By John Davis Cantwell, M.D., MACP, FACC
For the past 40 years, I have been doing pre-season Atlanta Braves baseball physicals at their spring training facility in Florida. Thirty-five years ago, I began doing pre-season cardiovascular examinations on freshman Georgia Tech athletes.
Usually every year there are several athletes noted to have hypertension. This is not surprising, since prior surveys suggest that 3.5 percent of children and up to 9 percent of young adults are hypertensive1. Yet, in all those years, we have never had to disqualify an athlete from competition due to this disorder.
I have a mental checklist in evaluating the hypertensive athlete, which includes:
- Using a wide cuff in large athletes. I also check the blood pressure in both arms at least once.
- Arranging to get multiple follow-up blood pressure (BP) readings with the athletic trainer or with the athlete (using an Omron home arm BP cuff), noting the findings on our graph paper chart.
- Taking a thorough family history, especially regarding hypertension, strokes and early coronary events (male relatives < age 55, female relatives < age 65).
- Asking about weekly caffeine and alcohol intake and use of nonsteroidal drugs, amphetamines and anabolic steroids.
- Checking the body mass index. The BodPod is a more accurate determination of excess body fat in heavily muscled, weight-training athletes.
- Discussing the athletes’ typical daily diet, including their sodium intake.
- Reviewing the urinalysis, blood creatinine, calcium, TSH and lipid results.
- Looking at the QRS voltage on the ECG. We find it to be falsely suggestive of myocardial hypertrophy, especially in some of the Georgia Tech track athletes, compared to the more precise echocardiographic readings.
- Remember the ABCDs in choosing drug therapy, when indicated: Ace/ARB, Beta blocker-best in young, whites. Calcium channel blockers, Diuretics-in older, blacks. However, I usually do not start with beta blockers in any athlete as it seems to affect the perceived exertion level in some, while athletes have enough issues with sweating and fluid balance without adding a diuretic. Accordingly, I usually start with low-cost generic ACE or ARB (like lisinopril, losartan), watching the creatinine and potassium levels. Be sure that any drug you prescribe is okay with the appropriate governing body, like the NCAA or International Olympic Committee (IOC).
- Consider a 24-hour continuous blood pressure monitor reading in selected cases. Unfortunately, this is not readily available.
- I rarely screen for pheochromocytomas, Conn’s syndrome, and renal artery abnormalities, but I do listen for abdominal bruits, check for radial and femoral pulse delays and auscultate the posterior chest to exclude coarctation, but have never found these disorders.
- Be aware of the new American College of Cardiology Guidelines on dealing with a hypertensive athlete.
Finally, bear in mind as Harvard cardiologist, Elliott Antman, M.D., recently stated: “The epidemiologic evidence clearly shows that increased blood pressure relates to an increased risk for cardiovascular events across a blood pressure range from 115/75 mmHg to 185/115 mmHg.” As Ventura and Lavie remind us, “Projecting into the athlete’s future, for every 20 mmHg systolic BP reading above 115 mmHg and/or 10 mmHg diastolic reading above 75 mmHg, there is a two-fold increase in mortality associated with strokes and coronary artery disease.”