A Functional Medicine Hypertension Protocol

Hypertension (high blood pressure) is a major cause of premature death. Despite this grave fact, nearly half of American adults have hypertension; an estimated 46% of adults with high blood pressure are aware they have it; and only 21% have it under control. Early diagnosis and successful intervention for blood pressure management are essential for preventing cardiovascular disease and increasing longevity. (42)

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What Is Hypertension?

Blood pressure is the force of blood pushing against the walls of your arteries as the heart beats and relaxes. Blood pressure is reported as two numbers (systolic over diastolic) and measured in units of millimeters of mercury (mmHg). Systolic pressure is the pressure when the heart pumps blood out, and diastolic pressure is the pressure between heartbeats as the heart muscles relax. Normal blood pressure is less than 120/80 mmHg.

Hypertension is consistently higher than normal blood pressure. 

In 2014, the Eight Joint National Committee (JNC 8) published evidence-based guidelines for managing high blood pressure in adults. These guidelines define hypertension as blood pressure that is 140/90 mmHg or higher. 

In 2017, the American College of Cardiology and the American Heart Association (ACC/AHA) released new guidelines for diagnosing and treating high blood pressure. These revised guidelines state that hypertension is diagnosed at 130/80 mmHg.

Hypertension Signs & Symptoms

Hypertension is often called a "silent killer" because most people don't have symptoms until blood pressure has reached a life-threatening stage called hypertensive crisis. A hypertensive crisis is when blood pressure reaches readings of 180/120 mmHg or greater, causing any of the following symptoms:

• Chest pain
• Shortness of breath
• Back pain
• Numbness
• Weakness 
• Changes in vision
• Difficulty speaking
• Confusion
• Dizziness
• Vomiting

Root Causes of Hypertension

Primary (essential) hypertension is high blood pressure unrelated to an underlying medical problem. Generally, primary hypertension results from lifestyle factors. Risk factors for primary hypertension can include a high-salt diet, a sedentary lifestyle, caffeine and alcohol consumption, smoking, family history, obesity, stress, and older age.

Secondary hypertension, less common than primary hypertension, is elevated blood pressure due to an identified medical condition. Possible causes of secondary hypertension include: 

Kidney Disease

Renal parenchymal disease, which includes diabetic nephropathy, glomerulonephritis, interstitial kidney disease, and polycystic kidney disease, is the most common cause of secondary hypertension, accounting for 2.5-5% of all cases. More than half of patients with kidney disease have hypertension, which worsens as the kidney disease progresses.

Endocrine Disorders

Medical conditions that create hormonal imbalances can cause high blood pressure. The most common conditions associated with hypertension include:

• Cushing's syndrome
• Hyperaldosteronism
• Pheochromocytoma 
• Thyroid disorders, including hypothyroidism and hyperthyroidism
• Hyperparathyroidism, causing hypercalcemia (high calcium levels)

Vascular Disorders

Hypertension may occur secondary to stenosis (narrowing) of one or both renal arteries, usually caused by atherosclerosis. Coarctation of the aorta, a congenital condition, is a narrowing of the aorta that often presents as high blood pressure in the arms and low blood pressure in the legs. (36)

Obstructive Sleep Apnea (OSA)

As many as half of patients with sleep apnea may have hypertension. Untreated OSA is a common reason for resistance to antihypertensive medications. Common blood pressure patterns associated with OSA include elevated nighttime blood pressure, blood pressure dips during sleep, and isolated diastolic hypertension. (44)

Medications & Supplements

Drug-induced hypertension is a significant contributor to secondary hypertension; common offenders include:

• Nonsteroidal anti-inflammatory drugs and acetaminophen
• Sodium-containing antacids
• Stimulant medications used to treat ADD/ADHD
• Antidepressants
• Atypical antipsychotics
• Decongestants containing phenylephrine or pseudoephedrine
• Appetite suppressants
• Systemic corticosteroids
• Estrogens (including oral contraceptives) and androgens
• Nicotine
• Herbal supplements: St. John's wort, Yohimbe, licorice, and ephedra

How to Diagnose Hypertension

A healthcare provider will diagnose high blood pressure by performing blood pressure checks, reviewing the patient's medical history, and ruling out conditions that cause secondary hypertension.

Step 1: Measure Blood Pressure

A diagnosis of hypertension requires the following:

• Measurement of blood pressure by a validated/calibrated blood pressure measuring device
• Proper methods for blood pressure measurement 
• At least two blood pressure readings that meet the threshold for hypertension on at least two separate occasions (38) 

The U.S. Preventive Services Task Force (USPSTF) recommends that patients take blood pressure measurements outside of the clinical setting to confirm a hypertension diagnosis and screen for white coat hypertension (high blood pressure in a doctor's office with normal at-home blood pressure readings) with 24-hour ambulatory or home blood pressure monitoring.

Step 2: Rule Out Secondary Hypertension

Initial testing for all patients with hypertension should include the following: 

• Fasting blood glucose
• Complete blood count (CBC)
• Comprehensive metabolic panel (CMP)
• Lipid profile
• Thyroid-stimulating hormone (TSH)
• Urinalysis
• Electrocardiogram

Together, these labs help screen for anemia, diabetes, high cholesterol, and kidney disease to stratify a patient's cardiovascular disease risk, screen for end-organ damage due to high blood pressure, and act as a beginning reference point as you continue care with your patient.

The Atherosclerotic Cardiovascular Disease (ASCVD) Risk Estimator is a tool that calculates a patient's 10-year ASCVD risk based on cholesterol levels, age, sex, race, and blood pressure. Determining the 10-year ASCVD risk aids informed decision-making in managing hypertension to prevent cardiovascular disease.

Common signs that warrant an investigation for secondary hypertension include: 

• Hypertension resistant to therapy
• A sharp rise in blood pressure in a previously stable patient
• Onset of hypertension in a patient younger than 30 without risk factors
• Onset of hypertension before puberty
• Patients with blood pressure greater than 180/110 mmHg
• Patients with end-organ damage
• Hypertension with electrolyte imbalances

Additional labs may be required in the following scenarios:

• If Cushing's syndrome is suspected: dexamethasone suppression test or 24-hour urinary free cortisol
• If parathyroid disease is suspected: serum parathyroid hormone
• If pheochromocytoma is suspected: plasma or urinary metanephrines
• If hyperaldosteronism is suspected: plasma aldosterone and plasma renin activity
• If renal hypertension is suspected: kidney imaging
• If sleep apnea is suspected: sleep study

Step 3: Order Labs That Can Help Personalize Treatment Plans

The following labs are not recommended by conventional medical guidelines but can provide additional insight into the mechanisms driving elevated blood pressure and cardiovascular risk.

Comprehensive Stool Analysis

What's going on in the gut influences cardiovascular health. Intestinal dysbiosis is associated with the translocation of gut microbes into vascular tissues, resulting in systemic inflammation, lipid and blood sugar dysregulation, atherosclerosis, hypertension, and a generally increased risk of cardiovascular disease. Additionally, nitric oxide, a natural vasodilator, requires a healthy balance in oral flora for sufficient endogenous production. Research suggests that nitric oxide deficiency is the first step in hypertension pathogenesis.

A comprehensive stool analysis (such as one of the tests listed below) that assesses the gut microbiome and detects the presence of parasites, yeast, and pathogenic and commensal bacteria can rule out dysbiosis contributing to cardiovascular inflammation and nitric oxide deficiency. Running this test with a serum trimethylamine N-oxide (TMAO) may be helpful. TMAO levels are influenced by diet and microbial flora. A positive correlation exists between elevated levels and increased risk for major adverse cardiovascular events, kidney disease, and death. (64)

• GI-MAP by Diagnostic Solutions
• Microbiomix by Genova Diagnostics
• GI360 by Doctor's Data

Mercury

Mercury exposure and toxicity induce vascular changes that increase oxidative stress, inflammation, and endothelial dysfunction. Consequences of exposure, commonly from mercury amalgams and seafood, include kidney dysfunction, atherosclerosis, and hypertension. Whole blood mercury by Access Med Labs is one example of a test that can quantify a person's level of mercury exposure.

Adrenal Stress Test

Stress can contribute to hypertension by over-activating the hypothalamic-pituitary-adrenal (HPA) axis and nervous system, resulting in the excessive release of stress hormones that act to constrict blood vessels and increase blood pressure. 

The following panels help assess the body's stress response:

• NeuroAdrenal Profile - Random by Doctor's Data
• Adrenal Stress Panel by Ayumetrix
• ASP with CAR by Genova Diagnostics

Micronutrient Assessment

Endothelial dysfunction is when the endothelium, the thin layer of cells lining the blood vessels, loses its normal function. It is characterized by dysregulated blood vessel tone, fluid imbalance, and vascular inflammation. Because of this, it is closely related to hypertension. Nutrient deficiencies, particularly magnesium, vitamin D, omega-3 fatty acids, antioxidants, folate, and vitamin B12, can contribute to endothelial dysfunction and arterial inflammation.

Screen for nutrient deficiencies with one of the following micronutrient panels: 

• Micronutrient Test by SpectraCell
• Cellular Micronutrient Assay by Cell Science Systems 
• NutrEva FMV by Genova Diagnostics

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Treatment Plan for Hypertension

The goal of treating hypertension is to bring blood pressure levels down to a normal range to reduce the patient's risk of end-organ failure and adverse cardiovascular events. 

Step 1: Reduce Blood Pressure to Target Level

Here's Why This Is Important:

High blood pressure places an excessive strain on the cardiovascular system, leading to the development of atherosclerosis and life-threatening events such as heart attacks and strokes. A reduction of 10 mmHg in systolic blood pressure decreases the risk of major cardiovascular events and results in a notable 13% reduction in all-cause mortality.

How Do You Do This?

The 2017 ACC/AHA Guidelines for Hypertension emphasize the importance of modifying diet, physical activity, and alcohol consumption alone or combined with pharmacological therapy to get all hypertensive patients to a goal blood pressure target of less than 130/80 mmHg.

Non-pharmacologic therapies should be recommended as first-line treatment for patients with:

• Elevated blood pressure (120-129/<80 mmHg)
• Stage 1 hypertension (130-139/80-89 mmHg) without clinical ASCVD or an estimated 10-year ASCVD risk <10% (77) 

The most effective non-pharmacologic interventions for lowering blood pressure include: 

• Weight loss: expect about a 1 mmHg reduction in blood pressure for every 1 kg reduction in body weight
• Heart-healthy diet, such as the DASH diet: eat a diet rich in fruits,  vegetables, whole grains, and low-fat dairy and reduce intake of saturated and trans fats
• Reduce dietary sodium to less than 1,500 mg/day
• Increase intake of dietary potassium, aiming for 3,500-5,000 mg/day
• Exercise: 150 minutes of dynamic aerobic exercise and resistance training weekly
• Moderate alcohol consumption: men should drink no more than two drinks daily; women should drink no more than one drink daily (77) 

According to these same guidelines, antihypertensive medications should be prescribed as first-line therapy for patients with: 

• Stage 1 hypertension (130-139/80-89 mmHg) with clinical ASCVD or an estimated 10-year ASCVD risk >10%
• Stage 2 hypertension (>140/90 mmHg) (77)

The primary agents used in managing hypertension include thiazide diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers. A single agent is sufficient for most when initial drug treatment is being considered. However, consideration can be given to starting two drugs of different classes for patients with stage 2 hypertension. (77) 

It should also be noted that the management of secondary hypertension requires addressing/treating its secondary causes because doing so can completely cure hypertension and eliminate the need for antihypertensive therapy.

Step 2: Reduce Inflammation

Why Is This Important?

Inflammation can contribute to endothelial dysfunction, arterial stiffness, and atherosclerosis, all of which are critical factors in developing and maintaining high blood pressure.

How Do You Do This?

Reducing inflammation involves a holistic approach. Here are several key strategies: 

• Anti-inflammatory diet: emphasize whole, unprocessed foods rich in anti-inflammatory compounds. This includes fruits, vegetables, whole grains, nuts, seeds, and fatty fish. Ensure an adequate intake of anti-inflammatory nutrients, such as vitamins A, C, and E, magnesium, and polyphenols, found in foods like berries, leafy greens, and green tea. 
• Large population-based cohort studies consistently show that regular exercise and higher fitness levels correlate to lower systemic inflammatory markers.  
• Poor sleep increases inflammation and blood pressure (51, 78). Adults should aim for 7-9 hours of quality sleep per night.
• Stress-induced inflammation is responsible for 75-90% of disease. Mind-body practices, such as mindfulness meditation and yoga, can increase the body's resilience to stressors by activating the parasympathetic nervous system. Research supports using these practices to reduce inflammation and blood pressure (7, 34).
• Address gut health through diet, prebiotics, probiotics, and gut-healing nutrients, such as L-glutamine. 
• Herbs such as ginger, Boswellia, and turmeric have been shown to reduce inflammation.

Step 3: Replete Nutrients

Why Is This Important? 

Nutrient deficiencies can impair endothelial function, increase arterial stiffness, and promote inflammation, all of which contribute to the development and progression of hypertension.

How Do You Do This?

Magnesium is important for skeletal and cardiac muscle health, and deficiency or insufficiency can contribute to endothelial dysfunction, high blood pressure, and chronic heart failure. Taking 500-1,000 mg of magnesium daily can reduce blood pressure by up to 5.6/2.8 mmHg.

CoQ10 is a powerful antioxidant that supports energy production and prevents blood clot formation. CoQ10, typically dosed at 100 mg daily, has been shown to lower blood pressure by as much as 17/10 mmHg. (24, 55)

The body requires L-arginine, L-citrulline, vitamin C, and nitrates for nitric oxide synthesis. Supplementation with these nutrients has been shown to boost nitric oxide levels and improve vasodilation. Not a fan of supplements? No problem! Get these nutrients by eating these foods:

• Nitrates: beets, leafy greens
• L-Arginine: nuts and seeds
• L-citrulline: watermelon
• Vitamin C: citrus fruits

The Risks of Untreated Hypertension

The risks of untreated hypertension are significant and can lead to life-threatening consequences, including hypertensive crisis, as well as long-term effects on cardiovascular health and mortality.

A hypertensive crisis requires emergent medical attention because it can result in the following complications:

• Stroke
• Loss of consciousness
• Memory loss
• Heart attack
• Eye and kidney damage
• Aortic dissection
• Pulmonary edema
• Eclampsia

Chronic hypertension significantly increases the risk of developing cardiovascular diseases, including coronary artery disease, peripheral artery disease, stroke, and heart failure. 

According to the World Health Organization (WHO), high blood pressure is a contributing cause of 8.4 million deaths annually, directly causing 13% of global deaths. It is the leading cause of 45% of cardiovascular deaths and 51% of stroke-related deaths. (1) 

Hypertension Case Study

You can read about how one patient successfully lowered his blood pressure here:

Michael's Journey to Lowering Blood Pressure and Insulin through an Integrative Medicine Approach: A Captivating Case Study

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Key Takeaways:

• Hypertension is a significant cardiovascular risk factor. The detection and appropriate treatment of high blood pressure can reduce cardiovascular mortality by 30.4% in men and 38% in women. 
• Treatment of hypertension should always include foundational lifestyle modifications, emphasizing a heart-healthy diet and physical activity. The decision to initiate pharmacologic therapy should consider the patient's ASCVD risk, the severity of hypertension, and personal preferences. 
• Nonpharmacological treatments can be implemented as an alternative to, or in conjunction with, prescription antihypertensives to effectively treat high blood pressure and optimize cardiovascular health and function.