George L. Bakris
LAS VEGAS — Adequate sleep and a low-sodium, high-potassium diet are some of the many approaches recommended for BP lowering in patients with cardiometabolic disease, according to a presentation at the National Lipid Association Scientific Sessions.
The cardiometabolic patient is often one with diabetes and obesity, George L. Bakris, MD, FAHA, professor of medicine and director of the Comprehensive Hypertension Center at University of Chicago Medicine and Cardiology Today Editorial Board Member, said during the presentation.
“It’s a very big spectrum of disease,” Bakris said. “[With] diabetes and prediabetes, fundamentally, what they all have in common is that it’s an inflammatory state.”
Bakris said that the table he prepared for the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure that summarized lifestyle activity and changes in BP for patients with hypertension. Experts then expanded the original table in the 2017 American College of Cardiology/American Heart Association BP Guidelines to include the Dietary Approaches to Stop Hypertension (DASH) diet, which is high in potassium as well as detailed descriptions of different types of exercise.
“It’s important for people to understand that the level of attention and detail in this table is warranted and is the base of hypertension treatment, not the BP lowering meds,” Bakris said. “Thus, these lifestyle changes can result in up to a 10 to 20 mm Hg reduction in BP without medications if they are consistently implemented. So these lifestyle recommendations are a very important part of daily living, especially for people who are meat and potatoes people and do or eat anything else,” Bakris said.
Sleep disorders beyond sleep apnea should also be considered in BP control, according to the presentation.
“If you fundamentally treat sleep apnea … you’ve lowered blood pressure equal to a low-sodium diet,” Bakris said. “It’s 1 mm per hour of using the sleep apnea apparatus. That’s not very impressive. It’s not just the brain getting more oxygen, it’s how well you are truly sleeping, and that’s a whole separate category that’s been underappreciated.”
In a meta-analysis of sleep apnea studies published in the Archives of Internal Medicine in 2007, BP was reduced in patients who were treated for sleep apnea, although the effect was not dramatic, according to the presentation.
Several studies focus on the benefits of treating patients with sleep deprivation. In a study published in Hypertension in 2006, researchers found that patients who slept for 5 hours or less had a twofold increased risk for hypertension. Another review article published in the Journal of the American Society of Hypertension in 2017 found that patients with a short sleep duration had an increased risk for hypertension and BP variability, a major risk factor for stroke.
“Your stroke risk with increased blood pressure variability if you’re over 70 is far higher than a sustained elevated pressure,” Bakris said. “That’s what you’re going to get if you don’t have good sleep.”
In the Nurses Health Study, which included 71,617 women and 10-year follow-up, women who slept for 6 hours had a 30% greater chance of having a CHD event. This decreased to 6% with 7 hours of sleep.
Health care providers should collect detailed information on a patient’s sleep history, Bakris said.
Sleep deprivation and obesity are strongly associated, according to the presentation.
“If your brain is not rested, it’s wondering why you’re not feeding it,” Bakris said. “You’re up, you’ve increased sympathetic activity, but you’re also gaining weight. People that have sleep disorders are generally overweight or obese, they’ll lose weight if you get them sleeping better because they’re not going to be eating, sympathetic tone goes down and insulin resistance goes down.”
The current BP goal for patients with kidney disease or diabetes varies by different associations, although it is agreed that patients at high CV risk should have a BP of no more than 130 mm Hg/80 mm Hg, according to the presentation.
Patients with metabolic syndrome should be treated aggressively for BP lowering and CV risk reduction, but conventional treatments are not as aggressive as health providers often think, Bakris said.
“It’s important to keep in mind that very early in the disease process or even in prediabetes … that if you are aggressive with these patients and with the risk factors that we already know are going to contribute to the disease progression, you can really have a huge benefit long term, but sleep has to be a part of it,” Bakris said. “It can’t just be lipids and blood pressure.”
The updated BP guidelines from the American Heart Association and the American College of Cardiology emphasize aggressive treatment in these patients. Bakris said he co-chaired the committee that helped with the 2017 BP guideline goals for the American Diabetes Association, and during those discussions, concern was raised about how patients with type 2 diabetes will react to BP measurements less than 130 mm Hg/80 mm Hg.
“We were worried because there are very good data from post hoc analyses of very large trials, but if you get too low, like below 120, you can actually exacerbate not only coronary disease, but you can actually have increased mortality,” Bakris said. It has consistently been shown that those with diabetes react differently to lower pressures than those without diabetes.
Another issue that the 2018 AHA/ACC BP guidelines did not address was low diastolic pressures, especially in patients with diabetes. Health care professionals should approach BP lowering in patients with diabetes on an individualized basis, Bakris said.
“In general, the data are consistent, and for the most part, there is a major overlap between the guidelines with over 95% agreement among all the guidelines,” Bakris said. “There are not big differences.” – by Darlene Dobkowski
Bakris GL. Session VI - What’s New in Hypertension: 2018. Presented at: National Lipid Association Scientific Sessions; April 26-29, 2018; Las Vegas.
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Thomas SJ, et al. J Am Soc Hypertens. 2017;doi:10.1016/j.jash.2016.11.008.
Disclosure: Bakris reports he is a principal investigator for studies for Bayer, a steering committee member for trials sponsored by Janssen and Vascular Dynamics and a consultant for Merck, Relypsa and Vascular Dynamics.