Transcription:

Scott Webb: Almost half of American adults have some degree of high blood pressure, also known as hypertension. That's more than 100 million men and women. And joining me today to help us understand hypertension and how he can help us is Dr. Atul Chugh. He's a cardiologist and clinical hypertension specialist at Franciscan Health. this is the Franciscan Health Doc Pod. I'm Scott Webb.

Doctor, thanks so much for your time and your expertise. Today. We're gonna talk about high blood pressure, hypertension, and I think a lot of us, when we think of hypertension, we think of it sort of as an old person's problem per se, but it's not really the case anymore. So what's the age of some of the younger patients that you're seeing that have high blood pressure?

Dr. ATUL CHUGH: You're correct. In the past we would normally think of folks over the age of 65 as being the target audience or the target patient population. However, we're now seeing hypertension or high blood pressure in a much younger population. US statistics show that the patient population between the ages of 12 and 19, actually 10% of those folks will be hypertensive. We're seeing this a lot and a lot more, and we think that the major driver of this is going to be the obesity epidemic, as one can imagine that a higher body mass index is directly correlated with a higher blood pressure. And we think that is going to be on the rise for quite some time, unfortunately.

Scott Webb: Yeah, I think you're right. And that is pretty alarming. Ages 12 to 19. You know, in my mind, I'm thinking 65 and older, but 12 to 19. And it would be maybe a separate podcast to talk about, preventing hypertension and high blood pressure. But for today, we'll focus on treating it. And I know there's dozens of medications out there for hypertension. So how do you approach finding the right ones? Is it trial and error? What sort of factors go into those choices?

Dr. ATUL CHUGH: What we realized over time with years and years of clinical trial, Data that not every anti-hypertensive agent is going to be created equal. There's some that are going to have greater benefit for stroke and myocardial infarction or heart attack reduction than others. going through the a hundred and 60 plus drugs that are available now in the market A few factors govern that. Number one is for that individual patient, what comorbidities is the patient coming with?

In other words, has the patient had a heart attack in the past? Are the patient have heart failure? Does the patient have kidney disease? And we know that each one of those agents that we talk about, has a secondary effects. So in other words, every blood medication has a secondary effect that would be more guided towards reduction in events like stroke or heart failure or recurrent mycardial heart infarction.

And if these patients' comorbidities match up with the agent, then of course that's the agent that we're gonna use to try and curtail any further events in those patients. And it really is an individualized effect. For instance there are gonna be patient. There who have naturally low potassiums those patients may actually benefit from those anti-hypertensives that actually raise the potassium level. Because we know that an increase in the potassium levels in patients can actually have an effect on the blood pressure and a good one. In other words, it would decrease the blood pressure. So those are the sort of things that we are factoring in as we're going through.

Scott Webb: Yeah, it Sticking with meds. I know that there's so many different classes of medications, alpha blockers, beta blockers, ace inhibitors, and so on. Maybe you can just sort of describe the purposes of some of those different classes of meds.

Dr. ATUL CHUGH: Are workhorse in the anti-hypertensive world tend to affect a system called the renin angiotensin aldosterone axis, which is the sort of the hormone. Balance that occurs from the kidney that helps us regulate our salt and also in turn helps us dilate or get our blood vessels to plump up. Those medications are ACE inhibitors angiotensin or receptor blockers or ARBs, we call them. And mineral corticoid receptor antagonists which we normally think of as espinolactone and aplaranone. And each one of these agents we like to use those in patients more who have either myocardial infarction in the past or heart failure because we feel that those medications also have a beneficial effect directly on the heart.

Part of the mechanism, how that works is actually decreases through a secondary mechanism, some of the inflammation and the stress hormone effect on the heart muscle. That's one of the reasons why we would use it. We have to be careful in those patients who do have high potassiums to begin with because those agents tend to increase the potassium. Beta blockers are interesting in that they have an effect on the heart. In addition to blood pressure lowering. What I mean by that is patients who have had a recent heart attack tend to have Events or decrease recurrent events with the addition of a beta blocker.

And we try to use them up to three years after the event of the heart attack. One of the effects of the beta blockers is that they do decrease the heart rate. So patients who have associated conditions like atrial fibrillation, which is one of the most common arrhythmias that we see, which speeds up the heart. The beta blockers tend to decrease the heart rate so that it helps not only with blood pressure control, but also helps with heart rate control as well. In addition, we have the agents called the diuretics, which are what we call water pills. There's multiple classes of those, but those patients who have heart failure tend to build up fluid in parts of their bodies that tends to be quite noticeable.

And frankly can be quite debilitating for patients. For instance, if they have Water around the lungs. That's a condition known as pulmonary edema. It makes breathing quite difficult. It's one of the major causes of hospitalization in the United States. So we like to have patients with heart failure to be on diuretics. Not to mention we also find another interesting facet of this is the issue of race. We find that African Americans Better with diuretics and another class of agent called the calcium channel blockers. We've seen in clinical trials a much greater reduction in blood pressure with these agents in our African American patients than we do with our non-African American patients. Each one of these agents, as you can imagine has its own specific idiosyncrasy when it comes to its its mechanism of action.

Scott Webb: Sure. It does seem like there's some real benefits to combining medications. I don't know that anyone loves to take pills, so it'd be great if there's just one magic pill, that we could all just take and make us better. But sounds like you do work with patients to figure out the right combinations based on age, race, family history and so on. So maybe you could talk a little bit about that, just the benefits of combining meds.

Dr. ATUL CHUGH: There's a couple of things that we think about in combination medications. First of all, it's just general convenience, right? What's been interesting in observational studies is that patients tend to do better and are more likely to stick to a drug regimen when their pill counts are lower. So the idea that we're gonna have one pill that combines two agents tends to increase our ability to keep a patient on a medication. Now, this has been a major concern for us as physicians. About 50% of our patients who do have hypertension tend to come off the medication. In two years time at And that is a concern because of course now you're leaving that patient hypertensive. After that two year time, about 50% of my patients are not going to be a goal because they just couldn't continue the medication dosage.

There's also Aside from the convenience of having just one pill, there's also some interesting side effect considerations that we probably should talk about here. The issue is that when you take two agents and you use lower doses of two agents rather than trying to ramp up one agent at higher doses. Theoretically, what we're trying to do is avoid the side effects that we see at high doses of one agent. The higher the dose of one agent, the more likely that patient is to have those side effects. So the thought process here is if we go ahead and use two agents at lower doses, perhaps what we will do is mitigate some of the side effects that we'd see if we'd used A one agent strategy.

So those are some of the issues that we have. Unfortunately, in the United States, we tend to have a pretty limited amount of a combination pills. Most of them are tagged with a diuretic called Hydrochlorothiazide which is a fine anti-hypertensive agent. But frankly, many of us have agents that go far beyond that. Having multiple combinations would be of greater benefit. But of course that adds cost to a patient for sure. And that's, I think one thing that I wanted to touch on here is that while there are many combinations out there that are outstanding, however, Cost is a major determinant factor in a patient's ability to take an agent.

And so as we are going back to that old question of how do we choose medications? Unfortunately, many times it's based upon what the patient's insurance is. And we do know that they're gonna be non generic agents out there that are going to be a lot more efficacious, but unfortunately we don't always have the luxury of being able to use them. So we unfortunately are probably causing ourselves to have a greater pill burden on our patients, simply because financially we don't always have the ability to get them on the best regimen possible because it's just financially prohibitive.

Scott Webb: Yeah. Having hosted maybe a thousand of these in my years doing this it does often seem to come back to insurance. You touched on there a little bit about side effects and I'm somebody who doesn't love doctor to start new medications. I always just feel I don't know, weird about it. What do you, yeah, what do you tell patients when they're starting new meds? How do you address that with them?

Dr. ATUL CHUGH: The one issue that I think that we see time and time again that we probably should talk more about with our patients is the simple idea of blood pressure reduction in general. Especially in the earlier phases does cause fatigue and perhaps a little bit of brain fog. And that's something that we've seen time and time again, is that the way that I talk about this with our patients is that, it's a bit like calibrating or turning down the thermostat in your house. It effects don't occur immediately. And in addition that drop in the blood pressure does take the body some time to acclimate. Imagine if you will, your brain and other vital organs of your body are used to seeing blood pressures in the 150 s and 160 s, and now we're dropping it down even by 10 points.

That can certainly take the body some time to really acclimate to that so it Does preserve that blood flow to those vital organs. And so the in that early effect particularly when we try to see someone who's very high, it's not uncommon to have a patient with a cysto blood pressure of 200 in my clinic. And so as we're trying to get their blood pressures down, especially if we're trying to drop at 30, 40 points we find that patients tend not to do very well with that and are gonna be more inclined to stop the agent right there and there. One of the ways we're, the strategies that we've used, particularly those patients are very sensitive to those changes, is to really go very slow with the up titration, slow and steady.

Oftentimes it takes us two months for the patient to get to goal, if even with changes that are made weekly by. So long story short there, that's one of the effects that we see, other effects that we see is a condition known as orthostatic hypotension, which is the idea that when a patient goes from a lying physician to a standing physician they find that they get a little lightheaded, dizzy, and in extreme cases can even pass out. And this is because the blood pressure when we go from a lying down to standing position, blood pools in the legs as a result of the gravity effect. And there's decreased amounts of blood flow to the brain especially in those patients whose blood vessels in the brain have been very used to those higher pressures.

So that's one of the major effects. We talked about those ace inhibitors and angiotensin receptor blockers and inspirolactone, one of the effects that we see is a rise in a number in their laboratory work called the creatinine, which means that you do have a buildup or a higher buildup of waste products in the body. And sometimes what we have to do, unfortunately, is to decrease the dose there so that we don't see that number go too high. When that person has a very rapid change in that creatinine. Say for instance, a patient who had a baseline creatinine of 1.3 then goes up to three.

Just after adding one of those, the condition that we're really thinking about is a condition known as renal artery stenosis, which is basically blockage of the blood vessel that supplies the the blood supply to the kidneys. So we then have to do a investigation of that with imaging and or invasive studies. Going back to lab work electrolytes can be somewhat changed as a result of anti-hypertensives. Again, going back to those same agents that we talked about the potassium can be raised to a point that can be quite concerning in those patients particularly if they're starting out with a higher potassium to begin with.

So it's important that we monitor the potassium in those patients. On those patients with beta blockers that we talked about that and some of the calcium channel blockers that slow down the heart rate. Sometimes if you have a patient who, who's starting off with a heart rate of 50 and we add a beta locker for the addition of blood pressure control. We find that the heart rate goes lower than that and then again leads to fatigue and just general Malays in patients. These are unfortunately the offshoots Of anti-hypertensive agents, which is why lifestyle changes sometimes are really important to start with because we can avoid some of these, if we can just use our bodies to really calibrate ourselves back to normal pressures.

Scott Webb: Yeah, I was gonna get to that here as we were getting close to wrapping up, weight loss, diet, behavior, lifestyle, like there are things that we can do right, doctors to not only perhaps prevent or slow the onset of hypertension, but also manage it along the way. Right?

Dr. ATUL CHUGH: Absolutely the issue of non-pharmacologic therapies, in other words, lifestyle changes for the treatment of blood pressure is very much preferred. If possible, one of the most dramatic times that we see, occurs when patients have bariatric surgery and we see this massive amount of weight loss. Patients who are oftentimes on seven or eight agents for the treatment of their blood pressure are completely off all medications for the treatment of their blood pressure. In general the general rule of thumb is set for every two pounds of weight loss that we see. We have a one millimeter reduction in the blood pressure.

So weight loss is a big issue. Corollary to the weight loss is this issue of sleep apnea. We know that this is a very prevalent condition in which patients stop breathing multiple times during the period of their sleep time over sometimes 50 or 60 times, even an hour. Reduction in blood pressures are noted once we see patients on CPAP therapy which is something that we try to identify in our situations where we have a condition of resistant hypertension where patients are hypertensive despite being on three agents at maximal doses.

Other issue is of course, diet. And we know that dietary sodium is very difficult to control overall given the high amounts of processed foods in our, diet. The optimal goal is to have less than 1500 milligrams per day, which is surprisingly difficult to do. Just that alone would can reduce the blood pressure by five or six points on the systolic side with that. Aerobic activity. Walking anywhere between 90 and 150 minutes per week has shown to have a nice reduction in the blood pressure as well. In some patients, we've seen much more pronounced reduction. And we see this more with aerobic activity than we do with, say, for instance, resistance therapies.

But either or are fine. And better than certainly, no activity at all. And of course, moderation and alcohol, we've seen that a reduction in particularly men who drink more than two units per day, or women who drink more than one unit per day tend to have higher blood pressures and just cutting back to just two daily. And one for women has also shown a small but very beneficial reduction in blood pressure. The other fascinating therapies or lifestyle changes that have really shown a nice reduction in blood pressures deep breathing exercises. And these have shown just deep breathing 10 minutes per day can actually have very nice blood pressure response that can equal up to a reduction in one pill of medication.

We've seen some very interesting studies, especially with a a special kind of breathing called resistance breathing. Which is where you breathe out against resistance where you closing the nostril and breathing out of against this is really was a nice study which showed a very profound blood pressure reduction, which we thought was very interesting, was just published recently.

Scott Webb: Yeah. That is interesting. My Apple Watch is always reminding me to breathe and take a breath, and maybe I'll instead of ignoring it. Maybe I'll actually start listening to that. That's really fascinating. Thinking to all the pharmaceuticals and drugs and therapies and all that. And maybe just some simple breathing might do the trick for some. This has been really educational today, doctor, as it always is. As we wrap up here, just wanna give you a chance, final thoughts, takeaways, you know, a diagnosis of hypertension, high blood press ure could be scary for folks and I, we probably want them to know that there's help available, the ways that they can help themselves and so on, but in your words, final thoughts and takeaways.

Dr. ATUL CHUGH: Hypertension is tough condition because for most patients it's just a number and most patients don't really perceive much of a symptom with it. It's why it's called the Silent Killer. And oftentimes we're finding these patients have hypertension or unaddressed hypertension when it's too late, when they're coming in with their first heart attack or their first stroke. So if you do get a screening and somehow you find that your blood pressure is over one 30 on the top number and over 80 on the bottom at any point of your measurement, I would urge you to go ahead and take a look at that further, perhaps getting a blood pressure cuff, seeing if you have hypertension. While getting on medications isn't exactly the most favorite thing for folks to do could potentially save your life.

Scott Webb: Yeah, That's the takeaway here is you know, you talked today about some side effects and other concerns, but in the end in failure to address hypertension, high blood pressure that's probably not gonna end well for most people. So, great stuff today. Great to have your time and expertise. Thank you so much. You stay well.

Dr. ATUL CHUGH: Thank you. You too, sir. Bye.

Scott Webb: And for more information, visit franciscanhealth.org/heart care. And if you found this podcast helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.