Clinical Services 3331 Disease Management Clinic HBES (4237) Blood Pressure Linda Macdonald, M.D. October 9, 2007 Coronado Thunderbirds

Clinical Services 3331 Disease Management Clinic HBES (4237) 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

Clinical Services 3331 Disease Management Clinic HBES (4237) 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

Clinical Services 3331 Disease Management Clinic HBES (4237) Measuring Blood Pressure

Clinical Services 3331 Disease Management Clinic HBES (4237) 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

Clinical Services 3331 Disease Management Clinic HBES (4237) Blood Pressure Categories CategorySystolic BPDiastolic BP Normal blood pressureLess than 120Less than 80 Pre-hypertension120 to to 89 Stage 1 hypertension140 to to 99 Stage 2 hypertension160 or higher100 or higher

Clinical Services 3331 Disease Management Clinic HBES (4237) 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

Clinical Services 3331 Disease Management Clinic HBES (4237) Why Do We Worry About High Blood Pressure?

Clinical Services 3331 Disease Management Clinic HBES (4237) 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.”

Clinical Services 3331 Disease Management Clinic HBES (4237) 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

Clinical Services 3331 Disease Management Clinic HBES (4237) 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%

Clinical Services 3331 Disease Management Clinic HBES (4237) Blood Pressure Control

Clinical Services 3331 Disease Management Clinic HBES (4237) 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)

Clinical Services 3331 Disease Management Clinic HBES (4237) Lifestyle Modification ModificationRecommendationApproximate drop in SBP Weight reductionMaintain normal body weight5-10 mmHg/ 10kg weight loss DASH eating planRich in fruits, vegetables, low fat dairy; reduced saturated & total fat 8-14 mmHg Less dietary sodium No more than 2.4 g sodium/day2-8 mmHg Physical activityAerobic 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

Clinical Services 3331 Disease Management Clinic HBES (4237) Diet

Clinical Services 3331 Disease Management Clinic HBES (4237) 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

Clinical Services 3331 Disease Management Clinic HBES (4237) 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

Clinical Services 3331 Disease Management Clinic HBES (4237) 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

Clinical Services 3331 Disease Management Clinic HBES (4237) Control Diet Potassium, magnesium, and calcium levels were close to 25 th percentile of U.S. consumption Macronutrients (carbohydrate, fat, protein) and fiber were similar to average U.S. consumption Typical “American” diet

Clinical Services 3331 Disease Management Clinic HBES (4237) Fruits & Vegetables Diet Potassium and magnesium close to the 75 th 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

Clinical Services 3331 Disease Management Clinic HBES (4237) Combination (DASH) Diet Potassium, magnesium, and calcium close to the 75 th 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

Clinical Services 3331 Disease Management Clinic HBES (4237) 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

Clinical Services 3331 Disease Management Clinic HBES (4237) Results (Change in SBP/Change in DBP) CategoryDASH – Control DASH – Fruits/Veg Fruits/Veg – Control All subjects-5.5/ / /-1.1 Men-4.9/ / /-2.0 Women-6.2/ / /-0.2 HTN-11.4/ / /-2.8 No HTN-3.5/ / /-0.3

Clinical Services 3331 Disease Management Clinic HBES (4237) DASH Results Weeks Systolic Blood Pressure

Clinical Services 3331 Disease Management Clinic HBES (4237) 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

Clinical Services 3331 Disease Management Clinic HBES (4237) Exercise

Clinical Services 3331 Disease Management Clinic HBES (4237) Aerobic Activity To promote and maintain health, all healthy adults age 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 Medicine American Heart Association 2007 Recommendations

Clinical Services 3331 Disease Management Clinic HBES (4237) 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 Medicine American Heart Association 2007 Recommendations

Clinical Services 3331 Disease Management Clinic HBES (4237) Pharmacotherapy

Clinical Services 3331 Disease Management Clinic HBES (4237) 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

Clinical Services 3331 Disease Management Clinic HBES (4237) Antihypertensive Medications ACE Inhibitors (ACEI) Angiotensin receptor blockers (ARB) Diuretics Beta blockers (BB) Calcium channel blockers (CCB) Alpha blockers Nitrates

Clinical Services 3331 Disease Management Clinic HBES (4237) Treatment Recommendations Area of Concern BP TargetLifestyle Modification Specific Drug Indications General CAD Prevention <140/<90YesAny effective BP drug or combination High CAD Risk* <130/<80YesACEI, ARB, CCB, thiazide, or combination Stable Angina<130/<80YesΒ-blocker AND ACEI or ARB *Diabetes, chronic kidney disease, known CAD or CAD equivalent, or 10y Framingham risk score >10%

Clinical Services 3331 Disease Management Clinic HBES (4237) 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

Clinical Services 3331 Disease Management Clinic HBES (4237) 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)

Clinical Services 3331 Disease Management Clinic HBES (4237) 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

Clinical Services 3331 Disease Management Clinic HBES (4237) 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