LIVing Free: How Stress and Lifestyle Affects Hypertension

Heath Wilt, DO, FACC AdventHealth Cardiology

Director, Cardiovascular Rehab Director, Noninvasive Imaging

Aim• Provide broad understanding of hypertension

• “Goal” or ideal blood pressure targets

• Risks of hypertension

• Methods for management

• Pharmacological

• Lifestyle/non-pharmacological

Case Study• Michelle is a 55 year old female who has noticed a gradual

increase in blood pressure over the last several years

• “Average” blood pressure now 140-150/80-90 mmHg

• Has been suggested to take meds, but is reluctant

• Wants to know, what are her options…

Michelle• Blood pressure 158/95 mmHg in office, Heart rate 90 bpm

• Weight: 95 kg (209 lb)

• Exam: obese, soft murmur that accentuates with handgrip. No abdominal bruit, mild non-pitting edema

• Recent blood work:

• Normal renal (kidney) function. Modest elevation of total cholesterol and LDL (“Lousy” cholesterol), Fasting blood sugar 109 mg/dL

• Options:

A) Medications

B) Weight loss

C) Improved dietary choice/intake

D) Screen for additional disorders/causes

Hypertension

• commonly referred to as “high blood pressure”

• causes are numerous

• most are “benign essential”“benign essential” “primary”

Hypertension

Hypertension• Blood pressure

• Top number = “systolic”

• Represents peak pressure generated

• Bottom number = “diastolic”

• Represents “resting” pressure between beats

Hypertension, CDC/NCHS Data Brief No. 289, October 2017

Hypertension, CDC/NCHS Data Brief No. 289, October 2017Heart Disease, 2018 Update; Circulation, pub Jan 2018

Why the change?

• 2017 Guidelines changes by AHA

• “More people” with hypertension

• Emphasize early management and awareness

• Result: estimated 3 million CV events to be reduced over 10 years

What’s the big deal?

• Effect of persistently elevated blood pressure are systemic

• Nearly every organ or body part affected

• Deemed the “silent killer”

Brain• Stroke

• Dementia

• Hemorrhage

• Aneurysm

Eyes

Kidneys • Uncontrolled blood pressure

• Anemia

• Electrolyte imbalances

Sexual organs (and other blood vessels) • Damages small blood vessels

• Less pliable, less adaptive

• Physically and hormonally

• Reciprocated BP increase

• Digestive issues

• Men: reduced blood flow = impotence

• Women: reduced blood flow = lubrication, comfort

Heart • Heart Failure

• Systolic and Diastolic

• Heart Attack

Heart Failure

Heart Failure

Heart Attack

• Promotes atherosclerosis

• Smaller, diseased vessels impair blood flow to muscle

• Thicker, adaptive heart muscle requires more blood

• Too much “strain” on the heart

Risk of heart disease with blood pressure

JACC, 35:1, July 2000

Risk of cardiovascular events per year

J. Clin. Med. 2019, 8:6, Apr 2019

Treatment

• Medications

• Very effective

• Unique properties, unique risks

• Risks with using… risk without

• New AHA guidelines promote more vigilance

Treatment• Treat the cause!

• Secondary hypertension

• Implies blood pressure is physiological consequence of another process

• Thyroid

• Electrolyte disturbances

• Blood vessel abnormalities

• 10% of cases

• Consider for atypical features

Treatment

• Treat the cause!

• Diet and lifestyle

• May be the difference between no medications or one versus multiple medications

Obesity

Obesity

• Overall response likely varies

• Estimated ~3-5 mmHg (systolic) for every 10 lb weight loss, or 1 mmHg for each 1 kilogram (~2.2 lb)

Reduction, 27 Mar 2018Circulation. 2014

Diet

• Salt excess

• Dense in calories

• Processed foods

Single most powerful influencer

• Rich in nutrients, potassium

• Unprocessed, whole foods

• Calorie “smart”

Diet• DASH diet

• Dietary Approach to Stop Hypertension

• fruits, vegetables, whole grains, and low-fat dairy foods

• included meat, fish, poultry, nuts, and beans but limited red meat, saturated fats and processed foods

• Proven to reduce blood pressure in the OMNIHeart Trial

• Limiting sodium to less than 2 gm/day allowed for an averaged loss of 11.5/5.7 mmHg

Diet

• Mediterranean diet

• higher consumption of olive oil, legumes, unrefined cereals, fruits and vegetables with moderate to high consumption of fish,

• more limited consumption of dairy products, moderated wine intake, but lower intake of non-fish meat products

• NU-AGE trial: average of 5/2 mmHg drop

Diet

• Common themes:

• Lower sodium

• Reduces arteriole constriction

• Reduces water retention

• More potassium and magnesium

• Relaxes tension on blood vessels

Diet

• Common themes:

• Less processed foods

• Saturated fats

• Higher levels of refined sugar

• Leads to increased cortisol, inflammation

Diet

• Healthy eating habits promote

• Awareness of foods ingested

• Calories, source, nutritional content

• “Routine” eaters show more weight reduction in controlled studies

• Portion sizes

• Be Mindful…

• Many diets can be used for improving health, but quality of food matters

• “…not all plant-based diets are equal… the market is full of highly processed vegan food products that, though plant-based, aren’t considered healthy.

JAHA, 7 Aug 2019 Roston, taken from https://www.slashgear.com/plant-based-diets-protect-heart-health-but-aha-warns-theres-a-catch, 10 Aug 2019

Alcohol

Moderate intake reduces BP 2-4/1-2 mmHg

Excess:

-negates benefits

-excess calorie

-may interfere with BP meds

Caffeine

• Intake and amount of caffeine is uncertain

• Effect is usually temporary

• Possibly due to release of adrenaline

• Possibly alters chemicals that relax blood vessels

Caffeine

• Typically, pressure rises 6 to 13 mmHg, usually for no more than 3 hours

• Effect is more pronounced in younger and caffeine-naive individuals

• In a two-year study of 45,589 men between the ages of 40 and 75, Harvard scientists found no link between coffee consumption and the risk of coronary artery disease or stroke, even in heavy drinkers

• Another study suggests 15% reduction in CV events in studied population

J Agric Food Chem. 2018 May 30;66(21)

Exercise

• Cuts risk of sudden death in half

• Reduces risk of stroke and heart attack by one-third

• Reduced risk of diabetes, dementia, many cancers

• Effect on blood pressure: drops ~ 5-10 mmHg

• Cumulative effect with weight loss

Tobacco

• Effect of tobacco products is multifactorial

• Nicotine (active ingredient):

• Potent vasoconstrictor to blood vessels

• Impairs relaxation of vessels by reducing nitric oxide (NO)

• Damaged vessels subsequently constrict in presence of NO

• Promotes inflammation

Tobacco

• Smoking

• Includes all of nicotine’s effects

• Worsens cholesterol profiles, promotes atherosclerosis

• Hardens vessels

• Decreases medication effectiveness

• Speeds heart rate

After the last drag…• 20 minutes: heart rate returns to normal levels

• 2 hours: circulation improves

• BP normalizes. Blood flow returns toes and fingers

• 12 hours: improved oxygen to brain, heart, body

• 2-3 weeks: withdrawal symptoms should be concluded. Exercise capacity and breathing improve significantly

Obstructive Sleep Apnea (OSA)

Meditation

• Meditation, Yoga, and Biofeedback have been shown to reduce vascular tone and improve blood pressure

• Likely through both psychological and physiological responses

• Improved psychological well-being

• Less objective measures of anxiety and depression

• Average drop in BP 3 mmHg after 20 weeksMarquez, JoHH 13 Nov 2018, 33(3) DeJesus, Circ 6 Mar 2019https://doi.org/10.1161/circ.139.suppl_1.P352Circulation. 2019;139:AP352 Roshi Journal of Advanced Medical Research; 7 (2) (Feb 2019)

Case Study• Michelle is a 55 year old female who has noticed a gradual

increase in blood pressure over the last several years

• “Average” blood pressure now averaging 140-150/80-90 mmHg

• Has been suggested to take meds, but is reluctant

• Wants to know, what are her options…

Michelle• Blood pressure 158/95 mmHg in office, Heart rate 90 bpm

• Weight: 95 kg (209 lb)

• Exam: obese, soft murmur that accentuates with handgrip. No abdominal bruit, mild non-pitting edema

• Recent blood work:

• Normal renal (kidney) function. Modest elevation of total cholesterol and LDL (“Lousy” cholesterol), Fasting blood sugar 109 mg/dL

• Options:

E) All of the above

A) Medications B) Weight loss

C) Improved dietary choice/intake D) Screen for additional disorders/causes

Michelle• Diagnosed with stage II hypertension

• Recommended to initiate single BP medication

• Dietary/exercise recommendations reviewed

• Enrolled in commercial dietary program

• Started walking program

• Extended lab panel drawn

A) Medications B) Weight loss

C) Improved dietary choice/intake D) Screen for additional disorders/causes

Michelle• At 1 month follow up:

• BP 140/80 mmHg

• Down 4 kg (9 lb)

• Labs revealed no significant abnormality, no diabetes but consistent with metabolic syndrome

• Discussed sleep study evaluation

Michelle

• At 6 month follow up:

• BP averaging 110-120 mmHg

• Current weight 81 kg (179 lb), down 30 lb.

• Using CPAP

• Exercising combination resistance training an aerobic

Summary

• Consequence of untreated hypertension can be devastating

• Causes are multifactorial, most commonly influenced by lifestyle

• Medications are management cornerstones but dietary and habit modification is foundational

• Lifestyle modification can have a cumulative effect, often times negating or reducing reliance on medications

Contact Information:

Heath Wilt, DO, FACC Shawnee Mission Cardiovascular Consultants

heath.wilt@adventhealth.com Instagram: @ABCSofHealth

Shawnee Mission Medical Bldg 9119 W 74th St , Ste 350

Shawnee Mission KS 66204 913-632-9400

AdventHealth- Overland Park 7840 W 165th St, Ste 210 Overland Park KS 66223

913-632-9400