Should my patient with Hypertension participate in organized sports?
Note: The decision tree below is a graphic interpretation of the ACC/AHA 2015 guideline,
as perceived by the creator of CardioRef, who was not a part of the expert panel involved in the guideline
creation.
I would strongly recommend that you read the full guideline
for further clarification. Feedback regarding the interpretive figure below is welcome.
Before applying the following decision tree, please note the following:*
"The diagnosis of hypertension is based on the subject having an elevated BP at or above certain levels
measured by routine sphygmomanometry under appropriate conditions on at least 2 separate occasions separated by at least 1 week" (Chobanian 2003)
"People >18 years of age with a BP >140 mm Hg systolic and/or >90 mm Hg diastolic are considered to have hypertension" (Chobanian 2003)
"In children and adolescents, hypertension is defined as average systolic or diastolic BP levels greater than the 95th percentile for sex, age, and height; however, earlier physical maturation of the competitive athlete leaves open to question
when an adult age criterion for hypertension should be applied to the adolescent." (Moyer 2013)
"In determining the level of competitive athletic activity that a hypertensive person may engage in, it is also important to determine the degree of hypertension-related target-organ damage."
"For the general population, increased levels of noncompetitive recreational physical activity are generally regarded as beneficial...
Those who are hypertensive derive protection from both all-cause and cardiovascular mortality by maintaining higher levels of cardiorespiratory fitness." (Church 2001)
"In an adolescent or young adult (ie, < 25 years of age) with stage 2 hypertension, it may be appropriate to refer this person for further evaluation
and therapy to a cardiologist or hypertension specialist. The workup for secondary forms of hypertension and proper pharmacological management is often
outside the scope of general pediatricians and family practitioners who might otherwise be seeing these athletes"
*Quotations above are from the ACC/AHA 2015 guidelines. The superscripted citations at the end of each quotation are the citations cited within the guidelines.
First, perform appropriate BP assessment
"Before people begin training for competitive athletics, it is reasonable that they undergo careful assessment of BP,
and those with initially high levels (>140 mm Hg systolic or >90 mm Hg diastolic) should have comprehensive out-of-office measurements
to exclude errors in diagnosis.
Ambulatory BP monitoring with proper cuff and bladder size would be the most precise means of measurement."
(Class I Recommendation; Level of Evidence B)
⇙ ⇘
Pre-HTN (BP 120-139/80-89)
"Those with prehypertension (BP of 120/80 mm Hg–139/89 mm Hg) should be encouraged to modify their lifestyles
but should not be restricted from physical activity."
No activity restrictions
Sustained hypertension (>140/90)
"Those with sustained hypertension should have screening echocardiography performed.
Athletes with LVH beyond that seen with “athlete’s heart” should limit participation
until BP is normalized by appropriate antihypertensive drug therapy."
If pathological LVH: Limit sport participation until BP normalized.
If no pathological LVH: See below
(Class IIa Recommendation; Level of Evidence B)
⇓⇓
Stage 1 HTN (BP 140-159/90-99) without target-organ damage
"It is reasonable that the presence of stage 1 hypertension in the absence of target-organ damage should not
limit the eligibility for any competitive sport. Once having begun a training program,
the hypertensive athlete should have BP measured every 2 to 4 months (or more frequently, if indicated)
to monitor the impact of exercise."
All sports = acceptable, if no LVH or other target-organ damage (with BP checks at least q2-4 months)
(Class I Recommendation; Level of Evidence B)
Stage 2 HTN (SBP > 160, or DBP >100)
"It is reasonable that athletes with stage 2 hypertension (a systolic BP >160 mm Hg or a diastolic BP >100 mm Hg),
even without evidence of target-organ damage, should be restricted, particularly from high static sports,
such as weight lifting, boxing, and wrestling, until hypertension is controlled by either lifestyle modification or drug therapy."
No sports until HTN is controlled
(Class IIa Recommendation; Level of Evidence B)
General Considerations
"When prescribing antihypertensive drugs, particularly diuretic agents, for competitive athletes, it is reasonable for clinicians to
use drugs already registered with appropriate governing bodies
and if necessary obtain a therapeutic exemption."
(Class IIa Recommendation; Level of Evidence B)
"When hypertension coexists with another cardiovascular disease, it is reasonable that eligibility for participation in
competitive athletics is based on the type and severity of the associated condition."
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jones DW, Materson BJ, Oparil S, Wright JT, Roccella EJ; National High Blood Pressure Education Program Coordinating Committee. JNC 7: complete report: seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.Hypertension. 2003; 42:1206–1252. doi: 10.1161/01.HYP.0000107251.49515.c2.
Church TS, Kampert JB, Gibbons LW, Barlow CE, Blair SN.Usefulness of cardiorespiratory fitness as a predictor of all-cause and cardiovascular disease mortality in men with systemic hypertension.Am J Cardiol. 2001; 88:651–656.
Moyer VA; U.S. Preventive Services Task Force. Screening for primary hypertension in children and adolescents: U.S. Preventive Services Task Force recommendation statement.Pediatrics. 2013; 132:907–914. doi: 10.1542/peds.2013-2864.
Disclaimer: This website is derived from published guidelines, but does not constitute medical advice nor does it replace clinical judgement. Only the text in quotation marks are direct quotations from the original guidelines. Text not in quotations as well as the method of information display are all that of the website creator and are not part of the original published guidelines. Please consult a physician to discuss any patient-specific matters.
Key: HTN = hypertension, BP = blood pressure, SBP = systolic BP, DBP = diastolic BP