Francis G. O’Connor, MD, MPH Medical Director, USUHS Consortium for Health

1. Hypertension, Athletes and the Sports Physician:Implications of JNC VII, The Fourth Report, and the 36th Bethesda Conference Guidelines Francis G. O’Connor, MD, MPH Medical Director, USUHS Consortium for Health and Military Performance (CHAMP) Uniformed Services University of the Health Sciences

2. Objectives • Outline key changes and additions to: • JNC VII • The Fourth Report • The 36th Bethesda Report • Discuss clinical implications for the sports clinician.

3. U.S. Department of Health and Human Services National Institutes of Health National Heart, Lung, and Blood Institute National Heart, Lung, and Blood InstituteNational High Blood Pressure Education Program The Seventh Report of the Joint National Committee onPrevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) Chobanian AV, Bakris GL, Black HR et al: The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of High blood pressure: the JNC 7 report. JAMA 2003;289:2560-72.

4. Why a New JNC Report? • Publication of many new studies. • Need for a new, clear, and concise guideline useful for clinicians. • Need to simplify the classification of BP.

5. Background • HTN prevalence ~ 50 million people in the United States. • The BP relationship to risk of CVD is continuous, consistent, and independent of other risk factors. • Each increment of 20/10 mmHg doubles the risk of CVD across the entire BP range starting from 115/75 mmHg. • Prehypertension signals the need for increased education to reduce BP in order to prevent hypertension. Hypertension is the most common cardiovascular disease encountered in the athletic population.

6. Background Benefits of Lowering BP Average % Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50%

7. Trends in awareness, treatment, and control of high blood pressure in adults ages 18–74, Adapted from JNC VII.

8. JNC VII Blood Pressure Classification High Normal of JNC VI replaced by Prehypertension. Four Stages of Hypertension in JNC VI consolidated to Two Stages.

9. Key Messages • For persons over age 50, SBP is a more important than DBP as CVD risk factor. • Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range. • Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN. • Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications to prevent CVD.

10. Key Messages • Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes. • Certain high-risk conditions are compelling indications for other drug classes. • Most patients will require two or more antihypertensive drugs to achieve goal BP. • If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually should be a thiazide-type diuretic.

11. Key Messages • The most effective therapy prescribed by the careful clinician will control HTN only if patients are motivated. • Motivation improves when patients have positive experiences with, and trust in, the clinician. • Empathy builds trust and is a potent motivator. • The responsible physician’s judgment remains paramount.

12. Implications for the Sports Physician • Diagnosis: • Evaluation of the hypertensive recommends the following: 12 lead electrocardiography; urinalysis; blood glucose and hematocrit; serum potassium, creatinine and calcium; and a lipoprotein profile. • Evaluation: • While echocardiography is recognized in JNC VII as more sensitive than electrocardiography for detecting left ventricular hypertrophy, there is no specific recommendationmandating screening echocardiography.

13. Implications for the Sports Physician • Treatment: • JNC VII specifically addresses compelling indications for pharmacologic intervention: heart failure; post myocardial infarction; high coronary disease risk; diabetes; chronic kidney disease; and recurrent stroke prevention. • In addition, other special situations e.g. minorities, are identified with suggested treatment strategies. • Specific comments into recommendations for athletes, however, do not appear in JNC VII. AMSSM should be a member of the writing group for JNC VIII.

14. The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. Pediatrics 2004; 114 Suppl: 555-76.

15. Why a Fourth Report? • Updates 1996 standard; reflects literature from 1997 to 2004. • The Fourth Report BP standards based on sex, age and height are more accurate and utilize data from the 1999-2000 National Health and Nutrition Examination Survey (NHANES) and new height percentile data from the CDC growth charts. • Hypertension for athletes under 18 years old is also classified as prehypertension, Stage 1, and Stage 2 hypertension to mirror the current recommendations for adults. • Enhanced focus on detection of early target organ damage.

16. Implications for the Sports Physician • Diagnosis: • A diagnosis requires at least three measurements. • 90 to 95% was high-normal, now prehypertension; • 95% to 99% plus 5mmHg is Stage I; Greater than 99% plus 5 mmHg is Stage II. • The plus 5mmHg is new from 1996. • Ambulatory blood pressure monitoring recognized as useful in “white” coat hypertension.

17. Implications for the Sports Physician • Evaluation: • All children and adolescents diagnosed with hypertension require a careful history and physical examination as well as further evaluation for a secondary etiology as clinically indicated. • Renal US for all children with sustained BP > 95% • To evaluate for target organ disease: • Echocardiogram, as well as a retinal examination, is currently recommended for all patients with a BP > 95th percentile.

18. Implications for the Sports Physician • Treatment/Clearance: • Similar to adults, any child athlete with Stage 2 hypertension should be restricted from participation until adequate control is obtained. • Children with identified target organ disease should have participation recommendations based upon the nature of their target organ disease. • Note that the Current PPE monograph is based upon the 1996 Report: • Athletes pick up an extra 5mmHg for clearance for sport.

19. 36th Bethesda Conference: Recommendations for Determining Eligibility for Competition in Athletes with Cardiovascular Abnormalities: Task Force 5: Systemic Hypertension. Kaplan NM, Gidding SS, Pickering TG, et al: Journal of the American College of Cardiology 2005, 45 (8):1346-8.

20. Why a 36th Conference? • Ten year Update. • Publication of many new studies. • New interventions.

21. 36th Bethesda Conference Guidelines • Recommendations for Determining Eligibility for Competition in Athletes with Cardiovascular Abnormalities 26th Bethesda Report • Congenital heart disease • Acquired valvular heart disease • Hypertrophic cardiomyopathy, myocarditis, and other myopericardial diseases and mitral valve prolapse • Systemic hypertension • Coronary artery disease • Arrhythmias

22. Recommendations for Determining Eligibility for Competition in Athletes with Cardiovascular Abnormalities 2005 12 Distinct Task Force Reports Preparticipation Screening Congenital Heart Disease Valvular Heart Disease Cardiomyopathies Hypertension Arrhythmias Sports Classification Drugs AEDs Commotio Cordis Legal 36th Bethesda Conference Guidelines

23. Implications for the Sports Physician • Treatment/ Clearance: • Note that the Current PPE monograph is based upon the 26th Bethesda Conference Report.

24. Implications for the Sports Physician • 26th versus 36th • Little variation is noted between the classification tables from the two conferences except for the addition of triathlon (IIIC), snowboarding (IIIB), and skateboarding (IIIB); the combination of single and doubles tennis into tennis (IC); the change of fencing from IIB to IB; and the absence of Australian rules football (IIC).

25. Table 1: 36th Bethesda Conference Recommendations

26. Implications for the Sports Physician • Evaluation: • Those athletes with stage 1 hypertension should have a blood chemistry (glucose, creatinine/GFR, electrolytes, lipid profile), hematocrit, urinalysis and electrocardiogram. • If an athlete has stage 2 hypertension, abnormal results, or a possible secondary cause then referral for therapy plus additional study including echocardiography is recommended. • Clearance: • Currently an athlete listed as severe hypertension (stage 2) has a blood pressure reading than 160/100 on two occasions and should be restricted from competition until the pressure is controlled. • Using the 26th Conference guidelines, a similar reading of 160/100 on three occasions would be classified as Moderate (stage 2) and would result in no restrictions for the athlete.

27. Key Websites • National Heart Lung and Blood Institute • http://www.nhlbi.nih.gov/ • Clinical Practice Guidelines • JNC VII • The 4th Report • American College of Cardiology • http://www.acc.org • Consensus Conference Reports • 36th Bethesda Conference Report

28. Conclusion • "After teaching over 500 residents and medical students the principles of sports medicine, and having the honor of training 14 incredibly competent primary care sports medicine fellows, I have begun to realize just how important this area truly is. I have always felt that you really did not have to know the difference between a basketball and a baseball; your patients surely will. More and more of our general population continue interests in sports beyond youth in many forms of recreational activity. We must all become 'team physicians' of sort to those recreational exercises we call our patients." David O. Hough