Hypertension in athletes

INTRODUCTION — Hypertension is among the most common conditions seen in primary care and the most common cardiovascular condition affecting athletes [1,2]. However, the management of hypertension in athletes can differ from standard approaches, primarily due to the potential side effects of some medications that may impair training and performance.

The evaluation and management of athletes with hypertension will be reviewed here. Standard management of hypertension is discussed separately. (See "Overview of hypertension in adults" and "Choice of drug therapy in primary (essential) hypertension".)

DEFINITIONS AND CONCEPTS — For the purposes of this discussion, we define athlete broadly and include participants at all levels of sport, including:

●Competitive athletes:

•Scholastic (eg, high school)

•Club

•Collegiate

•Professional

●Recreational athletes

●Persons who exercise for fitness and health

The fundamental parameters defining hypertension in both adults and children do not differ in athletes. In the adult, hypertension is defined as a systolic BP ≥130 mmHg and/or a diastolic BP ≥80 mmHg "based on the average of two or more properly measured, seated BP readings on each of two or more office visits" [3]. The definitions for Stage 1 and 2 hypertension and hypertension in pediatric populations are provided and discussed in detail separately. (See "Overview of hypertension in adults", section on 'Definitions' and "Definition and diagnosis of hypertension in children and adolescents".)

The static and dynamic components of cardiovascular stress vary depending upon the demands of a given sport or activity. As examples, a soccer midfielder making a run towards goal or an American football wide receiver running a pass route is engaged in dynamic exercise; a rugby hooker or prop in a scrum or an American football lineman pass-blocking is engaged in static exercise. Some sports, such as crew, involve substantial dynamic and static (or resistance) components. Systolic blood pressure rises during endurance and dynamic exercise; both systolic and diastolic blood pressures rise during resistance or static exercise. These increases in blood pressure reflect the body's efforts to increase cardiac output in order to meet the metabolic requirements of working muscles. The attached figure taken from the 36th Bethesda guidelines provides a classification of various sports based upon the relative static and dynamic cardiovascular loads entailed (figure 1).

EPIDEMIOLOGY — The main setting in which blood pressure (BP) is measured in athletes is during preparticipation physical evaluations (PPEs). PPEs are focused medical assessments for individuals engaged in competitive sports. When an elevated blood pressure (EBP) is noted during a PPE, the athlete should have their BP rechecked at the initial visit (ensuring proper cuff size and technique for the repeat measurement) or a subsequent visit. If a properly measured BP remains elevated at two separate visits, the diagnosis of hypertension is established. According to well-established PPE guidelines, EBP is the most common cardiovascular abnormality identified during the PPE [1,4]. Important definitions related to hypertension in the general adult population are reviewed separately. (See "Overview of hypertension in adults", section on 'Definitions' and "Evaluation of hypertension in children and adolescents", section on 'Definition' and "Sports participation in children and adolescents: The preparticipation physical evaluation".)

Although EBP is the most common cardiovascular abnormality identified during the PPE according to several observational studies, hypertension in athletes is not well-studied [4]. Based on the authors' unpublished data, including a study of 560 (318 men and 242 women) Division I American collegiate athletes across more than 20 sports, the prevalence of hypertension is approximately 3 percent.

In an observational study of 3697 athletes (men and women, ages 19 to 49) the authors noted that BP values were lower in athletes engaged in "dynamic type" sports (speed, endurance, ball games) than in "static type" sports [5]. Water sport athletes were noted to have higher BPs than their dry land counterparts. Of note, this study compared BP values but did not look at rates of hypertension.

According to a retrospective cohort study of 636 Division I male collegiate athletes in the United States, the prevalence of hypertension among American football players is higher than among non-football athletes [6]. Otherwise, there did not appear to be an increased risk for hypertension among participants in any particular sport, although data overall are limited. The study results also suggest that male athletes may be at increased risk compared with their female counterparts and support the common belief that the incidence of hypertension is greater among athletes with a higher body mass index (BMI) (eg, American football linemen, heavyweight wrestlers). A prospective study of 113 collegiate American football players noted significant increases in systolic and diastolic blood pressure when comparing pre- and post-season measurements, and found that 53 (47 percent) met criteria for prehypertension and 16 (14 percent) met criteria for stage 1 hypertension at season's end [7]. Intra-season weight gain and a family history of hypertension were among the strongest predictors of hypertension.

The association between EBP and increased BMI in athletes is supported further by several observational studies [8,9]. As an example, a study comparing a single blood pressure measurement taken from a convenience sample of 504 National Football League (NFL) players to men of the same age in the general United States population noted an increased risk of EBP among the NFL players (13.4 versus 5.5 percent), including an increased rate of BPs in the prehypertension range (64.5 to 24.2 percent) [8].

Other factors related to EBP in athletes, such as exercise type (eg, resistance training) and illicit drug use, are not well-studied. There is no known increased risk for hypertension in weightlifters or other strength athletes (eg, throwers – discus, shot put), although blood pressures measured in strength athletes during static resistance movements such as weightlifting can be dramatically elevated (isolated blood pressures of up to 480/350 mmHg have been described) [10-12]. One retrospective review reported episodes of acute aortic dissection among 31 strength athletes, primarily weightlifters [13]. The authors hypothesized that an anatomic predisposition was present among this small subset of athletes, including aortic enlargement.

PRE-PARTICIPATION EXAMINATION AND BLOOD PRESSURE SCREENING — Current screening recommendations for athletes specify that a blood pressure (BP) measurement be performed during the pre-participation examination (PPE) [1]. Sports medicine organizations recommend that PPEs be performed regularly at the discretion of the performing clinician. In most jurisdictions, it is appropriate to perform a PPE on an annual basis; however, the clinician should be aware of state and local laws regarding appropriate preparticipation evaluation. For child and adolescent athletes, an annual PPE is recommended. (See "Sports participation in children and adolescents: The preparticipation physical evaluation".)

The definitions for elevated blood pressure, Stage 1 and 2 hypertension, and hypertension in pediatric populations are provided and discussed in detail separately. (See "Overview of hypertension in adults", section on 'Definitions' and "Definition and diagnosis of hypertension in children and adolescents".)

In brief, hypertension in adults is defined as follows:

●Stage 1 – Systolic 130 to 139 mmHg or diastolic 80 to 89 mmHg

●Stage 2 – Systolic at least 140 mmHg or diastolic at least 90 mmHg

During a PPE, an appropriately trained clinician should obtain two measurements – at least several minutes apart – of a resting BP. Measurements should be performed while the athlete is seated and relaxed, with the back supported and both feet on the floor, ideally for a period of five minutes prior to the measurement [2]. The patient should not have ingested caffeine for 60 minutes and should not have smoked for 30 minutes prior to the measurement. Some athletes have large, muscular arms and clinicians must make certain to use an appropriately sized BP cuff to ensure accurate readings. A proper environment (eg, quiet, warm room) is important for obtaining an accurate reading. In the pediatric population, appropriate percentiles for sex, age, and height should be used to assess measurements, and anthropomorphic data should be obtained as needed. The proper tools and techniques for measuring blood pressure are described in detail separately (table 1). Of note, particularly in younger patients, if the BP in the arm is elevated, obtain a measurement in a leg to assess for aortic coarctation. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Office-based blood pressure measurement' and "Definition and diagnosis of hypertension in children and adolescents", section on 'Measurement of blood pressure' and "Clinical manifestations and diagnosis of coarctation of the aorta", section on 'Blood pressure and pulses'.)

When obtaining blood pressure measurements, the clinician should obtain an appropriate history including questions about possible causes of an elevated blood pressure (EBP) on the day of the examination that may be transient and not representative of the patient's true baseline [1,2]. These include tobacco use, ingestion of caffeinated beverages (including energy drinks), stimulant use (both licit and illicit), and any supplements or herbal medications. In addition, particularly with athletes, it is important to avoid BP checks within an hour following exercise or training activity.

If a properly measured blood pressure is elevated at the first examination, a second visit should be scheduled within a few weeks [2]. On the day of the PPE, the BP can be rechecked after the initial measurement (often 5 to 10 minutes later) by a clinician as indicated to confirm an elevated measurement. At each visit an EBP measurement should be confirmed with a second measurement. If the BP remains consistently elevated, a diagnosis of hypertension is made and an age-appropriate workup should follow.

If an athlete is found to have an elevated BP during the PPE they are allowed to participate in sport until their follow-up BP evaluation. The diagnosis of hypertension is not established until a second elevated measurement is obtained at a subsequent visit. No workup is required following the initial elevated measurement. Guidelines for establishing the diagnosis of hypertension and for sports participation once hypertension is diagnosed are discussed separately. (See 'Definitions and concepts' above and 'Guidelines for sports participation' below.)

For adult athletes whose initial BP measurement falls within the normal range but who remain a cause for concern, a shorter interval for additional blood pressure screening than the standard PPE is reasonable. As an example, an American football lineman with a high BMI whose blood pressure is at the high end of the normal range may warrant more frequent BP checks (eg, semi-annual).

In athletes undergoing stress testing, a "hypertensive response to exercise" (currently defined as systolic BP ≥210 in men or ≥190 in women; or diastolic BP ≥110 in men or women) may be an indication of underlying hypertension, even in those with normal resting BP levels. These numbers are difficult to apply broadly and more research is needed to determine the threshold for submaximal exercise hypertension [14]. We do not recommend that stress testing be performed in athletes to detect hypertension. For athletes who manifest an extremely high blood pressure (eg, exceeds threshold for Stage 2 hypertension per the major society guidelines) during a randomly obtained measurement, as might occur during a sideline evaluation, we suggest a follow-up visit within two to four weeks to remeasure the BP.

EVALUATION AND CLEARANCE FOR SPORTS PARTICIPATION

Guidelines for sports participation — We concur with the general management principles for hypertension in athletes as discussed in the guidelines published jointly by the American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and the American Academy of Pediatrics [1]. Recommendations for management are as follows:

●Athletes diagnosed with Stage 1 or Stage 2 hypertension without signs of end organ damage have no restrictions on their participation in sport. Athletes with elevated blood pressure should have their blood pressure (BP) rechecked annually. Athletes diagnosed with hypertension should be treated for hypertension and have their BP monitored according to standard guidelines. (See "Overview of hypertension in adults" and "Initial evaluation of adults with hypertension".)

●Athletes diagnosed with Stage 1 or Stage 2 hypertension accompanied by signs of end organ damage may not participate in sport until their BP is well-controlled. Important features to keep in mind when evaluating the patient newly diagnosed with hypertension are summarized in the following tables (table 2 and table 3 and table 4).

Controlled blood pressure is defined as two successive measurements below 130/80 obtained at least two weeks apart, and resolution of any transient signs of end organ damage that may have been present (eg, headache, chest pain). Ultimately, the goal of treatment is to achieve and maintain a blood pressure below 120/80 regardless of age or sport. These goals are consistent with the standards of treatment for hypertension. (See "Goal blood pressure in adults with hypertension".)

We suggest regular follow-up visits and a BP check every two to three weeks while initiating treatment until the BP is well-controlled; for reliable patients, the BP can be measured at home. For athletes with hypertension who are prohibited from participating in full sport, light aerobic exercise is permitted, but resistance training particularly with higher weights (eg, >50 percent of one-repetition maximum [ie, heaviest weight that can be lifted for given exercise]) should be avoided.

Although no widely established protocol exists describing how athletes being treated for hypertension should return to sport, once BP is well-controlled for a minimum of two weeks, a return to full sport is permitted. A graduated resumption of athletics should begin with basic conditioning exercises and then progress to more vigorous and sport-specific drills and activities. This is generally accomplished over a two to four week period but will vary according to the individual patient and the activity involved.

After return to sport, BP should be remeasured at regular intervals per the treating physician to ensure adequate BP control. Once the athlete's blood pressure appears to be well-controlled on a stable treatment regimen, one reasonable approach to monitoring is to reassess the patient and measure their BP after a few months, and then annually, assuming the BP remains well-controlled.

Workup of athlete diagnosed with hypertension — All athletes with a new diagnosis of hypertension should receive an appropriate workup as would be performed for any patient. The standard workup for hypertension is reviewed in detail separately. Issues of particular import in the assessment of the athlete with hypertension are described below, including the effects of supplements [2,4,15,16]. Of note, there is no evidence to suggest that particular training regimens, including weightlifting, contribute to hypertension. (See "Initial evaluation of adults with hypertension" and "Choice of drug therapy in primary (essential) hypertension" and "Evaluation of hypertension in children and adolescents" and "Nonemergent treatment of hypertension in children and adolescents" and 'Medications and supplements that can exacerbate hypertension or its complications' below.)

Evaluation of the athlete with hypertension includes a family history and a careful review of systems looking for symptoms associated with end organ damage or secondary causes of hypertension (table 2 and table 3 and table 4). Symptoms associated with end organ damage include headache, visual changes, chest pain, and shortness of breath. In athletes younger than 25 years diagnosed with hypertension, the examination should include a lower-extremity BP to assess for coarctation of the aorta [1]. Specifically, diminished or delayed femoral pulses (brachial femoral delay) and low or unobtainable blood pressure in a lower extremity raise concern and indicate the need for further investigation of possible coarctation. (See "Clinical manifestations and diagnosis of coarctation of the aorta".)

The workup of athletes with newly diagnosed hypertension often entails blood laboratory studies (hemoglobin, glucose, BUN and creatinine, basic electrolytes, lipid profile, thyroid function studies), urinalysis, and an electrocardiogram (ECG), depending upon what is uncovered by the history and review of symptoms. A thorough review of the athlete's diet and use of supplements, including ergogenics, medications, recreational drugs, and alcohol are in order. Athletes may have restrictive diets (eg, wrestler making weight) or increased dietary intake based upon their sport. Particularly given that some athletes are risk-takers, it is important to inquire about recreational drugs and alcohol, as well as performance-enhancing substances, which may be related to hypertension (eg, stimulants, testosterone and testosterone analogs).

Of note, it is important for any ECG to be interpreted by a clinician familiar with changes in the ECG commonly associated with athlete's heart. Athletes often manifest findings on the ECG that might suggest pathology in non-athletes but are normal variants in this population. These findings may include sinus bradycardia, sinus arrhythmia, and early repolarization. LVH criteria can also differ in athletes. (See "Hypertrophic cardiomyopathy: Clinical manifestations, diagnosis, and evaluation", section on 'Athlete's heart'.)

For athletes with hypertension possibly due to anxiety about blood pressure testing or a resulting diagnosis (so-called “white coat” hypertension) or highly variable BP measurements, 24 hour ambulatory monitoring may be necessary using a standard approach. (See "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring".)

Special considerations for child athletes — A renal ultrasound is recommended for child athletes with established hypertension [1]. In addition, an echocardiogram is recommended for child athletes with diabetes or renal disease associated with a BP between the 90^th and 94^th percentiles (table 5 and table 6 and table 7 and table 8). An echocardiogram is part of the initial evaluation of all children with a BP in the 95^th percentile or higher. When indicated, these imaging studies are performed in addition to the thorough history and physical examination, including a retinal examination, performed in any child with unexplained hypertension. The evaluation of such children is reviewed in detail separately. (See "Evaluation of hypertension in children and adolescents".)

TREATMENT STRATEGIES

Nonpharmacologic interventions — A number of lifestyle modifications can be used effectively to lower blood pressure (BP), including the measures listed below [15]. These nonpharmacologic interventions are discussed in greater detail separately. (See "Overview of hypertension in adults", section on 'Nonpharmacologic therapy'.)

●Weight loss

•10 lb (4.5 kg) weight loss can reduce systolic blood pressure (SBP) 5 to 20 mmHg

●Sodium restriction (limit salt added to food; avoid processed foods with high sodium content)

•2 to 4 g/day can reduce SBP 2 to 8 mmHg

●DASH diet (diet high in vegetables, fruits, low-fat dairy products, whole grains, poultry, fish, and nuts; low in sweets, sugar-sweetened beverages, and red meats)

•SBP reduction 8 to 14 mmHg

●Alcohol restriction (no more than two drinks per day for men or one per day for women)

•SBP reduction 2 to 4 mmHg

●Aerobic exercise activity (three to four sessions per week of at least moderate intensity, each session lasting at least 40 minutes)

•SBP reduction 4 to 9 mmHg

•For those in whom exercise is not a significant part of their life, guidelines are provided separately (see "Exercise in the treatment and prevention of hypertension")

●Stress management

The results of a number of studies suggest that a combination of aerobic activity and resistance training (eg, weightlifting) is the best approach to exercise for the purpose of lowering BP [17,18]. For athletes engaged in only one of these activities, adding the other type of exercise may aid in lowering their BP.

Medical therapy — If nonpharmacologic modifications fail to reduce BP adequately in an athlete with persistent hypertension, medical therapy is required. The ideal medication controls BP without compromising exercise capacity. In addition, the medication selected should be permissible under the rules of the governing body for their sport (ie, not a banned substance). Information regarding banned substances can be obtained at the following websites:

●World Anti-Doping Agency

●National Collegiate Athletic Association (USA)

There is no fundamental difference in the approach to the medical therapy of hypertension in athletes compared with the general population. However, some second-line therapies are best avoided. In athletes, diuretics are relatively contraindicated, as they can impair athletic performance due to volume depletion, and they are prohibited by many of the governing bodies in sport because they may be used to prevent detection of performance enhancing drugs. In addition, beta blockers decrease heart rate and thus can reduce exercise tolerance; they too are prohibited in some sports. Therefore, particularly for athletes involved in endurance sports or other sports requiring a high level of aerobic fitness (figure 1), we suggest avoiding both diuretics and beta blockers if possible.

Angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and long-acting dihydropyridine calcium channel blockers are better choices for athletes as they do not impede athletic performance and are permissible under the rules of most governing bodies in sport. Starting doses for athletes are the same as for members of the general population, as is the approach to increasing the dose as needed based upon patient response. As treatment is initiated and modified based on response, follow-up on a biweekly basis is performed to monitor BP, treatment compliance, general adverse effects, and effects on sport performance. There is no clear basis for selecting among these three medication classes based upon the nature of the sport the patient pursues (eg, endurance event, field sport, or power sport); any class is suitable. (See "Choice of drug therapy in primary (essential) hypertension" and "Renin-angiotensin system inhibition in the treatment of hypertension".)

Persistent hypertension — Athletes with hypertension that has persisted for a longer period (6 to 12 months) or that has not responded to lifestyle modifications and pharmacotherapy should be assessed with an echocardiogram [2,19]. The echocardiogram is aimed primarily at assessing the left ventricle (LV) for findings of concentric hypertrophy associated with diminished LV volume. Concentric LV hypertrophy with diminished LV volume is a form of end-organ damage and requires modification of activity (strenuous athletic activity is restricted) and implementation of appropriate medical therapy. In contrast, the concentric LV hypertrophy that may be seen in athletes who participate in sports that place a high static load on the heart (eg, weightlifting), does not result in diminished LV volume or function and is not pathologic. Eccentric hypertrophy involving the LV is generally an adaptation to the high stroke volume demands of dynamic exercise (eg, distance runners), and in these cases LV dimension is increased and function is preserved (in fact, enhanced).

Although hypertension must still be treated appropriately, patients with nonpathologic concentric LV hypertrophy (ie, normal LV volume and function) or eccentric hypertrophy consistent with athlete's heart do not require long-term activity modification once their hypertension is adequately controlled. (See "Overview of hypertension in adults" and "Hypertrophic cardiomyopathy: Clinical manifestations, diagnosis, and evaluation", section on 'Athlete's heart'.)

MEDICATIONS AND SUPPLEMENTS THAT CAN EXACERBATE HYPERTENSION OR ITS COMPLICATIONS — Medications and supplements that may contribute to elevated blood pressure include the following: human growth hormone, androgen hormones, nonsteroidal antiinflammatory drugs (NSAIDs), and a range of stimulants both licit and illicit (eg, caffeine, nicotine, ephedra-containing medications and supplements, amphetamines, cocaine). Other medications and supplements may increase the risk of complications associated with hypertension. (See "Prohibited non-hormonal performance-enhancing drugs in sport" and "Use of androgens and other hormones by athletes" and "Prescription and non-prescription medications permitted for performance enhancement".)

Creatine is the most notable and widely used supplement that theoretically may exacerbate the harmful effects of hypertension, specifically renal function, although evidence for this is scant and weak. In patients with compromised baseline renal function, some observational studies report that creatine supplementation worsens kidney dysfunction [20-23]. Given that kidney disease is a major potential complication of hypertension, we suggest that athletes with hypertension abstain from using creatine supplements. If hypertension resolves with treatment in such athletes, any decision about whether to use creatine and should be made after an informed discussion between the clinician and the patient, including the benefits and risks of creatine and the values and preferences of the patient.

Other performance-enhancing drugs that can produce elevations in blood pressure (BP) include human growth hormone, androgens (anabolic steroids), and erythropoietin. Animal studies have reported that supplemental testosterone reduces body fat and improves insulin sensitivity but also causes increased BP [24]. The proposed mechanism involves increased levels of vasoconstrictors, such as endothelin and angiotensin II, and the counterregulation of estrogen, a vasodilator. Further studies in humans are needed to clarify these effects. Although banned by the World Anti-Doping Agency, exogenous erythropoietin and related substances are used by some endurance athletes to improve performance. Hypertension is a well-described adverse effect of erythropoietin in patients with chronic kidney disease, and observational data and animal studies suggest that such use can cause elevations in BP [25-27]. (See "Use of androgens and other hormones by athletes" and "Hypertension associated with erythropoiesis-stimulating agents (ESAs) in patients with chronic kidney disease".)

NSAIDs are metabolized in the kidneys and can both independently increase BP and interact with other medications used to treat BP. Therefore, we suggest that athletes with hypertension abstain from NSAIDs. In the uncommon circumstance of an athlete with well-controlled hypertension and pain that responds only to NSAIDs, it may be acceptable to use an NSAID after the clinician and athlete have carefully considered the risks and benefits of such treatment. (See "NSAIDs and acetaminophen: Effects on blood pressure and hypertension", section on 'Effect of NSAIDs on blood pressure'.)

Stimulants can increase BP and clinicians should ask athletes about their use of both licit and illicit substances. Common stimulants include caffeine, nicotine, ephedra-containing over-the-counter decongestants, ephedra (ma huang)-containing herbal remedies, and amphetamines. Several prescription medications commonly used to treat attention deficit hyperactivity disorder (ADHD) are stimulants that can cause a similar physiologic response. Other illicit sympathomimetic drugs, such as cocaine and phencyclidine (PCP), can increase BP. Screening for drugs that may contribute to hypertension also provides an opportunity for the clinician to inquire about the use of alcohol and recreational drugs. (See "Cardiovascular effects of caffeine and caffeinated beverages" and "Cardiovascular effects of nicotine" and "Overview of herbal medicine and dietary supplements", section on 'Adverse effects' and "Acute amphetamine and synthetic cathinone ("bath salt") intoxication".)

COMPETITION — Generally, antihypertensive medications should be continued during competition. If an appropriate medication is chosen (eg, angiotensin-converting enzyme [ACE] inhibitors, angiotensin II receptor blockers [ARBs], or long-acting dihydropyridine calcium channel blockers), there is no need to withhold it from the athlete during periods of training or competitive events, or to reduce or in any way modify the dose.

Diuretics and beta blockers are not ideal antihypertensives for athletes whose sports have high aerobic demands. Nevertheless, if these agents are found to be the optimal therapy, and are not banned by the sport's governing body, clinicians must consider carefully how to time doses so the medication interferes with performance as little as possible. Diuretic doses should be timed to avoid maximal diuresis during competition. As an example, hydrochlorothiazides achieve maximal diuresis at two hours with peak effects on blood pressure at four to six hours. Thus, to avoid interfering with competition, it is best to take diuretics at least seven to eight hours prior (eg, for a night game, take diuretic early in the morning). In addition, as diuretics can have adverse effects on electrolytes, athletes and clinicians alike should be aware of the risks of hypokalemia and hyponatremia. Oral beta blockers in standard formulations reach peak effect approximately one to two hours later and thus it is best to take them at least three to four hours prior to competition.

It is unknown what if any medication adjustments are needed for extreme endurance events (eg, marathon, ironman). Given that these events place high demands on athletes, we suggest that a knowledgeable clinician review each case individually. As a general rule, we suggest taking any new medication for at least one week prior to any competitive event to help avoid any unanticipated problems.

PROGNOSIS — The potential long-term complications from hypertension in athletes are thought to be similar to those in the general population, and include myocardial infarction, stroke, renal failure, and death [28]. Hypertension is not recognized as a cause of exertional sudden cardiac arrest. (See "Athletes: Overview of sudden cardiac death risk and sport participation".)

Left ventricular hypertrophy deserves close attention in athletes, as the degree of hypertrophy can affect exercise capacity. It is important for an experienced clinician to review any echocardiographic studies obtained to distinguish between athletic heart (eccentric or concentric hypertrophy with an increase in left ventricular volume) and left ventricular hypertrophy of hypertension (concentric hypertrophy with a diminished left ventricular volume). (See 'Evaluation and clearance for sports participation' above and "Hypertrophic cardiomyopathy: Clinical manifestations, diagnosis, and evaluation", section on 'Athlete's heart' and "Left ventricular hypertrophy and arrhythmia".)

SUMMARY AND RECOMMENDATIONS

●Definitions and concepts – Hypertension is the most common cardiovascular condition affecting athletes. The fundamental parameters defining hypertension in both adults and children do not differ in athletes. In the adult, hypertension is defined as a systolic blood pressure (SBP) ≥130 mmHg and/or a diastolic blood pressure (DBP) ≥80 mmHg on each of two or more office visits. There is no evidence to suggest that particular training regimens, including weightlifting, contribute to hypertension. (See 'Definitions and concepts' above and 'Epidemiology' above.)

●Pre-participation examination – During a pre-participation examination, a trained clinician should measure a resting blood pressure (BP) while the athlete is seated and relaxed, ideally for a period of five minutes prior to the measurement. Some athletes have large, muscular arms and an appropriately sized BP cuff should be used. If a properly measured BP is elevated at the first examination, sports participation is permitted but a second visit should be scheduled within a few weeks. (See 'Pre-participation examination and blood pressure screening' above.)

●Indications for restrictions on sports participation – Once hypertension is diagnosed, restrictions on sports participation are as follows:

•No signs of end organ damage – Athletes diagnosed with Stage 1 or Stage 2 hypertension without signs of end organ damage have no restrictions on their participation in sport. Athletes should have their BP rechecked annually. Athletes diagnosed with Stage 1 or Stage 2 hypertension should be treated for hypertension and have their BP monitored according to standard guidelines. (See "Overview of hypertension in adults" and "Initial evaluation of adults with hypertension".)

•Evidence of end organ damage – Athletes diagnosed with Stage 1 or Stage 2 hypertension accompanied by signs of end organ damage may not participate in sport until their BP is well-controlled. Important features to consider when evaluating the patient newly diagnosed with hypertension are summarized in the following tables (table 2 and table 3 and table 4).

●Evaluation of newly diagnosed hypertension – All athletes with a new diagnosis of hypertension should receive a workup as would be performed for any patient, including an assessment of possible end organ damage and appropriate laboratory studies (table 2 and table 3 and table 4). Symptoms associated with end organ damage include headache, visual changes, chest pain, and shortness of breath. In athletes younger than 25 years, the examination should include an assessment for coarctation of the aorta. Any electrocardiogram (ECG) should be interpreted by a clinician familiar with changes in the ECG commonly associated with athlete's heart. The standard workup for hypertension is reviewed in detail separately. (See "Initial evaluation of adults with hypertension" and "Evaluation of hypertension in children and adolescents" and "Hypertrophic cardiomyopathy: Clinical manifestations, diagnosis, and evaluation", section on 'Athlete's heart'.)

●Lifestyle modification – Several lifestyle modifications can be used to lower blood pressure, including weight loss, sodium restriction, DASH diet, and alcohol restriction. These nonpharmacologic interventions are discussed in greater detail separately. (See "Overview of hypertension in adults", section on 'Nonpharmacologic therapy'.)

●Pharmacologic therapy – If nonpharmacologic modifications fail to reduce BP adequately, medical therapy is required. The ideal medication controls BP without compromising exercise capacity, and its use is permissible under the rules of the governing body for the patient's sport (ie, not a banned substance). Information regarding banned substances can be obtained at the following websites:

•World Anti-Doping Agency

•National Collegiate Athletic Association (USA)

Preferred medical therapies for athletes include angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and long-acting dihydropyridine calcium channel blockers; second-line therapies best avoided in athletes include diuretics and beta blockers. Generally, there is no need to withhold preferred therapies from the athlete during periods of training or competitive events, or to reduce or in any way modify the dose for sport. (See 'Medical therapy' above and "Choice of drug therapy in primary (essential) hypertension" and "Nonemergent treatment of hypertension in children and adolescents".)

●Echocardiogram for refractory hypertension – Athletes with hypertension that has persisted for a longer period (6 to 12 months) or that has not responded to lifestyle modifications and pharmacotherapy should be assessed with an echocardiogram. The echocardiogram distinguishes between pathologic changes associated with chronic hypertension and normal adaptations in athletes. (See 'Persistent hypertension' above.)

●Supplements and medications associated with hypertension – Medications and supplements that may contribute to elevated blood pressure include the following: human growth hormone, androgen hormones (anabolic steroids), nonsteroidal antiinflammatory drugs (NSAIDs), erythropoietin ("epo"), and a range of stimulants both licit and illicit (eg, caffeine, nicotine, ephedra-containing medications and supplements, amphetamines, cocaine). Other medications and supplements (eg, creatine) may increase the risk of complications associated with hypertension. (See 'Medications and supplements that can exacerbate hypertension or its complications' above.)

●Prognosis – The potential long-term complications from hypertension in athletes are similar to those in the general population, and include myocardial infarction, stroke, renal failure, and death. Hypertension is not recognized as a cause of exertional sudden cardiac arrest. (See 'Prognosis' above and "Athletes: Overview of sudden cardiac death risk and sport participation".)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges John P DiFiori, MD, who contributed to an earlier version of this topic review.