The Peter Attia Drive - Blood pressure： how to measure, manage, and treat high blood pressure (AMA #48 rebroadcast)

00:00:00.000 Hey, everyone. Welcome to The Drive Podcast. I'm your host, Peter Atiyah. This podcast,

00:00:16.540 my website, and my weekly newsletter all focus on the goal of translating the science of longevity

00:00:21.520 into something accessible for everyone. Our goal is to provide the best content in health and

00:00:26.720 wellness. And we've established a great team of analysts to make this happen. It is extremely

00:00:31.660 important to me to provide all of this content without relying on paid ads to do this. Our work

00:00:36.960 is made entirely possible by our members. And in return, we offer exclusive member only content

00:00:42.720 and benefits above and beyond what is available for free. If you want to take your knowledge of

00:00:47.940 this space to the next level, it's our goal to ensure members get back much more than the price

00:00:53.200 of a subscription. If you want to learn more about the benefits of our premium membership,

00:00:57.980 head over to peteratiamd.com forward slash subscribe.

00:01:04.480 Welcome to a special episode of The Drive. This week, we're rebroadcasting a previous AMA,

00:01:10.680 which focuses on blood pressure. Blood pressure is one of the most important and sadly overlooked

00:01:15.480 risk factors for chronic disease. It's a topic that affects nearly everyone, yet many people

00:01:20.520 either do not know their numbers or don't appreciate how profoundly blood pressure

00:01:24.620 influences long-term health. While this AMA was originally released to subscribers, we felt it

00:01:29.500 was important enough to make it available to everyone, while also giving those of you who

00:01:33.960 aren't subscribers a chance to experience what our AMA episodes are all about. In this AMA,

00:01:38.880 we talk about what blood pressure actually measures and why it matters for longevity,

00:01:43.780 how to accurately measure blood pressure at home, and why office readings can often be misleading,

00:01:48.300 the relationship between blood pressure, cardiovascular disease, dementia, kidney disease, and overall mortality,

00:01:55.860 what the latest evidence says about optimal blood pressure targets,

00:01:59.740 the lifestyle interventions including weight loss, exercise, nutrition, and sleep

00:02:03.660 that have the biggest impact on lowering blood pressure,

00:02:06.840 when medications become necessary, how they work, and how to think about the different treatment class options,

00:02:13.200 and practical strategies for monitoring and managing blood pressure over the long term.

00:02:18.300 So without further delay, I hope you enjoy this special rebroadcast of our AMA on blood pressure.

00:02:29.500 Peter, welcome to another AMA. How are you doing?

00:02:32.200 Very well, thank you.

00:02:33.360 Awesome. You know, before we get started on this one, some of the people who listened to

00:02:38.020 one or two AMAs ago when we were going over your DEXA results, we were talking and telling the

00:02:43.180 story about Reese's Pieces and how you had never heard of them and we did a call out to say hey

00:02:48.620 if anyone else has never heard of them please reach out and you will be pleased to know

00:02:53.200 we probably had about 30 to 40 people who are in the same boat as you and had no idea what

00:02:59.540 Reese's Pieces are so you are not the only one not the only one on this planet not the only one

00:03:06.360 I mean again 30 to 40 compared to our listenership is not a good percentage so you're definitely

00:03:12.360 in the minority but yeah shout out to everyone who reached out and the person who was the first

00:03:18.160 to reach out we have something special going in the mail for them and ironically they reached out

00:03:24.120 to us before we even sent the email saying the podcast was live so to say they are an active

00:03:30.140 listener would be an understatement so shout out to that person they know who they are today's ama

00:03:36.080 is going to be on one subject, but one important subject, which is blood pressure and all things

00:03:42.400 blood pressure. And people who have listened to the podcast will have heard us talk about

00:03:47.800 blood pressure before. Most recently, the episode we released with you and Ethan Weiss,

00:03:52.920 Ethan coming back for the second time, you both spoke a lot about blood pressure. And

00:03:57.500 as you said in that one, if you look at cardiovascular disease, three main risk

00:04:02.400 factors for cardiovascular disease are going to be smoking, which we don't necessarily talk a lot

00:04:07.800 about because as you've said before, we're kind of under the impression if you listen to this

00:04:11.320 podcast and you still smoke, you probably should know you shouldn't. So that's nothing really we

00:04:16.240 need to say there. The second is APOB, which clearly is a topic that we cover a lot and has

00:04:22.440 been covered. And then the third is blood pressure. And we kind of realized we hadn't done as much of

00:04:27.500 a deep dive on blood pressure and we get a lot of questions so we compiled all those and in today's

00:04:33.560 AMA we're kind of really going to talk about a few different sections multiple questions in each

00:04:38.300 section which is what is high blood pressure low blood pressure why should someone care you know

00:04:44.220 what does it affect because it goes beyond just the risk of cardiovascular disease as well as you

00:04:49.720 know how do you know where you're at this is one where you know unlike APOB you can't give yourself

00:04:55.040 an at-home blood test, but you can check your blood pressure and you can understand how it

00:05:00.820 changes throughout the day, what the different definitions mean. And then we'll end with really

00:05:06.100 the main focus, which is, okay, what can you do to control your blood pressure? What are the

00:05:11.320 lifestyle factors that you can do to lower it? How well do those work? If you have to look to

00:05:17.060 use medications, what are the most common drugs? What do we know about them? Are there factors that

00:05:22.400 would make one quote unquote better than the other. So that's really going to be our focus for

00:05:27.760 this AMA. And just given the importance of the topic and how many questions that we get on it

00:05:33.300 and what we compiled, we figured we would just focus the entire thing on it. So before we start

00:05:39.380 rolling on it, is there anything else that you want to add to set the stage? No, I think that's

00:05:44.260 a good way to land. I think presumably most people who listen to this podcast have had their blood

00:05:50.100 pressure measure at least some point in their life. Obviously, when you go to a doctor's office,

00:05:54.960 even if you're going for anything random, they'll typically check it. A lot of people will have at

00:05:59.820 home cuffs that they may be checking. So I think a lot of people have had their blood pressure

00:06:04.880 measured, but I think it might be helpful to know what does a blood pressure measurement actually

00:06:09.980 mean? What is it actually doing and measuring? To understand that, you have to think about what

00:06:15.200 the heart is doing. So the heart is pumping, obviously. That's what you feel if you put your

00:06:21.600 hand on your chest. And what you're feeling is kind of the pulsatile sensation of the pressure

00:06:29.260 difference in the arteries as the heart contracts. So just remember there's two phases of the

00:06:37.220 cardiac contraction. The first is called systole. And systole is when the ventricles are contracting.

00:06:44.780 The ventricles are the larger chambers, the left one being the muscular one because it has to pump

00:06:51.140 the blood against the systemic resistance of the whole body. And it's the one that's responsible

00:06:56.560 for getting blood out to the body. We're going to talk about that pressure today. So we're going to

00:07:01.040 talk about the systemic circulation. What we're not going to talk about today is a different blood

00:07:06.300 pressure, which is pulmonary blood pressure. It turns out that when people hear like 120 over 80

00:07:11.740 is my blood pressure. That is talking about the blood pressure in their circulatory system of the

00:07:18.180 periphery. But if you wanted to know the blood pressure in your lungs, which is controlled by

00:07:23.700 the right ventricle, those would be pulmonary pressures and those would be significantly lower.

00:07:28.440 Again, we won't talk about those, just park that over to the side. So when your left ventricle

00:07:33.140 contracts, you're in systole, blood is leaving the heart through the aortic valve, goes out the aorta

00:07:40.420 at the ascending part of the aorta, and then it immediately just starts moving to the rest of the

00:07:44.900 body, right? So at the arch of the aorta, it jumps off three little freeways, if you will, right? So

00:07:51.080 you have the common carotid subclavian and enominate arteries, and then it kind of goes over

00:07:56.200 the arch, comes down, and then it goes out to the rest of the body. And this is happening really

00:08:00.020 quickly. Even if your heart is beating as slow as one beat per second or 60 beats per minute,

00:08:05.880 you know, think about the rate at which that happens. I think everybody kind of understands

00:08:09.120 that part. So there's a pressure in the artery that is experienced by literally the blood pushing

00:08:16.700 against the walls of the artery during that phase. And that's obviously the bigger number.

00:08:22.080 But it's important to remember that there is a second equally important phase of the heart,

00:08:26.800 which is the relaxation of the ventricle. And that's how they fill. So that's called diastole.

00:08:31.960 So after the heart squeezes and blood leaves the heart, the heart has to relax to have blood come

00:08:39.660 back into the ventricles through the atria. By the way, it's also important to know that this

00:08:45.520 is when the heart itself receives its blood supply. So the heart receives its blood supply

00:08:50.720 during diastole, whereas all the other organs are receiving their blood supply during systole.

00:08:55.920 And even though the pressure in the arteries is lower during diastole, which I think would

00:09:02.180 be intuitive given what I just described, it's still more than zero.

00:09:06.560 There is still a tonic amount of pressure within the artery wall.

00:09:11.120 So when you have your blood pressure checked and it spits out two numbers, let's just say

00:09:15.120 it's 125 over 79.

00:09:18.560 What that means is when your heart is doing the squeeze and there's a greater force as

00:09:24.280 blood is leaving the aorta, the left ventricle via the aorta, it's whatever number I said,

00:09:29.500 I've already forgotten. I think 124 millimeters of mercury is the pressure. And when that ventricle

00:09:35.480 relaxes and begins to fill through the left atrium, the pressure drops to whatever else I

00:09:42.680 said. I forget, I think I said 79 millimeters per mercury. So millimeters of mercury is,

00:09:47.360 I'm not going to get into what those numbers mean and how you do that. But if anybody thinks back

00:09:51.260 to like a chemistry class, you can have a manometer that basically determines pressure

00:09:55.300 by how many millimeters it can raise mercury. So the higher that number, the higher the pressure.

00:10:00.820 Does it ever blow your mind when you think about what the human body does on a daily basis that

00:10:05.640 we don't even think about or see? Like as you were saying, even if it's 60 beats per minute,

00:10:10.360 which is one beat per second, like it's just constantly doing it, you've seen bodies cut

00:10:15.340 open from your time in surgery before. So it's like you see that more, but does it ever just

00:10:19.600 kind of blow your mind how we're able to function and we just don't even think about those little

00:10:23.900 things every day? It still does and it's been I think back to my very first time in the anatomy

00:10:29.340 lab or my very very first time being in surgery and it's no less amazing to me today than it was

00:10:35.440 then. I simply can't believe it. The next question then naturally is what does it mean to have high

00:10:41.720 blood pressure? Because I think this is something that it seems like in the past five or ten years

00:10:47.040 the definitions may be changed and there's a few different types of definitions. So I think it'd

00:10:51.740 be helpful to set the stage early of, you know, when we say high blood pressure, what are the two

00:10:56.720 numbers that we're referring to? So people can kind of, as they look back at their own blood

00:11:01.540 pressure results, can kind of know where they fit. Well, as you said, this has changed a little bit.

00:11:06.080 So prior to 2017, we had a little bit more leeway in the system, but the current updates, which have

00:11:13.060 been in place for about six years and which were updated after the SPRINT trial in 2015,

00:11:19.580 a trial that I'll explain in a moment, leave us where we are today. And where we are today is

00:11:24.320 normal blood pressure is defined as having a systolic blood pressure at or below 120 or

00:11:32.600 technically below 120 millimeters of mercury over something less than 80 millimeters of mercury.

00:11:37.960 So if blood pressure is both less systolically than 120 and diastolically 80, that's considered

00:11:45.220 normal.

00:11:45.980 So 119 over 79 normal, 121 over 79 technically not normal.

00:11:54.960 Elevated is when the systolic pressure is between 120 and 129, but the diastolic pressure

00:12:03.680 remains less than 80.

00:12:06.400 So we talk about elevated blood pressure as a slight elevation in the systolic but not the

00:12:11.800 diastolic pressure. And then we get into two stages of hypertension. The first stage is when

00:12:18.780 systolic blood pressure is 130, so we're between 130 and 139, or diastolic blood pressure is between

00:12:27.960 80 and 89. So does that make sense? Because you'll notice there's a bit of a gap in there,

00:12:31.740 right? So you could be 120 over 83, and now you're at stage one, even though your systolic is normal.

00:12:39.780 And then stage two hypertension is when either systolic exceeds 140 or diastolic exceeds 90.

00:12:48.700 So again, in summary, normal blood pressure is less than 120 and less than 80. Elevated is 120

00:12:56.900 to 129 over less than 80. Stage one hypertension is 130 to 139 or 80 to 89. Stage two is greater

00:13:07.360 than 140 or greater than 90. Okay. So where do these numbers come from? Because these aren't

00:13:12.960 just arbitrary, right? These are sort of based on something important. And that something important

00:13:17.400 is called the SPRINT trial. So there's a trial, I think it was published in 2015. I think it was

00:13:22.540 like about a year or two before these guidelines were shifted. And the purpose of this trial was

00:13:27.480 really to ask the question, what is the benefit of, for lack of a better word, aggressive blood

00:13:33.960 pressure control? So the study looked at just under 10,000 people who had a systolic blood

00:13:40.700 pressure of 130 or greater who were also at advanced cardiovascular risk, but who did not

00:13:47.620 have type 2 diabetes. And the reason for that patient selection is you wanted a group of people

00:13:51.840 who were at high enough risk for ASCVD that you could start to see events in a relatively confined

00:13:57.480 period of time. You have to remember, this is always the goal of clinical trials. Even when

00:14:01.200 you're doing large double-blinded trials, you want to be able to have enough events in the trial that

00:14:06.880 you don't have to run the trial for 10 years. So you've got a high-risk population, though it's

00:14:12.080 worth noting they don't have type 2 diabetes, and they have to have a systolic blood pressure over

00:14:16.940 130. So they were randomized into two groups. The first group, which we'll call the intensive

00:14:24.860 treatment, was treated to a systolic blood pressure of less than 120. And the standard

00:14:32.360 treatment were treated to a blood pressure of less than 140. Make sense? So one group is kind

00:14:38.500 of being treated to not be over 140. The other group was really being pushed down to 120. So

00:14:44.320 at coming in, the average blood pressure of all comers was about 140 over 78. Now, Ethan and I

00:14:51.700 talked about this a little bit, but just in case folks didn't hear that podcast or just in case

00:14:55.440 people need a little bit of a refresher is this study did a pretty rigorous job of assessing

00:15:00.640 blood pressure. So they used an office visit where blood pressure was measured three times

00:15:08.900 using the following protocol. So the patient would sit down for five minutes doing nothing,

00:15:14.580 not talking, not doing anything. Their back is supported, their legs aren't crossed. After five

00:15:20.400 minutes, blood pressure was taken with an automated cuff. This was sized properly and used in perfect

00:15:27.160 correct way, which we'll talk about in a little while later in this podcast. They would take that

00:15:31.040 reading. Five minutes later, they would repeat that. And five minutes later, they would repeat

00:15:36.100 that. So the blood pressure for that visit was deemed as the average of all three of those

00:15:43.920 readings. This is a lengthy procedure, right? It took 15 minutes to get those three readings and

00:15:48.760 to determine their blood pressure, but that number served as your blood pressure. So if you were on

00:15:54.600 day one, you were 137 over 81 and you had that reading. Well, if you were in the business as

00:16:02.700 usual group or the placebo group, or not the placebo group, but the standard treatment group,

00:16:06.800 they would make no adjustment to your medication. If you were already on medication, if you were

00:16:10.420 not on medication, they wouldn't add medication. But if you were on the intensive group, they would

00:16:15.000 treat you. So at one year, after one year of this, the average systolic blood pressure in the

00:16:22.340 intervention group, the high intensity group was 121.4 millimeters of mercury. In the standard

00:16:27.840 group, it was 136.2. This intervention was stopped early. I forget how long they wanted to run this

00:16:35.340 study for. I think they were looking to do this for five years. I could be mistaken on that. But

00:16:40.000 regardless, at just a little over three years in median follow-up, the study was halted. And this

00:16:46.580 is not uncommon in hard outcome studies. We see this quite often where the benefits in one of the

00:16:53.680 arms is so much greater that it becomes unethical to continue the study. And that was the case here.

00:16:59.600 So the primary outcome, which was a composite outcome of reduction in cardiovascular mortality

00:17:08.620 was significant. It was about a 25% relative reduction. So the hazard ratio was 0.075.

00:17:16.620 and the absolute risk difference was about 0.54% over the course of one year. That's actually

00:17:26.420 pretty significant, by the way. It doesn't sound like a lot, right? 25% reduction, a little over

00:17:31.200 half a percent, absolute risk reduction. But you have to remember, that's a single year reduction

00:17:36.120 in risk. That's quite significant when you consider that blood pressure, just like lipids,

00:17:41.080 are compounding risk factors. At the three-year mark, the total event rate was, I believe,

00:17:49.960 in an unadjusted way, I want to say 1.6% lower in the intensive group. And again,

00:17:58.900 this was for this primary outcome, so it was just a composite outcome. It was kind of a MACE-like

00:18:03.940 outlook. So it was myocardial infarction, non-myocardial infarction, acute coronary

00:18:08.000 syndrome stroke, acute heart failure, and cardiovascular death. What I found pretty

00:18:12.680 interesting about this study was that it also saw a benefit in all-cause mortality. I would not have

00:18:19.940 necessarily expected this. So I don't think it's that surprising that they saw a benefit in the

00:18:24.880 primary composite outcome, which really all pertained to heart attacks and strokes. It's

00:18:29.680 maybe a little surprising how big the benefit was in such a short period of time. But what I think

00:18:34.200 really caught people off guard in a pleasant way, was that all-cause mortality was also reduced

00:18:40.720 27%. And it was like a 1.2% absolute risk reduction. This is pretty interesting. It's

00:18:50.060 not that you wouldn't expect the death rate to be improved from a cardiovascular disease standpoint,

00:18:55.700 which it was, right? It was a 2x reduction in cardiovascular disease death specifically,

00:19:01.820 but it's that you would see also a reduction in all sorts of other types of death.

00:19:06.940 And this was seen in, not surprisingly, perhaps kidney disease. Amazingly, accidental death,

00:19:13.060 suicide, homicide was significantly less. So again, it's possible that maybe a larger study,

00:19:19.360 that wouldn't pan out. Maybe 100,000 people, you wouldn't have seen that. But nevertheless,

00:19:23.800 this was about as dispositive a study as you're going to see demonstrating the efficacy of

00:19:29.700 aggressive blood pressure lowering. And again, the takeaway is even over a relatively short period

00:19:35.020 of time, aggressive blood pressure management to a systolic pressure less than 120 compared to

00:19:40.660 standard of care, which we used to think was kind of 130 to 140 is tolerable, left very little

00:19:46.040 ambiguity about the importance of that kind of recommendation. To double click on something you

00:19:50.840 said, because I think it is important. And we've talked a little bit about it when you've talked

00:19:54.980 about statin therapy before which is the percentage that we saw in this trial over the one two and

00:20:03.520 three year mark you kind of mentioned that that can compound over a lifetime and so if you saw

00:20:09.560 that much of a difference in a short period of time it only gives you more confidence because

00:20:15.400 the reality is if someone goes with high blood pressure for most of their life untreated you're

00:20:20.100 not looking at only three years you could be looking at from 35 to 75 you could be looking

00:20:25.100 at 40 years and obviously you can't run a 40 year trial and I know you've talked about this before

00:20:30.620 with statins when I can't remember which study came out and I remember you saying the stock went

00:20:36.620 down because people thought the result would have been even more positive but you were kind of

00:20:41.700 talking about if you look at how short that period was and how long people live with high

00:20:47.740 ApoB or high blood pressure, even though this was a short period, it still gives you even more

00:20:52.740 confidence that this is something that people should take seriously, even at a young age,

00:20:57.700 even if it's not going to kill them in a year. Yeah. Compounding is insanely powerful when it

00:21:02.500 comes to this type of biology, whether it be smoking, ApoB, or blood pressure. When we're

00:21:07.860 dealing with endothelial exposure, again, let's just take a step back and talk about why these

00:21:12.880 things pose such a risk. ASCVD, cerebrovascular disease, you can think of them as blood vessel

00:21:19.380 diseases. And elevated blood pressure, hypertension, is a mechanical disruption to the endothelium.

00:21:25.980 Smoking is a chemical disruption to the endothelium. And of course, ApoB is the

00:21:31.840 concentration of the lipoprotein that itself goes through that disrupted endothelium and then causes

00:21:38.420 the pathologic sequence of events that we're very familiar with. So it's not surprising that these

00:21:43.820 are all area under the curve problems. When talking about normal blood pressure,

00:21:49.280 elevated blood pressure, high blood pressure, in the past when we've talked about HbA1c,

00:21:54.820 you've kind of mentioned before, you know, like pre-diabetes is about 5.7%. I think diabetes is

00:22:00.800 about 6.5%. And you've said like, hey, if you're at 6.4%, and so you're not technically having the

00:22:08.060 diabetes level does that mean like you should celebrate it's like no the difference between

00:22:12.460 those is so small that you want to take care of it earlier and so you've always kind of talked

00:22:16.720 about one that's kind of why you don't like the a1c metric and you look at other things

00:22:21.420 but two you always kind of want lower is better when it comes to blood pressure if someone has

00:22:28.260 let's say 119 over 78 so they're in the normal category but there may be kind of creeping to the

00:22:36.100 elevated category. If that was your patient, would you be worried about that? Or are you

00:22:40.780 happy with any blood pressure in the normal category?

00:22:45.040 No, we would be very happy with a blood pressure of 119 over 78. I mean, I think what's more

00:22:49.660 complicated with blood pressure is, and we'll talk about this, I'm assuming, is the complexity

00:22:54.840 associated with measurement and really making sure you're measuring it correctly, which is

00:22:58.840 kind of an obsession of mine. In other words, there's far more heterogeneity in how you measure

00:23:02.980 blood pressure than how you measure ApoB. I mean, once you have a lab that has a validated assay

00:23:07.340 for measuring ApoB, you can have much more confidence in the little bit of variability

00:23:11.640 you see in that. And I think when it comes to blood pressure, there can be enormous swings

00:23:16.760 in blood pressure based on erroneous measurement. The other thing you have to think about is with

00:23:21.220 ApoB, you can't go too low. With blood pressure, you can go too low. I mean, truthfully in practice,

00:23:28.200 this, if we're a little bit on the fence, if somebody some days is like 124, first of all,

00:23:33.860 we never make decisions on the basis of one day. We don't even entertain looking at your blood

00:23:38.100 pressure unless we've seen two weeks of checking it two to three times a day under perfect

00:23:43.960 conditions. Only at that level would we even begin to entertain what is high or what is low.

00:23:49.120 But let's assume you've done that. We've got kind of two weeks of twice daily average recordings

00:23:55.560 and you come out at 123 over 79, I would be very hesitant to go straight to medication

00:24:05.080 because as I said, with APB, you can't go too low. It's a one-way street, provided the symptoms

00:24:11.760 don't kick in from the medications. But with blood pressure, you run a much greater risk

00:24:16.600 of symptoms if you over-medicate somebody, especially if that's where you're starting.

00:24:20.620 You can get orthostasis, which means lightheadedness when you stand,

00:24:23.460 And that can lead to a whole cascade of problems as well. So I don't know if that answers your

00:24:27.820 question, but this is also a little bit of an art. We did get a lot of questions on those things. So

00:24:32.580 we'll dive deeper into those coming up here. But before we do, in looking at, okay, we know now

00:24:38.640 the definitions of high blood pressure, how common is it? Do we know what percent of the population

00:24:44.820 is walking around with high blood pressure, whether they know it or don't?

00:24:49.200 It's actually staggering. The overall prevalence in the United States for both stage one and stage

00:24:55.680 two hypertension is about 46% based on those new categories that I just rattled off earlier.

00:25:02.500 And this is based on surveys that collect blood pressure measurements or self-reported

00:25:07.520 antihypertensive medications. So you could argue that's not entirely accurate because that's also

00:25:12.100 including people who are medicated, because if you're just looking at the med scripts.

00:25:15.820 but clearly this is high. And I think the bigger issue is how much of this is hidden epidemic.

00:25:21.600 In other words, how many people walking around haven't been to the doctor in five years,

00:25:26.300 don't know their blood pressure because presumably they're not checking it on their own,

00:25:29.420 obviously aren't taking any medications. I think that's a harder number for us to come to grips

00:25:33.700 with. But I think it's safe to say that this is a silent epidemic. It clearly goes up with age.

00:25:38.840 So if you look at young people, sort of in the 20 to 44 age range, men might have as

00:25:45.280 high as a 30% incidence or rather prevalence of hypertension, while women would be just

00:25:51.020 below 20%.

00:25:52.200 Once you get more squarely into middle age, 45 to 55, half of men would at that point

00:25:58.400 present with hypertension, 44% of women.

00:26:01.760 And it just goes up and up and up.

00:26:03.460 And by the time you're 75 years of age and older, it's north of 80% effectively for both

00:26:10.760 sexes, men and women. We also see this slightly playing out differently in race. So for both men

00:26:18.340 and women, African-American has the highest prevalence of hypertension. In men, it's about

00:26:25.120 59% in women, 56%. That's followed by in non-Hispanic white, it's 47 and 41% respectively

00:26:35.220 for men and women. For non-Hispanic Asian, 45% and 36% for men and women. And for Hispanic,

00:26:42.500 44 and 42% for men and women respectively. So again, the takeaway there is African Americans

00:26:48.200 are at higher risk. And as you age, you're at higher risk. Men in the younger years seem to be

00:26:55.100 more prevalent than women, but as they get older, those tend to converge.

00:26:59.540 Translation, there's nobody who's not at risk. That's what I was going to say is not only is

00:27:05.880 it such high percentages, but going back to the conversation we had a few minutes ago of the

00:27:10.120 importance of compounding, when you look at 20 to 44, those people have a lifespan that could

00:27:16.240 easily be another 40 to 60 years. And if 30% of men and roughly 20% of women from 20 to 44

00:27:25.460 are walking around with high blood pressure, the longer you don't know what it is and the

00:27:30.140 longer it compounds can create kind of staggering amounts of issues. It is really interesting to see

00:27:36.080 how high all those numbers are, no matter if you're young or old.

00:27:41.280 Yeah. So I think the next place that I think makes sense to go is we've talked about this a little bit already, but maybe just kind of rounding out the conversation, which is what are those consequences of high blood pressure? How does it relate to cardiovascular disease? How does it relate to everything else? And ultimately, this leads to why someone listening to this, if they don't know their blood pressure, should really start to figure it out.

00:28:09.200 And if they do know and it's high and they've been ignoring it, should probably stop ignoring

00:28:12.800 it.

00:28:13.900 You know, we've known about a lot of these consequences since the 1960s from literally

00:28:18.280 the first iteration of the Framingham heart study.

00:28:20.840 So back then, we were kind of using a higher definition.

00:28:23.520 So we were defining hypertension as greater than 140 over 90.

00:28:27.560 But even reducing people to just below that from above that was associated with effectively

00:28:34.400 a, call it 35% to 40% reduction in stroke, about a 50% reduction in cardiovascular disease,

00:28:44.520 all told 64% of that in heart failure, 15% to 25% in myocardial infarction.

00:28:50.420 More recent meta-analyses suggest that if you consider people ages about 40 to 70,

00:28:56.280 each 20 millimeter of mercury increase in systolic blood pressure and each 10 millimeter

00:29:02.900 of mercury increase in diastolic blood pressure are associated with a doubling in the risk of

00:29:09.000 death from stroke, heart disease, or other vascular disease. I mean, to me, that's kind

00:29:14.100 of the data that I would want to be keeping in the back of my mind. If your blood pressure is

00:29:18.680 140 over 90, as opposed to 120 over 80, you've doubled your risk of death, not incidence, death

00:29:27.080 from stroke, heart disease, or vascular disease. So again, you can also then think about this on a

00:29:32.400 yearly basis using the data that I talked about earlier in the sprint trial, where you're talking

00:29:37.860 about 25 to 30% year-on-year reduction in relative risk. And that includes, of course,

00:29:45.900 the benefits we saw in all-cause mortality. If you look at the 2021 STEP trial, which basically

00:29:52.900 repeated the sprint trial, but in a different patient population, this was in Chinese adults,

00:29:58.240 age 60 to 80, very similar size trial, about 8,500 patients, randomized to a slightly higher

00:30:07.620 window. So this was a systolic blood pressure target of 110 to 130 was the intensive, or 130,

00:30:15.500 but no more than 150 in the standard. This was a median follow-up of about the same amount of time,

00:30:21.160 a little over three years. These people had isolated systolic hypertension. So diastolically,

00:30:26.100 these people had, I think, a mean hypertension of 76.4 in the intensive group and 79.2 in the

00:30:33.740 standard group. Coming in, these people had a mean baseline of 146 over about 83, and they were done

00:30:43.140 using a similar protocol of rigorous blood pressure measurement. Actually, I'm not even going to get

00:30:50.040 into the differences. There was a slight difference in it, but this was also done rigorously. Anyway,

00:30:53.580 I think the point here is the primary outcome, which was similar, found a 26% reduction in

00:31:03.000 cardiovascular outcomes on a relative basis. And the death from cardiovascular disease

00:31:07.500 specifically was a 28% reduction in risk. This study did not find a difference in all-cause

00:31:14.120 mortality between the two. And of course, the absolute risk reductions were comparable,

00:31:19.920 about 1% per year, which again, when you start to think about how many years you would undergo this

00:31:25.580 treatment, that's a pretty big deal. The STEP trial did not include people with diabetes. So

00:31:31.140 that's actually another important consideration. Again, I think all of this is to say the evidence

00:31:35.800 is pretty consistent that the consequences of high blood pressure, if nothing else, just on

00:31:42.540 cardiovascular disease and cerebrovascular disease are significant. And therefore, if you're serious

00:31:47.800 about the business of living longer, you definitely want to make sure your blood pressure is being

00:31:51.780 managed. And that was kind of a good touching on the CVD side. What do we know about high blood

00:31:58.840 pressure and its effect on other organs? Well, we kind of touched on part of them,

00:32:02.800 which is the brain. There are very few exceptions of things that are good for the heart that are

00:32:07.300 not good for the brain and vice versa. So the way to think about high blood pressure is because

00:32:11.800 it's a mechanical force, anything with small vessels is going to be troubled by it. And so

00:32:18.080 really the way you want to think about this is there are three organs that are most susceptible

00:32:22.620 to high blood pressure. We've just talked at length about one, which is the heart,

00:32:25.940 talked a little bit about one, which is the brain. The one we haven't talked about

00:32:29.680 is the kidney. So there's a very high incidence and prevalence of end-stage renal disease

00:32:36.220 in patients with hypertension. So again, you have to kind of go back a little bit to renal

00:32:41.600 physiology to understand how the kidney works and how delicate its vascular system is. I think

00:32:48.460 I've mentioned this on a previous podcast several times. The kidneys are tiny little things, right?

00:32:52.960 They weigh like one to 2% of your total body weight, and yet they're receiving 20 to 25%

00:32:59.040 of your cardiac output with each pump of the heart. So think about what must be true of the

00:33:05.280 vascular network of that organ to accommodate such perfusion. And therefore, it's highly

00:33:11.580 susceptible to elevated pressures there. So people with hypertension have faster rates of decline

00:33:19.060 in their renal perfusion than age-adjusted people with normal blood pressure. And this

00:33:24.920 results in a stark decrease in glomerular filtration rate. It's of course not the only

00:33:30.020 thing that can destroy the kidneys. Unfortunately, diabetes is also an enormous insult to the

00:33:34.880 kidneys, though for a different reason, which we're not going to get into today. And then when

00:33:38.480 you consider the fact that oftentimes high blood pressure and elevated glucose go hand in hand,

00:33:44.000 in fact, they are two of the five metrics that define the metabolic syndrome and therefore are

00:33:50.060 proxies for insulin resistance, you realize that I just think it's an epidemic that's not getting

00:33:54.580 enough attention, which is inappropriately or overly aggressive decline in glomerulofiltration

00:34:02.380 rate as a result of the double whammy of high glucose, high blood pressure. So in our patients,

00:34:08.580 we're very aggressive about checking a biomarker called Cystatin C, which we think is far superior

00:34:14.560 to creatinine as a way to keep tabs on their kidney function. And it's very common for us

00:34:21.220 to see people that have quote unquote normal kidney function, but it's far too low for their

00:34:26.200 age. So they might have a GFR of 60, so 60 milliliters per minute of glomerulofritration,

00:34:31.660 which technically gets considered normal. It's not normal until it's below 60.

00:34:36.180 We think normal is 100 for someone who's 50, and 60 might be normal if you're 75 years old,

00:34:42.000 but we don't think it's normal for someone who's 50 or 55. A lot of times that immediately hints

00:34:47.340 to us that they've got hypertension even before you put a cuff on them to just see those numbers.

00:34:52.400 The last thing I'll say is there's another trial that's similar to the SPRINT trial. It's called

00:34:56.480 the SPRINT MIND trial. It's basically a subset of the other trial, but it's looking at the impact

00:35:00.860 of intensive blood pressure lowering and the state of dementia. So it's the same cohort,

00:35:05.400 a little over 9,000 subjects. And the absolute risk reduction of dementia was 0.6%. That's

00:35:14.500 pretty significant. The relative risk reduction, about 16%, which again, this is consistent with

00:35:20.320 the observational data and the other long-term prospective studies we've seen. So there's really

00:35:25.500 no data that speak in the opposite direction. If you care about your brain, if you care about your

00:35:30.040 heart. And if you care about your kidneys, you need low blood pressure. I think we can say that

00:35:34.020 as confidently as we can say almost anything in medicine. That kind of leads to the next question,

00:35:39.400 which is the last one of this section is we need low blood pressure, but you kind of mentioned it

00:35:44.740 before. You don't want too low. And so even though low blood pressure doesn't seem like it has its

00:35:50.200 own category, like elevated or high or normal, what do we know about the consequences of having

00:35:55.740 of blood pressure. People who listen to the podcast might be familiar with a guy, we don't

00:36:00.520 have to name him, who was on a trip, maybe had some low blood pressure, maybe was dehydrated

00:36:06.200 from a flight, woke up, face planted into a nightstand, picked up some stitches on his head.

00:36:13.120 Again, no need to name him, but I think you may know some people who have been affected by low

00:36:18.220 blood pressure. So what do we know about that? Well, what we know is that there is no numerical

00:36:24.040 diagnosis for this. I think most observers would feel that if you truly measured accurately

00:36:31.100 a blood pressure below 90 over 60, we would argue that that would be probably low.

00:36:38.560 But the truth of it is low blood pressure is defined by symptoms more than it is by

00:36:44.040 numbers. So there are people who walk around with a blood pressure of 100 over 70 and they

00:36:49.880 never experience orthostasis, you know, the thing that your friend experienced when he face planted

00:36:54.660 into a table. There's no issues whatsoever. Yet there are other people, if you medicated them to

00:36:59.140 that level, they'd be syncopal all day long. So again, I think this kind of speaks to a little

00:37:05.060 bit of the art of it. And one of the reasons that you should need to be careful when you're using

00:37:10.500 medications for blood pressure, especially when other variables are changing. So we see this with

00:37:16.020 our patients where if they're on blood pressure medication when they come to us, but then

00:37:20.060 they lose weight and they're exercising, well, their blood pressure is going to start to come

00:37:24.180 down. There has to be a really clear manner in which you safely begin to reduce the dose of

00:37:29.300 their blood pressure medication or else you could indeed induce some of the symptoms such as dizziness

00:37:33.860 or lightheadedness, fainting as we've talked about, lack of concentration, blurred vision.

00:37:38.460 I mean, again, these things tend to be far more extreme, but you want to be mindful of all these

00:37:43.900 things. This kind of leads to the next section, which is how do people know where they're at?

00:37:50.440 One of the questions that we got, which is an interesting question, is are there any symptoms

00:37:54.980 that might indicate a person has high blood pressure? Unfortunately, just like is the case

00:38:02.200 with elevated ApoB, there are no symptoms generally. High blood pressure is often referred

00:38:07.940 to as a silent killer because it really doesn't have a warning sign. Someone might say, well,

00:38:13.260 gosh, I've never had headaches or anything like that. Therefore, I must be fine. But the reality

00:38:17.920 of it is, unless you're accurately measuring your blood pressure, there's truly no way to know if

00:38:23.660 you have hypertension. That gets to a question that I think is worth covering a little bit,

00:38:29.520 because I know you mentioned earlier, you take your blood pressure throughout the day a few

00:38:34.460 times. You have all your patients when they come on, take it for two or three weeks, multiple times

00:38:39.640 a day and so if people are kind of listening to this and they maybe don't have a doctor's

00:38:44.060 appointment or obviously when you go to the doctor they're not going to let you typically

00:38:48.980 sit there for five minutes not do anything take it wait five minutes while not do anything take

00:38:55.680 it again wait five minutes take it a third time you know it's the doctor's office it's not optimized

00:39:00.620 for the proper blood pressure testing like they were doing in those trials so i think the reality

00:39:06.620 is a lot of people are going to have to do this at home. And so what type of advice do you give

00:39:12.120 patients where it's like, hey, we want you to do your blood pressure? How should they think about

00:39:16.320 that? Well, I think as you said, this is definitely an area where you as the patient need to be in

00:39:21.500 charge. I couldn't care less what my blood pressure is in the doctor's office because of

00:39:25.540 the same reasons you've stated. I'm probably running up the stairs to get there. And I'm

00:39:29.440 certainly not behaving according to protocol when I'm there. Sometimes the person checking

00:39:33.520 my blood pressure, doesn't put my arm in the right position. So that doesn't really matter.

00:39:37.660 What matters to me is the type of blood pressure measurement that we've talked about. So in the

00:39:42.880 show notes, we have found some really good videos on this and it took a while because I really want

00:39:48.360 to make sure people understand the different ways to measure blood pressure. And I do both a manual

00:39:55.180 cuff where you're using a blood pressure cuff and a stethoscope. And then I use a couple of

00:40:02.240 different automated cuffs. And I want people to understand how to use both of them. I think this

00:40:07.920 type of stuff is better learned watching illustrative videos. So we're going to link to

00:40:12.580 the best versions of these that we've found, and we've got several videos on them. But I do want

00:40:18.100 to, again, before I explain just how blood pressure is measured, because I think that is worth

00:40:22.080 understanding, I want to just talk about some of the common things that can really screw up a

00:40:28.460 blood pressure reading. So having a cuff that's the wrong size. It's very important to make sure

00:40:33.980 the cuff fits your arm correctly. And you'll pay attention to this when you're buying a cuff.

00:40:38.000 You make sure it's fit to your arm. You want to make sure the cuff fits over your skin directly.

00:40:43.260 Don't be lazy and check your blood pressure over your clothing. If you can't roll your sleeves all

00:40:47.640 the way up, take your shirt off and put a different shirt on. But if you're trying to do it over your

00:40:51.160 clothing, the variance in blood pressure can be significant. You want to make sure your back is

00:40:56.560 supported. Sounds silly, but the variance here can be somewhere between five and 10 millimeters of

00:41:01.800 mercury if your back and feet are not supported. So if you're just hanging off a chair, you know,

00:41:07.080 you don't have your feet on the ground. You don't want your legs to be crossed. When you cross your

00:41:11.800 legs, you can see anywhere from a five to eight millimeter per mercury increase, not doing the

00:41:18.000 five minute rest. At a minimum, I tell patients three minutes, but I think five is the right way

00:41:22.940 to go. That can easily account for 10 to 20 millimeters of mercury. Now, it doesn't always

00:41:27.140 do it. A lot of times, I'll just sit down and take my blood pressure right away, and it's totally

00:41:31.600 fine, but sometimes it's actually quite high on an initial blood pressure reading if I've been

00:41:36.620 running around or just whatever's going on. Usually, if I wait that five minutes doing

00:41:42.460 nothing, which means I'm not checking my phone or talking to somebody, it'll come down 10 points

00:41:47.340 easily. Believe it or not, not talking. Just talking during or right before your blood pressure

00:41:53.040 can easily be 10 to 15 points. Being in pain can have a significant impact on this. So it could be

00:42:00.660 anywhere from 10 to 30 millimeters per mercury. Another one that people take for granted, and I

00:42:04.620 think about this a lot when I do my heart rate variability checks in the morning, is having a

00:42:08.900 full bladder. So having a full bladder can raise your heart rate and raise your blood pressure by

00:42:13.060 10 to 15 points. So all of these things need to be kind of optimized to make sure you're getting

00:42:17.740 a good reading. When you start to then look at arm positioning, for every inch that your arm

00:42:24.880 is below your heart, you'll see about an average of nearly two millimeters of mercury per inch.

00:42:32.540 And similarly, it's about two millimeters of mercury per inch for every inch your arm is

00:42:37.040 above your heart. And if you don't believe this, it's pretty amazing to do. Put a cuff on and have

00:42:42.120 your blood pressure measured with your heart way above your head and dangling way down beneath you.

00:42:47.300 So again, all of these things matter, which is why I think it's very important for people to be

00:42:51.960 their own blood pressure checker, because it's very difficult to have all of these things

00:42:56.640 optimized in the doctor's office. I'll just say a word on what the heck blood pressure actually,

00:43:02.100 like how you're measuring it with a manual cuff. If you choose to do this, you'll need a stethoscope,

00:43:06.740 of course. This is something everybody learns in medical school and nursing school. But basically,

00:43:11.140 let's just assume your blood pressure is 120 over 80. You're putting a cuff over on your arm

00:43:16.220 and you have a stethoscope over the brachial artery, which is a little bit on the medial side

00:43:22.860 of the antecubital fossa, which I realized as I say that, that means nothing to anybody.

00:43:27.880 But if you think about like where your arm bends, that little area is called the antecubital fossa.

00:43:32.180 If you have your palm up and you put your hand in that little area and move in towards your body,

00:43:38.080 so to medial, you'll feel a pulse. That's your brachial artery. So you want the stethoscope

00:43:43.060 sitting there. You want the cuff about an inch above the crease in your arm. And while the

00:43:49.200 stethoscope is there, you insufflate the cuff. And you insufflate until you feel the loss of

00:43:54.700 that pulse. Presumably that's approximately your systolic level. You continue to inflate the cuff

00:44:00.500 to about 30 millimeters of mercury beyond that. So let's just assume that's about 120. You take

00:44:05.600 it up to now 150. Okay. Now you start to slowly release the valve of the cuff and you're going

00:44:13.460 to hear nothing. You're going to hear nothing. You're going to hear nothing. And then you're

00:44:16.640 going to hear your first tapping, thudding sound. And that is the systolic reading. That is the

00:44:24.180 first bit of blood that is now going through the artery because you've now lowered the cuff

00:44:28.840 pressure just enough so that blood can travel through. Let's just say in this hypothetical

00:44:33.300 patient, that occurs at 117. And that would make sense because you approximately heard it vanish

00:44:38.740 at about 120. So that becomes your systolic. You're going to continue to hear as you slowly

00:44:44.780 continue to release pressure, you're going to hear these sounds change. They kind of change

00:44:50.840 from like a murmur maybe into kind of more of a swooshing sound. By the way, as the patient,

00:44:55.940 you will feel this. It has a very weird feeling in your arm. In fact, I can usually tell my blood

00:45:02.240 pressure just by the sensation from the onset of that sensation at systole and the reduction of

00:45:09.100 that sensation at diastole. You'll keep kind of going down this line until at some point

00:45:13.640 the sound becomes a little muffled and then it decreases and stops. And when it stops,

00:45:19.720 that's your diastolic reading. Because by definition now, the pressure is below that

00:45:24.980 minimum pressure in the artery where the artery is feeling the expansion of the blood during the

00:45:31.020 total relaxation phase of the heart. And then you note that number. That number might be 75.

00:45:35.820 You'll see that on the cuff, on the manometer. So that's how you measure a blood pressure

00:45:39.860 manually. Automated cuffs have their own algorithms. On average, they're pretty good,

00:45:44.680 but the gold standard, of course, is measuring manually. But if you do measure with an automated

00:45:49.500 cuff, there's lots of good ones out there. But I would just say, make sure you're doing everything

00:45:54.360 correctly. It was really interesting when you went through that list of things that can raise

00:45:59.280 or lower if you do it properly or not. And some people, I'm sure some patients too might be turned

00:46:04.560 off when it's like, okay, you want me to dedicate 10 to 15 minutes of my day twice a day to do this

00:46:12.160 over three weeks? It can sound like a lot of time, but I think hopefully based on what we talked

00:46:17.600 about earlier, the importance of it kind of gets people to do it the correct way because there's

00:46:22.880 no point in thinking you know your blood pressure if you're not doing it the correct way and you

00:46:26.480 just have a false reading and it leads to either wrong treatment or no treatment.

00:46:30.900 And I will just say that I find the manual readings more accurate. I find that automated

00:46:35.440 readings can be easily 10 to 15 millimeters of mercury off for me, especially systolically.

00:46:41.900 I've had multiple different people check manually and those readings are always consistent. The

00:46:46.960 automated cuffs tend to overestimate. I don't know why that is. I've never found a completely

00:46:51.340 compelling reason, but I suspect that that varies from person to person.

00:46:54.580 And so yours are often, the automated is higher.

00:46:57.960 The automates tend to run higher than me, yeah.

00:47:00.100 Interesting.

00:47:00.540 And I've even had my doctor check this on three separate occasions.

00:47:05.240 It's unambiguously higher, and that's using literally two of the most expensive automated

00:47:09.740 cuffs that you can buy.

00:47:11.760 No idea if this is accurate.

00:47:12.900 I would just be curious if the algorithm tends to run slightly higher solely for the fact

00:47:18.460 that they would rather tell people they are higher when they're normal than tell people

00:47:23.160 they are normal when they're higher and they miss readings. But I don't know, that's a bit of a

00:47:27.600 conspiracy theory there. I'm going to go with more of an Occam's razor. Like I think there's just

00:47:32.360 the automated cuffs are not directly measuring systole and diastole, right? They tend to be

00:47:37.180 measuring sort of mean arterial pressure and then using some algorithm to try to impute the others,

00:47:42.760 but regardless. And do you encourage, because the manual version is obviously more intimidating for

00:47:49.120 people who have never done it before than an automated, which is much easier. So even with

00:47:54.520 that said that the manual is better, are you fine if your patients use an automated cuff at the

00:47:59.760 beginning just to understand? Yeah, for sure. The next follow-up question we received kind of fits

00:48:04.580 well right here, which is, you know, we talked about all the little things that can affect your

00:48:09.220 blood pressure when you read it, such as crossing your legs, full bladder, feet dangling, whatever

00:48:14.440 it may be. What do we know about the blood pressure variation throughout the day? Earlier,

00:48:20.160 we kind of talked about as you age, the percentages get higher and higher, but I think also throughout

00:48:26.480 the day, your blood pressure can vary quite a bit. And so what do we know about that?

00:48:31.880 Well, it can. I mean, the most important observation is that blood pressure should

00:48:35.700 really be dropping to somewhere between 10 and 20% at night relative to daytime, just based on

00:48:41.920 the fact that you're horizontal. So the heart shouldn't have to work as hard to get blood to

00:48:46.740 your head. And also we should see a reduction in sympathetic tone overnight and an increase

00:48:51.260 in parasympathetic or vagal tone. So, you know, when people do continuous blood pressure monitoring

00:48:56.660 tests, which are pretty cumbersome, where you have a cuff around your arm hooked up to a device

00:49:01.680 and it just goes off every 15 to 30 minutes and you wear this for a couple of days, that's one

00:49:07.220 of the things you'd be looking for is kind of that reduction of at least 10% in blood pressure while

00:49:11.400 you're sleeping. The other thing, of course, is stress. So we'll talk about exercise, I guess,

00:49:15.480 as well, but just transient stress can also raise blood pressure significantly. I certainly notice

00:49:21.160 when I'm wound up, my blood pressure is routinely over 140 systolically, if I'm even just slightly

00:49:28.360 irritable, which I think really speaks to the old adage that stress can kill you. You think of like,

00:49:33.580 oh, how can stress kill you? Well, I mean, I think hypercortisolemia, if left unchecked,

00:49:37.560 is harmful and so is hypertension. If you're constantly in a sympathetic tone, there's both

00:49:42.580 mechanical and chemical reasons why that's problematic. You mentioned exercise just now,

00:49:46.780 which is a question we received because you've talked about it on a few podcasts,

00:49:50.700 what blood pressure is going to increase with exercise. I think the one I'm thinking of is

00:49:55.780 Lane Norton in particular. You all talked about that. What do we know about blood pressure and

00:50:01.240 exercise? Does it go up? Why does it go up? Ultimately, too, is if for some reason someone's

00:50:07.180 testing their blood pressure during exercise and it is going up. Is that something they even need

00:50:12.200 to worry about or is that just natural? No. An increase in systolic blood pressure during

00:50:17.020 exercise is completely normal. We do this on our patients when they're getting a VO2 max test. We

00:50:21.480 also have their blood pressure checked. What we're really looking for is a rise in diastolic pressure.

00:50:27.700 So the normal physiology should be that systole goes up, diastole stays about the same. Sometimes

00:50:35.400 it even goes down. The reason for that is that the vasodilation of the arterioles, which is there

00:50:41.340 to provide more oxygen to muscles during exercise, actually causes a reduction in systemic vascular

00:50:48.520 resistance. So again, we tend to see the rise in systolic blood pressure, but typically no change

00:50:54.440 or potentially even a decrease in diastolic blood pressure. I actually haven't checked my blood

00:50:58.340 pressure in a while during exercise, but it could easily be 180 to 200 millimeters of mercury.

00:51:03.960 Frankly, it would be very interesting for me to know what my peak blood pressure is doing

00:51:07.240 a heavy deadlift or squat.

00:51:08.980 I'm sure at that moment, it gets insanely high, which is probably why in patients that

00:51:13.320 have very dilated aortas, we would say, hey, maybe doing very heavy valsalva type maneuvers

00:51:18.840 might not be in your best interest.

00:51:20.780 For those of us who maybe just got a little lost on the end there, can you explain what

00:51:25.580 a valsu, the word you use, the type of movement?

00:51:29.400 Valsalva is just anytime you're increasing intra-abdominal pressure so much.

00:51:33.780 So if you think about like when you're really bearing down, which you would be doing,

00:51:37.400 obviously, if you're trying to pick something very heavy off the ground or do a very heavy squat,

00:51:41.180 that type of pressure is associated with pretty significant increase in obviously blood pressure.

00:51:46.740 Peter, the last question that we got kind of in this section on helping people understand where

00:51:51.240 they're at and kind of what this all means before we get to the next piece, which is how to lower is

00:51:56.800 Some people have heard or their doctors have told them they have primary hypertension versus

00:52:01.840 secondary hypertension. Some other terminology that people have maybe heard from doctors.

00:52:07.780 Can you just walk through what each of those mean?

00:52:11.980 Secondary hypertension is high blood pressure that's caused by a correctable other medical

00:52:19.200 condition. And about 10% of people diagnosed with hypertension actually have a secondary cause,

00:52:27.260 a driver. And that's why it's sort of important to make sure that if somebody shows up with

00:52:32.800 high blood pressure, you don't automatically assume that it's what we would just call primary

00:52:39.040 or what used to be called, quote unquote, essential hypertension back when I was in

00:52:43.040 medical school. So there are a couple of clues to consider that somebody might have secondary

00:52:48.940 hypertension. If a person's already being treated for high blood pressure and it's not having any

00:52:54.140 effect, so it's not responding to medications, we'd call that medication resistance. That's a

00:52:59.320 bit of a clue. If they no longer respond to medications that they previously responded to,

00:53:04.820 similarly, if their blood pressure is incredibly high, north of 180 millimeters of mercury

00:53:10.780 systolically, if the onset occurs really suddenly or increases really suddenly, again, that's all

00:53:17.720 cause for alarm. If it's high and you're really young, 30-year-old people that otherwise have no

00:53:23.900 risk factors, such as family history for high blood pressure and they're not obese, and yet

00:53:28.060 they show up with high blood pressure, all of these things make you start to think of something

00:53:33.800 else going on. I'll just share a brief story of an example of this. I had a friend who got this

00:53:40.760 was probably back in 2013, maybe 2014. I don't know, somehow we were talking and he mentioned

00:53:46.220 his blood pressure was really high. This guy was a really serious athlete. He would mention he wakes

00:53:50.880 up every morning and his blood pressure is through the roof. And again, through the roof was like

00:53:54.700 180 or 190 over 120, insanely high. And he would exercise and it would go down a bit,

00:54:01.360 but it was generally pretty high. And his doctors were putting him on all sorts of medications and

00:54:05.140 it wasn't really having an effect. And every medical student will know the story of what's

00:54:09.880 called the pheochromocytoma, which is a tumor of the adrenal glands that secretes catecholamines.

00:54:14.920 These are not that common, but he sounded like the perfect case. So I said, look,

00:54:18.760 I'd want to rule out this type of tumor in you. So have your doctor check your urine for the

00:54:26.160 metabolites of epinephrine and norepinephrine. So he goes and asks his doctor. His doctor says,

00:54:30.940 no, that's a dumb test. We're not going to do that. And then I remembered that he had had an

00:54:35.000 MRI earlier. He had surgery six months before that, and they had done an MRI of his chest.

00:54:41.680 and I said, it's possible that that MRI also captured your adrenal glands, which sit on top

00:54:47.020 of the kidneys, which can often be seen in a chest MRI. So I said, can you send me that MRI?

00:54:52.200 And he did. And sure enough, there was an adrenal nodule on that MRI, but it didn't get called by

00:54:58.520 the radiologist. They sort of missed it. Again, that's not that uncommon because they weren't

00:55:01.560 really looking at the adrenals. So I said, take this to your doctor and say, look, you've got an

00:55:06.140 adrenal nodule and high blood pressure, they really need to check for these metabolites.

00:55:13.760 His doctor still didn't want to do it. He said, okay, one, you need a new doctor. This guy's an

00:55:18.180 idiot. But two, let's go get it done somewhere else. So we did. To make a long story short,

00:55:21.740 he ended up having a pheochromocytoma, which meant he just needed to go to surgery.

00:55:25.520 They removed that adrenal gland and his blood pressure completely normalized.

00:55:30.220 Again, that's pretty uncommon. It's an extreme example of what you don't want to miss.

00:55:35.200 So what are some other things you don't want to miss? Well, you don't want to miss

00:55:38.420 kidney disease. You don't want to miss any stenosis of the renal artery. You don't want

00:55:43.980 to miss thyroid conditions. You don't want to miss hyperaldosteronism, which can be idiopathic,

00:55:50.020 meaning it can be caused by steroids that you're taking. So people that are on continuous doses of

00:55:54.660 corticosteroids, but can also be caused by the adrenal gland itself undergoing hypoplasia.

00:55:59.680 There are a lot of secondary causes of hypertension, and when you consider that in total they amount

00:56:06.080 to probably 10% of cases of hypertension, and when you consider how many people have

00:56:11.640 hypertension, it's important that these things be run to ground before we just immediately

00:56:16.540 assume that somebody has primary hypertension, which again is just code speak for we don't

00:56:21.340 really know what the cause is.

00:56:23.740 In that conversation, you kind of mentioned family history there, which is something we

00:56:27.200 haven't talked about.

00:56:28.180 We've talked in the past a lot about how family history is really important to know your family

00:56:32.540 history because that can really help understand the different causes of death and what you may

00:56:37.840 need to look out for. Does hypertension, is that something that runs in families? And if your

00:56:44.660 parents, grandparents had a history of hypertension that should even make you more

00:56:49.420 aware of this potential issue? Absolutely. And it's the main reason that I think so much about

00:56:54.820 this. Both my parents have hypertension and therefore I understand that despite all of the

00:57:00.620 things that I do to have low blood pressure, it won't be surprising to me at some point if

00:57:06.400 my genes overcome my lifestyle and at some point I'll need to take medication. My goal in checking

00:57:14.080 my blood pressure so frequently is to make sure that I don't spend a couple of years or even a

00:57:19.180 year not recognizing if that transition has taken place. So would I love to say that I'm going to go

00:57:25.300 my whole life without having to take blood pressure medication? Sure. But the second best option would

00:57:29.860 be being on blood pressure medication the second I need to be on it. That parallel seems very

00:57:35.820 similar to how you talk with patients about ApoB as well, which is check it often. And if you can

00:57:41.520 lower it through various lifestyle factors, do it. But the second you find out that you kind of

00:57:46.700 can't, you want to address it with medication. I think that leads to this next section really well,

00:57:53.360 which is a lot of people are asking what are the drivers of primary hypertension and how can people

00:58:01.180 address them with lifestyle factors? I think there's two pieces that are worth talking about

00:58:06.180 there, which is one, what lifestyle factors can lower blood pressure? And two, do we know anything

00:58:12.880 about how much those lifestyle factors can lower blood pressure. I think there's a really big

00:58:19.080 opportunity here with lifestyle to lower blood pressure. In fact, I want to be clear. I think

00:58:23.920 lifestyle, I hate the word, you know, I hate that word lifestyle so much. I don't know why I hate it,

00:58:28.240 but I know that it's shorthand for whatever we're talking about. But regardless, lifestyle is a far

00:58:34.420 greater hammer on blood pressure than it is on lipids for two reasons. I think the first is

00:58:41.300 why lifestyle is not a great hammer for lipids is that, frankly, to get your ApoB to the levels

00:58:48.940 where it's no longer an issue is very difficult to do without a very extreme diet that is so

00:58:55.740 extreme that it comes with a whole bunch of other problems with it. So profound fat reduction and

00:59:01.760 calorie restriction will lower cholesterol levels dramatically. But again, it comes with so many

00:59:07.540 other problems that it's simply not worth it. It's sort of robbing Peter to pay Paul.

00:59:11.960 But with blood pressure, that's not the case. The benefits of weight loss are dramatic. The

00:59:17.240 benefits of exercise, reducing insulin resistance, avoiding type 2 diabetes, and getting good sleep,

00:59:24.000 as we'll discuss here in a moment, are pretty significant. In addition, the electrolyte

00:59:29.540 management thing is kind of interesting, though controversial, and we'll talk about that. But

00:59:33.720 let's start with something that is pretty clear as day, which is the impact of weight loss on

00:59:39.420 blood pressure. We'll link to it in the show notes. But if you look at kind of the best meta

00:59:43.440 analysis of this, it says that basically for five kilo reduction in weight, well, let's just put it

00:59:51.740 in per kilos. For every kilo of weight loss, you're going to see a little more than one millimeter of

00:59:57.500 mercury reduction in systolic and almost one millimeter reduction in diastolic. So again,

01:00:03.140 we're agnostic as to how one gets there, right? Weight loss is primarily going to be accomplished

01:00:07.940 by reducing intake. Reducing intake can be accomplished by those three things we always

01:00:12.140 talk about, CR, DR, TR, or combinations thereof. Here's where I think things are a little more

01:00:18.860 controversial, and that is what's the role of sodium on this? Now, I think it is safe to say

01:00:25.820 that there is pretty significant heterogeneity in the population here. I think there probably

01:00:32.240 are some people that are more sensitive to sodium, dietary sodium, from a blood pressure

01:00:38.120 perspective than others. And we talked about this at length with Rick Johnson, who's a nephrologist,

01:00:43.280 and his take was that salt plays a role, but the role can be reduced by drinking water with

01:00:51.920 or before a salty meal. He points out that if you're getting thirsty with a salty meal,

01:00:57.460 it means you've already raised sodium. And if you have, you're probably also getting the increase

01:01:01.740 in blood pressure. So it's really about pairing water prior to a salty meal. So salt sensitivity

01:01:09.380 is sort of a quantitative trait in which an increase in oral sodium can disproportionately

01:01:16.200 increase blood pressure. So the question then becomes, who are the patients that are probably

01:01:20.940 more sensitive to this? The data might suggest we see this more in African-Americans. We see this

01:01:26.220 more in older people. We see this more in people who already have higher blood pressure. And in

01:01:31.640 people who have metabolic syndrome, diabetes, or chronic kidney disease. And we'll probably see it

01:01:37.020 less in people who are not otherwise in those situations. You'll sort of have to pick and

01:01:43.140 choose your battles and see where you are on that spectrum. But again, this is also something that

01:01:48.160 you can be empirical about this and decide, hey, what happens if I kind of reduce my sodium intake?

01:01:53.800 What bearing is that having? Now, I would caution people that going to very extreme levels of sodium

01:02:00.160 restriction, even if it might improve blood pressure, seems to be associated with worse

01:02:04.860 overall health outcomes. So some advocate reducing sodium to as little as 1500 milligrams per day.

01:02:11.940 Keep in mind the average American is somewhere between three and a half and four and a half

01:02:16.980 grams of sodium per day. To suggest we're going to reduce that to as little as 1.5 grams per day

01:02:22.760 is pretty significant. Now that will very likely reduce systolic blood pressure by five to six

01:02:27.380 millimeters of mercury in somebody who already has hypertension. But that also, at least according

01:02:32.360 to the most recent meta-analysis I've seen from the Institute of Medicine, also increased all

01:02:37.360 cause mortality. So we have to be a little bit careful there. There's some evidence that

01:02:41.500 increasing dietary potassium, so eating potassium-rich foods, bananas, potatoes, things like

01:02:45.800 that, and not doing this through supplements, by the way, because you can sort of get into a bit

01:02:49.180 of trouble there, can lower blood pressure based on the relationship that we see between potassium

01:02:53.380 and an aldosterone in the kidney. Let's talk about exercise. So this is again an area where

01:02:57.820 I think there's very little ambiguity here. So if you look at aerobic exercise, you look at a

01:03:02.440 meta-analysis of RCTs that were at least four weeks in duration, found that endurance exercise

01:03:08.460 was very effective in patients with hypertension. They're looking at reductions of systolic blood

01:03:14.200 pressure in as little as four weeks of aerobic training, reducing it by as much as eight

01:03:18.640 millimeters per mercury and diastolic lowered by at least five millimeters per mercury.

01:03:23.360 So as far as duration and intensity goes, the takeaway of this meta-analysis was that at least

01:03:30.880 90 to 150 minutes a week at somewhere between 65 and 75% of your maximum heart rate was the sweet

01:03:38.460 spot. And that's actually right in the zone of what we would call zone two. For most people,

01:03:42.740 zone two is about 75% of their maximum heart rate. And we tend to advocate at least three

01:03:48.320 hours a week of that, which would be 180 minutes. So right then and there, you say, look, if you're

01:03:52.280 getting your zone two in at three hours per week at roughly 75% of your maximum heart rate,

01:03:57.760 you're already capturing the benefits of much of the exercises. As far as dynamic resistance

01:04:02.840 training, this is something that I don't think is entirely intuitive. You might think, well,

01:04:07.840 gosh, resistance training would transiently increase blood pressure, which it does. But

01:04:12.060 the interesting thing is it actually reduces blood pressure slightly as well. Not nearly as

01:04:18.380 much as aerobic training, but we're looking at about two millimeters of mercury on systolic,

01:04:24.220 about three millimeters of mercury on diastolic. And this is doing kind of 90 to 150 minutes a week

01:04:31.320 at somewhere between 50 and 100% of one rep max. So this is anywhere from modest weights up to

01:04:39.220 very heavy weights. This could also be done using isometric resistance, so you don't even have to

01:04:44.280 be lifting weights. And that showed even a greater reduction in systolic blood pressure, about six

01:04:49.160 millimeters of mercury, and diastolic of about three millimeters of mercury. So again, let's

01:04:54.620 just talk about insulin resistance and type 2 diabetes. Why are these things increasing blood

01:05:00.080 pressure is probably the easiest way to think about it. Well, I think insulin resistance does

01:05:04.540 a number of things, but among them is it reduces the bioavailability of nitric oxide. And nitric

01:05:10.300 oxide, of course, acts very locally to increase vasodilation. So therefore, with less nitric

01:05:16.340 oxide, we have less vasodilation. There are different ways that this can happen. I think

01:05:21.000 one of the ways that this happens, and we see this also, by the way, in impaired kidney function,

01:05:25.840 is there's an inhibition of one of the important cofactors in nitric oxide synthase, or one of the

01:05:32.180 important variables that allows nitric oxide synthase to make nitric oxide. So there are

01:05:37.900 actually biomarkers you can measure, like one's called SDMA and one is called ADMA. And these

01:05:44.100 are typically things that we see elevated in people with high homocysteine or people with

01:05:48.900 impaired renal function. So again, to think about these as kind of a cascade of things,

01:05:53.440 insulin resistance, we proxy by metabolic syndrome. Two of the five factors of metabolic

01:05:58.520 syndrome are elevated glucose and elevated waist circumference or obesity. So type 2 diabetes then

01:06:04.440 in some ways just becomes this triple whammy where you have the first insult being the high glucose

01:06:10.380 load, which then has the microvascular damage to all of the organs of interest, heart, brain,

01:06:18.020 kidney. You then have the blood pressure load or the blood pressure damage that comes from that.

01:06:23.800 And then of course you have the ApoB burden that comes from type 2 diabetes. Type 2 diabetes and

01:06:28.160 insulin resistance are associated with hypertriglyceridemia, which is then associated

01:06:31.600 with an increase in ApoB as you now need more low-density lipoprotein particles to traffic

01:06:38.000 not just the cholesterol ester, but now the triglycerides as well. The last thing I want

01:06:42.720 to talk about here, and this is an easy one to miss, is the role of sleep. Both sleep deprivation

01:06:47.720 and insomnia will also drive hypertension. This is something I notice in myself. I check my blood

01:06:52.920 pressure so often, but I notice that if I have a really lousy night's sleep, all things equal,

01:06:57.740 my blood pressure is definitely higher, just as my blood sugar is, by the way. So I always

01:07:02.780 notice the effect, and anybody who's ever worn a CGM will tell you that if they have a horrible

01:07:06.540 night of sleep, their glucose tolerance goes out the window, and so too does your blood pressure

01:07:11.040 response. So if you look at either very long or very short sleep, you're going to see in all cases

01:07:18.140 an increase in hypertension. And this can be as much as a 40% increase in the risk of hypertension

01:07:24.200 if you're sleeping less than five hours a night or more than 10 hours per night. You could argue,

01:07:29.840 of course, that sleeping more than 10 hours a night is a proxy for other things that are going

01:07:33.900 on, be it either chronic disease or heavily fragmented sleep. I know you hate the term

01:07:38.620 lifestyle, but it does seem like when it comes to lowering blood pressure, it's really that

01:07:44.300 whole gamut of what you talked about. Everything from nutrition to sleep to exercise is stuff that

01:07:50.440 you have to pay attention to as it relates to blood pressure. You want to make sure you get

01:07:56.060 as far as you can on these because I do think that most people, I don't know what the percentage is,

01:08:01.260 but it could easily be that half the people who have hypertension could manage it without the use

01:08:07.120 of pharmacologic. And on that front, we do get a lot of questions on the pharmacologic side,

01:08:13.840 which is what are the most common drugs prescribed for hypertension if someone has

01:08:18.860 hypertension and they're thinking about taking drugs, how much can they lower blood pressure

01:08:23.760 on average? Just a little overview on that I think would be really helpful.

01:08:28.280 Yeah, look, a detailed overview of this is probably more than people would want. So I'm

01:08:32.000 not going to really get into the mechanisms of how these drugs work. We can link to materials

01:08:36.420 on that in the show notes. But we really today have four, I would call first line drug categories

01:08:42.840 for hypertension. So the thiazide diuretics, calcium channel blockers, angiotensin converting

01:08:49.660 enzyme inhibitors or ACE inhibitors, and angiotensin 2 receptor blockers, ARBs. So

01:08:56.680 thiazide diuretics, calcium channel blockers, ACE inhibitors, and ARBs. Notice I didn't mention

01:09:03.000 beta blockers in there. We're really not using those for first line agents in high blood pressure.

01:09:09.220 So for primary hypertension, all first line agents are pretty much good for about 12 to 15

01:09:17.480 millimeters reduction of systolic blood pressure and about 9 to 11 millimeters reduction

01:09:22.560 in diastolic blood pressure. The blood pressure lowering effects of ACE inhibitors are pretty

01:09:28.380 high. They're at the upper end of that spectrum. And that's typically at about one half the

01:09:33.600 recommended maximum dose. So you don't start somebody at the maximum dose of these things.

01:09:39.220 you typically work your way up. You don't want to overshoot these things. It's not like a

01:09:43.940 cholesterol medication where you could start somebody at a mega dose, and if they get symptoms,

01:09:48.500 it's just like a muscle ache or something, you can take it away. But here, if you overshoot this,

01:09:52.420 you can cause some damage. The ARBs are right there on par with the ACE inhibitors. In fact,

01:09:58.580 we did an internal white paper on this very recently. The consensus view is that basically

01:10:05.080 across the board, the ARBs are probably slightly better drugs than the ACE inhibitors. So in every

01:10:12.060 manner that we compare them in terms of efficacy and side effects, the ARB is as good, if not

01:10:18.160 slightly better than the ACE inhibitor. The ACE inhibitors have been around longer. And so one of

01:10:23.140 the things that you have is you have more of them and they're cheaper. So a lot of times people

01:10:27.180 don't necessarily have a choice in them because their insurance company is going to pay for an

01:10:30.680 ACE inhibitor, they're not going to pay for an ARB. But if ACE inhibitors are causing symptoms,

01:10:35.400 such as a cough, which is probably one of the more common symptoms, you want to know that you

01:10:38.880 have other agents there as well. Thiazide diuretics and calcium channel blockers are also

01:10:43.660 highly efficacious. Those are easily in the 15 millimeter of mercury and 9 to 10 millimeter of

01:10:49.600 mercury impact on blood pressure, but they do tend to come with more side effects. And I wouldn't

01:10:55.840 consider myself at all an expert in the treatment of hypertension, but we typically do not like to

01:11:00.620 rely on those as first-line agents and instead rely on those as add-on agents if we've maxed out

01:11:08.400 an ACE inhibitor or an ARB and we still need more reduction. I think it's worth pointing out here,

01:11:15.240 by the way, that these blood pressure-lowering medications by themselves are larger than any

01:11:22.620 single lifestyle factor. However, when you consider the sum total of all lifestyle factors, it can be

01:11:30.620 at least on par with what we see pharmacologically. And some of the other questions that we received

01:11:37.680 are people saying, Hey, I do have to go on a drug for primary hypertension. And you kind of mentioned

01:11:44.800 there's four different ones. And one of the factors could be costs, but are there any other

01:11:49.780 known factors that would make one medication maybe quote unquote better than another for people with

01:11:55.920 specific? Like with anything else going on or is there anything else people should be thinking

01:12:01.420 about if they have to take one of these and their doctor's willing to work with them on which one

01:12:05.640 to take? I think there are definitely some rules of thumb on this. So somebody who's got heart

01:12:10.820 failure or reduced ejection fraction, you would want to avoid a calcium channel blocker because

01:12:16.040 obviously calcium channels play an important role in contractility of the heart. So to give a

01:12:21.820 calcium channel blocker to reduce blood pressure would be potentially problematic at reducing

01:12:26.380 cardiac output as well. So that's something you want to keep in the back of your mind.

01:12:29.660 It used to be, I think, the dogma that anybody with diabetes should be on an ACE inhibitor over

01:12:37.220 an ARB if you're going down that path. I would say when we looked at these data, which we did

01:12:43.440 for our internal white paper, we didn't see a strong enough case for that. I thought the data

01:12:48.420 we're inconsistent here. So I think I would say this, the textbook answer is for type 2 diabetes

01:12:53.440 and chronic kidney disease, ACE inhibitors might offer some benefit. But I think that both of these

01:12:59.300 are probably reasonable. Obviously, you want to be careful about somebody with renal artery

01:13:04.340 stenosis. This is kind of one of those reasons you want to rule that out. But in the case of

01:13:08.320 renal artery stenosis, you wouldn't want to be using either of those. Diuretics, we probably

01:13:12.740 want to avoid in people who already have gout or significant hyperlipidemia, type 2 diabetes,

01:13:19.080 because they can actually increase somewhat insulin resistance. We personally find that

01:13:24.620 those drugs are kind of ones that we want to reserve for when we don't have other factors.

01:13:30.120 Again, ACE inhibitors and ARBs, we tend to avoid certainly in pregnancy or in somebody with a

01:13:35.120 history of angioedema. And race might also play a role here. It would appear that in African

01:13:40.060 Americans, thiazide diuretics, or calcium channel blockers might actually be more effective than

01:13:44.620 ACE inhibitors or ARBs or even beta blockers when it comes to reducing cardiovascular events.

01:13:50.640 Again, I'm not talking much about beta blockers and certainly not about alpha blockers. It's not

01:13:53.840 that these other categories aren't used, but they certainly would not be considered first line today.

01:13:59.240 All right. So Peter, I think that covered the vast majority of questions we received on blood

01:14:05.200 pressure and kind of a follow-up a little more detail to how people should think about this,

01:14:11.000 why they should care, why they should care early and often, how to monitor what theirs is, how to

01:14:16.920 know what lifestyle factors can affect it if you have to do medications, how to think about it. So

01:14:22.600 hopefully people found that overview helpful. And again, we just thought it would be important to

01:14:27.500 gather all these questions because we've been talking about blood pressure recently, but we've

01:14:30.940 never gone as deep as we just did on that risk factor compared to something like ApoB. So with

01:14:38.120 that said, anything you would want to say to people about blood pressure who are listening and

01:14:44.360 why they should care? No, I mean, not that I haven't already said. I guess if there's one

01:14:48.820 thing in my book that I didn't write enough about just due to space constraints, but I felt as

01:14:54.900 strongly about it as some of the other stuff I wrote about it would be this. This is such an

01:14:58.720 important part of the longevity playbook and it's not sexy, right? It's not like taking rapamycin or

01:15:04.860 taking some little drug that's going to whack your senescent cells or doing anything like that. I

01:15:09.560 mean, it's just bread and butter primary care medicine, but it's so needle moving. I view it

01:15:15.360 as sort of catastrophic when I see people and I see them all the time who are biohacking their

01:15:21.280 way into obscurity all the while ignoring their blood pressure. With that, I think we will wrap

01:15:28.080 this one. So until next time, have a good one. Yep. Thanks, Nick. Thank you for listening to

01:15:34.160 this week's episode of The Drive. Head over to peteratiamd.com forward slash show notes. If you

01:15:41.120 want to dig deeper into this episode, you can also find me on YouTube, Instagram, and Twitter,

01:15:46.480 all with the handle peteratiamd. You can also leave us review on Apple podcasts or whatever

01:15:52.640 podcast player you use. This podcast is for general informational purposes only and does

01:15:58.320 not constitute the practice of medicine, nursing, or other professional healthcare services,

01:16:02.460 including the giving of medical advice. No doctor-patient relationship is formed.

01:16:07.920 The use of this information and the materials linked to this podcast is at the user's own risk.

01:16:13.640 The content on this podcast is not intended to be a substitute for professional medical advice,

01:16:17.880 diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any

01:16:23.780 medical condition they have, and they should seek the assistance of their healthcare professionals

01:16:28.280 for any such conditions. Finally, I take all conflicts of interest very seriously. For all

01:16:34.060 of my disclosures and the companies I invest in or advise, please visit peteratiamd.com forward

01:16:40.620 slash about where I keep an up-to-date and active list of all disclosures.

01:16:47.880 Thank you.

The Peter Attia Drive - September 07, 2026

Blood pressure： how to measure, manage, and treat high blood pressure (AMA #48 rebroadcast)

Episode Stats

Transcript