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blood pressure

Switching to a Mediterranean diet will help treat elevated blood pressure. Metro Photo
Treating early with lifestyle changes can improve your long-term outcomes

By David Dunaief, M.D.

Dr. David Dunaief

We have focused a large amount of effort on the treatment and prevention of hypertension (high blood pressure) in the U.S, where it’s pervasive: it affects approximately 45 percent of adults over 18 in the U.S. (1).

Since 2017, this insidious disorder’s severity has been categorized into three stages, each with its recommended treatment regimen. One of the most interesting shifts with this recategorization was the recategorization of what we used to call “prehypertension” into what we now call “elevated” blood pressure and “hypertension stage 1.” 

Elevated blood pressure is defined as systolic blood pressure (the top number) of 120-129 mmHg and diastolic blood pressure (the bottom number) of less than 80 mmHg, while Stage 1 includes systolic blood pressure of 130-139 mmHg or diastolic blood pressure of less than 80-89 mmHg (2).

The consequences of both are significant, even though there are often no symptoms. For example, they increase the risk of cardiovascular disease and heart attack dramatically. In an analysis of the Framingham Heart Study, researchers found a 3.5-fold increase in the risk of heart attack and a 1.7-fold increase in the risk of cardiovascular disease among those with prehypertension (3). This is why it’s crucial to treat it in these early stages, even before it reaches the more severe levels of hypertension.

Another study, the Women’s Health Initiative, which followed more than 60,000 postmenopausal women for an average of 7.7 years, showed an increase in heart attack deaths, heart attacks and strokes compared to those with normal blood pressure (less than 120/80 mmHg). In the Strong Heart Study, prehypertension independently increased the risk for cardiovascular events at 12 years significantly (4).

This may or may not impact mortality, but it certainly does impact quality of life, which can be dramatically reduced with heart disease, heart attack and hypertension.

Elevated blood pressure treatment

In my view, it would be foolish not to treat elevated blood pressure. Updated recommendations for treatment, according to the Joint National Commission (JNC) 8, the association responsible for guidelines on the treatment of hypertension, are lifestyle modifications (5).

Lifestyle changes include a Mediterranean-type diet or the DASH (Dietary Approaches to Stop Hypertension) diet. It’s important to focus on fruits, vegetables, reduction in sodium to a maximum of 1500 mg (2/3 of a teaspoon on a daily basis), exercise, weight loss and no more than moderate amounts of alcohol (1 or fewer drinks for women and 2 or fewer drinks for men on a daily basis) (6). Some studies have also shown that a diet rich in potassium helps to reduce blood pressure (7). 

Fortunately, foods like fruits, vegetables, beans and legumes have significant amounts of potassium. However, do not take potassium supplements unless instructed for other reasons by a physician; high potassium can be very dangerous and may precipitate a heart attack.

The danger in treating elevated blood pressure comes only when medication is used, due to side effects. For example, the Trial of Preventing Hypertension (TROPHY), suggests the use of a hypotensive agent, the blood pressure drug Atacand (candesartan) to treat prehypertensive patients (8)(9). The drug reduced the incidence of hypertension significantly compared to placebo over two years. However, after stopping therapy, the following two years showed only a small benefit over placebo. Still, the authors implied that this may be a plausible treatment. The study was funded by Astra-Zeneca, the makers of the drug. 

In an editorial, Jay I. Meltze, M.D., a clinical specialist in hypertension at Columbia University’s College of Physicians and Surgeons, noted that the results were interpreted in an unusually favorable way (10). 

Elevated blood pressure is an asymptomatic disorder that has been shown to respond well to lifestyle changes — why create symptoms with medication? Therefore, I don’t recommend treating elevated blood pressure patients with medication. Thankfully, the JNC8 agrees.

However, it should be treated — and treated with lifestyle modifications. The side effects from this approach are only better overall health.

References:

(1) cdc.gov. (2) heart.org. (3) Stroke 2005; 36: 1859–1863. (4) Hypertension 2006;47:410-414. (5) Am Fam Physician. 2014 Oct 1;90(7):503-504. (6) J Am Coll Cardiol. 2018 May, 71 (19) 2176–2198. (7) Archives of Internal Medicine 2001;161:589-593. (8) N Engl J Med. 2006;354:1685-1697. (9) J Am Soc Hypertens. Jan-Feb 2008;2(1):39-43. (10) Am J Hypertens. 2006;19:1098-1100.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com. 

Blood pressure readings taken at night may be the most accurate. Stock photo
A simple technique can help indentify cardiovascular risk

By David Dunaief, M.D.

Dr. David Dunaief

Hypertension affects approximately one-third of Americans, according to the latest statistics from the Centers for Disease Control and Prevention, and only about half have it controlled (1). What could we possibly learn about blood pressure that we have not heard already? Studies teach us about diagnostic techniques and timing, as well as consequences of hypertension and its treatment. Let’s look at the evidence.

Technique

When you go to the doctor’s office, they usually take your blood pressure first. But do they take readings in both arms and, if so, have you wondered why? I take blood pressure readings in both arms because there may be significant benefit from this.

An analysis of the Framingham Heart Study and Offspring Study showed that when blood pressure was taken in both arms, when there was a difference of more than 10 mm Hg in the systolic (top number) blood pressure, then there may be an increased risk for the development of cardiovascular disease — stroke and heart disease (2).

This is a simple technique that may give an indication of who is at greater cardiovascular disease risk. In fact, when this interarm blood pressure comparison showed a 10 mm Hg difference, it allowed the researchers to identify an almost 40 percent increased risk of having a cardiac event, such as a stroke or a heart attack, with minimal extra effort expended.

So, the next time you go to the doctor’s office, you might ask them to take your blood pressure in both arms to give you and your doctor a potential preliminary indication of increased cardiovascular disease risk.

Timing

When do we get our blood pressure taken? For most of us it is usually at the doctor’s office in the middle of the day. This may not be the most effective reading. Nighttime blood pressure readings may be the most accurate, according to one study (3). This was a meta-analysis (a group of nine observational studies) involving over 13,000 patients. Neither the clinical nor daytime readings correlated significantly with cardiovascular events when multiple confounding variables were taken into account, while every 10 mm Hg increase at night had a more significant predictive value.

With patients, if blood pressure is high in my office, I suggest that patients take their blood pressure at home, both in the morning and at night, and send me readings on a weekly basis. At least one of the readings should be taken before antihypertensive medications are taken, since these will alter the readings.

Salt impact

There has always been a debate about whether salt plays a role in high blood pressure and heart disease. The latest installment is a compelling British study called the Health Survey from England. It implicates sodium as one potential factor exacerbating the risk for high blood pressure and, ultimately, cardiovascular disease (4). The results show that when salt intake was reduced by an average of 15 percent, there was a significant blood pressure reduction and that this reduction may be at least partially responsible for a 40 percent reduction in stroke mortality and a 42 percent reduction in heart disease mortality.

One potential study weakness was that physical activity was not taken into account. However, this study’s strength was that it measured salt intake through 24-hour urine tests. Most of our dietary salt comes from processed foods we least suspect, such as breads, pastas and cheeses.

Age-related macular degeneration

When we think of blood pressure-lowering medications, we don’t usually consider age-related macular degeneration as a potential side effect. However, in the Beaver Dam Eye Study, patients who were taking blood pressure medications were at a significant 72 percent increased overall risk of developing early-stage AMD (5). It did not matter which class of blood pressure-lowering drug the patient was using, all had similar effects: calcium channel blockers, beta blockers, diuretics and angiotensin receptor blockers.

However, the researchers indicated that they could not determine whether the blood pressure or the blood pressure medication was the potential contributing factor. This is a controversial topic. If you are on blood pressure medications and are more than 65 years old, I would recommend that you get yearly eye exams by your ophthalmologist.

Fall risk

One study shows that blood pressure medications significantly increase fall risk in the elderly (6). Overall, 9 percent of these patients on blood pressure medications were seriously injured when they fell. Those who were considered moderate users of these medications had a 40 percent increased risk of fall. But, interestingly, those who were consider high-intensity users had a slightly less robust risk of fall (28 percent) than the moderate users. The researchers used the Medicare database with 5,000 participants as their data source. The average age of the participants in the study was 80.

Does this mean that we should discontinue blood pressure medications in this population? Not necessarily. This should be assessed at an individual level between the patient and the doctor. Also, one weakness of this study was that there was no dose-response curve. In other words, as the dosage increased with high blood pressure medications, one would expect a greater fall risk. However, the opposite was true.

In conclusion, we have some simple, easy-to-implement, takeaways. First, consider monitoring blood pressure in both arms, since a difference can mean an increased risk of cardiovascular events. Reduce your salt intake; it appears that many people may be sensitive to salt, as shown by the British study. If you do take blood pressure medications and are at least 65 years old, take steps to reduce your risk of falling and have annual ophthalmic exams to check for AMD.

References:

(1) CDC.gov/blood pressure. (2) Am J Med. 2014 Mar;127(3):209-215. (3) J Am Soc Hypertens 2014;8:e59. (4) BMJ Open 2014;4:e004549. (5) Ophthalmology online April 30, 2014. (6) JAMA Intern Med. 2014;174(4):588-595.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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By Ernestine Franco

The Sound Beach Civic Association brought together a number of health professionals at a health and wellness expo Oct. 21.

At the health fair, professionals were on hand to provide blood pressure screenings, nutritionists discussed how to live a healthier life, representatives from the police department collected unused and unwanted medication and the Sound Beach Fire Department provided tips for calling 911 in case of an emergency

Participants, screeners and presenters participating in the even included: The Chiropractic Joint, The Community Growth Center, Ear Works Audiology, Echo Pharmacy,
Harbor View Medical Services, John T. Mather Memorial
Hospital, the LI Chapter of NYC + PANDAS/PANS Awareness Group and NY PANS Awareness Group, North Shore Youth Council, Rite Aid, Santi Yoga Community, Senior Callers, Suffolk Center for Speech,  Suffolk County Health Department, Suffolk County Police Department’s 7th Precinct., Wellness and Chiropractic Solutions and Young Living Essential Oils.

Patty Pulick, a Sound Beach resident, said she absolutely loved the health fair.

“The various tables were very informative,” she said. “I got my sugar checked, learned about healthy alternatives and discussed hearing issues. It was great that the SCPD was there so I could dispose of my unused medications. I hope they have it again.”

Civic association president Bea Ruberto extended her gratitude to BPN Home Improvement Inc., Echo Pharmacy, Harbor View Medical Services, John T. Mather Memorial Hospital, Matt’s One Stop, Pern Editorial Services, Schwamb Plumbing and Heating and St. Charles Hospital, who sponsored the event.

“I would also like to give a special thank you to all the volunteers who worked tirelessly to coordinate this event, as well as Bonnie Boeger, a Coldwell Banker residential broker who provided water,” Ruberto said. “As everything else we work on, it’s the generosity of the people in the Sound Beach community that made this event possible.”

Cocoa components reduce cardiovascular risk

By David Dunaief, M.D.

Dr. David Dunaief

Valentine’s Day is one of the wonderful things about winter. For many, it lifts the mood and spirit. A traditional gift is chocolate. But do the benefits of chocolate go beyond Valentine’s Day? The short answer is yes, which is good news for chocolate lovers. However, we are not talking about filled chocolates, but primarily dark chocolate and cocoa powder.

The health benefits of chocolate are derived in large part from its flavonoid content — compounds that are produced by plants. These health benefits are seen in cardiovascular disease, including stroke, heart disease and high blood pressure. This is ironic, since many chocolate boxes are shaped as hearts. Unfortunately, it is not necessarily the chocolates that come in these boxes that are beneficial.

Let’s look at the evidence.

Effect on heart failure

Heart failure is very difficult to reverse. Therefore, the best approach is prevention, and dark chocolate may be one weapon in this crusade. In the Swedish Mammography Cohort study, those women who consumed dark chocolate saw a reduction in heart failure (1). The results were on a dose-response curve, but only to a point. Those women who consumed two to three servings of dark chocolate a month had a 26 percent reduction in the risk of heart failure.

For the dark chocolate lovers, it gets even better. Women who consumed one to two servings per week had an even greater reduction of 32 percent. However, those who ate more than these amounts actually lost the benefit in heart failure reduction and may have increased risk. With a serving (1 ounce) a day, there was actually a 23 percent increased risk.

This study was a prospective (forward-looking) observational study that involved more than 30,000 women over a long duration, nine years. The authors comment that chocolate has a downside of too much fat and calories and, if eaten in large quantities, it may interfere with eating other beneficial foods, such as fruits and vegetables. The positive effects are most likely from the flavonols, a subset of flavonoids, which come from the cocoa solids — the chocolate minus the cocoa butter.

Impact on mortality from heart attacks

In a two-year observational study, results showed that chocolate seemed to reduce the risk of cardiac death after a first heart attack (2). Again, the effects were based on a dose-response curve, but unlike the previous study, there was no increased risk beyond a certain modest frequency.

Those who consumed chocolate up to once a week saw a 44 percent reduction in risk of death, and those who ate the most chocolate — two or more times per week — saw the most effect, with 66 percent reduced risk. And finally, even those who consumed one serving of chocolate less than once per month saw a 27 percent reduction in death, compared to those who consumed no chocolate.

The study did not mention dark or milk chocolate; however, this was another study that took place in Sweden. In Sweden, milk chocolate has substantially more cocoa solids, and thus flavonols, than that manufactured for the U.S. There were over 1,100 patients involved in this study, and none of them had a history of diabetes, which is important to emphasize.

Stroke reduction

I don’t know anyone who does not want to reduce the risk of stroke. We tell patients to avoid sodium in order to control blood pressure and reduce their risk. Initially, sodium reduction is a difficult thing to acclimate to — and one that people fear. However, it turns out that eating chocolate may reduce the risk of stroke, so this is something you can use to balance out the lifestyle changes.

In yet another study, the Cohort of Swedish Men, which involved over 37,000 men, there was an inverse relationship between chocolate consumption in men and the risk of stroke (3). Those who ate at least two servings of chocolate a week benefited the most with a 17 percent reduction in both major types of stroke — ischemic and hemorrhagic — compared to those who consumed the least amount of chocolate. Although the reduction does not sound tremendous, compare this to aspirin, which reduces stroke risk by 20 percent. However, chocolate consumption study was observational, not the gold standard randomized controlled trial, like aspirin studies.

Blood pressure

One of the most common maladies, especially in people over 50, is high blood pressure. So, whatever we can do to lower blood pressure levels is important, including decreasing sodium levels, exercising and even eating flavonoid-rich cocoa.

In a meta-analysis (a group of 20 RCTs), flavonoid-rich cocoa reduced both systolic (top number) and diastolic (bottom number) blood pressure significantly: −2.77 mm Hg and −2.20 mm Hg, respectively (4). These studies involved healthy participants, who are sometimes the most difficult in whom to show a significant reduction, since their blood pressure is not high initially. One of the weaknesses of this meta-analysis is that the trials were short, between two and 18 weeks.

Why chocolate has an effect

Consuming a small amount of dark chocolate twice a week may lower the risk of heart disease.

Chocolate has compounds called flavonoids. The darker the chocolate, the more flavonoids there are. These flavonoids have potential antioxidant, antiplatelet and anti-inflammatory effects.

In a small, randomized controlled trial comparing 22 heart transplant patients, those who received dark flavonoid-rich chocolate, compared to a cocoa-free control group, had greater vasodilation (enlargement) of coronary arteries two hours after consumption (5). There was also a decrease in the aggregation, or adhesion, of platelets, one of the primary substances in forming clots. The authors concluded that dark chocolate may also cause a reduction in oxidative stress.

It’s great that chocolate, mainly dark, and cocoa powder have such substantial effects in cardiovascular disease. However, certain patients should avoid chocolate such as those with reflux disease, allergies to chocolate and diabetes. Be aware that Dutch-processed, or alkalized, cocoa powder may have lower flavonoid levels and is best avoided. Also, the darker the chocolate is, the higher the flavonoid levels. I suggest that the chocolate be at least 60 to 70 percent dark.

Moderation is the key, for all chocolate contains a lot of calories and fat. Based on the studies, two servings a week are probably where you will see the most cardiovascular benefits. Happy Post-Valentine’s Day!

References: (1) Circ Heart Fail. 2010;3(5):612-616. (2) J Intern Med. 2009;266(3):248-257. (3) Neurology. 2012;79:1223-1229. (4) Cochrane Database Syst Rev. 2012:15;8:CD008893. (5) Circulation. 2007 Nov 20;116(21):2376-2382.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

Consider monitoring blood pressure on both arms. Stock photo

This week, I’d like to discuss some of the nuances of hypertension, or high blood pressure, a contributing risk factor for heart disease. Hypertension affects approximately 33 percent of Americans, according to the latest statistics from the Centers for Disease Control and Prevention, and only 52 percent of these have it controlled (1). What could we possibly learn about blood pressure that we have not heard already? New information is always coming out about this common disease. Studies are teaching us about diagnostic techniques and timing, as well as consequences of hypertension and its treatment. Let’s look at the evidence.

Technique

When you go to the doctor’s office, they usually take your blood pressure first. But do they take readings in both arms and, if so, have you wondered why? I take blood pressure readings in both arms, and when one of my longtime patients asked me why, I joked that I need to practice. In truth, it’s because there may be significant benefit from taking readings in both arms.

An analysis of the Framingham Heart Study and Offspring Study showed that when the blood pressure was taken in both arms, when there was a difference of more than 10 mm Hg in the systolic (top number) blood pressure, then there may be an increased risk for the development of cardiovascular disease — stroke and heart disease (2).

This is a simple technique that may give an indication of who is at greater cardiovascular disease risk. In fact, when this interarm blood pressure comparison showed a 10 mm Hg difference, it allowed the researchers to identify an almost 40 percent increased risk of having a cardiac event, such as a stroke or a heart attack, with minimal extra effort expended.

So, the next time you go to the doctor’s office, you might want to ask if they would take your blood pressure in both arms to give you and your doctor a potential preliminary indication of increased cardiovascular disease risk.

Timing

When do we get our blood pressure taken? For most of us it is usually at the doctor’s office in the middle of the day. This may not be the most effective reading. Nighttime blood pressure readings may be the most accurate, according to one study (3). This was a meta-analysis (a group of nine observational studies) involving over 13,000 patients. Neither the clinical nor daytime readings correlated significantly with cardiovascular events when multiple confounding variables were taken into account, while every 10 mm Hg increase at night had a more significant predictive value.

Twenty-four ambulatory blood pressures readings were taken with these patients, which means these were standardized readings. Does this mean that nighttime readings are more important? Not necessarily, but it is an interesting finding. With my patients, if blood pressure is high in my office, I suggest that patients take their blood pressure at home, both in the morning and at night, and send me readings on a weekly basis. However, at least one of the readings should be taken before antihypertensive medications are taken, since these will alter the readings.

Salt impact

There has always been a debate about whether salt really plays a role in high blood pressure and heart disease. The latest installment in this argument is a compelling British study called the Health Survey from England. It implicates sodium as one potential factor exacerbating the risk for high blood pressure and, ultimately, cardiovascular disease (4). The results show that when salt intake was reduced by an average of 15 percent, there was a significant blood pressure reduction and that this reduction may be at least partially responsible for a 40 percent reduction in stroke mortality and a 42 percent reduction in heart disease mortality.

The graphs of sodium reduction mimicked the line graphs for the reductions in deaths from stroke and heart disease. One potential study weakness was that physical activity was not taken into account. However, a strength of this study was that it measured salt intake through 24-hour urine tests. Most of our dietary salt comes from processed foods that we least suspect, such as breads, pastas and cheeses.

Age-related macular degeneration

When we think of blood pressure-lowering medications, we don’t usually consider age-related macular degeneration as a potential side effect. However, in the Beaver Dam Eye Study, those patients who were taking blood pressure medications were at a significant 72 percent increased overall risk of developing early-stage AMD (5). It did not matter which class of blood pressure-lowering drug the patient was using, all had similar effects: calcium channel blockers, beta blockers, diuretics, and angiotensin receptor blockers.

However, the researchers indicated that they could not determine whether the blood pressure or the blood pressure medication was the potential contributing factor. In addition, another study actually suggests the opposite — that blood pressure medications may reduce the risk of AMD (6). However, this was a retrospective (backward-looking) study, and it has yet to be published.

This is a controversial topic. If you are on blood pressure medications and are more than 65 years old, I would recommend that you get yearly eye exams by your ophthalmologist.

Fall risk

As we age, falling risk seems to increase. One study shows that blood pressure medications significantly increase fall risk in the elderly (7). Overall, 9 percent of these patients on blood pressure medications were seriously injured when they fell. Those who were considered moderate users of these medications had a 40 percent increased risk of fall. But, interestingly, those who were consider high-intensity users had a slightly less robust risk of fall (28 percent) than the moderate users. The researchers used the Medicare database with 5,000 participants as their data source. The average age of the participants in the study was 80.

Does this mean that we should discontinue blood pressure medications in this population? Not necessarily. This should be assessed at an individual level between the patient and the doctor. Also, one weakness of this study was that there was no dose-response curve. In other words, as the dosage increased with high blood pressure medications, one would expect a greater fall risk. However, the opposite was true.

In conclusion, we have some simple, easy-to-implement, takeaways. First, consider monitoring blood pressure in both arms, since a difference can mean an increased risk of cardiovascular events. Reduce your salt intake; it appears that many people may be sensitive to salt, as shown by the British study. If you do take blood pressure medications and are at least 65 years old, take steps to reduce your risk of falling and have annual ophthalmic exams to check for AMD.

References: (1) CDC.gov/blood pressure. (2) Am J Med. 2014 Mar;127(3):209-215. (3) J Am Soc Hypertens 2014;8:e59. (4) BMJ Open 2014;4:e004549. (5) Ophthalmology online April 30, 2014. (6) ARVO 2013 Annual Meeting: presentation. (7) JAMA Intern Med. 2014;174(4):588-595.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.