Rilmenidine vs Telmisartan or other BP meds for Longevity

[DrFraser]

In general terms, the benefits to super tight management of BP go down with age and risks go up. It however sounds like your are 65 going on 50, rather than most of of my ER patients who are 40 and look like they are 65.
I’d first thing not be overly excited about letting it sit in the 120’s - however, if really going for optimal, add a dose of something you tolerate well is reasonable. Propranolol is a bit of nasty drug, but a long acting beta blocker could be an option - but I’d generally favor a tiny dose like 2.5 mg of Amlodipine and be pretty happy with goaling in the upper 110’s or low 120’s and not push harder on that.
I obviously don’t know all your medical history, but in general terms with a generic patient in this situation, that would be my usual approach.

[Jonas]

Can you elaborate on the risk? Thanks

[DrFraser]

Risks are that as people get older, than have more postural hypotension, even with no meds. Pretty much, all the BP meds make this worse. This increases rate of syncope (fainting) and trauma - along with the population being more frail and more likely to bleed in their head or fracture bones at that age.
Risk of other underlying conditions resulting in more hypotension than desired go up with age (e.g. acute renal injury, sepsis).
Risk of organ dysfunction due to BP meds, primarily renal injury also goes up with age.
Then on the other side - the benefits of targeting lower BP’s seems less beneficial as people get older.
So ultimately the risk/benefit ratio looks a little different, and caution is required.

[Jonas]

Same with my mom and so we had to increase it to 80mg, her doc said Telmisartan is weak ARB so we also had to add 5mg amlodipine.

[Jonas]

Is this guideline still current then by AHA?

[Joseph_Lavelle]

@DrFraser I’ve had this off and on for a long time. Besides staying off unnecessary medications, any tips on what a person can do when it occurs to hasten to blood flow to the brain? Create abdominal pressure? Rapid breathing?

Is it true that low resting HR athletes suffer with this more than average?

[ageless64]

Thanks so much for your input. I’m not too worried about injury after syncope. I do get the occasional lightheadedness if going from sitting to standing, but I’ve got good bone mineral density (T-score is +1, Z-score +1.3) and reasonable muscle mass (RSMI 8.75).

My CAC score is 60.

I started propranolol because I was concerned about high resting heart rate, which I’ve read is associated with an earlier death. I was able to get the prescription since it’s first a line intervention for essential tremor, which I have a mild case of but doesn’t really bother me.

Does a high resting pulse rate concern you if other fitness indicators are solid?

What is a better beta blocker than propranolol?

[desertshores]

80mg daily of telmisartan is the max. recommended dose

FWIW: I was prescribed metoprolol years ago by my cardiologist as a prophylactic because of my age. I had no side effects and it worked well for me. I take metoprolol in the morning and telmisartan in the evening. Metoprolol definitely lowered my resting heart rate.

"Telmisartan
Class: Angiotensin II receptor blocker (ARB)
Mechanism: Blocks the action of angiotensin II, a hormone that causes blood vessels to constrict, thereby lowering blood pressure.

Lisinopril
Class: Angiotensin-converting enzyme (ACE) inhibitor
Mechanism: Inhibits the enzyme that converts angiotensin I to angiotensin II, a potent vasoconstrictor, thereby relaxing blood vessels and lowering blood pressure.

Metoprolol
Class: Beta-blocker
Mechanism: Blocks the effects of the hormone epinephrine (adrenaline), which causes the heart to beat faster and blood vessels to constrict, thereby lowering blood pressure and heart rate.’

[DrFraser]

The answer is a boring one. Positional change slowly. Lying to sitting for a minute or two, then to standing. In more severe cases, mineralocorticoid steroids likely fludrocortisone or similar can be used with abnormal tilt table testing. However, that usually isn’t necessary (nor healthy as will raise blood pressure).
Valsalva may not be a win, as it will hugely diminish venous return to the heart and thus limit cardiac output. It might also to a smaller degree limit flow to abdomen and legs which could shunt to the brain - but I don’t think on balance that you’ll do better with that approach. I’ve not seen research on this however.

@ageless64 When I’m 65 in 9 years, I’ll probably optimize mine if I remain in good shape - which is the plan. There are increased risks, but they are small. In regards to mild increased resting HR, there is modest evidence for this being a mortality risk, but I don’t think we have any evidence that slowing it with a beta blocker has an outcome benefit. Overall, it is an association - and my suspicion is that it is purely explained by level of conditioning and balance of sympathetic to parasympathetic nervous system. So if you are in good shape there, I’d not be losing sleep about this - and it is something that otherwise you probably can’t (and maybe have not need to) change.

[Barnabas]

@desertshores

80mg daily of telmisartan is the max. recommended dose

There does exist a 160mg telmisartan pill. I gather that it is not recommended to go above 80mg for hypertension–my understanding is that there is not significant SBP reduction from 160mg vs 80mg.

But that there are other impacts that become statistically significant at the 160mg dose. @DrFraser has mentioned this elsewhere in this thread: There is a dose dependency of telmisartan-mediated PPARγ activation, and further induction of monocytic PPARγ can be achieved with higher doses.

[DrFraser]

I doubt you’ll get much more lowering of BP going 80 to 160 mg of Telmisartan, but for neuroprotection - that seems to be a sensible dose. If my BP continues in the low 120’s as it has been lately - for no good reason, my next move is going up to 160 mg for myself. I suspect it’ll take 5 mmHg off my systolic, which is all I need and better protect my brain and improve insulin sensitivity.

[Joseph_Lavelle]

@DrFraser Thanks. Yes, boring. But worth knowing if it became a problem. It just annoying. If I breathe rapidly it seems to fade more quickly. Oddly it’s not a balance thing unless I keep walking after my vision starts to go. I don’t lose my balance even if my vision entirely fades to black.

[Olafurpall]

Soleus muscle activation has been found to be helpful in adults with diastolic bood pressure under 65 mmHg. Calf Muscles and Blood Pressure Can Predict Dementia Risk - Neuroscience News

[desertshores]

Does artificially lowering blood pressure, i.e., telmisartan, metoprolol, etc. cause an increased risk of dementia?

Dr. Oracle:
“The relationship between artificially lowering blood pressure through medications and the risk of dementia is complex and not fully understood. Current evidence suggests that antihypertensive treatment may actually have protective effects against cognitive decline and dementia in many cases.
ARBs may have larger benefits on overall cognition compared to placebo and some other antihypertensive classes ([1])
Some evidence suggests ARBs could be among the most effective classes for cognitive protection”

The relationship between blood pressure, antihypertensive treatment, and cognition may be non-linear and age-dependent ([5])
Intensive blood pressure control is generally not recommended for the oldest patients due to risks"

My blood pressure before medications was 130 -140 systolic and 80 to 90 diastolic.
Decades ago my cardiologist prescribed metoprolol as a prophylactic.
This lowered my blood pressure to ~125 systolic and ~75 diastolic.

As biohackers like myself are prone to overdo things.
Maybe I have overdone this. I asked my primary physician for some additional help in lowering my blood pressure because I was trying to optimized it because of some papers I had read.
He accommodated me by prescribing telmisartan 20mg tablets.
So I take 1, 20mg telmisartan tablet in the morning and 1, 50mg tablet of metoprolol XR in the evening.

This has resulted in a resting heart rate of ~50 bpm and blood pressure of 103 systolic and 55 diastolic.

BTW: The real reason I wanted to have low blood pressure is because my brother who was lean and healthy and exercised and ate a better diet than me suffered a hemorrhagic stroke.
“Can be caused by hypertension, aneurysms, or arteriovenous malformations.”
Unfortunately, I didn’t ask him what his blood pressure was before his stroke and now it’s too late to ask.

Oddly, with my low blood pressure, I never feel dizzy when standing up, getting out of bed, etc.

After reading the papers I am now in a quandary. I think I will stop either metoprolol or temisartan.

I might experiment by switching between them to see which results in a more normal blood pressure.
Metoprolol is a beta blocker that slows the heart rate and blood pressure and is prescribed for its cardiac benefits.
Metoprolol is an ARB seemingly is used to reduce high blood pressure to protect the kidneys.

After reading several papers, I found myself feeling uncertain as to which course to take.

Effects of Antihypertensive Drugs on Cognitive Function in Elderly Patients...

[RapAdmin]

@ageless64

I started propranolol because I was concerned about high resting heart rate

Do you have any idea why you have such a high resting heart rate? I find it extremely surprising given your high VO2max. I am hoping that as I increase my VO2max my resting HR will go down, but perhaps my assumption is wrong.

[ageless64]

I have no idea. My cardiologist isn’t concerned because it’s still within a range that is considered medically normal and my ECG is normal. Meditation with 6 second box breathing usually increases the heart rate, which is also not typical. I’m wondering if that breathing rate is too stimulating and maybe I need to slow it down further. Anyhow, I’m guessing it’s either some undiagnosed issue or I just have some quirky genetics.

But in your case improving V02 Max will likely lower your resting heart rate. That’s what happens for most people. It might even be doing that for me, it’s just not bringing it down to the level of most fit people Maybe without being in shape it would be even higher. I have no baseline measurement so I can’t really be sure.

[tj_long]

Perhaps too much high-intensity training and too little low-intensity training? Sympathetic nervous system constantly overactive? IMHO a fit and healthy person does not have a resting heart rate over 60.

[ageless64]

Perhaps, but I do 40 minutes zone 2 cycling three times a week, so I doubt that’s it.

[tj_long]

Of course, it depends on the goals, but IMHO 3 * 40 min is too little. Too little per workout (according to Iñigo San Millán and Alan Couzens) and too little per week. You should aim for at least 1 hour per workout and 4 hours per week. If you’re interested, you should follow Alan Couzens (from X), he also has an online book, it’s more for athletes, but it gives you good principles for training.

[sunshine4]

I’m debating going higher than 80 on telmisartan or just moving to telmisartan 80/amlodipine 5 or 10 (as I believe its conveniently the same pill)

I’ve read there isnt much blood pressure benefit going to telmisartan 160, and in one study I thought I read ldl was increasing going up to 160. But if there are additional weight loss/energy benefits I might continue on with going higher on telmisartan

I’m reading high 110s - around 117 in the daytime (not the fault of telmisartan though, I take nicotine/vape). Good, but not quite optimal I’m guessing