Create: 02/05/2014 - 23:13
Cardiovascular Health for men 2013- An evidenced based approach. Part 1 Hypertension- T.O'Connor, MD. Heart disease is the leading cause of death for men of most racial/ethnic groups in the United States, including African Americans, American Indians or Alaska Natives, Hispanics, and whites. For Asian American or Pacific Islander men, heart disease is second only to cancer. (1) Half of the men who die suddenly of coronary heart disease have no previous symptoms. To Even if you have no symptoms, you may still be at risk for heart disease. Between 70% and 89% of sudden cardiac events occur in men. (2) These statistics echo the fact that men in America are not getting to goal in terms of primary care for their hearts. The etiology of cardiovascular disease is multifactorial and the discrete mechanism of action remains elusive and in as such, is beyond the scope of this paper. The focus of this document is to aid men all over America and the world for that matter in protecting their hearts-with this, to live as long as possible with the best quality of life! Please read this document with its related video on the Metabolic Doc TV at www.metabolicdoc.com Print this document, make notes and bring it to your primary care provider and demand that you "get to goal"! ----------------------------------------------------------------------------------------- There are three main medical risks that lead to cardiovascular disease: 1. Hypertension and Pre-hypertension 2. Lipid abnormalities 3. diabetes and impaired fasting glucose (controversial risk, yet very important) Hypertension is defined as a systolic blood pressure equal to or greater than 140 mmHg and/or a diastolic blood pressure equal to or greater than 90 mmHg. Any blood pressure between 120-139/80-89 is considered pre-hypertension and optimal blood pressure is less than 120 and less than 80 mmHg. If your blood pressure is anything less than optimal, do something about it! After smoking cessation and excessive alcohol intake, the first and obvious issue to address is your body weight related to diet and exercise behavior. There is a laundry list of evidence relating eating poorly and being overweight to hypertension and heart disease. The bottom line is that you have to evaluate your behavior and make some changes. Its easy to read about diet and exercise- in the end, its going to take a sustained effort to get you to goal and keep your there! I recommend a diet and activity behavior that you can live with for life! Yo-Yo diets are useless and futile, while achieving a realistic and manageable diet and exercise regimen that works for you, will save your life! Anything else is failure! For the record, I like a low calorie/carbohydrate Mediterranean diet and "cheat" with a small meal or two every couple of days. This works for me- find out what your style is! Once you deal with your behavior in terms of diet and exercise and despite this, you are still in the high pre-hypertensive or hypertensive range, its time to consider protective regimens/ supplements and or medications. There is an overwhelming amount of data supporting specific dietary and supplemental regimens, including many natural constituents that have been shown in scientific studies to have positive effects on blood pressure control. I recommend that you look further into this with a qualified physician in addition to a Naturopathic doctor. A limited list of these approaches include the DASH diet- Dietary Approaches to Stop Hypertension, which is essentially a low salt and higher natural potassium diet with a focus on fruits and vegetables. The average man ingests 4,200 mg or salt per day in the USA and the DASH study has shown that reducing salt intake to 2,300mg and even 20/10 mmHg above goal blood pressure, consideration should be given to initiating therapy with two agents, one of which usually should be a thiazide-type diuretic. -The most effective therapy prescribed by the most careful clinician will control hypertension only if patients are motivated. Motivation improves when patients have positive experiences with, and trust in, the clinician. Empathy builds trust and is a potent motivator. -In presenting these guidelines, the committee recognizes that the responsible physicianâ€™s judgment remains paramount. JNC 8, the next set of guidelines are due out by late fall/winter 2013/14- an unprecedented late presentation for these revised guidelines. Until this time, JNC 7 stands as the current standard-of-care. One of the more plausible reasons why it has taken so long for these revisions to go public, lies within the infighting among the experts about what should be the first-line drugs recommended for the various sub-populations of hypertensive patients. For example, Thiazide diuretics have been first line agents and that will most likely not be the case in JNC 8. The reason for this relates to the discovery of evidenced-based reviews of the past and more recent literature on outcomes with Thiazide diuretics. In short, most hypertensive experts agree that Thiazide diuretics should NOT BE first-line agents for the essential hypertension (a patient that has hypertension- with out a diagnosis of organic disease, eg, heart disease, stroke or diabetes). I stand with this and I do typically not use thiazide diuretics as first-line for my newly diagnosed hypertensive patients. The remaining portion of this paper will focus on the top two most common medication I prescribe for my men with hypertension. Again, this paper is solely for educational purpose and to lend insight into how I treat some of my private patients. It should never be a substitution for advice from your personal health-care provider and you should never self-prescribe these medications to yourself! SEE YOUR DOCTOR! Medication #1: Ace- Inhibitors: The first line of drugs I like for most of my hypertensive men, that DO NOT have existing heart disease is an Ace-inhibitor (AI). Rarely, I start with an angiotensin receptor blocker (ARB), although, this will not be discussed in this paper. AIs are a group of drugs that cause dilation of blood vessels via a complex mechanism-of-action. Essentially, they block the formation of a potent protein called angiotensin II, thereby causing a reduction of arteriolar resistance (blood pressure). In addition to blood pressure lower effects, AI's have shown to be very effective in protecting kidney's in diabetics, hearts in both people with existing heart disease and most importantly, protecting people with out diagnosed heart disease! There is substantial literature supporting primary prevention of heart, stroke and blood vessel protection in people with out cardiovascular disease, diabetes or hypertension. PLEASE UNDERSTAND THIS! it means that these drugs used only by expert physicians and personalized for you, can protect your cardiovascular system before you have disease. Medication # 2: Bystolic (Nebivolol Hydrochloride) Another great medication for hypertension and even high pre-hypertension is a drug called, Bystolic (Nebivolol Hydrochloride). Bystolic is classified as a beta- blocker, yet we know that itâ€™s a new 3rd-generation beta-blocker and therefore has a novel and unprecedented mechanism-of-action. Beta blockers are typically categorized as selective or nonselective to beta receptors. Bystolic may be considered both, depending on the drugâ€™s concentration in the body. At low concentrations, typically achieved in extensive metabolizers (the majority of the population), and at doses of 10 mg and below, Bystolic is beta1-selective. However, at higher concentrations, in poor metabolizers and at higher doses, Bystolic loses its selectivity and blocks both beta1 and beta2 receptors. Bystolic also possesses novel vasoactive factors. It provides vasodilation by releasing endothelial nitric oxide. The vasodilation properties result in an overall positive hemodynamic side-effect profile. I have found that men with the right medical/personal profile and cardiovascular risks, in addition to a higher resting heart rate- over 80 beats/minute, Bystolic at low doses in addition to an Ace inhibitor works wonders! I have also discovered that this combination of an Ace-inhibitor with very low dose Bystolic, eg, 2.5 to 5 mg daily result in well tolerated and consistent blood pressure control. The usual side effects related to beta-blockers, such as malaise/fatigue, sexual dysfunction and exercise intolerance are essentially non existent with low dose Bystolic and that sexual health can be actually enhanced with this regimen!