Blood pressure, 2017 AHA/ACC Guidelines, Hpertension, Integratvie medicine, Preventive medicine, Lifestyle

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Hypertension Becomes a Much Bigger Threat

L. Terry Chappell, MD

On November 13, 2017, everything having to do with adult blood pressure changed. Instantaneously, according to the major cardiology associations in the US, thirty million more Americans no longer could claim to have normal blood pressure. The number of adults now classified as having Stage 1 hypertension rose from 32 to 46%, and another 12 % of the population are now determined to have elevated blood pressure. The new normal for BP is 130/80 mmHg for almost everyone, instead of the previous goal of 140/90. All of the newly labeled patients are now expected to be treated primarily with aggressive lifestyle changes.

The New Guidelines

The American Heart Association (AHA) and the American College of Cardiology (ACC), along with nine other health professional organizations presented new guidelines at the AHA’s fall Scientific Sessions in Anaheim.¹ The previous guidelines began with the category of prehypertension. No longer is there prehypertension, but now BP is considered elevated if systolic levels are between 120 and 129 mm Hg and diastolic levels are less than 80. Previously, Stage 1 hypertension began at 140/90. The new guideline reclassifies Stage 1 hypertension as whenever the systolic BP is 130-139 or the diastolic is between 80-89. Stage 2 hypertension now begins when the systolic BP is at least 140 or the diastolic BP is at least 90 mmHg. Thus Stage 1 HBP is lowered from 140/90 to 130/80, and this applies to either systolic or diastolic readings.

Approximately 35% of current hypertensive patients are not adequately controlled. With the new guidelines, it is estimated that 53% of patients whose treated BP is currently considered well-controlled will no longer meet that standard. They require additional treatment.

Lifestyle changes are the primary treatments for those with elevated BP and Stage 1 hypertension. Those in both categories will try to prevent disease progression by maintaining the BP between 120/70 and 130/80. The systolic BP guidelines for the elderly had changed from 140 mmHg to 150 mmHg two years ago. But now the upper limit of a normal systolic BP has plunged twenty points to 130/80 for those over 60 years of age, as with the rest of the adult population. The current guidelines are a major attempt to switch the emphasis of treatment to prevention. There are 106 recommendations and 481 pages in the new guidelines. The plan is for every person in these redefined categories to get a comprehensive package of interventions.

Soon after the AHA/ACC guidelines were issued, the American Academy of Family Physicians (AAFP), which did not participate in the AHA/ACC review, rejected them. They insisted that Stage 1 hypertension does not begin until the BP reaches 140/90. Patients with kidney disease or diabetes previously had a lower acceptable limit of 130/80, and that continues. We now have two definitions of hypertension, those from cardiologists vs. those from family docs.

An important caveat in the 2017 AHA/ACC guidelines is that additional medications should be prescribed for patients with Stage 1 hypertension only if increased risk is also present. Unfortunately, plenty of increased risk occurs. Additional risk includes previous myocardial infarction, dementia, stroke, peripheral vascular disease, aneurysms, heart failure, high lipids (according to the AHA 10-year risk calculation), diabetes, and kidney disease. Furthermore, socioeconomic status and psychosocial stress are new risk factors that should be considered.

Despite the expressed intent to shift treatment toward lifestyle changes and avoid increases in medication use, it appears likely that more medications will be prescribed as well. The Stanford Prevention Research Center predicts that 29 million currently treated patients will now require additional medications to achieve BP control.²

There are six primary lifestyle goals that are specified by the new guidelines: weight loss, reducing sodium, enhancing potassium, 90-150 minutes per week of physical activity, limited alcohol intake, and following the DASH (Dietary Approaches to Stop Hypertension) diet, which emphasizes reduced solid fats and moderate sugar. For many years, integrative physicians have prescribed a much more comprehensive lifestyle program to achieve positive health improvements for their patients. These differing approaches are summarized in Table 1.

It is the purpose of this article to embrace the new guidelines and to suggest a more vigorous drug-free lifestyle program that will be acceptable to the patient, affordable, and effective in preventing vascular disease. Such a program might even enable a patient to discontinue BP medications that he/she is currently taking, which is often a goal that a patient has, perhaps separately from the physician. Integrative medicine has arrived. It is time to show what can be accomplished.

Accurate Measurement of Blood Pressure

According to a quality improvement project coordinated by Brent Egan in South Carolina involving 16 primary care clinics, which followed NIH recommendations, blood pressure readings should include the following for office assessment: Patient arrives without a recent stressful incident and no urgency to visit the rest room. In the previous 30 minutes, no alcohol, food, cigarettes or caffeine, and no exercise are allowed. He or she should be wearing loose clothing. The patient sits in a quiet room, preferably designated for measuring BP, without talking to anyone for three to five minutes. A proper-sized cuff is applied snugly around the upper arm. Both feet are flat on the floor. Three automated readings of BP are taken. An average of the three readings is the BP recorded for that visit.

At some point, the patient should purchase a BP unit to take his or her own BP at home. At least one reading a day should be taken at varying times of the day. The readings should be averaged over a two-to-four-week interval, with one or two outliers discarded if needed.

A BP reading taken soon after the patient arrives at the office or immediately upon the nurse coming into the exam room is not very accurate. One study showed an average reading eight points higher with the usual procedure as compared to a reading following the optimal protocol.

The SPRINT study (Systolic Blood Pressure Intervention Trial) at Kaiser Permanente of Northern California also gave a report at the AHA fall conference.³ SPRINT used the optimal protocol for recording office blood pressures. They found that blood pressure targets of 120-125 mmHg achieved results with a 70% reduction in increased risk for cardiac events and a 28% reduction in all-cause mortality. This correlated with a systolic BP of 130-132 the way most doctors and nurses take BP. However, SPRINT also found that when systolic BP was over-corrected to 115-125, there was an increased risk of 9% for cardiac events, especially heart failure and cardiovascular death. More kidney failure occurred, and there was a 51% increase in visits to the ER due to hypotension and electrolyte abnormalities. Thus, the best BP target appears to be 120/70 to 130/80 with lifestyle factors the primary treatment.

Tests to Uncover Risk Factors That Interact with Hypertension

Blood tests that might affect blood pressure include a serum creatinine, glucose, CBC, total cholesterol, HDL, LDL, triglycerides, chol/HDL ratio, and hepatic panel (all of which might be included in a routine comprehensive metabolic panel). Additional tests that could be helpful include a TSH, T4, Free T3, the small dense LDL, Lp(a), vitamin D3, fibrinogen, CRPsens, homocysteine, ferritin, serum insulin, HBA1C, and a toxic metals challenge test. Serial CRPsens and HBA1C testing might join BP readings as simple ways to monitor the effects of lifestyle factors.

Hypothyroidism can cause either high or low blood pressure. Correction of hypertension in affected patients can occur with treatment of the thyroid disorder.

Circulation tests for the early detection of cardiovascular disease include cardio risk (ultrasound of carotids), calcium score of coronary arteries with CT scan, stress EKG, and echocardiogram. Family history is an important risk factor. Genetic tests such as MTHFR and ApoE might be useful for selected patients.

Each physician must establish a database of tests that should be accomplished for each patient. That could include the above listed tests. Some tests could be omitted and others added, as the doctor prioritizes.

What must be kept in mind is that the most powerful risk factor for vascular disease is hypertension, more powerful than smoking, hyperlipidemia, or inactivity. Increased risk begins with an accurate reading of 120/70. If any of these tests are positive, BP control becomes even more important! If possible, the goal is to achieve BP control without the use of medications, which have potential side effects that create new risks and lessen the benefit of the therapy. Many factors contribute to cardiovascular risk but not to the degree that hypertension does. Since hypertension is the primary factor, it should be treated as such.

Making Blood Pressure a Priority

Hypertension is known as the “silent killer” because the symptoms often do not occur until the damage is advanced. Most doctors are interested in preventive medicine, but effective action does not always occur. If there is concern that blood pressure could be a problem, the patient should have home monitoring records to review. If there is a discrepancy between home and office readings, the patient’s cuff should be compared to the office cuff. Both high and low blood pressure need to be addressed. Adrenal stress, anemia, and low thyroid function contribute to hypotension.

Factors such as diet, exercise, stress, and the use of supplements should be discussed and put into the record. Compliance with and side effects from prescribed medications are reviewed. Risk factors that interact with hypertension and have been identified for each patient should be discussed.

Especially since the AHA/ACC guidelines state that lifestyle improvements rather than increased medications should be utilized to lower Stage 1 hypertension to normal levels, a more aggressive attention to lifestyle is now required. Setting goals, journaling, and increased monitoring with office visits or phone consultations by nurses, PAs, NPs, and physicians are often required for success. Team care is essential. Patients with Stage 1 hypertension should be seen monthly and those with Stage 2 every two weeks. Patient-shared decision making is a concept that is crucial for each patient to accept a treatment plan involving lifestyle changes that pertain directly to him or her. All staff members must buy into the benefits of lifestyle improvements and give positive reinforcement as much as possible. Hopefully, third parties will be more likely now to help pay for the extra time required to implement effective lifestyle changes.

Hypertension is both a disease and risk factor. It can cause coronary artery, cerebral artery, peripheral artery disease, and aneurysms. It can lead to kidney disease, macular degeneration, and intestinal infarctions. Poor BP control contributes to 68,000 preventable deaths yearly. Hypertension accounts for 54 % of all strokes and 47% of all coronary artery disease. When combined with diabetes, multiple complications can result. The guidelines did not address isolated systolic hypertension or the additional risk for CAD and kidney disease created by lowering the diastolic BP below 60 mmHg in diabetic patients. These should be included.

Many patients resist treatment for hypertension. Some experience side effects from multiple medications prescribed. The cost of drugs can be a financial burden. Generics should be prescribed whenever possible. Some patients resist the pharmaceutical emphasis of conventional medicine. For those, the AHA/ACC guidelines emphasizing lifestyles should be welcome.

Modifiable Lifestyle Factors for a Suitable Treatment Plan

Certainly, smoking cessation, for well-established reasons, is a high priority. Air pollution is a risk that might be hard to avoid. Assessment and treatment for toxic metals, especially lead, mercury, cadmium, arsenic, and aluminum is major factor. Accumulations of lead and cadmium have been strongly linked to vascular disease.⁴ High levels of toxic metals have been detected in many US cities. Lead is a common pollutant in the environment. Cadmium is found in cigarettes and batteries. Gadolinium dye used for MRI testing is an emerging risk factor. Not only is it toxic but as with other metals, it also stays in the body much longer than most doctors realize. Typically, toxic metals reside in the bloodstream for no more than two weeks. Then they are stored in the bone, brain, and fats. Blood tests might not detect accumulated metals. A challenge test with a chelating agent is suggested to assess the body burden of toxic metals and the risk that results. A series of intravenous EDTA chelation treatments is generally the best way to reduce such metals to a safe level.

The Trial to Assess Chelation Therapy (TACT) headed by Gervasio Lamas⁵ showed that treatment with 40 IV infusions of EDTA significantly reduced future cardiac events in patients with established coronary artery disease. Toxic metals appeared to be the primary mechanism of action. Sometimes hyperbaric oxygen alone or with chelation can be used to treat resistant cases of hypertension.

Desensitization for airborne, mold, food, and harmful chemicals can lower hypertension as well as improve quality of life. Sensitivities of this type are extremely common. Low-dose antigen (LDA) therapy has been particularly effective in treating these problems. Simply identifying food allergies and avoiding those foods can be helpful. NSAIDs should only be used with extreme caution to control pain. They are known to raise BP and increase mortality.

Obesity, overweight, and the metabolic syndrome are identified by history, physical exam, and BMI measurements. Ideally, a BMI of 25 is a suitable goal. Each physician’s office should have a program for weight loss and a list of healthy foods recommended for most patients. Even ten pounds of weight loss can lower blood pressure by several points. A baseline diet for weight loss and blood pressure control might be Trowbridge’s anti-yeast low carbohydrate diet, a Mediterranean diet, the DASH diet, or a vegetarian diet. The most important aspect of any diet is the maintenance phase. The amount of improvement in BP control with weight loss has been reported to be comparable to treatment with metoprolol. If a patient has cravings, either for food or cigarettes, a simple supplement called Crave Arrest can be very helpful. If candida imbalance is suspected from a symptom questionnaire or from stool testing, probiotics and anti-fungal agents will probably be required. Otherwise, the toxins produced by yeast will contribute to hypertension.

Dietary factors that have been shown to reduce hypertension at least for some patients include raw foods, onion, garlic, whole oats, soy, olive and sesame oil, dark chocolate, pomegranate juice, fish, and reduction of excessive of salt intake. Five servings of fresh fruits and vegetables daily can reduce elevated blood pressure.⁶

Alcohol consumption is discouraged because it can raise blood pressure and contribute to kidney and liver damage. However, small amounts of red wine (<300ml per day) can have a positive effect on mortality. Multiple studies have shown that supplemented intake of dietary fiber (30 grams per day) can lower both systolic and diastolic blood pressure. Similar amounts of flax seed can also be of benefit. A cup or two of coffee has a relaxing effect for some patients, but excessive caffeine and sugar can raise blood pressure. Green tea is a good alternative.

Approximately two and a half hours of exercise per week is generally recommended. The type of exercise depends of the capabilities of the patient. A pedometer reading of 10,000 steps per day can be recommended for motivated patients. Interval training with three twenty-second bursts of almost all-out effort three times a week plus warm-up might often achieve fitness with a total of 10 minutes per week! Especially for those who have difficulty performing vigorous exercise, a vibration machine such as the Vibabody, will accomplish a mild workout in ten minutes. A sit-down trampoline has similar benefits. Either one can be purchased for $200-300.

The effects of stress are sometimes more difficult to identify and measure but can be a very important factor.⁷ Heart rate variability testing, salivary adrenal measurements, serial urine neurotransmitter assessments, and brain wave testing are four ways to objectively document dysfunction due to stress. Once an abnormality is identified, there are specified ways to improve the response of the body to stress. Herbal preparations and homeopathics can reduce anxiety and improve autonomic dysfunction. Adrenal supplements can improve adrenal exhaustion. Neurotransmitters can be balanced with specific amino acids. Neurofeedback, a form of biofeedback, can improve brain wave function. Other techniques not specifically linked to testing include meditation, yoga, and tapping techniques such as NAET and the Emotional Freedom Technique (EFT). Various devices, including portable sauna and biomat, can generate far infrared waves, which are particularly effective in reducing stress. The price of the far infrared devices is in the range of $600-1400. Qi Gong, Yoga, Tai Chi, Heart Math, Transendental Meditation, and the Relaxation Response are all techniques that can reduce the effects of stress, if practiced regularly. Acupuncture and manipulation by chiropractors and osteopaths might also be helpful.

Special workshops like those presented by Steve Kaufman for Pain Neutralization, Dietrich Klinghardt for Neural Therapy, William Schrader for LDA and IV nutrient therapy, and Frank Shallenberger and Robert Rowen for Ultraviolet Blood Irradiation teach skills that are applicable for lowering blood pressure without drugs.

Medications and Supplements

There are five major drug categories for blood pressure treatment. They include the following with the most common side effects listed: thiazide diuretics (low potassium leading to fatigue), ACE inhibitors (high potassium causing arrhythmias and cough), calcium channel blockers (constipation, swelling, headaches), beta-blockers (dizziness, fatigue), and angiotension receptor blockers (dizziness). For Caucasian patients with BP exceeding 140/90 mmHg, an ACE inhibitor or ARB is usually the initial prescription, followed by a calcium channel blocker. For blacks, the calcium channel blocker is first line. A diuretic is next for whites and blacks, and then spironolactone as a fourth drug. Lower doses from multiple categories are preferred in an attempt to minimize side effects. Several drugs from other categories, such as clonidine, alpha blockers, and hydralazine, are occasionally called upon for resistant cases.

Nutritional supplements could be considered a sixth category.⁸ Most effective in that category might be garlic and magnesium. The latter is commonly deficient. One way to find the most effective dose of magnesium is to gradually increase the dose until the patient gets diarrhea. Then reduce the dose to the highest level tolerated by the patient.

Other nutritional supplements that might help lower high blood pressure include vitamin C with lysine (as recommended by Linus Pauling), fish oil, calcium (balanced with at least half as much magnesium), potassium, thiamine, l-arginine to increase nitric oxide, folic acid, vitamin B6, and a tomato extract containing lycopene. Vitamin D3 deficiency is common. If detected with a blood test, vitamin D supplementation might significantly lower blood pressure. The vitamin D effect can be enhanced with ultraviolet blood irradiation. Coenzyme Q10 lowers blood pressure independently with doses of 200-400 mg a day and is particularly important to replace if a patient is taking a statin drug, which can reduce the body’s production of endogenous CoQ10 by 40%. Vitamin B12 shots can be self-administered at home several times per week to reduce stress and increase energy. The shots either work well within a month or there is no effect. Jonathan Wright has been a proponent of B12 injections for many years. He has taught many physicians about the effective use of many nutritional supplements and the frequent need for hydrochloric acid for proper digestion.

Herbal preparations and homeopathics can be helpful to treat anxiety and depression, which in turn might benefit patients who have hypertension. Examples of herbs for anxiety are kava, valerian, and passiflora for anxiety and St. John’s wort, l-tryptophan, and SAMe for depression. CBD and hemp oils have a nice relaxing effect.

In order for optimal results, several lifestyle changes must be addressed, and long-term maintenance must be practiced. Medications for hypertension, anxiety, and depression can be prescribed, but often have side effects. Natural supplements are usually safer and can be quite effective. Each physician must choose which modalities she wants to utilize in her practice. Additional training might be required. Enough team care support must be provided for each intervention to be successful. A great deal more can be done to improve hypertension with lifestyle interventions than the six measures recommended in the AHA/ACC guidelines.

Two textbooks that contain further information on detecting and treating hypertension with integrative medicine are Nutritional Medicine by Alan Gaby and Integrative Medicine by David Rakel. Some of the organizations that teach techniques mentioned in this article include the International College of Integrative Medicine (ICIM), the American College for Advancement in Medicine (ACAM), the American Academy of Environmental Medicine (AAEM), the Academy of Integrative Health and Medicine (AIHM), and the Institute for Functional Medicine (IFM).

Conclusions

The AHA/ACC has given us a new paradigm for detecting and treating hypertension, our number one cardiovascular risk factor. We should embrace it, improve it, and work together to achieve the best results possible. First, we must be certain that we have a consistent protocol for measuring blood pressure and treating it effectively. We should have three to five minutes of silent relaxation prior to taking the readings, both at home and in the office. Home readings usually have precedence over office readings. Second, the AHA/ACC guidelines are preferable over the older guidelines reaffirmed by the AAFP, because they save added lives and reduce complications from the disease. Effective lifestyle changes and a more natural treatment are strongly preferred to reduce BP to acceptable levels with an upper limit of 130/80 mmHg. Third, additional medications are to be avoided whenever possible to control Stage 1 hypertension. In fact, fewer medications than currently used are preferable. The lifestyle recommendations in the AHA/ACC guidelines are a good start, but we can do far better with the suggestions that have been offered by integrative physicians for many years. Fourth, more testing, office visits, phone call follow-ups, procedures, supplements, and devices will be required for lifestyle improvements to succeed. A team care approach is usually necessary. This will increase the cost of care somewhat in the short run, but in the long run, better BP will result in improved health and reduced costs for individual patients and society at large.

References

1. Whelton PK, chairman. Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. November 13, 2017 (Epub ahead of print).

2. Ioannidis, JP. Diagnosis and treatment of hypertension in the 2017 ACC/AHA guidelines and in the real world. JAMA. 2018;319:115-116.

3. Go A. Systolic blood pressure intervention trial (SPRINT). N Engl J Med. 2015; 373: 2103-2016.

4. Solenkova NV, et.al. Metal pollutants and cardiovascular disease: mechanisms and consequences of exposure. Am Heart J. 2014; 168:812-822.

5. Lamas GA, et.al. Effect of disodium EDTA chelation regimen on cardiovascular events in patients with previous myocardial infarction: the TACT randomized trial. JAMA. 2013; 309: 1241-1250.

6. Hypertension. In: Gaby AR, ed. Nutritional Medicine. Concord, NH: Fritz Perlberg Publishing; 2011: 323-335.

7. Dickinson HO, et.al. Lifestyle interventions to reduce raised blood pressure: a systematic review of randomized controlled trials. J Hypertens. 2006; 24:215-233.

8. Plotnikoff, GA, Dusek J. Hypertension. In Rakel D, ed. Integrative Medicine, 4th edition. Philadelphia: Elsevier; 2012: 230-241.

L. Terry Chappell, MD

After graduating from the University of Michigan Medical School, Dr. Chappell became certified by the American Board of Family Medicine and later by the National Board of Physicians and Surgeons. He is the author of Questions from the Heart and has published many articles in the Townsend Letter and in other journals showing the effectiveness of chelation therapy for vascular disease.

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