Mature Man Athlete Have Sore Left Chest Pain Dizziness

Coaching Hypertensive Athletes

BY Dr. Jeff Sankoff

Hypertension can cause concern for coaches and athletes alike. Listen to what Doctor and Tri Coach Jeff Sankoff has to say about what merits your attention.

Hypertension, or high blood pressure, is frequently referred to as the ‘silent killer’ because it often goes undetected, does not present symptoms and over the long term, if left untreated, can cause severe disease. Hypertension can cause heart attacks, strokes, kidney failure and vascular disease.

The incidence of hypertension increases with age and with an increasing number of masters triathletes, it is becoming much more common for athletes to report this as an underlying medical condition to their coaches. Studies of elite athletes have shown that as many as 10% have hypertension. This can play a role in the development of ventricular hypertrophy of the heart. Fortunately, working with athletes who have hypertension is not terribly difficult but there are some important things to consider.

What Constitutes Hypertension

Hypertension is defined as blood pressure higher than 140/90, although more recent guidelines are more conservative with an upper range of 130 as the cutoff. This should be measured on separate occasions over a defined period of time, usually from several weeks to months. In the vast majority of cases, hypertension is essential, that is to say without any obvious underlying cause. However, in about 10% of cases, there are underlying causes such as renal artery stenosis which, when remedied, will usually correct the high blood pressure.

Management of hypertension varies depending on the severity of the blood pressure elevation and whether or not the patient has any co-existing disease or risk factors for other diseases (e.g.; obesity, diabetes, etc.). The most important considerations for coaches with athletes who have been diagnosed with hypertension are: how does this diagnosis affect an athlete? Does training and racing affect hypertension? And, does the treatment of hypertension pose any concerns for training and racing?

The Effects of Hypertension on Performance

High blood pressure on its own is not a limiter to training and racing however, it should be taken as a sign of a potential underlying disease. It is well known that hypertension is a leading cause of both heart disease and stroke but not all people with hypertension will develop either of these problems. 

When a coach becomes aware that an athlete is being treated for hypertension, it is prudent to discuss the extent and severity of this diagnosis. How long has the athlete been aware of this issue? Have they been treated for it? Do they have other risk factors for vascular disease such as a family history or a history of smoking, diabetes or obesity? If the answer to this last question is yes, then a physician should first clear the athlete before they participate in high-intensity physical activity. If no, then simply counsel the athlete to comply with their anti-hypertensives and to be diligent about reporting any symptoms of unexpected shortness of breath, chest discomfort or palpitations.

High blood pressure alone has never been shown to adversely affect or limit athletic performance. As long as there aren’t any other know cardiovascular diseases present, then the condition doesn’t necessitate an adjustment to a training plan.

The Effects of Exercise on Hypertension

While hypertension does not affect exercise performance, exercise definitely has effects on hypertension. For more than three decades, exercise has been prescribed as one of the mainstays of therapy for controlling hypertension. In milder cases, it may actually be all that is needed. Moderate-intensity aerobic exercise has a modest but significant effect on decreasing blood pressure and this can be long-lasting. Even strength training exercises have proved to be beneficial in this regard. The one caveat to this is isometric training, often paired with heavy resistance work, which can cause breath-holding. These exercises can dramatically increase blood pressure and should be avoided by athletes with hypertension. 

The Effects of Anti-Hypertensive Therapy on Training and Racing

For athletes who are training and racing while taking blood pressure medications, there are two things coaches should consider: one, whether or not the drug will impact the athlete’s performance and two, whether or not the drug is on the banned substances list.

Blood pressure medications fall under several different classes and treating physicians will start with one or another depending on a patient’s overall profile. While it is beyond the scope of this article to explore pharmacology and mechanism of the effect of these agents, it is important for a coach to recognize that many of these agents can cause dehydration sensitivity. For athletes who are not on beta-blockers, coaches need only emphasize the importance of maintaining adequate hydration. Some antihypertensives increase urine output, while others make the kidneys more susceptible to injury.

For athletes taking beta-blockers, these drugs can prevent the heart rate from increasing and as a result, can restrict performance. If you have an athlete who is taking one of these agents and they complain that they are unable to exert themselves normally, or if they complain of lightheadedness while training, they may wish to discuss switching to a different class of anti-hypertensives for the purpose of improving the exercise tolerance.

Finally, it is important to note that many of the classes of anti-hypertensive medications are listed as banned substances both in and out of competition. A coach with an athlete who is taking one of these medications needs to have their athlete apply for a therapeutic use exemption (TUE), lest they be tested and face a suspension. Remember that coaches with knowledge of an athlete taking a medication on the banned substance list may also face sanctions, so it is incumbent upon them to both encourage and document the communication relevant to this application.

As always, train hard and train healthy.

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About Dr. Jeff Sankoff

Jeff Sankoff is an Emergency Physician, long time triathlete and USAT/IRONMAN University Certified coach. He has completed 6 IRONMAN races (including Kona) and more than fifty races at the 70.3 distance including 5 World Championships. He produces the TriDoc Podcast that can be found on most popular podcast platforms and iWork’s with LifeSport Coaching. You can learn more about him at his website: TriDoc Coaching.