1. Vital Signs in Clarifying the Diagnosis and Guiding Therapy Pieter J De Wet, MD, MD(H), FAAFP, ABHIM QHI Wellness, Tyler, TX,

2. Presentation Objectives: To learn how to interpret & use information from vital signs (BP, pulse, tilt-test & body temperature) to clarify underlying diagnosis To learn how to use BP, pulse, tilt-test & body temperature to guide therapies To learn how to interpret and manage low or high blood pressure readings, slow or fast heart rate, abnormal heart rhythms and low AM axillary temperatures from an integrative medical perspective.

3. Synopsis: During this presentation I will be reviewing the subject of vital signs obtained as part of a medical exam to help participants understand how to obtain accurate vital signs readings and how to interpret them as part of an integrative medical work-up. I will also be discussing what further work-ups might be appropriate based on the patient’s vital signs and what integrative therapies might be most helpful in treating patients with certain findings on vital signs. We will include discussion of low and high resting blood pressure readings, tilt testing, abnormal pulse readings, including high or low pulse rate and abnormal rhythms. We will also be discussing early AM axillary temperature readings, how to interpret them and how to treat based on findings.

4. Pulse: low heart rate, high heart rate: low stroke volume, increased pulse rate, weakened heart, increased sympathetic drive arrhythmia

5. Hypertension Persistent elevation of arterial blood pressure (BP) ~72 million Americans (31%) have BP > 140/90 mmHg Most patients asymptomatic Increasing prevalence with aging of population and epidemic of overweight Control of BP leads to a reduction in event Control of BP leads to a reduction in events Approximately 50% reduction in heart failure Approximately 40% reduction in stroke Approximately 20-25% reduction in MI

6. Guidelines in measuring BP Condition: - – Posture (sitting, supine, standing) – Circumstances (no caffeine, no smoking) Equipment: – Cuff size – Manometer Technique: – Number of readings – Performance – Recordings

7. Target-Organ Damage Brain: stroke, transient ischemic attack, dementia Eyes: retinopathy Heart: left ventricular hypertrophy, angina Kidney: chronic kidney disease Peripheral Vasculature: peripheral arterial disease

8. Etiology of Hypertension Essential hypertension: – > 90% of cases – Hereditary component Secondary hypertension: – < 10% of cases Common causes: – chronic kidney disease, – renovascular disease Other causes: Rx drugs, street drugs, natural products, food, industrial chemicals

9. Blood Pressure Readings CLASSIFICATION – Optimal <120 <80 – Normal <130 <85 – High Normal130-139 or85-89 – Stage 1 Hypertension 140-159 or90-99 – Stage 2 Hypertension≥ 160 or≥ 100 – Stage 3 Hypertension≥ 180 or≥ 110

10. Clinical Controversy White coat hypertension: elevated BP in clinic followed by normal BP reading at home Aggressive treatment of white coat hypertension is controversial Patients with white coat hypertension may have increased CV risk compared to those without such BP changes

11. Classification for Adults Classification based on average of > 2 properly measured seated BP measurements from > 2 clinical encounters If systolic & diastolic blood pressure values give different classifications, classify by highest category > 130/80 mmHg: above goal for patients with diabetes mellitus or chronic kidney disease Prehypertension: patients likely to develop hypertension

12. Clinical Controversy Ambulatory BP measurements may be more accurate & better predict target-organ damage than manual BP measurements using a sphygmomanometer in a clinic setting (gold standard) Many patients may be misdiagnosed, misclassified because of poor technique, daily BP variability, white coat HTN

13. JNC 8 “Cliff Notes” Treat to 150/90 mm Hg in patients over age 60 and 140/90 for everybody else. Any of 4 classes of drugs could be chosen. Destination is important and not the journey. Recommendation 1 There is moderate to high quality evidence from RCTs that in the general population aged 60 years or older, treating high BP to a goal of lower than 150/90 mm Hg reduces stroke, heart failure, and coronary heart disease (CHD). There is also evidence (albeit low quality) that setting a goal SBP of lower than 140 mm Hg in this age group provides no additional benefit compared with a higher goal SBP of 140 to 160 mm Hg or 140 to 149 mm Hg

14. JNC 8 “Cliff Notes” Recommendation 4 The panel cannot make a recommendation for a BP goal for people aged 70 years or older with GFR less than 60 mL/min/1.73m2 No outcome trials reviewed by the panel included large numbers of adults older than 70 years with CKD. Antihypertensive treatment should be individualized, taking into consideration factors such as frailty, comorbidities, and albuminuria.

15. When should high blood pressure be treated? In men 45 -74 significant risk of death elevations begin at SBP of ≥165, serious risk elevations begin at ≥185 according to Framingham Study SBP ≤105 risk of death elevations as high as that ≥175 Risk of death rises by 1% per year above 90 th percentile vs the bottom 20 %. This corresponds with SBP of 159 for men 45-54; 173 for men 55-64; 184 for men 65-74; 165 for women 45-54; 183 for women 55-64; 190 for women 65-74 People with SBP lower than these levels for each age group or sex should not be treated for high blood pressure. Evidence of benefit in treating DBP ≥95 is robust for reducing morbidity, disability and mortality from cardiovascular disease, and NOT robust in those with DBP <95 (15% of men over 45 years old). With allowance for age, only top 5% should be treated.

16. What causes hypertension? Stress Nutrient deficiencies: Omega 3 fatty acids, Vitamin D, L-arginine, which is the source of the blood vessel “relaxing factor” Nitric Oxide as well as L-lysine, vitamin C, magnesium, calcium, potassium, coenzyme Q10, chromium, Vitamin B6. Other factors: poor diet, high sugar, high starch, high grain, partially hydrogenated fats, GMO foods, low vegetable and fruit intake, toxins like heavy metals, insulin resistance, pharmaceuticals (such as NSAIDS), tobacco, lack of exercise, central obesity Salt: NOT a significant cause of hypertension

17. Low blood pressure (hypotension) blood pressure reading of 90 millimeters of mercury (mm Hg) or less systolic blood pressure (the top number in a blood pressure reading) or 60 mm Hg or less diastolic blood pressure (the bottom number) is generally considered low blood pressure. low blood pressure can cause symptoms of dizziness and fainting. In severe cases, low blood pressure can be life-threatening.

18. Low blood pressure Blood pressure is considered too low only if noticeable symptoms are present. Hypotension is the opposite of hypertension which is high blood pressure. It is best understood as a physiological state, rather than a disease. It is often associated with shock, though not necessarily indicative of it. For some people who exercise and are in top physical condition, low blood pressure is a sign of good health and fitness. For many people, excessively low blood pressure can cause dizziness and fainting or indicate dehydration, acute blood loss, shock, serious heart, endocrine or neurological disorders. Severely low blood pressure can deprive the brain and other vital organs of oxygen and nutrients, leading to a life-threatening condition called shock.

19. Symptoms of Hypotension The cardinal symptoms of hypotension include lightheadedness or dizziness. If the blood pressure is sufficiently low, fainting and often seizures occur. Low blood pressure is sometimes associated with certain symptoms, many of which are related to causes rather than effects of hypotension: – chest pain, shortness of breath, Irregular heartbeat, fever higher than 38.3 °C (101 °F), headache – stiff neck, Severe upper back pain, cough with phlegm, prolonged diarrhea or vomiting – dyspepsia (indigestion), dysuria (painful urination), adverse effect of medications – acute, life-threatening allergic reaction, seizures, loss of consciousness – profound fatigue, temporary blurring or loss of vision – connective tissue disorder Ehlers-Danlos Syndrome, Black tarry stools

20. Tilt Table Testing A tilt table test, occasionally called upright tilt testing, is a medical procedure often used to diagnose dysautonomia or syncope. Patients with symptoms of dizziness or lightheadedness, with or without a loss of consciousness (fainting), suspected to be associated with a drop in blood pressure or positional tachycardia are good candidates for this test. The procedure tests for causes of syncope by attempting to cause syncope by having the patient lie flat on a special table or bed and then be monitored with ECG and a blood pressure monitor which measure continuous, beat to beat, non-invasively. The table then creates a change in posture from lying to standing.

21. Preparations Before taking the test, the patient may be instructed to fast for a period before the test will take place and to stop taking any medications. On the day of the tilt table test, an intravenous line may be placed in case the patient needs to be given medications quickly; however, this may influence the results of the test and may only be indicated in particular circumstances. More recently, most investigators monitor cerebral perfusion using mean flow velocity recording with transcranial Doppler ultrasound in supine horizontal position, during and after head-up tilt. An 18 MHz ultrasound transducer is placed on the temporal bone above the cheekbone, using headgear to hold the probe in place

22. Procedure A tilt table test can be done in different ways and be modified for individual circumstances. In some cases, the patient will be strapped to a tilt table lying flat and then tilted or suspended completely or almost completely upright (as if standing). Most of the time, the patient is suspended at an angle of 60 to 80 degrees. Sometimes, the patient will be given a drug, such as Glyceryl trinitrate (nitroglycerin) or isoproterenol, to create further susceptibility to the test. In all cases, the patient is instructed not to move. Symptoms, blood pressure, pulse, electrocardiogram, and sometimes blood oxygen saturation are recorded. The test either ends when the patient faints or develops other significant symptoms, or after a set period (usually from 20 to 45 minutes, depending on the facility or individualized protocol).

23. Diagnostic Symptoms A tilt table test is considered positive if the patient experiences symptoms associated with a drop in blood pressure or cardiac arrhythmia. A normal person's blood pressure will not drop dramatically while standing, because the body will compensate for this posture with a slight increase in heart rate and constriction of the blood vessels in the legs. If this process does not function normally in the patient, the test could provoke signs and symptoms ranging from minor lightheadedness to a very severe cardiac episode, depending on the person.

24. Side Effects of Tilt Table Testing A common side effect during tilt table testing is a feeling of heaviness and warmth in the lower extremities. This is due to blood pooling in the legs and, to onlookers, the patient's lower extremities may appear blotchy, pink, or red. Dizziness or lightheadedness are also likely to occur in susceptible patients. Tilt table testing could provoke fainting or syncope; in fact, this is the purpose of the test. It may not be appropriate, or indeed even possible, to stop the test before this occurs, as the drop in blood pressure or pulse rate associated with fainting can come on in seconds. This is why the patient's blood pressure and ECG should be continuously monitored during the test. In extreme cases, tilt table testing could provoke seizures or even cause the heart to stop. The heart resumes beating normally upon being returned to a flat or head-down position.

25. Managing Side Effects of Tilt Table Testing If at any time in tilt table testing a patient loses consciousness, he or she will be returned to a supine or head down position and will be given immediate medical attention, which could include being given fluids or perhaps atropine or a sympathomimetic drug like epinephrine or ephedrine which will raise blood pressure and heart rate rapidly.

26. Indications for Tilt Table Testing The disorders that can be examined with tilt table testing include those with the following symptoms: – Syncope (a past or recent history of fainting), – Dysautonomia: Autonomic symptoms may include nasal congestion, palpitations, non-anginal chest discomfort, recurrent queasiness, bowel and/or bladder incontinence, nocturia (more than twice nightly), generalized flushing, and excess or abnormal sweating. – General symptoms included dizziness or lightheadedness, dysania (prolonged stiffness and fogginess upon arising), occipital headache, and inability to stand in place. – Chronic Fatigue Syndrome, Fibromyalgia Syndrome

27. Indications for Tilt Table Testing: CFS/ Fibromyalgia Chronic Fatigue Syndrome and Fibromyalgia are frequently associated with orthostatic intolerance, including (symptomatic) Orthostatic Tachycardia Syndrome, and Neurally Mediated Hypotension Argument for tilt table testing in the majority of patients with CFS/FMS include: – The high positivity rate for orthostatic intolerance (82%) and neurally mediated hypotension (NMH) (42%) in these patients, – And the fact that these conditions are potentially treatable. The best predictors of a positive test are: – Inability to stand in place (postural weakness / frailty) – Fainting – Flushing. – Combined, these three predictors have a sensitivity of 71% and a negative predictive value of 75%. Thus a history of fainting, flushing, and postural weakness [falling, failing, frailty] reasonably predicts a positive passive tilt table test, and their absence reasonably predicts that the test will be negative.

28. Simple orthostatic blood pressure measurement Is inadequate because the orthostatic symptoms in CFS/FM are usually delayed. Simply having the subject stand still while BP and HR are monitored can suggest orthostatic instability if there are increases in symptoms or HR, or a precipitous fall in BP. However, this can be dangerous because some subjects faint abruptly or develop prolonged asystole under such circumstances, so they are best studied in a laboratory equipped to handle these contingencies.

29. References regarding Tilt Table Testing 1. Martinez-Lavin M, Hermosillo AG, et al., “Orthostatic sympathetic derangement in subjects with fibromyalgia,” J Rheumatol 1998 Apr; 25(4):823-825 2. Low PA, et al., “Postural tachycardia syndrome (POTS),” Neurology 1995 Apr; 45 (4 Suppl 5): S19-25. 3. Lapp CW, “Neurally Mediated Hypotension and Symptomatic Orthostatic Tachycardia in CFS,” AACFS Clinical &Research Conference, San Francisco, October 1996 4. Bou-Houlaigah I et alia, “The relationship between neurally mediated hypotension and the chronic fatigue syndrome,” JAMA 1995; 274:961-967 5. Streeten DH and Anderson GH Jr, “Delayed orthostatic intolerance,” Arch Int Med 1992; 152: 1066-1072. 6. Personal communication with Dr. I. Bou-Houlaigah, 1996

30. Abnormal Pulse Introduction to Arrhythmia An irregular heartbeat is an arrhythmia (also called dysrhythmia). Heart rates can also be irregular. A normal heart rate is 50 to 100 beats per minute. Arrhythmias and abnormal heart rates don't necessarily occur together. Arrhythmias can occur with a normal heart rate, or with heart rates that are slow (called bradyarrhythmias -- less than 50 beats per minute). Arrhythmias can also occur with rapid heart rates (called tachyarrhythmias -- faster than 100 beats per minute). In the United States, more than 850,000 people are hospitalized for an arrhythmia each year

31. What are the types of arrhythmias? The types of arrhythmias include: Premature atrial contractions. These are early extra beats that originate in the atria (upper chambers of the heart). They are harmless and do not require treatment. Premature Ventricular Arrhythmias (PVCs). These are among the most common arrhythmias and occur in people with and without heart disease. This is the skipped heartbeat we all occasionally experience. In some people, it can be related to stress, too much caffeine or nicotine, or too much exercise. But sometimes, PVCs can be caused by heart disease or electrolyte imbalance. People who have a lot of PVCs, and/or symptoms associated with them, should be evaluated by a heart doctor. However, in most people, PVCs are usually harmless and rarely need treatment.

32. Ventricular Arrhythmias There was a Holter monitoring study done by Harold Kennedy, MD in the 1960s that showed ventricular arrhythmias (even non- sustained V-tach), when NOT treated for about 10 years, had no higher risk of death or hospitalization than the people with no significant arrhythmias, as long as the ventricular arrhythmia patients had no coronary disease, cardiomyopathy or valvular heart disease. There are also studies that show that all anti-arrhythmic drugs can be pro-arrhythmic. Therefore, many doctors inappropriately treat ventricular arrhythmias when they shouldn’t (as long as valvular heart disease & cardiomyopathy are ruled out with echo-Doppler and coronary disease is ruled out with stress-thallium SPECT scanning.

33. Tachyrrhythmais Atrial fibrillation. Atrial fibrillation is a very common irregular heart rhythm that causes the atria, the upper chambers of the heart, to contract abnormally. Atrial flutter. This is an arrhythmia caused by one or more rapid circuits in the atrium. Atrial flutter is usually more organized and regular than atrial fibrillation. This arrhythmia occurs most often in people with heart disease and in the first week after heart surgery. It often converts to atrial fibrillation.

34. Tachyarrhythmias Paroxysmal supraventricular tachycardia (PSVT). A rapid heart rate, usually with a regular rhythm, originating from above the ventricles. PSVT begins and ends suddenly. There are two main types: accessory path tachycardias and AV nodal reentrant tachycardias (see below). Accessory pathway tachycardias. A rapid heart rate due to an extra abnormal pathway or connection between the atria and the ventricles. The impulses travel through the extra pathways as well as through the usual route. This allows the impulses to travel around the heart very quickly, causing the heart to beat unusually fast. AV nodal reentrant tachycardia. A rapid heart rate due to more than one pathway through the AV node. It can cause heart palpitations, or heart failure. In many cases, it can be terminated using a simple maneuvers, such as breathing in and bearing down, and others performed by a trained medical professional. Some drugs can also stop this heart rhythm.

35. Tachyarhythmias Ventricular tachycardia (V-tach). A rapid heart rhythm originating from the lower chambers (or ventricles) of the heart. The rapid rate prevents the heart from filling adequately with blood; therefore, less blood is able to pump through the body. This can be a serious arrhythmia, especially in people with heart disease, and may be associated with more symptoms. A heart doctor should evaluate this arrhythmia. Ventricular fibrillation. An erratic, disorganized firing of impulses from the ventricles. The ventricles quiver and are unable to contract or pump blood to the body. This is a medical emergency that must be treated with cardiopulmonary resuscitation (CPR) and defibrillation as soon as possible.

36. Bradyarrhythmias These are slow heart rhythms, which may arise from disease in the heart's electrical conduction system. Examples include sinus node dysfunction and heart block. Sinus node dysfunction. A slow heart rhythm due to an abnormal SA (sinus) node. Significant sinus node dysfunction that causes symptoms is treated with a pacemaker. Heart block. A delay or complete block of the electrical impulse as it travels from the sinus node to the ventricles. The level of the block or delay may occur in the AV node or HIS-Purkinje system. The heart may beat irregularly and, often, more slowly. If serious, heart block is treated with a pacemaker.

37. Is there a normal body temperature? Most people think of 'normal' body temperature as 37C (98.6F), measured using a thermometer in the mouth. However, the concept of there being a normal body temperature is somewhat misleading. In fact normal body temperature can vary according to a wide range of factors including a person's age, the time of day and whether someone is active or not. The 'normal' benchmark for body temperature was established by a 19 th century German physician called Dr Carl Wunderlich. He is credited with taking temperature readings from thousands of patients, which led him to propose that 37C was normal body temperature.

38. What is a fever? In most adults, an oral temperature above 100.4 °F (38 °C) or a rectal or ear temperature above 101 °F (38.3 °C) is considered a fever. A child has a fever when his or her rectal temperature is 100.4 °F (38 °C) or higher. A rectal or ear (tympanic membrane) temperature reading is slightly higher than an oral temperature reading. A temperature taken in the armpit is slightly lower than an oral temperature reading. The most accurate way to measure body temperature is to take a rectal temperature.

39. What can cause a fever? A fever may occur as a reaction to: Infection. This is the most common cause of a fever. Infections may affect the whole body or a specific body part (localized infection). Medicines, such as antibiotics, narcotics, barbiturates, antihistamines, and many others. These are called drug fevers. Some medicines, such as antibiotics, raise the body temperature directly. Other medicines interfere with the body's ability to readjust its temperature when other factors cause the temperature to rise. Severe trauma or injury, such as a heart attack, stroke, heat, exhaustion or heatstroke or burns. Other medical conditions, such as arthritis, hyperthyroidism, and even some cancers, such as leukemia, Hodgkin's lymphoma, and liver and lung cancer.

40. Basal body temperature Is the lowest body temperature attained during rest (usually during sleep). It is generally measured immediately after awakening and before any physical activity has been undertaken, although the temperature measured at that time is somewhat higher than the true basal body temperature In women, ovulation causes an increase of one-half to one degree Fahrenheit (one-quarter to one-half degree Celsius) in basal body temperature (BBT); Monitoring of BBTs is one way of estimating the day of ovulation. The tendency of a woman to have lower temperatures before ovulation, and higher temperatures afterwards, is known as a biphasic pattern. Charting of this pattern may be used as a component of fertility awareness.

41. Basal Temperature Test The Basal Temperature Test is not to be used as a replacement for a proper medical assessment. Instead it can help you determine whether you may have a thyroid imbalance and a low functioning thyroid gland in particular. Low thyroid function can cause many symptoms ranging from fatigue to difficulty losing weight. Because the thyroid gland reflects the body’s metabolic rate and heat is generated during metabolism, assessing body temperature can give clues regarding the function of the thyroid gland.

42. Taking a Basal Temperature Shake down a thermometer until the mercury falls below 95 degrees Fahrenheit if using an older thermometer. Place it by your bed at night when you retire. Upon waking, before getting up (yes, even to use the bathroom) place the thermometer under your armpit for 10 minutes. Digital thermometers may automatically stop before that. That’s fine. Try to lay in bed as still as possible during this time. Rest and close your eyes. Don’t get up until after the 10 minutes have passed or until a digital thermometer has registered your temperature. Record the temperature, time, and date. Conduct the same test for at least three mornings at the same time each day.

44. Assessing Your Basal Temperature Test A Healthy resting temperature ranges between 97.8 to 98.2 degrees Fahrenheit. Natural fluctuations can occur during menstrual cycles. If you are still menstruating, perform the test on the second, third, and fourth days of the menstrual cycle. Post-menopausal women or men can conduct the tests any days of the month. If your temperature is consistently lower than the range indicated above for at least three days, this may be an indication of hypothyroidism. Conversely, temperatures consistently higher than this may indicate hyperthyroidism or possible infection. Work up may include: – If temp is low, blood work including Thyroid-stimulating hormone (TSH), free T3, free T4, reverse T3, and thyroid antibodies. (Normal TSH does not rule out hypothyroidism) – For elevated temps, do workups for inflammation and infections

45. Basal Temperature Testing for Fertility or Birth Control Use a thermometer that reads to the tenths place (ie: xx.x) a digital thermometer is ideal. You don't need a specifically designed thermometer for taking BBT readings. Do not use a standard (mercury) thermometer, which isn't specific enough. Get enough sleep and, if possible, regular sleep. Irregular sleep patterns (including less than three hours of uninterrupted sleep) can result in false readings. Take your temperature every day at the same time, before getting out of bed. Set an alarm and keep the thermometer at your bedside or under your pillow. Don't stand up, walk around, eat anything, drink anything, or engage in any kind of activity (even shaking a mercury thermometer) until after you've taken your BBT (which is supposed to be taken at full rest). Make a graph on paper or on the computer, with dates on the bottom and basal temperature on the side. You can find and print fertility charts online, as well as sign up for a fertility charting service. Look for a gradual or sudden rise in temperature (between 0.5 and 1.6 degrees F). Fertility is highest during the two to three days before your basal temperature rises so if you can observe any month-to-month patterns in when your temperature rises, you can predict the best time to conceive (or the best time to abstain if you're using this method for birth control).

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