Part 3 of Top 10 Medications: Lisinopril (3), Amlodipine (8), and Losartan (10)

CONDITIONS TREATED: MAINLY HYPERTENSION/HIGH BLOOD PRESSURE

Hypertension or high blood pressure is known as the silent killer, a dangerous disease that may not show symptoms before a catastrophic event occurs. High blood pressure can negatively affect all systems of the body and is a primary risk factor in leading causes of preventable death including stroke, cardiovascular disease, and kidney disease. In 2019, more than 500,000 deaths had hypertension as a primary or contributory cause.

High blood pressure is common and treated aggressively, the #3, #8 and #10 top selling medications in the United States are used to treat hypertension. Hypertension is diagnosed after 3+ readings of blood pressure over 140/90 mmHg (millimeters mercury).

Everyone should know their blood pressure, it's a vital that's taken at every visit to your provider for a reason. Measure it at drug stores, gyms, or other locations a cuff is available and if you get a high reading, get a home cuff and start measuring and recording patterns more frequently. If your blood pressure is consistently high or you get frequent high readings, it's time to take action to lower it.

Lisinopril is the #3 prescribed medication in the United States and one of several ACE (angiotensin converting enzyme) inhibitors, generally considered safe and effective. Lisinopril is often the first medication prescribed for hypertension. ACE inhibitors improve kidney function, the kidneys are responsible for filtering the blood and need protection from the damage caused by hypertension. Dry cough is the main side effect in about 20% of users. This is caused by a build up of a kinin called bradykinin. Kinins are produced by the body in response to tissue injury.

Losartan is the #10 prescribed medication in the United States, often prescribed after the #3 medication, Lisinopril, causes a cough. It is an ARB (angiotensin receptor blocker) that's effective, but less so than Lisinopril. ARBs also are protective of the kidneys. The full effect of Losartan takes longer to achieve, up to 6 weeks.

Amlodipine is the #8 prescribed medication in the United States. As a calcium channel blocker, Amlodipine relaxes the peripheral blood vessels to allow for higher volume and less pressure. This mechanism of action may also be helpful for improving circulation in those with Raynaud's disease or chronic anemia. Amlodipine is frequently used in hypertension of pregnancy and postpartum. It is considered safe for long-term use.

Standards of care puts lifestyle medicine as the first treatment in cases of hypertension. Here are the ways the cornerstones of health can regulate blood pressure. It's best to shoot for below 120/80, but as we age, there's some evidence slightly higher blood pressure, with systole in the 120s-130s, can result in longer life. The top number is systolic pressure, and the bottom number is diastolic pressure.

DIET

• Sodium is a hotly debated topic. Popular opinion is 25% of the population is salt-sensitive, but this number is from research showing how dramatic increases or decreases in sodium affects blood pressure. This same research also showed an inverse relationship between blood pressure and sodium - 11-16% of cases showed blood pressure increased with decreased sodium.

• Choose sea or Himalayan salt over table salt. Table salt is refined to contain over 90% sodium chloride, the less refined sea or Himalayan salts contain other trace elements. While the weight of sodium chloride has been found to be the same in samples of all 3 salts, using the Himalayan or sea salt results less total sodium used for the same amount of flavor (I argue better).

• You can test your sodium sensitivity by limiting intake to 2300mg or less per day. The DASH diet (Dietary approaches to stop hypertension) is a popular blue-print with many recipes and meal plans available online.

• Sodium is less of a concern when consuming whole foods made from simple (1 ingredient) ingredients. For instance, prepared pesto sauce usually contains a lot more sodium than pesto sauce you make at home from olive oil, basil, garlic, pine nuts, parmesan, and your own measurement of salt and pepper.

• Hypertension, obesity and type 2 diabetes are common co-morbidities. For the majority of people with hypertension, decreasing sodium starts with limiting highly refined and processed foods that are salted to the max for your tasting pleasure. Most of these foods are also high in inflammatory fats and refined carbohydrates/sugars, also designed to tantalize your taste buds. Instead, eat foods that nature made like vegetables, fruits, nuts, seeds, beans, meats, poultry, fish, whole grains, whole unflavored dairy (raw dairy best). Focus your menu on recipes that put together simple ingredients to make a dish. Simple ingredients don't really have ingredients, rice is rice and meat is meat.

EXERCISE

Stress management will be extensively covered next, but the difference between compensated and uncompensated stress must be discussed. The stress response is innate - hormones are released which increase heart rate, respiratory rate, blood sugars, and blood pressure in order to provide energy needed to take action. Exercise is compensated stress, meaning the body is moving in response to its changing environment, the increased rates are necessary for proper function. Exercise and the recovery from exercise teaches the body how to physically recover from stress. Exercise also releases feel good chemicals, endorphins, which help us cope with uncompensated stress later.

STRESS MANAGEMENT

Uncompensated stress occurs when our bodies make all those stress hormones that increase heart rate, blood pressure and blood sugars but don't undertake physical action in response. Managing stress is lifestyle medicine - stress will always exist and it's important to learn how to reduce the body's response. Managing stress is about developing resilience, resilience prevents the release of stress hormones which increase blood pressure.

Breath work is safe and effective for everyone, especially people who suffer from high blood pressure and stress. This includes those with white coat syndrome or elevated blood pressure readings that are situational. How can breath work regulate blood pressure? I'll try and explain as succinctly as possible.

• The pressure from inflating the lungs on the inhale inhibits the vagus nerve, or cranial nerve X, called a vagal break. The vagus nerve supplies parasympathetic innervation to the heart and lungs, controlling heart rate through the sinoatrial (SA) node. When the vagus nerve is mechanically inhibited during the inhale, the sympathetic nervous system takes over control of heart rate, causing heart rate to increase. Exhaling takes pressure off the vagus nerve and it becomes active again, slowing down heart rate. The difference between the heart rate of the inhale and the heart rate of the exhale is heart rate variability.

• Heart health has long been correlated with an increase in heart rate variability. There are devices which measure heart rate variability available for purchase. The Whoop is the most popular of these devices.

When you're stressed, the inhale is likely held. If someone comes up from behind and scares you, what happens to the breath? Typical response is a gasp. Paradoxically, when you're relieved about something, you sign and exhale.

Develop awareness of your breath by noticing what it does. I've witnessed people with blood pressure of 180/110 bring it down to 120/80 after 20 minutes practicing even inhales and exhales, hooked up to a belt that ensures diaphragmatic breathing. This effort will likely be reversed the moment of return to the "real world". This highlights why practice is important - breath awareness is developed through consistent breathing exercises. Next time you feel stressed, notice if you're holding on the inhale.

SLEEP

Achieving 7-8 hours of restful sleep is essential for regulating or lowering blood pressure. Sleep helps the body regulate stress hormones, and lack of sleep can cause swings in these hormones, increasing blood pressure. Insomnia is an important problem to address.

Intolerance of caffeine is a common cause of insomnia. Depending on your genetics, you may need to stop drinking caffeine, or at least stop it by a certain time of day to fall asleep at a decent hour. The magic number is often no caffeinated beverages after 12pm, for some that needs to be pushed back even earlier, and for some caffeine is not tolerated at all. Some people can drink a cup of coffee 1 hour before bed and sleep for 8 hours, no problem.

• A trial off caffeine is a useful experiment when determining the cause of insomnia. It's possible to stop caffeine slowly enough to prevent the dreaded headache. Usually, physical symptoms can be avoided by switching to black tea right away. Black tea is a good substitute for coffee as it has less caffeine, but also has theanine, an anxiety reducing amino acid. Stick to 1 cup per day, but if you get a headache, it's fine to take sips. After 1 week or so of only 1 cup of black tea daily, stop black tea and only brew a cup if you get a headache, only taking small sips of the tea until the headache goes away. The headache is usually resolved within a couple sips. Eventually, you won't brew the tea and you'll be off caffeine. Give abstinence a week or so, notice how your sleep changes.

• Be aware of caffeine in decaffeinated products. Choose caffeine free instead.

• Be aware caffeine is in iced teas, sodas, even root beer. Often, when I'm out for dinner, I ask for something with no caffeine, no sugar, and no alcohol. The only option available is frequently water or sparkling water.

CONCLUSION

It is important to lower elevated blood pressure, you could even say your life depends on it. Lifestyle medicine is extremely effective at lowering blood pressure with or without medication. Medications are generally safe, but do have side effects many people like to avoid. The most common, associated with all the medications, is a low level fatigue. Success following the above lifestyle steps is highly likely over time. Be patient, and remember, it's completely safe to take medications and practice lifestyle change. In fact, it's recommended.