146 SECTION 3 • MEDICAL PROBLEMS IN THE ATHLETE
HYPERTENSION IN ATHLETES
- Systemic hypertension remains one of the most
common life-threatening cardiovascular disorders in
the United States and affects athletes of all ages and
sports. The diagnosis, work-up, and the initial non-
pharmacologic approach to treatment does not differ
between athletes and nonathletes. This approach is
well described in the JNC-VII recommendations
(Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure,
2003). - Care must be taken not to overdiagnose the condition
in young athletes and to use proper fitting cuffs with
three different measures on three different days,
adjusting for norms for age, and height (Luckstead,
2002) (see Table 25-6).- An appropriate search for secondary etiologies and
target organ damage assessment should guide the
history, physical, and laboratory evaluation. - History should include an inquiry about perform-
ance enhancing substances (e.g., anabolic steroids)
and lab should include EKG, urinalysis, complete
blood count(CBC), electrolytes, fasting glucose,
lipid profile, blood urea nitrogen(BUN), creati-
nine, and uric acid. It often includes a chest X-ray
and echocardiogram to assess for left ventricular
- An appropriate search for secondary etiologies and
hypertrophy as well as a stress test to assist in deter-
mining the intensity level of activity participation
(Maron and Mitchell, 1994; Strong and Steed, 1982).- Nonpharmacologic treatment should be properly
initiated with enthusiastic physician endorsement
(Whelton et al, 2002; Niedfeldt, 2002). It includes
engagement in moderate physical activity, maintenance
of ideal body weight, limitation of alcohol (1 oz/day),
reduction in sodium intake (100 mmol/day), mainte-
nance of adequate potassium intake (90 mmol/day), and
consumption of a diet high in fruit and vegetables
and low in total and saturated fat. - When indicated, pharmacologic treatment should be
initiated. Generally, angiotensin converting enzyme
(ACE) inhibitors, calcium channel blockers, and
angiotensin-II receptor blockers are excellent choices
for athletes with hypertension. Their low side effect
profile and favorable physiologic hemodynamics
make them generally safe and effective. It is prefer-
able to avoid diuretics and beta-blockers in young
athletes. Volume and potassium balance issues limit
diuretic use and beta-blockers adversely impact the
cardiovascular training effect of exercise (Kugler
and O’Connor, 1999; Kugler, O’Connor, and
Oriscello, 2001). Both substances, as well as a
number of other antihypertensives are banned by the
National Collegiate Athletic Association and the
TABLE 25-6 Classification of Hypertension (Boys and Girls Combined) (mmHg)
HIGH NORMAL BP SIGNIFICANT HTN SEVERE HTN
AGE (YEARS) (90TH–94TH PERCENTILE) (95TH–98TH PERCENTILE) (99TH PERCENTILE)
6–9
Systolic 111–121 122–129 >129(129)*
Diastolic 70–77 70–85 >85(84)
10–12
Systolic 117–125 126–133 >133(134)
Diastolic 75–81 82–89 >89(89)
13–15
Systolic 124–135 136–143 >143(149)
Diastolic 77–85 86–91 >91(94)
16–18
Systolic 127–141 142–149 >149(159)
Diastolic 80–91 92–97 >97(99)
18
Systolic not given [140–179]† >(179)
Diastolic not given [90–109] >(109)SOURCE: (Committee on Sports Medicine and Fitness, 1997)
*The values in parentheses are those used for the classification of severe hypertension by the 26th Bethesda
Conference on cardiovascular disease and atheletic participation (Maron and Mitchell, 1994).
†The values in brackets are those for mild and moderate hypertension given by the 26th Bethesda Conference
(Maron and Mitchell, 1994).