Health Matters August 2005

Managing High Blood Pressure - Part 2
In our June issue of Health Matters, we provided an overview of high blood pressure (BP), or hypertension (HTN). We discussed the importance of each individual understanding her/his blood pressure target of less than 130/90, and the importance of understanding one's medications. In this issue, we will discuss treatment and medications. While people tend to think about drug treatment for high blood pressure, non-drug strategies can also be effective. These include:

Weight reduction,
Regular aerobic exercise,
Avoidance of excess alcohol intake,
Avoidance of smoking, and
Moderate restriction of salt in the diet (Salt Substitute, which is potassium chloride, can be used as a substitute for regular salt, which is sodium chloride, in individuals without kidney problems.)

These lifestyle changes are recommended for everyone, particular those with high blood pressure. In some patients, such modifications may be sufficient to control hypertension.

The indication for medications is a blood pressure that is consistently above 140/90. For those with diabetes or chronic kidney problems, treatment could begin with a blood pressure of greater than 130/80.

There are various classes of antihypertensive agents that are commonly used to manage high blood pressure. We will describe the major drug classes here with the names of some genetic medications in each class. This is not an exhaustive list of medications. To find information on a specific medication, please see www.medlineplus.gov.

Diuretics: Diuretics lower blood pressure mainly by causing the kidneys to increase the excretion of water and salt (sodium) and also by widening or "dilating" the blood vessels - this is called vasodilation. The diuretics used to treat hypertension are thiazides, primarily chlorthalidone and hydrochlorothiazide. In some cases, a "potassium-sparing" diuretic - amiloride, spironolactone, or triamterene - or potassium supplements are given in combination with a thiazide diuretic because the thiazides can cause potassium deficiency due to increased excretion of potassium in the urine.

Side effects are uncommon with thiazide diuretics.

ACE Inhibitors: Angiotensin converting enzyme (ACE) inhibitors block production of the hormone angiotensin which increases blood pressure. By reducing angiotensin production, ACE inhibitors allow blood vessels to relax (vasodilation) thereby lowering blood pressure. The available ACE inhibitors include benazepril, captopril, enalapril, and several others.

Side effects are quite rare with ACE inhibitors. They may cause a persistent dry hacking cough that is reversible with discontinuation of therapy. In rare instances they can also cause "angioedema" or the relatively rapid onset of swelling of the lips, tongue, and throat, which can potentially--although very rarely-- interfere with breathing. These symptoms should be considered a medical emergency and ACE inhibitors should be discontinued.

Angiotensin II receptor blockers (ARB's): The angiotensin receptor blockers work to block the effects of angiotensin on blood vessels, rather than inhibiting angiotensin production the ACE inhibitors do. Thus, they also lower blood pressure by vasodilation. The available ARBs include candesartan, irbesartan, losartan, telmisartan, and valsartan.

Side effects with ARB's are also very rare. They do not produce the cough that can be found with ACE inhibitors and angioedema is even less common.

Calcium channel blockers (CCB's): Calcium channel blocker drugs reduce the amount of calcium entering the muscle cells that line the blood vessel walls. Muscle cells require calcium to contract or squeeze. By inhibiting the flow of calcium across muscle cell membranes, CCB's cause muscle cells to relax and blood vessels to dilate, reducing blood pressure. They also reduce the force and rate of the heartbeat. CCB's include amlodipine, diltiazem, felodipine, and several others.

The side effects that may be seen with calcium channel blockers vary with the specific agent used. Patients who take dihydropyridines may develop headache, dizziness, flushing, nausea, or fluid accumulation in the legs called edema. The nondihydropyridines - diltiazem or verapamil - can cause the heart rate to slow too much and verapamil can cause constipation.

Beta blockers: Beta blockers block the receptors for adrenalin (epinephrine) in the body and in doing so, they relax the blood vessels, slow down the heart, and reduce the force with which the heart pumps. Available beta blockers include acebutolol, atenolol, betaxolol, and several others. Some beta blockers have combined activity, blocking both the beta and alpha receptors (see the next section). These include labetalol and carvedilol.

Beta blockers may worsen symptoms of asthma or emphysema. They can mask symptoms of low blood sugar (hypoglycemia) in patients with diabetes who are treated with insulin. Beta blockers can also cause depression, fatigue, dizziness, insomnia, decreased exercise tolerance, a slow heart rate, and cold hands and feet due to reduced blood flow to the limbs.

Alpha blockers: Similar to beta-blockers, alpha-blockers work to block different receptors for adrenalin (epinephrine) in the body and in doing so, they also relax the blood vessels. They have less effect on the heart than do beta-blockers The available alpha blockers include doxazosin, prazosin, and terazosin.

Alpha blockers can cause dizziness, particularly when standing up, headache, weakness, and drowsiness. Because they help shrink the prostate, they are frequently used in older men with symptoms related to enlargement of the prostate.

Direct vasodilators: Direct vasodilators work in other ways to relax or reduce the tone of blood vessels. The two drugs in this class are hydralazine and minoxidil. These are typically reserved for severe and resistant hypertension.

Side effects associated with direct vasodilators include headache, weakness, nausea, constipation, peripheral edema, and rapid heartbeat. Minoxidil also may cause excessive hair growth. As you may have guessed, the medication Rogaine, which is used to treat baldness, is the topical preparation of minoxidil.

Centrally acting agents: Centrally acting agents, such as clonidine, guanabenz, guanfacine, and methyldopa, act in the brain itself and are now used relatively infrequently because of the high rate of side effects. They can cause dizziness when standing, drowsiness, impaired judgment, dry mouth, nausea, constipation, and a decrease in sexual function.

What is the best medication for me?
While we take several factors into account when determining the best blood pressure medication for someone, there is a relatively standard approach that we follow. For those with hypertension and no other significant underlying disorder, we recommend beginning with a thiazide diuretic based on their proven long-term benefit, improved outcomes compared to other drugs, and low cost.

If low-dose thiazide alone proves ineffective, experts recommend that an ACE inhibitor be added or substituted, although a calcium channel blocker may be used next in black or elderly patients as they tend to be more effective in those individuals. A high percentage of hypertensive individuals will require more than one medication - at times three to four medications are necessary to effectively control an individual's blood pressure.

There are conditions in which certain antihypertensive drugs may be specifically recommended. For example, ACE inhibitors are frequently preferred in patients with diabetes mellitus who have increased levels of protein in the urine and in those with heart failure. Beta blockers are given to patients with angina, heart failure, or a prior heart attack. Calcium channel blockers are frequently used in those with angina.

Other antihypertensive agents should be avoided in certain conditions. For example, ACE inhibitors and ARB's should be avoided during pregnancy and beta blockers should be used with caution in those with asthma or chronic lung disease. Diuretics can worsen gout.

In conclusion, weight reduction, regular exercise, the avoidance of excess alcohol intake, smoking cessation, and a restriction of salt in the diet are all important components of controlling blood pressure. Medications are often necessary to help control blood pressure. The target pressure is less than 130 for the systolic and less than 90 for the diastolic and everyone with hypertension should have a blood pressure cuff at home for regular monitoring.

What Kills Oregonians?
(Adapted from the Oregon Department of Human Services CDSummary Newsletter available at http://www.oregon.gov/dhs/ph/cdsummary) While this may seem like a morbid question, the answer is instructive if we focus on those conditions which claim a large number of lives each year, so that we can change our behavior. The most recent complete set of data is from 2003. 30,813 Oregonians died during that year, and of these deaths, approximately 23% were attributable to cancer, about 23% to heart disease, about 8% to cerebrovascular disease (strokes), and about 6% to chronic lower respiratory disease (emphysema).

These diseases reflect the primary condition at the time of death, but don't indicate the underlying behavioral factors that cause the diseases. Researchers have estimated the number of deaths resulting from the major external modifiable, nongenetic, lifestyle factors. These "lifestyle choices" can be considered the "actual causes" of death and included things like tobacco use, diet, and activity patterns. Here we review the major modifiable health habits that contribute to death.

Tobacco: The leading cause of premature death among Oregonians is tobacco use, accounting yearly for 5,000 - 7,000 fatalities yearly or 16 - 22% of all deaths. Tobacco - primarily cigarette smoking - contributes substantially to deaths from lung cancer, coronary artery disease (heart attacks), stroke, hypertension, emphysema, and pneumonia. In 2003, research shows that 21% of Oregonians were smokers.

Poor diet and a lack of exercise: Approximately 1,400 Oregonians die prematurely each year as a consequence of a poor diet and/or a sedentary lifestyle. Dietary and activity factors are associated with coronary artery disease, other vascular disease, stroke, hypertension, cancer and diabetes. Approximately 40% of Oregonians are overweight with a Body Mass Index (BMI) of 25-29 and 20% are obese with a BMI over 30. You can calculate your BMI by going to: http://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm.

Alcohol: Alcohol misuse results in the deaths of an estimated 1,000 Oregonians yearly, with 71% being in males. Motor vehicle crashes, chronic liver disease (cirrhosis), liver cancer, strokes, and suicide are the most common alcohol-related causes of death.

Infections: Infections, although no longer the leading cause of death as they were a century ago, still cause many deaths, particularly in the elderly. About 600 yearly deaths are due to infection, principally pneumonia and sepsis (infection in the blood). Some of these would be prevented by using both the influenza vaccine - which should be administered yearly to those over age 65 - and the pneumococcal vaccine - which should be administered once to those over age 65. About 70% of Oregonians over age 65 receive influenza vaccinations and about 70% have received a pneumococcal vaccination during their lifetime. (Deaths due to HIV infection and viral hepatitis are categorized under sexual behavior.)

Motor Vehicles: Approximately 500 Oregonians die in motor vehicle accidents (MVA's) each year, including 150 that are estimated to be alcohol-related. Seat belts have been shown to reduce the risk of significant injury and death in MVA's by about 45%-50%. Most Oregonians do buckle-up with 88% of Oregon adults reporting consistent seat belt use.

Firearms: 400 Oregonians were shot to death during 2003, with 66% involving handguns. Suicide is the leading manner of firearm death, accounting for almost 75% of the total. In 2004, firearms were present in 40% of Oregon households - in 7%, weapons were kept loaded and unlocked. 23% of Oregonians who kept their firearms loaded and unlocked also reported binge drinking, a potentially dangerous combination. In 12% of homes where both children and guns were present, the guns were kept loaded and unlocked.

Sexual Behavior: Unprotected sexual intercourse is associated with approximately 200 deaths yearly, mostly from viral hepatitis and HIV infection, but also from cervical cancer which is primarily caused by the sexually transmitted human papilloma virus (HPV). In 2003, there were 8,553 new cases of sexually transmitted diseases reported in Oregon--all of which are preventable by adopting safe sexual habits.

Drug Abuse: An estimated 200 Oregonians die each year from drug use, both street drugs and the abuse of prescription medicines. Included in this category are deaths resulting from certain mental disorders such as depression leading to suicide from drug overdose, and AIDS and hepatitis C both transmitted by needles used to inject illegal drugs. The toll is probably higher since violent deaths, such as homicide and MVA's, are not included here, but are frequently drug-related. Problems with drug abuse are likely to increase due to the current epidemic of methamphetamine abuse.

Conclusions: Behavioral factors contribute to early death in almost 40% of all deaths. These statistics provide a sense of the relative impact of various behaviors on health. Improving life habits could lead to substantial improvement in both longevity and quality of life in many individuals.

Smokers can receive assistance by calling the Oregon Quit Smoking Line at 877-270-STOP. We are proud that Providence St. Vincent Medical Center also has the largest smoking cessation program in the country, thanks to the dedicated work of the department of medicine faculty member Dr. Chuck Bentz. More information on smoking cessation can be found at: http://www.oregonquitline.org/.

Good eating and exercise habits are also vital and have been addressed in many of our prior issues of Health Matters. We are currently developing our own formal weight management program that will focus on interventions shown to provide long term weight control. We believe that this program will far exceed the gimmicks of existing community based weight management programs where the focus is generally to get you to purchase expensive dietary supplements. Our program will focus on positive health habits associated with long term weight management. This program is still under development, with an expected kick-off date in the early Fall. For more information, please contact our office at (503) 292-9560.

Support for Women Living with a Heart Condition
Heart to Heart is a support group for women living with heart disease or a heart condition. It is provided in affiliation with the American Heart Association and facilitated by Janice Isenberg, a licensed clinical social worker with over 25 years experience, who is living with heart disease. Group size is limited, so please call early to reserve a spot. Date: Tuesday, September 13-October 25

Time: 6:00 - 7:30 p.m.
Place: Metro Family YMCA - 2831 S. W. Barbur Blvd, Fish Bowl, 3rd floor
To Register: Call 971-235-1014, pre-registration required
Fee: $25.00 for 6 sessions

New Weight Management Program
We are pleased to announce a new program available to GreenField patients called "Transformation: The Greenfield Health Weight and Lifestyle Management Program." In an effort to help our patients for whom weight has become a physical, medical and/or emotional burden, Dr. Cynthia Ferrier and the GreenField health team have partnered with Ronda Gates, M. S., a well-known health educator who has developed successful health promotion programs nationwide. We have developed this program to help participants to learn skills and strategies to re-gain a healthy lifestyle and appropriate weight loss with fewer health consequences.

The introductory Transformation session will consist of a weekend intensive September 24th and 25th followed by six in-depth weekly 2.5 hour sessions. Content will include physical evaluation, health assessments, diet and fitness instruction, menu planning, shopping education and discussion of the emotional aspect of our diet and exercise habits. This will be followed by 16 weeks of weekly check-ins with the GreenField team, evaluation of progress and re-assessment of one’s individual personal program. The second half of the program will also include monthly meetings of the group to discuss specific health or exercise topics in more detail. In addition to the instruction and evaluation, participants will also receive more than $200 worth of exercise equipment and tools to support weight management.

This 6 month program is offered to GreenField patients at an introductory rate of $795. Please call us if you have any questions. Dr. Ferrier would be happy to discuss the program with you.

Office Notes
Our office will be closed on Monday, September 5 th in observation of the Labor Day holiday. As always, one of our physicians will be available on call for all urgent and emergent needs.

Sincerely,
Your GreenField Health Team:

Beth Davis, your Benefits Coordinator and Biller (email)
Chuck Kilo, MD (email)
Cynthia Ferrier, MD (email)
Dia Gaede, CMA, your Health Coordinator (email)
Elizabeth Hays, MD (email)
Eric Murray, MD (email)
Jill Arena, your Clinic Administrator (email)
Joel Swartzmiller, IT Manager (email)
Pam Mockenhaupt, CMA, your Health Coordinator (email)
Paula Koeller, MD (email)
Ron Potrue, Clinic Management Consultant (email)
Shelly Banta, your Clinic Manager (email)
Tiana Schmitt, MA, your Health Coordinator (email)

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GreenField Health System
9427 SW Barnes Road, Suite 590
Portland, OR 97225
Phone: 503.292.9560
Fax: 503.292.9510
Web: http://www.greenfieldhealth.com

questions, concerns, comments appreciated: questions@greenfieldhealth.com

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