Hypertension in Special Populations: Athletes

Rosa Maria Bruno; Giulia Cartoni; Stefano Taddei


Future Cardiol. 2011;7(4):571-584. 

In This Article



All hypertensive patients should be encouraged to adhere to lifestyle changes. In athletes with grade 1–2 hypertension at low/moderate added cardiovascular risk, it is possible to delay the initiation of pharmacological treatment by several weeks, in order to assess the efficacy of lifestyle changes. Compared with the general population, athletes and other physically active patients are often more motivated to comply with nonpharmacological interventions. Patients should be asked to reduce processed food intake due to the high sodium content of such foods, which are very common in the diet of adolescents, and increase their intake of food rich in potassium (endurance athletes may tend to be hypokalemic). Weight loss should be recommended for overweight athletes, if possible under specialist supervision. The use of blood-pressure raising substances, such as NSAIDs, or illicit substances, must be discouraged. In patients with secondary hypertension, clinical evaluation for sports participation is preferably postponed to after removal of the cause of hypertension.


Pharmacological treatment must be initiated promptly in high risk patients or if lifestyle measures are unable to reach blood pressure target. Since the main benefits of antihypertensive treatment are due to blood pressure lowering per se rather than to the chosen antihypertensive drug, current guidelines do not suggest any specific drug as first-line treatment. However, the physician should take into account a number of basic principles: avoidance of drugs with previous unfavorable effects in the individual patient; presence of cardiovascular risk factors, associated conditions, or other comorbidities that can benefit or be worsened by certain drugs; the presence or type of subclinical organ damage; interaction with other drugs.[4] In athletes two further aspects should be considered: some antihypertensive drugs are considered doping substances and are banned by several sports associations;[101] others have a negative effect on exercise performance Table 5.[52,70,71] The literature on this topic is very incomplete. However, blockers of the renin-angiotensin system and dihydropiridine calcium antagonists appear to be the first choice antihypertensive agents particularly in endurance athletes, since they have no major effects on energy metabolism or cardiovascular adaptation to exercise Table 5.[70,72] Blockers of the renin-angiotensin system are contraindicated in female athletes during the reproductive age. α-blockers and centrally acting α-agonists can be used in association as second- or third-choice drugs. On the other hand, conventional antihypertensive drugs such as diuretics and β-blockers are usually not recommended in athletes. Diuretics have reportedly been used as masking substances, favoring the excretion or dilution of illegal substances; furthermore they allow rapid weight loss, being useful in sports in which categories are weight-related, such as boxing: for these reasons they are considered doping substances in several sports. Diuretics have also adverse effects on sports performance, since they impair exercise performance and capacity in the first weeks of treatment through a reduction in plasmatic volume, although exercise tolerance appears to be restored during long-term treatment.[70,73] Loop diuretics can also precipitate hypovolemia, orthostatic hypotension, and electrolyte imbalance (loss of potassium, magnesium), in patients who are exercising intensely or competing in warm weather. Thus diuretics are contraindicated in elite athletes who are required to undergo drug testing; nevertheless they can be used as second- or third-choice drugs and at low dosage in physically active patients with hypertension and salt-sensitive hypertensive athletes (e.g., black athletes). In order to avoid electrolyte disturbances, a potassium-sparing diuretic can be associated. This is similar for β-blockers, which are prohibited in certain competitive sports (precision sports such as shooting, ski jumping, archery, diving) due to their antitremor and anxiolytic effect. In addition, β-blockers can adversely affect sports performance in endurance athletes, as a consequence of their negative inotropic and chronotropic effect on the heart and impairment of muscle blood flow, thus increasing the perception of greater exertion during exercise.[74] Finally, inhibition of lipolysis and glycogenolysis could impair energy metabolism.[75] Therefore β-blockers should be used in athletes only when it is mandatory, as in the presence of coronary artery disease, rather than merely for their antihypertensive effect. For mandatory cases, a combined α-β blocker may be the best choice, since they are expected to provide a lesser impairment of muscle blood flow and of maximum oxygen uptake.