Sodium is only an issue if you have high bp.....yay or nay?

[bieberhole69]

If you have healthy kidneys and drink sufficient amounts of fluids, and are otherwise healthy, sodium is not going to give you hypertension on it's own. And because pretty much everyone on this board is likely hydrating quite a bit, a drastic reduction in sodium could be a bad thing over time.

Are you asking bc you're worried about becoming hypertensive or because you already have hypertension?

Oh, and a small PSA: hypertension guidelines have recently changed and hypertension is now defined as greater than 130/80 instead of the old 140/90.. The change was made because the difference between the two pressures was associated with double the risk of some sort of vascular event. If you have to go with a med for BP, go with an ace inhibitor or a thiazide diuretic. Technically calcium channel blockers are also first line but they tend to have more side effects.

Actually it's this for most:

ACEI or ARB first
CCB no longer first line because they don't have mortality reduction benefits (this was proven through much research), add on to aforementioned if BP not controlled
Beta blocker if the first two aren't controlling it enough
Thiazide diuretic if you have fluid overload

For African-Americans it's like this:

Thiazide diuretic (due to fluid overload being the usual factor for this part of the population)
CCB
ACEI, ARB, or B-blocker are used when the other two don't work well enough--but we don't use them first because AAs have limited response to these drugs

Also--some people are just plain prone to hypertension from sodium. Particularly African-Americans, but others can be too (if you're one of these people and on this board, you're probably (hopefully) aware of whether or not it's an issue for you). When that's the case, it's important to keep it constant, which is likely the main reason putting people on 2000mg sodium diets (that have healthy kidneys) helps--they're paying attention and keeping it constant.

 

[parrajm]

I should have said otherwise healthy white dude in my original post here, my apologies.

http://www.acc.org/latest-in-cardio...7-guideline-for-high-blood-pressure-in-adults

Those are the current recs since we've gotten more detailed than anticipated. It's dense but interesting.

A side note on beta blockers: Beta blockers aren't considered first line for htn and haven't been for years but for anyone already on one doing well, if it's not broken don't fix it. Unless it's atenolol in which case switch it bc atenolol carries an increased risk of stroke and you can get the same benefit from metoprolol. Generally people using beta blockers as antihypertensives are heart failure patients who get significant morbidity and mortality benefits from beta blockers.

You bring up an important caveat to htn treatment. Black ppl need slightly different treatment considerations as their htn actually normally is "sodium dependent." Guidelines in those cases suggest starting either a thiazide or a CCB are beneficial. An odd finding in one of the major recent studies (ALL HAT trial) found a 40% greater risk of developing diabetes on thiazides. There are multiple view points about how to look at that finding but, ultimately good BP control considerations win the day despite diabetes itself being an independent risk factor for CV disease and stroke. Black ppl already being at increased risk of diabetes to begin with, therefore, should likely start with a CCB. Most physicians I know will do just that. Of note, the ALL HAT trial was the trial with the most African Americans in it compared with other similar trials and therefore the diabetes risk may be specific to AAs. And for anyone who down plays the absolute shittiness of diabetes, understand that I've nicknamed it "the beginning of the end" for a reason (I'm talking type 2, type 1 does much better generally).

As for why thiazides are effective, it's not solely because of sodium reduction. In fact, the effect on sodium reabsorption (and therefore overall diuresis) in the kidney is the least important effect of thiazides. The diuretic effects of thiazides actually only hold for about 3 or 4 days. Additionally if this were the important factor in BP control we would be using stronger diuretics called loop diuretics to control BP. One more reason that sodium reduction via diuretics can be shown to the least likely mechanism they affect BP is the fact that ace inhibitors also decrease sodium retention by down regulating aldosterone which affects the sodium channels in the distal part of the nephron. So if sodium dependence alone were the consideration, ace inhibitors would work just as well thiazdes and less so than CCBs in our "sodium dependent" populations. However this is not what we observe in practice. The mechanism of thiazides is widely believed to actually be vasodilation oddly enough. This is why I generally take issue with the concept of sodium dependent htn outside of heart failure patients and kidney failure patients. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2904515/ that's a paper talking in more detail about what I just mentioned for anyone looking to geek out a bit more on hypertension.

Also, for the majority of ppl reading this, the nitty-gritty of which drug is best isn't nearly as important as the overall reduction in BP. So if you get control of your BP, you're ahead of the game. My ace inhibitor fanboy ways stem from them showing the highest reduction in BP (in white dudes) while having the most favorable side effect profile. Side effects = non-compliance = poor outcomes. You should expect roughly a 15 decrease in systolic (top number) BP from each drug you add. Before starting an ace inhibitor, ask your physician if you are at risk of renal artery stenosis bc if you have unilateral renal artery stenosis as that is a contraindication. If you develop a cough on ace inhibitors, switch to an ARB ( angiotensin receptor blocker) which does the same thing without the cough side effect. Without that cough, there's no reason to go with an ARB bc they are significantly more expensive.


Hope this clears things up. Any questions feel free to message me.