A Functional Medicine Hypertension Protocol

Blood pressure is the force of blood pushing against the walls of your arteries as the heart beats and relaxes. Blood pressure is reported as two numbers: systolic over diastolic. Systolic pressure is the pressure when the heart pumps blood out, and diastolic pressure is the pressure between heartbeats as the heart muscles are relaxed. Normal blood pressure is 120/80 mmHg.

Nearly half of American adults have hypertension (high blood pressure). It is estimated that 46% of adults with high blood pressure are unaware they have it, and only 21% of adults have their hypertension under control. Diagnosis and management of high blood pressure are essential for preventing chronic disease and reducing the risk of cardiovascular disease. (1, 2)

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What is Hypertension?

Hypertension, or high blood pressure, is consistently higher-than-normal blood pressure. In 2017, the American College of Cardiology and the American Heart Association (ACC/AHA) released new guidelines for diagnosing and treating high blood pressure. Per 2003 guidelines, hypertension was defined as 140/90 mmHg or higher. New guidelines have revised this to state that hypertension is now diagnosed at 130/80 mmHg.

A hypertensive crisis is a sudden and severe increase in blood pressure, reading 180/120 mmHg or higher, and requires emergent medical attention.

Hypertension Signs & Symptoms

Hypertension is often called the "silent killer" because most people don't have symptoms.

Most often, symptoms will only occur during a hypertensive crisis and may include the following:

• Headache
• Dizziness
• Changes in vision
• Shortness of breath
• Chest pain
• Altered mental status and confusion
• Anxiety
• Nausea and vomiting
• Decreased urine output

What Causes Hypertension?

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

Secondary hypertension is elevated blood pressure due to an identified medical condition. Compared to essential hypertension, the prevalence of secondary hypertension is low. However, it is important to recognize when screening for secondary medical conditions is indicated, as diagnosis and treatment can completely cure hypertension and eliminate the need for antihypertensive therapy. (3)

Common signs that warrant an investigation for a secondary cause of hypertension include (3):

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

The following should be ruled out as secondary causes of hypertension:

Kidney Disease

Renal parenchymal disease, which includes diabetic nephropathy, glomerulonephritis, interstitial kidney disease, and polycystic kidney disease, is the most common cause of secondary hypertension, accounting for 2.5-5% of all cases. More than half of patients with kidney disease have hypertension, which worsens as the kidney disease progresses. (3)

Endocrine Disorders

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

Cushing's Syndrome

Excess serum cortisol causes blood pressure elevations. Cushing's is most commonly caused by ACTH-secreting pituitary tumors or corticosteroid use. Classic signs and symptoms of Cushing's syndrome include rapid weight gain, a round face, a hump on the back of the neck, and purple stretch marks.

Hyperaldosteronism

Aldosterone is a hormone produced and secreted by the adrenal glands, which regulates blood pressure by promoting sodium retention and potassium excretion. In hyperaldosteronism, the body retains salt and water, increasing blood pressure. In addition to hypertension, hyperaldosteronism can present with low serum potassium, fatigue, headache, muscle weakness, and numbness.

Pheochromocytoma

A pheochromocytoma is an adrenal tumor that secretes epinephrine and norepinephrine, causing high blood pressure, headaches, sweating, rapid heart rate, tremors, shortness of breath, panic, and anxiety.

Thyroid Disorders

High blood pressure can result when the thyroid gland underproduces (hypothyroidism) and overproduces (hyperthyroidism) thyroid hormones.

Hyperparathyroidism

The parathyroid gland secretes a parathyroid hormone (PTH), which increases serum calcium levels. Hypercalcemia can cause blood pressure to rise. Other symptoms of hyperparathyroidism include fatigue, constipation, weakness, and bone and muscle pain.

Vascular Disorders

Hypertension may occur secondary to stenosis (narrowing) of one or both renal arteries, usually caused by atherosclerosis. Coarctation of the aorta, a congenital condition, is a narrowing of the aorta that often presents as high blood pressure in the arms and low blood pressure in the legs. (3)

Obstructive Sleep Apnea (OSA)

As many as half of patients with sleep apnea may have hypertension. Untreated OSA is a common reason for resistance to antihypertensive medications. Common blood pressure patterns associated with OSA include elevated nocturnal blood pressure, blood pressure dips during sleep, and isolated diastolic hypertension. (5)

Medications & Supplements

Reviewing the patient's medication and supplement list is an important aspect of a comprehensive health evaluation. Drug-induced hypertension is a significant contributor to secondary hypertension; common offenders include the following:

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

Functional Medicine Labs to Test for Root Cause of Hypertension

Functional medicine labs help practitioners personalize treatment options for their patients. Below are some of the most common labs ordered for patients suffering from hypertension.

Basic Cardiovascular Evaluation

An important aspect of managing hypertension is ordering a basic cardiovascular panel. This should include a CBC, CMP, HbA1c, hs-CRP, lipid panel, and urinalysis. Together, these labs help to screen for anemia, diabetes, high cholesterol, kidney disease, and cardiovascular inflammation. This panel acts as a baseline evaluation in determining a patient's risk of cardiovascular disease, a screening for end-organ damage due to high blood pressure, and a reference point to refer back to as you continue care with your patient.

Hormones

A thyroid panel is used to diagnose thyroid disorders. This panel should be included within the basic cardiovascular evaluation, given the importance of thyroid health and function to cardiometabolic health and general wellness.

The decision to order additional labs to rule out endocrine disorders causing secondary hypertension should be based on the patient's history and presenting signs and symptoms. Serum cortisol is used as a first-line test to diagnose Cushing's syndrome, and plasma metanephrines can be used as an initial test to evaluate pheochromocytoma.

Serum aldosterone can be ordered to screen patients with hypertension for hyperaldosteronism. Patient posture affects aldosterone levels, so it is recommended that the patient be ambulatory for at least 30 minutes before blood collection. Aldosterone is often ordered with plasma renin activity (PRA) to assess the Renin-Angiotensin-Aldosterone System (RAAS), an essential hormonal system that regulates blood pressure.

Mercury

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

Comprehensive Stool Analysis

What's going on in the gut absolutely influences cardiovascular health. Intestinal dysbiosis is associated with the translocation of gut microbes into vascular tissues, resulting in systemic inflammation, lipid and blood sugar dysregulation, atherosclerosis, hypertension, and a generally increased risk of cardiovascular disease. Additionally, nitric oxide, a natural vasodilator, requires a healthy balance in oral flora for sufficient endogenous production. Research suggests that nitric oxide deficiency is the first step in hypertension pathogenesis (6, 7)

A comprehensive stool analysis that assesses the gut microbiome and detects the presence of parasites, yeast, and pathogenic and commensal bacteria can rule out dysbiosis contributing to cardiovascular inflammation and nitric oxide deficiency. Running this test with a serum trimethylamine N-oxide (TMAO) may be helpful. TMAO levels are influenced by diet and microbial flora. A positive correlation exists between elevated levels and increased risk for major adverse cardiovascular events, kidney disease, and death. (4)

Other Labs to Check

Additional tests to consider ordering outside of blood work and stool testing include an electrocardiogram (ECG), renal Doppler ultrasonography, and a sleep study to assess heart function, rule out causes of secondary hypertension, and evaluate cardiovascular risk.

Additionally, a referral to a functional dentist for a comprehensive dental evaluation can help diagnose oral health, hygiene, and anatomy problems potentially contributing to sleep apnea and mercury exposure and negatively impacting cardiovascular health.

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

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Conventional Treatment for Hypertension

The 2017 ACC/AHA Guidelines for Hypertension emphasize the importance of modifying diet, physical activity, and alcohol consumption alone or in combination with pharmacological therapy to manage high blood pressure. Effective dietary interventions will be discussed below. Engaging in 150 minutes of dynamic aerobic exercise and resistance training weekly facilitates reductions in blood pressure. (8)

The same guidelines recommend pharmacological intervention for adults with stage 1 hypertension with a 10-year ASCVD risk of 10% or greater or with stage 2 hypertension. First-line agents in managing hypertension include thiazide diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers. (8)

Functional Medicine Treatment Protocol for Hypertension

A functional medicine approach to hypertension considers cardiovascular risk factors and underlying contributors to high blood pressure, including diet, exercise, sleep, and stress, to create a multi-faceted holistic treatment plan.

Therapeutic Diet and Nutrition Considerations for Hypertension

The Dietary Approaches to Stop Hypertension (DASH) diet is a dietary pattern high in vegetables, fruits, low-fat dairy, whole grains, poultry, fish, and nuts. By emphasizing these foods, it is inherently rich in potassium, magnesium, calcium, protein, and fiber and low in saturated fat, refined sugars, and sodium. Studies show that the DASH diet can reduce blood pressure by 11.2/4.5 mmHg, making it an effective first-line intervention for stage 1 hypertension.

Everyone with high blood pressure should consume less than 2,300 mg of sodium daily. Combining the DASH diet with modest sodium restriction (1,500-1,800 mg sodium daily)  results in additive antihypertensive effects.

At a cellular level, potassium acts to blunt the effects of sodium and support the relaxation of blood vessels. Incorporating high-potassium foods is an important aspect of dietary intervention in treating hypertension. Patients with hypertension should meet a daily potassium goal of 3,500-5,000 mg by consuming potassium-rich fruits and vegetables, including apricots, lentils, squash, kidney beans, and spinach.

Supplements Protocol for Hypertension

Below are some evidence-based nutritional and herbal supplements to consider incorporating into your patient's nonpharmacologic treatment plan for hypertension.

Magnesium

Magnesium is an important mineral for skeletal and cardiac muscle health, and deficiency or insufficiency can contribute to high blood pressure and chronic heart failure. Magnesium supplementation results in blood pressure reductions up to 5.6/2.8 mmHg.

Dose: 300-1,000 mg daily

*Note: magnesium in higher doses can cause loose stool and should be dosed to the patient's bowel tolerance; decrease the dose if loose stool develops

Coenzyme Q10 (CoQ10)

CoQ10 is a powerful antioxidant that supports energy production and prevents blood clot formation. CoQ10 has been shown to lower systolic blood pressure by up to 17 mmHg and diastolic blood pressure by up to 10 mmHg. (9, 10)

Dose: 100 mg daily

Lycopene

Lycopene is a carotenoid antioxidant found highly concentrated in tomatoes and responsible for giving a variety of fruits and vegetables their red color. A 2013 meta-analysis concluded that high-dose lycopene (greater than 12 mg daily) effectively decreases systolic blood pressure, especially among people with higher baseline systolic pressure and those of Asian descent. After four weeks, this study concluded an overall antihypertensive effect of 10/4 mmHg in patients.

Dose: 15-20 mg daily

Nitric Oxide Support

Neo40 is a patented formula that increases nitric oxide production through the endothelial nitric oxide synthase pathway. It is proven to significantly reduce blood pressure by an average of 6/6 mmHg and improve endothelial compliance.

Dose: Dissolve two tablets on the tongue daily for 30-45 days, then decrease to one tablet daily

Garlic

A 2008 meta-analysis concluded garlic preparations are superior to a placebo in reducing blood pressure in people with hypertension. Proposed mechanisms responsible for this antihypertensive effect include the stimulation of nitric oxide and hydrogen sulfide gases and the inhibition of angiotensin-II, collectively resulting in vasodilation and blood pressure reduction.

Dose: 600-900 mg of aged garlic extract daily

Hibiscus

Hibiscus tea incorporated into the diet of patients with prehypertension and mild hypertension, not taking any antihypertensive medications, resulted in reductions in systolic and diastolic blood pressure after six weeks.

Dose: 240 mL brewed hibiscus tea three times daily

Carditone

Carditone is a popular herbal blend formulated by Ayush Herbs that contains shankhpushpi, arjuna, tribulus, rauwolfia, and rose. This formula is rich in antioxidants, magnesium, and herbs that support the heart and kidneys, lower blood pressure, and reduce stress. This 2019 study confirmed Carditone's efficacy and safety in treating adults with prehypertension and stage 1 hypertension.

Dose: 1 caplet once daily

When to Retest Labs

Patients should be informed to self-monitor blood pressure at home with an approved blood pressure monitor. Education regarding correct blood pressure measurement should be provided to patients to ensure accurate readings. Optimally, patients should measure and record blood pressure at least twice daily, in the morning and the evening, especially after changing a treatment regimen to monitor efficacy.

Patients should be advised to follow up in one-month intervals for reassessment until blood pressure goals are met, at which point routine follow-ups can be postponed to every 3-6 months.

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Summary

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