcohol in moderation

No more than 2/day for men

No more than 1/day for women

2-4 mmHg



Diet



Diet & Blood Pressure

Salt– Excess can increase blood pressure

Potassium– Insufficient can increase blood pressure

Weight– Excess can increase blood pressure

Alcohol– Excess can increase blood pressure



Diet & Blood Pressure

• Several research studies have shown beneficial effects of diets rich in magnesium, potassium, calcium, fiber, and protein

• Studies looking at supplementation of individual nutrients have not shown much improvement in blood pressure



DASH Clinical Trial

• Looked at the effect of dietary patterns rather than individual nutrients for blood pressure lowering

• Studied three different diet patterns:– Control (typical) diet– Fruits and vegetables diet– Combination (DASH) diet



Control Diet

• Potassium, magnesium, and calcium levels were close to 25th percentile of U.S. consumption

• Macronutrients (carbohydrate, fat, protein) and fiber were similar to average U.S. consumption

• Typical “American” diet



Fruits & Vegetables Diet

• Potassium and magnesium close to the 75th percentile of U.S. consumption

• High amount of fiber• More fruits and vegetables and fewer snacks and

sweets than control diet, but was otherwise similar



Combination (DASH) Diet

• Potassium, magnesium, and calcium close to the 75th percentile of U.S. consumption

• High amounts of fiber and protein• Rich in fruits, vegetables, and low fat dairy foods• Reduced amount of saturated fat, total fat, and

cholesterol



DASH Clinical Trial

• Study subjects were provided with meals that were prepared in research kitchens

• All diets contained approximately 3 grams sodium per day

• Each subject was given the appropriate calories to maintain weight and diet was adjusted for weight loss or weight gain



Results (Change in SBP/Change in DBP)

Category DASH – Control

DASH – Fruits/Veg

Fruits/Veg – Control

All subjects -5.5/-3.0 -2.7/-1.9 -2.8/-1.1

Men -4.9/-3.3 -1.6/-1.3 -3.3/-2.0

Women -6.2/-2.7 -3.9/-2.5 -2.3/-0.2

HTN -11.4/-5.5 -4.1/-2.6 -7.2/-2.8

No HTN -3.5/-2.1 -2.7/-1.8 -0.8/-0.3



DASH Results

120

122

124

126

128

130

132

134

0 1 2 3 4 5 6 7

Control

Fruits/Veg

DASH

Weeks

Sy

sto

lic B

loo

d P

res

sure



DASH Meal Plan

• Fruits: 4-5 servings/day– 1 medium fruit; 6 ounces fruit juice

• Vegetables: 4-5 servings/day– 1 cup raw leafy; ½ cup cooked

• Low fat dairy products: 2-3 servings/day– 8 ounces milk/yogurt; 1.5 ounces cheese

• Grains: 7-8 servings/day– 1 slice bread; ½ cup cereal, rice, pasta

• Meat, Fish, Poultry: 2 or less servings/day– 3 ounces

• Nuts, Seeds, Dried Beans: 4-5 servings/week– 1/3 cup nuts; 2 tablespoons seeds, ½ cup cooked beans



Exercise



Aerobic Activity

To promote and maintain health, all healthy adults age 18-65 years need moderate-intensity physical activity for a minimum of 30 minutes on five days each week OR vigorous-intensity for a minimum of 20 minutes on three days each week. Also, combinations of moderate- and vigorous-intensity activity can be performed to

meet this recommendation. American College of Sports MedicineAmerican Heart Association2007 Recommendations



Muscle-Strengthening Activity

To promote and maintain good health and physical independence, adults will benefit from performing activities that maintain or increase muscular strength and endurance for a minimum of two days each week. It is recommended that 8-10 exercises be performed on two or more nonconsecutive days each week using the major muscle groups.

American College of Sports MedicineAmerican Heart Association2007 Recommendations



Pharmacotherapy



Antihypertensive Medications

• All antihypertensive medications are effective at lowering blood pressure

• Some provide additional benefits• Newer medications are not necessarily better

than older medications• Medications control hypertension, they don’t

cure it• Medications only work if they are taken every day



Antihypertensive Medications

• ACE Inhibitors (ACEI)• Angiotensin receptor blockers (ARB)• Diuretics • Beta blockers (BB)• Calcium channel blockers (CCB)• Alpha blockers• Nitrates



TreatmentRecommendations

Area of Concern

BP Target Lifestyle Modification

Specific Drug Indications

General CAD Prevention

<140/<90 Yes Any effective BP drug or combination

High CAD Risk*

<130/<80 Yes ACEI, ARB, CCB, thiazide, or combination

Stable Angina <130/<80 Yes Β-blocker AND ACEI or ARB

*Diabetes, chronic kidney disease, known CAD or CAD equivalent, or 10y Framingham risk score >10%



Side Effects

• Unintended effects of a medication• Many medications cause minor side effects

• All antihypertensive medications can cause you to feel dizzy if you stand up quickly, especially when you first start taking the medication



Monitoring

• Blood pressure should be rechecked within 2 to 4 weeks after starting a new blood pressure medication

• Blood pressure can be monitored at home or in the clinic

• Some antihypertensive medications also require laboratory or heart rate monitoring (ACEI, ARB, diuretic, BB, some CCBs)



Adherence to Therapy

• Medications won’t work if you don’t take them as prescribed

• Medications must be taken daily to keep blood pressure under control

• Talk to your provider about any problems that you have with taking your medication



Summary

• High blood pressure increases risk of cardiovascular, kidney, and eye disease

• Lifestyle modification is an effective means of lowering blood pressure

• Medications are needed to achieve optimal blood pressure levels in many people

Documents

Clinical Services 3331 Disease Management Clinic 505-844-HBES (4237) [email protected] Blood Pressure Linda Macdonald, M.D. October 9, 2007 Coronado Thunderbirds