Unmanaged BP: Risks You Can’t Ignore

Kim Allan Williams, Sr., MD, MACC, MASNC, FAHA, FESC

Thank you so much for having me again, Dr. Marbas.

Laurie Marbas, MD, MBA

Absolutely. funny for you to call me Dr. Marbas. But we’ll jump in. Today we want to highlight it for you. If you can help us understand what happens when there’s uncontrolled hypertension because so many times there are no symptoms. But if maybe you can just give us some insight on what that would be and maybe just start with how prolonged high blood pressure kind of physiologically damages the body’s organs and systems over time, would you say?

Kim Allan Williams, Sr., MD, MACC, MASNC, FAHA, FESC

Now just introduce it with sort of an important statement of why you’re asking this and what the impact is. If you look at the leading causes of death around the country and the world, it’s food and nutrition that outrank everything else. But if you don’t live a healthy lifestyle and you look at disease states, it’s hypertension. It’s over 70% of all Medicare beneficiaries, the expenditures. This is a serious disease with serious impacts. It doesn’t just kill people; it disables them. People end up with hypertensive nephrosclerosis, which means that they lose their kidneys, have a hypertensive stroke, or have hypertensive heart failure. all the aneurysms and peripheral artery disease. Every blood vessel disease is accelerated. The blood pressure. 

Just think about it for a moment. What happens to the heart? If you look at your weightlifters, all the muscle gets thick. It’s Arnold Schwarzenegger who won the Mr. Universe contest. But if you’re heart muscle or skeletal muscle, if your heart muscle goes against a weight, every beat and the blood pressure are greater than 130. It does get thick. It does get muscular. The problem is that the heart isn’t designed for that, and it will ultimately outstrip its blood supply letting you lead the patient up for rhythm disturbances that can be fatal, and that thickening of the heart makes the heart stiff. People will get short of breath when they try to walk around, called diastolic dysfunction or heart failure with preserved ejection fraction because it’s not a squeezing problem. It’s a relaxation problem. Squeeze, find, relax, and slow. The pressure backs up into the left atrium, and then that ends up in the lungs. People do not feel good trying to exercise. Well, if you put all of the complications—kidney, brain, and heart—together, this is a devastating disease. If I could get everyone to do one thing, it would be a whole-food plant-based diet. Why? We used to think, based on a lot of trial evidence, that this was all about sodium, and there are some sodium-sensitive populations, and perhaps African-Americans are more than others. sensitive and respond to diuretics that way.

But it’s more than that. It’s a fact that when you eat a whole-food plant-based diet, you’re going to ingest fiber. That fiber gets fermented in your gut by promoting good bacteria, which then ferment the fiber and set you up for a larger degree of bloodstream short-chain fatty acids, that’s acetate, propionate, and butyrate. Nobody wants the chemical names, but the fact of the matter is that those are good for blood vessels. If you had bad bacteria, I know there are still some. Despite everything that you and I have done, there are still people out there with dead bodies in their refrigerators, and then they take those dead bodies out and consume them. When you’re eating decaying flesh, you’re changing your microbiome. Those are the bacteria in your GI tract. If anyone can search this out, go to your search engine, put in hypertension, microbiome, and you’ll see all this literature pop up about which species of Klebsiella, for example, that when it’s in your GI tract, in large numbers, it contributes to blood pressure elevation. then there’s some other species, bacteriophages in particular, that, when you have a lot of those units, it lowers your blood pressure. Now, it just so happens that that’s true of almost all the cardiac risk factors—diabetes, obesity, and high cholesterol—all of which are improved by inflammation. I don’t want to leave that one out. All of them are improved by changing your microbiome.

Laurie Marbas, MD, MBA

Okay. Yes, that answers a lot of questions. We know it’s fantastic. You are a wealth of information. Any time I’ve ever had you in an interview or spoken to you, it’s beyond my expectations. But can we get to what happens with uncontrolled hypertension, which you kind of mentioned with the heart in the background, is there anything else besides the kidneys? You kind of mentioned it briefly: other organs that we should be aware of, the brain, for example, what’s happening. Exactly.

Kim Allan Williams, Sr., MD, MACC, MASNC, FAHA, FESC

Let’s, well, let’s talk about them one at a time. Okay. In the brain, the most common finding is that if you were to do an MRI study or CT study, you’d find in the report chronic vascular disease, meaning small blood vessels. What they’re pointing out is that they’re little pieces of the brain that get damaged when your blood pressure is not controlled, and you’ll get tiny little hemorrhages, so-called lacuna infarcts. It’s a part of the brain, and people will lose their memory, their cognitive function, and have a higher incidence of dementia. They’re willing to lose their lives to lose their personalities and their ability to get around, do things and live independently. It has so many issues. Then on top of that, there are strokes, and these are catastrophic events. People will think that they just bleed into their brains or create aneurysms. The aneurysms cause weakness in the wall because the blood pressure has destroyed the blood vessels of the brain. Well, it’s a little bit more than that. You can promote more plaque in the brain, and then the blood pressure can break the plaque. When that plaque breaks off, whether it’s from the carotid or any way up, you’ll end up showering plaque material into small blood vessels. The tiniest clot can stop you if it’s in the wrong location, can stop you from speaking, or can stop you from moving. Hopefully, with rehabilitation, a change in diet, and control of your blood pressure, you can get better.

However, the biggest risk factor for stroke is having had a prior stroke. That’s because most people are not changing their lifestyle. They’re not doing the things that would stop them from being in that position again. That’s the brain. In the kidneys, a major issue for cardiology, believe it or not, is that once the kidneys start to go bad, they can’t excrete the poisons that make plaque happen in your coronary arteries, and you can’t excrete enough fluid if you’re in end-stage renal disease. Without dialysis, you can’t get enough fluid off to lower your blood pressure. It’s the kidney that keeps everything going so that the heart can do its job. You see a lot of people with chronic kidney disease who don’t understand. and it’s beyond understanding based on the current literature that says that the vast majority of our chronic kidney disease is produced by the consumption of animal protein and that plant-based protein will improve your kidney function.

It’s more than just that old thing of, your creatinine; the measure of your kidney function improves because you stopped eating creatine when you stopped eating animals. It’s more than that. We need to do more sophisticated tests such as Cystatin C so that people can see. Yes, I went vegan, and my kidneys did get better. Not just the number getting better, but either way, what you see with chronic kidney disease is this terrible slow progression and rise they end up on and end-stage kidney disease. You go from stage one to 2 to 3 to 4 to 5, and then you’re on dialysis for as long as you can survive dialysis. Well, that doesn’t have to happen. You have this isn’t just our International Journal of Disease Reversal and Prevention saying this; although we do have articles to that effect, we’re talking National Kidney Foundation, Journal, Nephrology. These are mainstream journals begging people to stop overloading the kidneys with the acid load that comes from animal protein. I’m hoping that anyone who has any hints knows someone, or knows a nephrologist will point out to them that a whole-food plant-based diet can be not just life-saving but dialysis-saving. Kidney saving. Okay. Are you ready for the heart? 

Laurie Marbas, MD, MBA

Yes. 

Kim Allan Williams, Sr., MD, MACC, MASNC, FAHA, FESC

Okay. The interesting part about the heart is that it’s made up of a bunch of stuff. You have to, I  always liken it to a house to try to explain it to people. If they haven’t taken gross anatomy and say, well, you’re, your heart is kind of like your home. It has got its doors, That would be the valves. It doesn’t have any windows, I hope. But some people do have windows in between the rooms, and that would be congenital heart disease, having a ventricular septal defect, or Patent Foramen Ovale, which is pretty common in the atrium. A clot in your toe could end up on your brain if your window isn’t closed. But then you have a plumbing system—that’s your coronary arteries—that feeds the oxygen to all of the muscles. Then you have your electrical system. That is the rhythm generation. But then you have the walls of the heart, and they get real and can get thick. you have, and those doors can deteriorate over time and not close well or not, open well. 

It turns out that high blood pressure, or hypertension can ruin pretty much all of those things. How in the world does it ruin an electrical system by making the muscles so thick that all the electrical activity cannot be done in a coordinated fashion? You look at an electrocardiogram, and you see a so-called intraventricular conduction delay. Well, if your muscle isn’t beating all at the same time, then it’s not all relaxing at the same time. Which means that you can set up rhythm disturbances. Then how about the doors? If the blood pressure is high, it tends to affect the aortic valve. That’s the main valve that goes out to the body, and it also affects the aorta. That is where that valve leads the blood, to distribute blood to the entire body. You end up with aortic dilation, and that would be enlargement. Well, if you’re fortunate, that gets caught and you get blood pressure medicine, and it can regress. If you’re not so fortunate, you can get what’s called a dissection where that aorta tears. That is usually catastrophic. Very painful. It is very difficult to manage. I do have a patient who survived their dissection because they happened to be in the emergency room about something else when it happened. That’s to say it’s not all that survivable when it happens, but some people have chronic dissection, but the acute ones are very tough. 

That’s the valves, that’s the aorta. But how about the muscle itself? As I mentioned, if that gets thick it can affect the blood supply—that is, the pipes—can’t feed in enough blood to keep the muscle healthy. You end up with scar tissue. Scar tissue results in truly more rhythmic disturbances. We go back to Framingham, back in the 70s, and Daniel D. Savage, one of the first academic African-American cardiologists. His big contribution before he had a premature death was the identification of so-called left ventricular hypertrophy or thickness of the main pumping chamber. The left ventricle is at huge risk for sudden cardiac death. The blood pressure does promote, with shear forces, more plaque generation in the coronary arteries. If you add all that together, you have a situation where that overload can ruin the blood vessels, the electrical system, the anatomy, the valves themselves, and the muscles start to deteriorate. Thickening is only the beginning. Ultimately, the heart would start to dilate. You’d end up meaning to enlarge. You end up with heart failure, which is reduced pumping as well as poor relaxation. I know that’s a lot to take in, but you know that everything that the heart is supposed to do can be ruined by uncontrolled high blood pressure.

Laurie Marbas, MD, MBA

Then what about some other thing? Is there anything else—fatigue, mood, sexual function, vision, or anything else—that can be affected by hypertension?

Kim Allan Williams, Sr., MD, MACC, MASNC, FAHA, FESC

Those are good points. That is, sexual function tends to deteriorate as you develop more plaque. But there is also the fact that some medications, such as diuretics in high doses, can impair sexual function in men. Beta-blockers don’t have a bad reputation for not being good for blood pressure anyway, but they’re fourth or fifth line, but people still use them on occasion. If they’re on other drugs, maybe that’s okay. Beta-blockers tend to lower the libido rather than cause erectile dysfunction, for example. This so-called rumor mill that blood pressure medications can ruin sexual function is sort of true and not true. When you talk about the eyes, Yes, there is such a thing as hypertensive retinopathy, and I had family members with uncontrolled hypertension who ended up blind. Hemorrhaging into the back of your eyeball is a risk. It doesn’t happen very often. I’m sorry it happens a lot, but it’s usually not catastrophic. Occasionally, it is. Look at so many organs. They’re all dependent on good blood flow and good blood vessels, and they can all be ruined by blood pressure that’s not controlled.

Laurie Marbas, MD, MBA

Well, I have one more question about uncontrolled blood pressure. Are there any physical warning signs that maybe someone should be aware of because maybe someone doesn’t go to the doctor very often? But is there anything that they should be mindful of physically or something? Maybe I need to go get my blood pressure checked to be seen.

Kim Allan Williams, Sr., MD, MACC, MASNC, FAHA, FESC

The interesting part is that people are sort of a lay population; they’ll tell you, I know, my blood pressure is elevated because I got a headache. That’s accurate for a tiny number of people. It’s usually called the silent killer for a reason people don’t know their blood pressure. They don’t realize it’s elevated until something happens. What happens? The fatigue is probably not as common as the shortness of breath, feeling you can’t get air when you’re trying to exercise or trying to go up a flight of stairs while carrying groceries. That has to do with so-called diastolic dysfunction or heart failure with preserved ejection fraction from the thickness of the heart. Unfortunately, if you wait for symptoms, something has already happened—something not good—and all of your blood vessels are at risk. We would have recommended it used to be life simple seven. Now it’s the essential eight where everyone should be monitoring their blood pressure, not just in the office but at home. Why? Because office pressures can be inaccurate, They can be an overestimate of what the real pressure is; unfortunately, in some populations, it could be an underestimate, what you call mass hypertension, of what’s going on at home. If there are life issues at home. Know what your blood pressure is. Get your blood sugar checked, and get your cholesterol checked. Make sure that you’re maintaining an ideal body weight. No smoking, exercising, and making certain that you’re getting enough sleep, as well as doing a whole-food plant-based diet. That would be life’s essential eight.

Laurie Marbas, MD, MBA

Perfect, and I think that’s a great way to, at least in this part of our conversation. I hope you guys found this to be enjoyable, inspirational, and insightful. If you’re a summit purchaser, stay here, because we’re about to dive in even a little bit deeper into this discussion. If you’re not, click on the button below or to the side and get access to the rest of the conversation. If you’re watching this, thank you for being a valuable member of our community. Let’s continue the conversation with Dr. Williams. Dr. Williams, we kind of just spoke to Life’s Essential Eight. Let’s talk about when someone is on hypertensive medications, how does that look? How do they get started? Then, when these hypertension medications aren’t working, can we speak a little bit more about what’s so special about a plant-based diet or other lifestyle interventions that might be helpful in treatment?

Kim Allan Williams, Sr., MD, MACC, MASNC, FAHA, FESC

Why don’t we start there, with so-called resistant hypertension? I’m convinced, after 44 years of academic medicine, that there probably is no such thing. There were some hints at that in that there are a handful of randomized trials about renal denervation catheters where you could go up into the veins that drain the kidneys and burn with radio frequency, the nerves and is supposed to tell the kidneys to stop sending out anything and any of the hormones that raise the blood pressure. The interesting thing is that the procedure does work, but it never gets there. The big impact because the control group ends up having good blood or blood pressure control because they’re going to a doctor for the study is hilarious. You end up with this minor difference in so-called resistant hypertension, which is defined as someone having an elevated blood pressure that won’t go down on three different drugs.

Well, if everybody is that inherent, they do pretty well. But in the beginning, what you mentioned is probably the most important thing that we could learn about blood pressure. It is embedded in our 2017 American College of Cardiology hypertension guidelines, and that is lifestyle. We should drop our sodium, increase our potassium, and decrease the saturated fat and cholesterol in our diet. We try to exercise daily, trying to get up between 150 and 300 minutes a week of dynamic exercise, cutting the amount of alcohol completely if we can, and approaching an ideal body weight lifestyle does make a difference. If you add up all of those things that I just mentioned, the literature for each one of them would be five or 10 millimeters of mercury. You put them all together; you’re talking about 45, 50, or 60 millimeters of mercury. Who needs medication? Who will make the lifestyle changes? But the good news is that we do have good medications. 

How it starts is that someone will go to a doctor or go to an emergency room because they hurt their ankle or something and find that the blood pressure is elevated and get referred in. If the blood pressure is more than 180, they should be starting drugs right away, even if it’s a pain response. You could argue about the 160s, but ultimately, people are going to be followed up. The most important thing about that follow-up is to immediately go and get a blood pressure cuff and measure it every day. If it’s still markedly elevated, call somebody away. Don’t wait for the week or the two weeks that it takes to get you in. But ultimately, our recommendation would be to always measure your blood pressure before you take your pills. You have a cold, you have to get a new variant, and you might not even feel that you have a fever. It might feel like a cold or anything like that. But you got dehydrated and your blood pressure’s 90 over 50, and then you’re taking your blood pressure pills? No. 

I’m always there, but the other side is way more common. That is, the medications are being taken, the lifestyle is not optimized, and the blood pressure medications do not have you anywhere near your target. In that case, you do take your pills, and you call the doctor and say, Hey, my blood pressure is 160. I know you told me it should be less than 130. Notice I’m only talking about systolic pressure; we kind of gave up on diastolic because it wasn’t so helpful. That’s what it looks like. Start with blood pressure, write them down, and send them to your doctor. Everybody’s got a bylaw; they have to have a portal with their electronic health record these days. The free communication of a lot of numbers is the thing that’s going to get you under control.

Laurie Marbas, MD, MBA

Just to speak, let’s say someone is hypertensive and is on medications, and they start a whole-food plant-based diet. They start exercising and utilizing all the lifestyle components that you’ve mentioned. How long does it take to see improvement? What about those who don’t see improvement? Is there something special or something that we need to be more focused on? Maybe it is what is considered an ideal weight? Maybe it’s something like that, but what are your recommendations there?

Kim Allan Williams, Sr., MD, MACC, MASNC, FAHA, FESC

Some people do not respond, and sometimes they have a so-called secondary cause, such as renal artery stenosis. It’s a fancy term for the blood vessel that feeds the kidneys; having plaque or so-called fibromuscular dysplasia, which is sort of an artery wall with muscle, that muscle overgrowth can create a narrowing. The blood pressure in the kidney might be 70, and the blood pressure in the body might be higher because the kidney puts out hormones to raise the blood pressure. Because it thinks it’s going to die and thinks the patients are going to die, the blood pressure is 170. The kidney is trying to preserve itself and the body, not realizing that on the other side of that, the blood pressure is extremely high. You do have some resistant conditions that are so-called secondary hypertension, and there are a handful of them: elevated cortisol, elevated catecholamines, and the so-called pheochromocytoma. But the vast majority of our secondary workouts are negative. As I have mentioned, I have been doing academic cardiology for 44 years. I’ve seen four of them come back. You cut out the adrenal tumor, and things get better. There are conditions, but most of the time people are going to respond because it’s so-called essential hypertension. It’s mostly diet, overweight, and a lack of exercise. We fixed the lifestyle. But I think what you’re getting at is, how effective is it going to be for some? I mentioned that it might be 45 or 50 millimeters of mercury off of someone who’s hypertensive and does everything the right way.

Laurie Marbas, MD, MBA

Are there any particular foods that you would emphasize over others, on the whole, the plant-based diet?

Kim Allan Williams, Sr., MD, MACC, MASNC, FAHA, FESC

I would have to say that after reading about it in our journal, Arugula Rocket, I never enjoyed the taste of it much, but I do now that I know that the nitric oxide and basal dietary capacity are good. But I have to tell you personally, being African-American and having a stressful transition from being this good—I say this out loud at the University of Chicago in college—I was playing so much tennis and I was steady on the side of medical school. You can’t play your way through medical school at the University of Chicago. I had this, probably somewhere around an act of coupling my academic time. How much time do I spend sitting, reading, and studying? Tennis was not played six hours a day. It was one hour a week. Under that kind of pressure, with a family history of hypertension pretty much coming and going and everybody, I had a blood pressure of 140 over 90, I was already a vegetarian. But I was doing that over-lacto kind of vegetarian diet. Well, I would make a specific choice based on my physiology books to cut the sodium. It had a dramatic effect. You have a blood pressure of 125. 

Fast forward about goodness 2025 years when I learned about my cholesterol being elevated and went on a whole food plant-based diet, that 125 went down to 104. The blood pressure improvement is dramatic. That’s my personal blood pressure story. But the ones that have impressed me the most are the people who did not do what I said a few paragraphs ago, which is to measure your blood pressure every day. I will see people more than once. They’re passing out in their car. They are going one of them made a big appointment with his primary care doctor instead of calling me, made a big point, and said, I don’t know if these medications are working a feeling so terrible and got his blood pressure measured and it was 78 over 40 and the doctor said well, what are you doing? He said, Well, Dr. Williams put me on a plant-based diet and medication because my blood pressure was 160. The doctor told him that you need to eat meat so that you can take your blood pressure medicine.

Laurie Marbas, MD, MBA

No, he didn’t. My heavens.

Kim Allan Williams, Sr., MD, MACC, MASNC, FAHA, FESC

He did. Anyway, we have some learning to do in our physician community, but ultimately we straightened the patient out and ended up off medication because the plant-based diet had dramatically improved his blood pressure.

Laurie Marbas, MD, MBA

It reminds me of patients, and I’ve had more than a few who start a plant-based diet, and their endocrinologists or other doctors will say, eat more sugar as you continue your insulin or your diabetic medications. You’re missing the point here.

Kim Allan Williams, Sr., MD, MACC, MASNC, FAHA, FESC

It’s cut them down well, as it were. Absolutely. Certainly, you cut them. That is the art of plant-based medicine, and plant-based cardiology is prescribing. There aren’t a lot of books on it. You have to learn by doing and by logic.

Laurie Marbas, MD, MBA

I call it positive collateral damage when you have someone, let’s say, your patients, and maybe they were doing the cooking and they got better, but maybe a family member also had hypertension or diabetes. They also get better. Make sure you tell those who are living in your home and are still thinking they could get better too. Because I saw medications decrease in family members who were not patients.

Kim Allan Williams, Sr., MD, MACC, MASNC, FAHA, FESC

Absolutely.

Laurie Marbas, MD, MBA

Well, thank you, everyone, for listening. Thank you, Dr. Williams, for again spending your time with us today. I’m sure it was very insightful and informative for many people.

Kim Allan Williams, Sr., MD, MACC, MASNC, FAHA, FESC

It was so much my pleasure.