Hey everybody, it's Dr. Juan Davila and welcome to the Follow-Up Visit podcast. Today's episode is hypertension, probably one of the most common diagnoses that we see and that we write down in our charts on the day to day. So I felt like it was fitting to start with hypertension. Hypertension is a pretty prevalent disease process. I think something in the ballpark of 48 % of the population here in the United States has been diagnosed with hypertension or has hypertension.

And something in the ballpark of 1.3 billion people across the world have been diagnosed with hypertension. So pretty substantial groupings of people. The hard part to this is that only 20 % of people have it under control. And that is not where we want to be. On top of that, only 51 % are on actual treatment, which means that there are some people that are on treatment for their hypertension that still don't have it under control, which is really difficult. And then even on top of that, 60 %...

of the population are aware that they have it, which means 40 % of the population are unaware they even have hypertension. So very important topic to start on. I think it's important for us to discuss. so we'll start with physiology, which is what is blood pressure? Why do we have it? Why do we care? And why do we keep track of that? And how do we even figure out what blood pressure is? So blood pressure is a normal thing. You know, when I think sometimes saying the word blood pressure has a negative connotation, but blood pressure

by itself is an important component to the way that your body functions. It's what it's dictates how blood is moving through the vessels, your arteries and your veins and getting oxygen to the places and organs that need it. So we in medicine, all of your physicians and nurse practitioners and PAs and nurses and all those amazing people will check your blood pressure. so blood pressure is the result

of multiple things. And so just like any math problem, blood pressure is the answer of a bunch of variables being added together. So what are those variables? So the variables that create your blood pressure are going to include cardiac output. So I like to think about this as how hard your heart is squeezing. And so the force at which your heart contracts will dictate how much blood moves through the heart out of it and then how fast your heart contracts will dictate.

how much blood is moving through there. So the contractility of the heart, the force at which it squeezes, results in cardiac output, right? So that's one variable, cardiac output contractility. Peripheral vascular resistance is another variable. So this is pretty much how much force is the heart having to fight against to get blood out of the heart and through the blood vessels. And there's multiple things that dictate this, the size of your blood vessels, whether they're open or closed.

There's something blocking it as well as the viscosity of the blood. How thick is your blood? That all plays a role in that peripheral vascular resistance. So that's another variable. Blood volume is another variable. So how much actual blood is in your vessels at any given time? Is there too much? Is there too little? This plays another factor in determining blood pressure as well as the elasticity of the blood vessels. So how much will they bend and shape and mold every time that heart squeezes?

And so are they flexible or the rigid? This also helps dictate blood pressure. And lastly, and this is kind of a plus or minus variable. It's kind of a secondary variable, but I think it's important to mention which are barrel receptors, which there's some in the neck that measure the pressure and then will adjust accordingly by sending hormones, which is another regulator to help regulate the blood.

and then any local auto regulation. So blood vessels that are shifting in size at a smaller level. So all of these things combined equal your blood pressure. So that's really what's happening in the body to create blood pressure at a normal rate. All of these things are becoming fluid. The heart contracts faster, contracts slower, harder. Your blood vessels will open, they'll close. All of these things will help regulate the blood pressure so that it maintains in a normal place.

The moment that we have dysregulation of one and most likely multiple of these things, that's when we start having blood pressure start to come up. And so my heart all of a sudden starts contracting harder for some reason, or there's blockages in my artery and now there's a lot of peripheral resistance that my body has to work through. So my blood pressure comes up. The arteries get harder, so they're not flexible anymore. So now they won't open up to drop my blood pressure anymore, or there's too much volume.

My heart isn't moving fluid fast enough, so I'm holding on to a lot of extra fluid because my kidneys can't put it out. So all of these variables will start to increase the blood pressure and ultimately end up in what we call a pathologic state, which is hypertension. So the pathological state of hypertension has multiple degrees, right? We don't just say, you have high blood pressure without any written down way of doing that. And so the way that we kind of have hierarchical

degrees of blood pressure, a breakdown like this. The first is normal. A normal blood pressure is gonna be this top number, 120 systolic blood pressure over our bottom number, which is a diastolic number of 80. So 120 over 80 or less is a normal blood pressure. The way I like to think about systolic and diastolic blood pressure, systolic is the force at which your heart contracts. So your heart contracts and it shoots blood out of the heart into the rest of your body.

The force at which it does that is that top number, 120 millimeters of mercury of force coming out of the heart. Then the heart will relax. And when it relax, it expands and sucks blood back into the heart. The force at which that happens is the diastolic number, that relaxation part. That's the second number. So it'll do that with say 80 millimeters of mercury or less. This is normal. So that's where those two numbers come from. Cystolic,

blood heart contracting, shooting blood out of the body, diastolic heart relaxing, sucking blood into the heart. So the normal is less than 120 over 80. When we say your blood pressure is elevated, so maybe not hypertension yet, but it's higher than it should be. You're going to be somewhere between 120 and 129 over 80. Hypertension type one, and this is usually where we start to discuss treatment and therapy and whether we need it or not, is when that blood pressure is 130.

to 139 over 80 to 89. So in that range, depending on the aggressiveness of your physician and other diseases that you may have, will dictate medications that will be started at that point. Once you hit stage two hypertension, that's anything higher than 140 over 90. At that point, you need to be on some sort of therapy because there are risk factors associated with an elevation like that. And we'll talk about those here in a minute. And then we call something hypertensive crisis. When your blood pressure is

180 or above or 120 and above. That means that the blood is moving with so much force through your body that it is likely damaging end organs, your brain, your eyes, your kidney, your liver, your lungs, your heart, your nervous system. All of these things are being damaged because that blood is moving through there with so much force that is not able to leave the oxygen and the physical force that it is putting on those vessels. So if you can imagine a water hose or you can imagine your organs trying to drink out of a

fire hose, it's almost impossible. You'll get hurt doing that. There'll be damage done to your face if you try to drink out of a fire hose with the force that that water comes out. That's what happens in a hypertensive crisis. That blood is moving through there so hard that it's damaging the arteries, it's damaging the organs, and it is just way too high for you to sustain. So this is the pathology of blood pressures, right? This is the way that we categorize them and the way that we dictate whether or not something needs treatment or not.

So like we said, anything above 140 over 90 needs to be treated because there's inherent risk that comes with that. That inherent risk comes with end organ damage, like we talked about, damage to the kidneys, damage to the lungs, damage to the brains, damage to the eyes, damage to hormone producing organs. All this damage can cause other issues. Most importantly, there is damage to the lining of your arteries. So inside of your artery, there's a cell,

group being called endothelial cells and they line the interior of the artery. When the blood is moving through there with so much force, it is damaging those endothelial cells. So again, the fire hose reference, if you have too much pressure, the inside of your hose is getting damaged. Unlike a fire hose, our arteries can heal themselves and they do that. And we call that remodeling. And as the endothelium is remodeling, it's making itself thicker so it can tolerate the blood pressure that's coming through there.

That is both helpful because it reduces the risk of damaging that artery and rupturing you bleeding internally, but it also creates a problem when endothelial cells start to do that. You start to get thickening of the lining of the interior wall of the artery, which increases your blood pressure. Right. We increase vascular resistance like that. It also makes the artery more rigid, again, increasing peripheral vascular resistance because now the artery is rigid and it's not going to bend or adjust. So our

We're trying to prevent one problem from occurring and inadvertently creating another problem which perpetuates blood pressure issues. So what do we do about all this? Right. We have all these things that are happening inside of our body. The blood pressure is high. It's damaging our body. Our body is trying to help keep itself alive, but at the same time, it's creating other underlying issues. So how do we rectify this situation? Well, we have medications that we use for this. Right. So typically, if you're at stage two or above,

your physician is probably going to be recommending medications to treat. If you're below stage two, they may be more prone to recommend lifestyle modifications. So when we talk about lifestyle modifications, which is a lot of people's want to go to because we're all shifting into this more holistic approach, you have to think about how that lifestyle modification is going to have an impact on my variables. Is the lifestyle modification that I'm going to make going to improve my heart?

contractility, my cardiac output. Is it going to reduce my peripheral vascular resistance? Is it going to modify my blood volume? Is it going to change the elasticity of my vessels? Is it going to have an impact on regulators such as hormones or baroreceptors? These are the things that we need to think about when we're thinking about holistic lifestyle modifications. So when you think about I'm going to cut out sugar and I'm going to cut out salt from my diet.

These things will have an impact on your blood pressure, mostly because they're reducing volume, because now you're not holding on to a bunch of volume. You're reducing the strain on the kidneys, which is having a hormone response by improving renin aldosterone system compliance. And so now all of a sudden my blood pressure will come down because I've cut out those two things that hold on to water and shift some of my modulators. Will eating less fat have an effect on my on my blood pressure? Absolutely.

However, that's going to take more time because when I reduce my fat intake, then I produce less plaques, which means that my body has to utilize more fats, which will ultimately result in improvement in lower resistance. But it will take time versus cutting out salt and sugar from my diet may have a quicker response because of how quickly those modulators will get influenced. So we have to take those things into account when we're thinking about lifestyle modifications. How do they impact the variables that create my blood pressure problem?

And then if we're doing those things, and I usually recommend doing those things as well as taking medication so that we can make sure that we stay on top of controlling all of our medical issues and risk factors is using medications like ACE inhibitors, ARBs, diuretics, beta blockers, calcium channel blockers, and other vasodilators and alpha blockers. And these medications work on the variables. Our ACE inhibitors and our ARBs work on the kidneys. They improve blood flow, which

reduces the body's perception of volume and it reduces peripheral vascular resistance and that improves your blood pressure. Beta blockers work on the contractility of your heart, how fast it's pumping and how hard it's pumping. Our calcium channel blockers will dilate out veins and arteries and will help reduce peripheral vascular resistance and improve blood flow.

and then diuretics will have an effect on our volume. So you can see that these medications are working on those variables to help improve them and modulate them. So depending on where the underlying issue may come from may dictate what medication works best for you. And so all of these things are taken into account. So hypertension is common as it is and how common of a conversation it is, is very complex when it comes to your provider trying to make decisions of what the best path forward is gonna be.

And like I said, a lot of this is all risk management. During the course of the podcast, you will hear me say risk management a lot because the primary role of your provider is to manage the risk of something bad happening to you while you're under their care. My entire job is to reduce the risk of something bad happening to you. So if I don't control your blood pressure, you have a high risk of having a stroke or a heart attack or end organ damage like kidney disease that results in dialysis.

So all of these disease processes have carry risk. On the contrary, the medications also carry risk. There are side effects to a lot of these medications that we have to be mindful about and mitigate. So then the question becomes, what is the most concerning risk here? And so this is what we call a risk to benefit ratio. And every provider has a art form of deciding where those lines exist. And you want to find a provider who may have a better

may live in your realm of risk versus benefit accommodation, but that takes a little time to find. But again, so there's risk benefit, right? So, lacinepril as a medication can sometimes cause a chronic cough. Okay, the chronic cough as a side effect, although it's a nuisance and it's super annoying, is a lower risk, because that's not going to kill me or cause end organ damage, is a lower risk than me getting uncontrolled hypertension of 140 over 90 or above.

causing end organ damage over the course of the next 10 to 20 years. So those are the decisions that are being made. So we don't like to just throw medications out all willy nilly. There's conversations that we want to make sure that we're having so that you understand the risks that you're taking, but the benefits that you're also going to get out of it. Right. Are there lifestyle modifications that can improve this? Absolutely. But those things usually need to be measured with the risk that is present. If you come into my office and your blood pressure is 180

over 120, it is unlikely that I'm going to send you out of the office without any medication because of the risk that that level of blood pressure poses to your health. Can we do lifestyle modifications as well? Absolutely. But that is not the solution immediately, urgently and acutely. We need to make some sort of therapy to drop that number as quickly as possible to reduce the risk of adverse events. So.

When it comes to prevention of hypertension or management and mitigation, lifestyle plays the biggest role. Making sure that we're doing exercise and cardio exercises to keep the heart nice and healthy and happy. This improves cardiac efficiency. This improves the heart's ability to utilize oxygen efficiently. And it also allows our body to use oxygen efficiently, which means that our heart rate gets lower and our contractility gets softer.

and it reduces the risk of developing hypertrophy of the heart, which will ultimately create hypertension. We wanna make sure that we're eating a diet that has a healthy amount of fats, not too many fats and not too little fats, because whenever we don't eat enough fats, we can get rigidity that develops in the vessels, which also increases hypertension. This is the reason that a bunch of people over the age of 60 have hypertension is because of the rigidity of the vessels due to calcium deposition and the loss of pliability to their arteries.

So we wanna make sure that our diet is having a healthy amount of in it to ensure that we maintain pliability, flexibility of our cell walls. We wanna make sure that we're resistance training. This again goes back to making sure that our hearts are efficient at utilization of oxygen over the course of time. So cardio and resistance training, a diet that is having a healthy amount of fats and not over consuming. We wanna make sure that we stay mobile.

and keep our bodies in motion because that again helps to improve our body's efficiency at utilizing all of the components of oxygen as best as possible. All of this to also say that there are outlying factors that will influence blood pressure as well. If you have diabetes, that's a risk factor. If you have high cholesterol, that's a risk factor. If you have any other disease, and we're going to talk about the vast majority of them over the course of the podcast, will have an influence on your blood pressure because they are influencing the regulators of your.

blood pressure, so it's not as cut and dry as, as long as you do these things, you'll avoid this. There are other things that can affect the modulators and regulators of your blood pressure. So sometimes it's not just a primary blood pressure issue. Sometimes the blood pressure is just a symptom of something else. And we're going to get into that discussion as we go through all the different disease processes and make reference to secondary hypertension. So I hope that gives you guys a general synopsis of what blood pressure looks like, how the physiology of your body works.

to make blood pressure happen and how some things can become discordant in a way that they trigger pathology that results in hypertension and what your doctor's doing to try to treat that hypertension and what you can be doing at home through lifestyle modifications, improved exercise, both cardio and resistance training, improved diet, making sure we're eating a healthy amount of fat, making sure that we're taking in enough protein and carbohydrates to keep our body nice and healthy and avoiding other secondary disease processes that influence

hypertension or cardiac function. All of these things have an impact. So I hope that we've given you a good overview of that. If you have a specific disease process that you're curious about, we'll probably hit it later on in the podcast and make reference to how it influences blood pressure, since it is such a big and overarching disease process that is present. So I hope you guys enjoy the podcast. I hope to see you back in a couple of weeks for the next episode. Until then, take care and salud.