Recognize Hypertension’s Silent Danger

Steven Lome, DO, RVT

I’m doing great. Thank you so much for having me.

Laurie Marbas, MD, MBA

Well, I think before we even get started, I would appreciate it if you could give a little bit of a summary of an interesting situation that happened to you last year when you were running a half marathon. Just so people can understand, you are an amazing expert, but you’ve had some incredible things happen this past year. If you could kind of give a quick rundown of your story, please.

Steven Lome, DO, RVT

It’s been crazy. My whole life has been very well set up to be a lifestyle medicine type of physician. I was 100 pounds heavier a long time ago, and I got into exercise, thinking exercise was the key to good health than diet. Then I got into running, and I ran some marathons and half marathons. Try to ignore the diet part; it didn’t work. I ended up getting strict on the diet. But one of the things I ended up doing last year was running a half marathon with my two older kids out in Monterey, California. It was a normal day, and I thought everything was going to be great. At mile three, the runner had a full cardiac arrest in front of me. He died. It was a fatal rhythm called ventricular fibrillation. I had to do CPR and shock him, and eventually, he found out he had a widowmaker blockage and got it fixed. But after he had that cardiac arrest at mile three, I figured I had to keep going.

Laurie Marbas, MD, MBA

But he revived and survived.

Steven Lome, DO, RVT

Yes. He was revived. He was good that I got to keep going because what else am I going to do? He’s in the ambulance. He’s on his way. There’s nothing more I could do for him. Then I crossed the finish line, and a second runner collapsed literally in front of me. Same thing. It’s uncanny how similar such situations were. It hit his head, and there was no pulse. The same rhythm—the fatal rhythm—had to shock him. We got to him fast. He woke up and stopped the Strava app on his watch so he could record his race time, and he wanted to get up and see how we got to him so fast. But he also went to the hospital, and got a Widowmaker stent, and they both made complete, full recoveries, and they both now are following very clean, whole food plant-based diets, which is amazing because they’re a great example of how exercise is only a small percentage of being healthy in regards to heart health, high blood pressure, and everything. It’s going to be about 20% of it, but a vast majority of heart health is dietary-related. You can never out-exercise your diet is the expression.

Laurie Marbas, MD, MBA

Perfect. Then you guys ran a half marathon last month,?

Steven Lome, DO, RVT

Yes. It was just a few weeks ago that I was celebrating the first anniversary of that event when the two runners had cardiac arrest. They are amazing people, man. I tell you. Their resiliency and their mental strength to come back a year later and take on that same race. We did it together. We stuck together the whole way. We finished holding hands, arms up. We did it. a bit emotional when the runners hit the spot at the course where they had their cardiac arrest. But at the end of the day, they fought through it. They did it. it was a great moment.

Laurie Marbas, MD, MBA

That’s fantastic. If you want to see more about it, you should check it out. Just click on today’s show, and Dr. Stephen Lome and you guys can see this cool interview with them and meet them in person. That was cool. You were there in person, but they don’t recall that you saw them again.

Steven Lome, DO, RVT

Right.

Laurie Marbas, MD, MBA

On the TV show. Well, let’s just dive in here. I have some questions for you. Let’s start with: why is hypertension often labeled the quote-unquote, silent killer, and what makes its progression so stealthy?

Steven Lome, DO, RVT

Yes. Hypertension is extraordinarily common. They say about 70% of adults over the age of 50 have it. Tens of millions of people in America have high blood pressure, and honestly, it slowly creeps up on you as the blood pressure goes up over time in America. That’s not the way it’s supposed to happen. But with our lifestyle in America, our diet, and the rates of overweight and obesity, that’s what ends up happening. As the blood pressure creeps up to 130, 140, 150, the top number, the systolic blood pressure, there are just no symptoms. People don’t feel their pressure is high. At least most people don’t. So it is silent. But the whole time that the blood pressure is elevated, it is putting a lot of strain on your system—not just your heart, but your kidneys, your other vessels, and your brain. It can lead to lots of different issues. If there was a clear symptom related to high blood pressure, I think a lot more people would be aware of it and would come to the doctor to get things fixed. But without the symptom, it just kind of slowly attacks our system, putting at risk a heart attack, stroke, any damage, and other things without your knowledge. That’s what makes it so, so deadly. Because of the lack of symptoms, it’s somewhat underdiagnosed. A lot of people don’t know they have high blood pressure.

Laurie Marbas, MD, MBA

Exactly. We’ll get to that here in a minute. But I do have a question here. What are the initial signs or symptoms? You said there aren’t any symptoms, but how would someone know there are any symptoms? Would someone maybe suggest I get my blood pressure checked? What would be some of the more subtle signs?

Steven Lome, DO, RVT

Yes. That is a great question. First of all, everybody should be seeing a doctor every year. When you go see your doctor, they should check your blood pressure. Let’s say they haven’t seen a doctor in a while or are just wondering how often or when I should check my blood pressure. For those of you who are at risk for high blood pressure, whether there is a strong family history, you’re overweight, drink alcohol regularly, have sleep apnea, or have a high salt or unhealthy diet, It will be nice for you to have some way to check your blood pressure intermittently regularly. There’s no specific rhyme or reason, but once a month or something, just so you have the number, because again, you may be somebody who has no symptoms. 

Now, symptoms of high blood pressure frequently don’t develop until the blood pressure is pretty advanced and pretty severe. Say the top number is at least 160 or 170. I’ve even had people come in with blood pressures ranging from 200 to 20 for the top number 220 over 120. They don’t even feel it. But a lot of people, when the blood pressure is that high, have a little sense that they’re feeling tired. They may have a headache, they may have some visual changes when it gets bad—what we call a hypertensive urgency or hypertensive emergency—people could get chest discomfort, just pressure, shortness of breath, and even the most feared type of stroke symptoms can develop. That becomes more of a medical emergency when high blood pressure is that bad and is causing those symptoms. 

But frequently, the blood pressure could be very high and have no symptoms. if I have a patient whose blood pressure is 220 or 120 in the office and they feel completely fine. It’s not that they need to go to the emergency room, but we do need to quickly address this because the higher the blood pressure is, the more years, and the more months and years that it’s elevated, the more strain it puts on your system. It’s a cumulative effect over time. I kind of compare it to smoking cigarettes: the more you smoke and the more years you smoke, the more the cigarettes are damaged, the blood pressure is the same, the higher the blood pressure is from smoking more cigarettes, and the more years you leave it elevated for, the more damage and risk to your system.

Laurie Marbas, MD, MBA

Early detection is key. Can maybe we speak a little bit about what normal blood pressure is? We spoke about it with some other speakers, but I think it’s important to reiterate. I hear them as we lead into a few other questions, but when someone goes to get their blood pressure checked or maybe they check it at home or someone checks at home, these numbers might require some type of intervention. What does that look like? What do you advise patients?

Steven Lome, DO, RVT

Yes. The two numbers are: the number on the top is called systolic, which is the blood pressure when the heart is squeezing; the number on the bottom is called diastolic; which is the blood pressure. When the heart is relaxing, the number at the top should be less than 120. The number at the bottom should be less than 80, so it is normal to be less than 120 over 80. It’s important to understand the less than because I had people come in to say, My blood pressure’s 110 over 60. It’s too low. No, that’s great. That’s exactly what we want. It is 110 over 60, or even 100 over 60. Those numbers are great for kids and young, healthy people in their teens and, hopefully, 20s when they’re fit then their blood pressure frequently exceeds 100 over 60. That’s where it should be. 

Nowadays when adults get older; everybody’s so used to having high readings. When all of a sudden it comes out, 100 over 60 people think, That’s low. But no, that’s not too low. That, that’s great. When the top number becomes between 120 and 130 and the bottom between 80 and 85, that’s when you’re getting into that. We used to call it pre-hypertension, just kind of borderline that where we would say, this is crazy dangerous, but it’s kind of our, hey, warning. You’re creeping up there, and you should make some aggressive lifestyle changes so you don’t hit the next level. If you’re over 130 for the top and over 85 for the bottom regularly, and there are different guidelines from different societies, I follow the American Heart Association and the American College of Cardiology guideline documents. Then we’re calling stage two hypertension, which frequently would require, it’s every hypertension requires intensive lifestyle changes that we can get to. But when you’re doing the best you can with your lifestyle or you’re still working on getting things lifestyle-wise, then there’s the pharmacotherapy, the medications.

Laurie Marbas, MD, MBA

Blood pressure medications are indicated to get it down, even while you’re proceeding with lifestyle interventions as the first step. However, medications are needed in some cases. But I want to kind of get this back a little bit to the silent progression. When you mentioned you’ve had patients with blood pressures in the 200 systolic range and they come in and they’re minimally symptomatic, how does that happen? How does the body adapt to or respond to these prolonged, elevated blood pressures? What mechanisms are at play?

Steven Lome, DO, RVT

Well, the human body is amazing at how it can adapt to so many different things and situations, honestly. But since the blood pressure is as high as 220 over 120, that didn’t happen overnight. that happened over many months, or sometimes over many years. In those instances, the heart itself—being a cardiologist—is usually my focus. The heart muscle thickens up, and it thickens up. I think of just any muscle; if you work any muscle hard, you lift a lot of weights, and your biceps can get bigger. Well, if your heart has to pump against higher blood pressure, it will thicken as well, which can lead to some serious problems. But you get changes in the artery wall. There’s neurologic change, and even the kidneys start to have issues. But over time, that high blood pressure has certainly increased the risk of clogging the arteries. and making the vessels, you can think of them as being more fragile and prone to stroke, plaque rupture, or hemorrhage in the brain. Is that the most feared complication? It’s amazing how it happens. It’s very similar to when people become diabetic; their sugars go up. When it happens over a very slow period, symptoms take longer to develop, whereas when it happens rapidly, then they get more symptoms.

Laurie Marbas, MD, MBA

Yes, perfect. Can we speak a little bit about heart failure? What exactly is that? What are the symptoms of the different types of heart failure that someone might show signs of before they even realize they have high blood pressure?

Steven Lome, DO, RVT

Congestive heart failure is the number one reason in the United States for somebody to be admitted to the hospital. It’s a situation where the heart simply isn’t pumping enough blood to meet the demands of the body. There are many different causes of heart failure, heart attacks, or heart valve conditions. But certainly one of the top risk factors for developing congestive heart failure is having high blood pressure. When the blood pressure is high, especially over many, many years, again, the heart muscle thickens, and when it’s bad, it can make the heart weaken because you can kind of think about going back to lifting weights with your biceps. You start lifting weights, you can do it for a little while, but then you’re going to hit a point where you’re going to say, My muscles are fatigued. I just can’t keep doing this. I have to put the weights down because the muscles are fatigued while the heart muscle gets the same way. 

When it’s pumping against such high blood pressure over some time, it reaches a point where it just says, I just can’t keep doing this. It starts to weaken. When it starts to weaken, it’s not pumping enough. The pressure builds up. When the pressure builds up, the heart pumps up enough blood to all your organs, including the kidneys, for you to get rid of water and urinate out with the fluids that you’re taking in. Water accumulates in your body; a lot of times, it accumulates in the legs because of gravity. People have their legs hanging down, but they eventually work their way up. Can get into the lungs and make people very short of breath. Congestive heart failure when it’s from hypertension alone, that’s not a good thing because that means the hypertension is very uncontrolled and there’s very significant permanent damage done to the heart. Now, there are other times when the heart can remain strong and doesn’t weaken, but because of the thickening of the heart muscle, it has abnormalities in what we call relaxation. The diastolic function, which means the feeling of blood, squeezes hard, but if it can’t relax adequately to fill with blood to prepare for the next heartbeat, then the overall output of the heart goes down too. That causes the same type of congestive heart failure symptoms.

Laurie Marbas, MD, MBA

What are the typical treatments for that, and how does lifestyle or plant-based eating help with heart failure?

Steven Lome, DO, RVT

Well, when heart failure is related to hypertension, you could think of it as the cause of hypertension, and thus heart failure is lifestyle-related and the best treatments are always going to improve lifestyle, no question about it. Trying to normalize the blood pressure is critical. Yes, as we said, in the short term, sometimes medications are needed. But in almost every single case, if somebody is intensive enough with their lifestyle change, you could reverse hypertension, which may not completely reverse all the damage done from the high blood pressure on the heart, but it can reverse quite a bit of it. The critical thing when somebody has heart failure related to hypertension is controlling the blood pressure and the water balance. then other complicating factors can happen from that, whether the kidneys are strained or heart rhythm issues develop, such as atrial fibrillation. Controlling those things is critical to keeping the water out and helping somebody breathe better and feel better from congestive heart failure.

Laurie Marbas, MD, MBA

Okay. If you have someone, let’s say that they are doing everything they’re supposed to. We have someone who’s eating a whole-food plant-based diet. They’re at an adequate, healthy weight. They’re exercising regularly. If they still have elevated blood pressure, maybe we’re requiring two or more medications. What should they do? Is it just written on the wall? This is your fate, or is there something else we should be looking at?

Steven Lome, DO, RVT

Yes. It’s a great question. First of all, just to address what some people think, blood pressure is genetic, but just like diabetes or heart disease, we always see the genes load the gun. But diet and lifestyle pull the trigger. Even if you have a genetic risk, your lifestyle choices are way more powerful than your predisposed genetic risk. Let’s say somebody is doing perfectly. I have patients telling me they’re doing perfect. I go, all. Let’s examine what you think is perfect and make sure that they’re doing things. 

Regular exercise, whole-food, plant-based, low-fat diets, and reaching an ideal body weight. Because a lot of people may not be overweight, or my body mass index is 24.5. But, technically, your ideal weight might be 10 pounds lighter than that, and that might be the 10 pounds you need to get your blood pressure down. We think about alcohol because some people still think that red wine isn’t all that bad for you. That’s not true. Any amount of alcohol is bad for your cardiovascular system, not to mention the cancer risk. I make sure there’s no alcohol being consumed. Then, one of the most overlooked things that raise blood pressure is sleep. Sleep is critical, whether it is just somebody getting interrupted, sleeping because they have a lot of pain in their back, waking up to pee all the time, or sleep apnea. Snoring, stopping, and breathing. 

Statistics show the number one cause of resistant high blood pressure, which we define as high blood pressure despite being on three different medications or more, is sleep apnea which is uncontrolled. Snoring and stopping breathing. It even raises the blood pressure throughout the day, not just at night. Even if the person says, I don’t snore, well, you could have sleep apnea without snoring. That can happen. In such a situation, I would have them referred for a sleep evaluation to make sure that they don’t have any sleep apnea present as well. 

Look at the sodium in the diet. We try to increase potassium in the diet, and I think that’s pretty much it. Eat your veggies. It usually works well. There are some other things—ground flaxseeds, blueberries, other things—that have some softer amount of clinical trials that can kind of help lower blood pressure, but there’s no other magic remedy—the natural, garlic pills, or anything else—that has been adequately shown to help with blood pressure when somebody is doing everything else perfect. Following up on that, tell me everything is perfect. We went through all those things that we can still identify. Then we start thinking, Is there something else going on? Is there a hormonal issue? Is there an adrenal tumor, or is there what we call a secondary cause? That requires further investigation. If you’re in a situation where you’re doing everything perfectly and your blood pressure is still high, make sure you see your doctor and do some other tests that need to be run.

Laurie Marbas, MD, MBA

Can we speak a little bit about the sleep apnea? I interviewed a sleep specialist and a physician, and it was helpful. She had mentioned that nighttime dipping doesn’t occur because your blood pressure naturally drops overnight. But what would you say the mechanism is for that? High blood pressure is secondary to sleep apnea. Can you just give a little bit of the physiology that’s occurring there?

Steven Lome, DO, RVT

Yes. I’m not a sleep medicine specialist, and perhaps they could speak in more detail. But my understanding is that the sympathetic nervous system, which is adrenaline-mediated, is hyperactive when somebody doesn’t sleep well. That is one of the main driving forces, very similar to how alcohol intake activates the sympathetic nervous system. I know that one of the main physiologic mechanisms is that even during the daytime, your general level of adrenaline ends up being higher when you don’t sleep while we have sleep apnea.

Laurie Marbas, MD, MBA

Perfect. Well, I think this is a good point here. I just want to thank everyone for joining us today. I hope you found this conversation insightful and engaging. If you’re making a purchase or staying here because we’re about to dive even deeper into this cool conversation. If you’re not, click on the button below or to the side and get access to the rest of the conversation. 

Now, if you’re still watching this, thank you for being a valuable member of our community. Let’s continue our conversation with Dr. Lome. When we get to hypertension and someone is discovered to have hypertension, they go to the doctor; this is elevated. Maybe it was 150 over 90 or something. Are there other tests they should be doing at that point to make sure other things haven’t been damaged already? Yes, of course, they’ll be hopefully advised on lifestyle intervention. Not always, but sometimes they are. Is there anything else that we should be concerned about at that point, as we’re starting medication?

Steven Lome, DO, RVT

Absolutely. The first thing we do is just routine blood work. The most critical is kidney function. I make sure that nothing has damaged the kidneys. That’s important, too, because when it gets to the point where medications are needed, we need to make sure our kidney function and electrolytes are good before we start them. That’s one thing. I’m assuming this person has no symptoms, and the lack of symptoms, routine blood work, checking, kidney function—we check the thyroid because thyroid abnormalities can raise blood pressure to come in too. It’s a simple blood test. It might as well just exclude any thyroid disease. 

Then, here in our cardiology office, of course, we do an EKG as well, where they put the stickers on and we measure the heart’s electricity. We could see if there’s hypertrophy or thickening of the heart muscle, which tells us there’s more urgency to address. That has probably been elevated for a while and is already starting to affect the heart. That’s an important piece of information. Besides those things, if there are no symptoms, there’s no other specific testing that we would do. Again, if we think they have sleep apnea, we would refer them for a sleep evaluation. If any of the other symptoms are going on, we may focus testing on those other symptoms.

Laurie Marbas, MD, MBA

Would you, let’s say, be your activity, your exercise prescription, or be with someone with hypertension? What would that look like?

Steven Lome, DO, RVT

Yes. Most of the research on hypertension focuses on aerobic exercise and endurance exercise. The current recommendations are 30 to 60 minutes, five days out of the week, of moderate-intensity aerobic exercise. That means two days you get to rest. The other five days, you should be doing 30 to 60 minutes of moderate intensity. Modern intensity is a type of exercise or degree of exercise where you’re getting a bit short of breath, maybe a little bit sweaty. But if somebody asked you a question, you’d be able to speak to them in a full sentence. You’d be able to answer them pretty well. 

Some people talk about, What heart rate should you have? Usually, we would say 50 to 70% or so of your age predicts your maximum heart rate. When you’re going more to 70 to 85% of your heart rate, that gets to be in the more vigorous physical activity level. I know you could do vigorous exercise, so you have no time. You’re a busy executive, and as I said, I have no time. Fine. Cut the number of minutes and half of exercise. You do, but make it vigorous. That’s considered okay to do. 

Then, specifically for heart health, they say that in addition to aerobic exercise and endurance exercise, it is very helpful to add resistance training two days a week two sessions, maybe an hour each. I’m not a gym guy. I’m not going to go bench press 300 pounds or whatever. Crazy. Well, it doesn’t have to be that. It is very simple core training: stepping up and down on a box and doing push-ups against a desk. Anything that just kind of activates the muscles in the core and gets you some good resistance training, too. That’s been shown to be beneficial as well.

Laurie Marbas, MD, MBA

Perfect. Resistance training, I think, is neglected by so many of us because it’s just easier to put on your sneakers and go for a walk, jog, or hike versus moving something heavy. I just did an osteoporosis workshop last night, and it was such an important piece to speak to throughout your life to be doing these things. But I want to just hone in on the last question a little bit. If you can speak, are there any particular foods in the whole plant-based diet that are more beneficial or that some of you might want to pay attention to a little bit more than everything? Where would you say, do this, do that, or maybe not this?

Steven Lome, DO, RVT

Yes. I think this is a great question. There are a couple of different ways that I could answer that. One way is to say that one of the most powerful things about a whole plant-based diet is not necessarily the food you are eating. But the food that you’re not eating. When you’re eating whole food plant-based strictly, you’re not eating processed foods. Which are extremely high in salt. 70% of the salt in the American diet comes from processed foods. Then even animal-based foods are very high in salt and can raise blood pressure. 

A lot of the benefits of eating, plant-based, honestly are simply because you’re excluding all those other harmful foods from your diet. Now, in regards to what’s in some of these plant-based foods, phytonutrients, and that are good for your blood pressure, specifically what a lot of people point to in my world of cardiology is the natural kind of nitrates, the beets and beet greens, and arugula is the rocket lettuce, they call it, because of the nitric oxide effects that you have when you eat the green leafy vegetables. 

Now, in our whole medical world and lifestyle medicine, we want evidence to back a statement. We want a randomized, controlled clinical trial. Unfortunately, we don’t have randomized controlled clinical trials saying you eat a bunch of arugula and you don’t eat arugula, and let’s see whose blood pressure gets better. It’s hard to say if this specific food or that specific food has solid evidence to say that it helps support and/or lower blood pressure. But there are a few things I’ve seen: some trials on the ground, flax seeds with some benefits, and some blueberries. There were very small trials, not very well done, not long-term, but, I think of it, though, as more as it’s not always necessarily what you eat is what you’re not eating. 

The Dash Diet, which a lot of people talk about, is not 100% plant-based. It’s mostly plant-based. However, the writer and the authors of the Dash Diet specifically said that a 100% plant-based is the best. But clearly, being exclusively whole-food-plant-based is superior to being 90% whole-food plant-based. There is individual variability, but for a vast majority of people, you want to go all in to have the greatest effect.

Laurie Marbas, MD, MBA

Perfect. I think that’s a great way to end it. My sweeping recommendation for every human alive is a whole-food plant-based diet. Absolutely. There are some nuances to, as you said, the individual, but everyone will benefit from plants. That should be a great way to end it. But thank you, Dr. Lome, for spending time with us today and sharing your knowledge. We appreciate it.

Steven Lome, DO, RVT

Absolutely. Thanks for having me again.