0

CMHC PULSE

Cardio Metabolic Health Congress – Official Blog

How to Handle High Blood Pressure

While the new guidelines from the American Heart Association and the American College of Cardiology indicate that nearly half of U.S. adults qualify for high blood pressure, the AHA has additionally noted that as many as one in seven people being treated for high blood pressure does not have the condition under control. Known as resistant hypertension, the problem is defined as having high blood pressure despite taking a diuretic and at least two other blood pressure medicines. Because there is a strong, direct correlation between high blood pressure and additional cardiovascular risks & health problems, Dr. Randall Zusman—a cardiologist at Massachusetts General Hospital—emphasizes the importance of staying below the clinically outlined thresholds, and surmounting the obstacles that prevent people from reaching specific blood pressure targets.

Quoted in an article in Harvard Health, Dr. Zusman states: “Many cases of alleged resistant hypertension occur because people don’t take their medications as prescribed, for various reasons.” Yet because some people have habits that hinder the success and efficacy of blood pressure drugs, or underlying & undiagnosed medical conditions, blood pressure can be difficult to tame and treat.

Medication Adherence

The AHA estimates that three out of four Americans do not take their medication as directed; medication adherence is a common problem that can lead to severe repercussions: in addition to growing rates of cardiovascular disease, all-cause mortality, and hospitalizations. Poor medication adherence additionally takes the lives of 125,000 Americans annually, and costs the U.S. health care system almost $300 billion each year. In other instances, Zusman cites some patients who encounter side effects, or those who try to self-manage drug regimens. “I can’t tell you how many people come in to my office and say, ‘I felt lightheaded one day, so I stopped taking one of my pills.” Many patients are unaware that various medications have ‘different modes of action,’ and the specific combination is designed to lower the blood pressure. Moreover, abruptly stopping a beta blocker can cause one’s heart rate and blood pressure to rise, which ultimately puts the heart at risk.

Pharmaceutical Options

There are more than 200 different approved pharmaceuticals on the market to treat high blood pressure. They fall into several classes, including diuretics (water pills); angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs); calcium-channel blockers; beta blockers; renin inhibitors; and aldosterone blockers. Yet there are a host of other drugs used to reach blood pressure goals, including vasodilators, alpha blockers, central-acting agenda, and more. Drugs prescribed by clinicians may depend on comorbid medical conditions such as atrial fibrillation or angina, and different people respond better to certain drugs—depending on sex, age, race, and other factors.

Issues with Drugs & Diet

Zusman states that many people do not understand the reasoning surrounding the importance of a low-sodium diet, given that “a high-sodium diet interferes with commonly prescribed blood pressure drugs, making them less effective.” Because the typical Western diet is full of prepared and processed foods, which are the primary culprits and contributors of sodium, many Americans are already predisposed to high-sodium consumption. Other issues with drugs include continuous usage of nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen (Advil) and naproxen sodium (Aleve): all of which can raise blood pressure.

Additional Secondary Causes

People diagnosed with resistant hypertension sometimes have an underlying medical condition that elevates blood pressure, including excess of the hormone aldosterone, which causes the body to hold on to sodium and water but lose potassium; renal artery stenosis, a narrowing of the arteries supplying the kidneys; and obstructive sleep apnea, in which the upper airway becomes blocked during sleep, causing pauses in breathing. Zusman notes that those with resistant hypertension are far more likely to have one of the aforementioned conditions, compared to the general public.

Linking Cerebral Small Vessel Disease (SVD) & Type 1 Diabetes

Findings published in Diabetes Care indicate a correlation between adults diagnosed with type 1 diabetes, and cerebral small-vessel disease and micro-bleeds. Professor of nephrology at Helsinki University Central Hospital in Finland Per-Henrik Groop, MD, DMSc, FRCPE wrote: “Type 1 diabetes is associated with a fivefold increased risk of stroke, with cerebral small-vessel disease (SVD) as the most common etiology…cerebral SVD in type 1 diabetes, however, remains scarcely investigated and is challenging to study in vivo per se owing to the size of affected vasculature.”

Cerebral small vessel disease is commonly observed in the elderly population: a neurological disease that typically causes stroke and dementia, mood disturbance, and problems with gait. While its clinical symptoms can be inconsistent, it is often related to vascular risk factors. Cerebral micro bleeds are small, chronic brain hemorrhages caused by structural abnormalities of small vessels of the brain.

Groop and colleagues analyzed data from 191 healthy younger adults with type 1 diabetes, all of whom were diagnosed before age 40 years. The participants ranged in age from 18 to 50 years; the mean age was 40, and the participants were comprised of 53% women. The study was performed at Helsinki University Hospital, and data from 30 adults without diabetes were used for comparison. All participants were enrolled in the Finnish Diabetic Nephropathy Study, and underwent MRIs to asses the incidence of cerebral small-vessel disease.

An article in Healio analyzed the results: among the cohort of participants with type 1 diabetes, 67 participants (35%) were diagnosed with cerebral small-vessel disease: compared with three participants (10%) in the control group. In the diabetes group with cerebral small-vessel disease, 45 (24%) had cerebral micro-bleeds, and 44 (23%) had white matter hyperintensities. The presence of albuminuria (P = .021), a symptom of kidney disease; use of antihypertensive medication (P = .033); and higher systolic blood pressure (P = .009) were observed more frequently in those participants with cerebral micro-bleeds. Systolic BP was the only independently associated factor (OR = 1.03 for each 1-mm Hg increase; 95% CI, 1.00-1.05). Age was the only independently associated factor for white matter hyperintensities (OR = 1.11 for each 1-year age increase; 95% CI, 1.04-1.19).

“Our results indicate that cerebral SVD starts early in type 1 diabetes but is not explained solely by diabetes-related vascular risk factors or the generalized microvascular disease that takes place in diabetes,” the researchers wrote in their findings. “[Cerebral micro-bleeds] were mainly observed in the lobar brain regions, which has been associated with cerebral amyloid angiopathy, a condition generally affecting the elderly, whereas [cerebral micro-bleeds] in the deeper parts associate with hypertensive vasculopathy.”

Previous studies have likewise confirmed that patients with diabetes may have an increased burden of cerebral SVD.

SOURCE
http://care.diabetesjournals.org/content/early/2018/12/09/dc18-1302