Hypertension

| Description |

• Responsible for more deaths and disease than any other biomedical risk factor worldwide1

• The major risk factor for stroke and coronary heart disease (CHD) and a major contributor to congestive heart failure, chronic kidney disease, and their progression1

| Risk Factors2 |

• Obesity (BMI >25)• Chronic stress• Poor diet, high salt and alcohol intake• Age• Physical inactivity

| Management guidelines1 |

• Initiate a comprehensive management plan to reduce BP, reduce overall cardiovascular risk and minimise end-organ damage• Advise lifestyle risk reduction for all patients, especially those with high-normal BP or hypertension.

Complementary medicines

CARDIOVASCULAR

| Practice points|

• Coenzyme Q10 (CoQ10) may signifi cantly reduce elevated blood pressure (BP) and is well tolerated• Fish oil may modestly reduce elevated BP and has multiple other cardiovascular benefi ts. Dosage should be based on EPA+DHA, not total fi sh oil• Magnesium supplementation may be benefi cial for some patients at risk of defi ciency, although evidence is mixed

| Primary recommendation |

COQ10

Mechanism of action• Antioxidant7• Improves endothelial function7

Research• Defi ciency noted in hypertensive patients. Randomised controlled trials (RCTs) and meta- analyses fi nd signifi cant antihypertensive activity9

• Treated or untreated hypertensives may have reductions in systolic blood pressure (SBP) of 11-17 mmHg and and diastolic blood pressure (DBP) 7-10 mmHg12,13

Dosage• 100-150 mg/d7

Adverse effects• Extremely well tolerated.7Interactions• Unlikely: May increase or decrease the anticoagulant effect of warfarin. Clinical trial found no interaction,

case reports exist of changes to INR. Use with caution under supervision of a healthcare professional11

• HMG-CoA-reductase inhibitors decrease plasma CoQ10. Supplementation may be benefi cial11

• May have additive effects with antihypertensive drugs. Supplementation may be benefi cial11

OMEGA-3 FATTY ACIDS

Mechanism of action• Improve endothelial function10

• Lower vascular resistance10

Research• Several meta-analyses have found a modest effect of omega-3s on BP7

• Found to be as effective as other lifestyle interventions for lowering BP in untreated hypertensives10

• A meta-analysis found a mean dose of EPA+DHA 3.8 g/d

COQ10

OMEGA-3 FATTY ACIDS

REFERENCES 1. Australian Heart Foundation. Guide to management of hypertension 2008. Updated 2010. 2. Sarris J, Wardle J. Clinical Naturopathy 2e. An evidence-based guide to practice. Chatswood: Elsevier, 2014 3. Huang N. Lifestyle management of hypertension. Australian Prescriber 2008;31(6):150-53. 4. US Department of Health & Human Services. Dash eating plan. Accessed 02/02/2016 http://www.nhlbi.nih.gov/health/health-topics/topics/dash/ 5. Australian Heart Foundation. Position Statement. Fish, fi sh oils, n-3 polyunsaturated fatty acids and cardiovascular health. 2008 6. Natural Medicines 2016. Fish oil professional monograph. https://naturalmedicines.therapeuticresearch.com/databases/food,-herbs-supplements/professional.aspx?productid=993 7. Braun L, Cohen M. Herbs and Natural Supplements. 4th edition. Chatswood: Elsevier, 2015. 8. Reid K, Frank OR, Stock NP, Fakler P, Sullivan T. Effect of garlic on blood pressure: a systematic review and meta-analysis. BMC Cardiovasc Disorder 2008;8:13 9. Reinhardt KM, Coleman CI, Teevan C, Vachhani P, White CM. Effects of garlic on blood pressure in patients with and without systolic hypertension: a meta-analysis. Ann Pharmacol 2008;42:1766-71 10. Miller PE, Van Elswyk M, Alexander DD. Long-chain omega-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid and blood pressure: a meta-analysis of randomised controlled trials. Am J Hypertens 2014;27(7):885-96. 11. Blackmores Institute 2015. Complementary Medicines Interactions Guide 7th ed. 12. Rosenfeldt F, Haas S, Krum H, Hadj A, Ng K, Leong J, Hohgson J, Watts G. Coenzyme Q10 in the treatment of hypertension: a meta-analysis of the clinical trials. J Human Hypertens 2007;21:297-306 13. Ho MJ, Bellusci A, Wright JM. Blood pressure lowering effi cacy of coenzyme Q10 for primary hypertension. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD007435. DOI: 10.1002/14651858.CD007435.pub2. 14. Oregon State University, Linus Pauling Micronutrient Information Center 2016 Magnesium http://lpi.oregonstate.edu/mic/minerals/magnesium 15. Sontia BS, Touyz. Role of magnesium in hypertension. Arch Biochem Biophys 2007;458:33-39

• Reduced SBP by 4.51 mmHg and DBP 3.05 mmHg in untreated hypertensives • Reduced SBP by 1.25 mmHg and DBP 0.62 mmHg in normotensives10

DosageDosing should be based on EPA+DHA, not total fish oil.≥2 g/d EPA+DHA10

Adverse effectsOmega-3 fatty acids are very well tolerated. Up to 3 g/d EPA+DHA is generally recognised as safe (GRAS).6InteractionsClinical studies with surgical patients fi nd no clinically signifi cant bleeding risk when omega-3 supplements are taken with aspirin or warfarin.7

Unlikely: doses >3 g/d EPA+DHA may increase the risk of bleeding with warfarin, aspirin, antiplatelet drugs.11

Possible additive effect with antihypertensive drugs. Can be used together with monitoring11

| Secondary recommendation |

Magnesium: Modulates vascular tone and reactivity.7 Low magnesium is associated with higher blood pressure.14 Defi ciency occurs only in some hypertensive patients. Mixed fi ndings in supplementation studies.15 May benefi t some individuals with low magnesium at a dose of 360-600 mg/d.7 High doses may cause diarrhoea. Divide doses to decrease risk.7

| Diet and lifestyle recommendations |

• Engage in physical activity Regular aerobic exercise can lower SBP by an average of 4 mm Hg and DBP by an average of 2.5 mmHg. Aim for 30 minutes of moderate-intensity physical activity on most, if not all, days of the week1

• Maintain a healthy body weight Every 1% reduction in body weight lowers SBP by an average of 1 mmHg. Weight loss of 10 kg can reduce SBP by 6–10 mmHg.1• Decrease alcohol consumption Reducing consumption can lower SBP by 3.8 mmHg in patients with hypertension.3 Hypertensive patients should limit intake to a maximum of 1 standard drink per day for women and 2 for men, with at least 2 alcohol-free days per week.1• Quit smoking - Refer patients to Quitline (13 QUIT)1• Reduce salt High dietary sodium is linked to increased incidence of stroke and risk of death due to CHD. Reducing intake to 1700 mg sodium/d can lower SBP by 4-5 mmHg in patients with hypertension. Limit salt intake to ≤4 g/d.3

• Increase potassium-rich foodsIncreasing dietary potassium by 2100 mg/d may reduce BP by 4-8 mmHg in hypertensive patients. Increase fruit, vegetables, legumes, plain unsalted nuts. Avoid in patients with impaired renal function and those taking potassium-sparing diuretics.1,3

• DASH eating plan (Dietary Approaches to Stop Hypertension)4Rich in potassium, calcium, magnesium, fi bre and protein; low sodium, sweets, sugary beverages, red meats, saturated and trans fats.Increase vegetables, fruits, fat-free/low-fat dairy, whole grains, fi sh, poultry, beans, seeds, nuts and vegetable oils.For more information visit http://www.nhlbi.nih.gov/health/health-topics/topics/dash/• Include fi sh and garlicHigher fi sh intake is associated with lower risk of CHD mortality, total CHD and stroke.5,6,7 Omega-3s from fi sh reduce serum triglycerides and may modestly reduce BP.5,6,7 2-3 serves of oily fi sh per week are recommended for supporting general health,5 however higher quantities (2-4 g/d EPA+DHA) may be required to decrease blood pressure in hypertensive patients 6,7,10

2 meta-analyses conducted in 2008 found garlic may reduce SBP by 8 or 16 mmHg, and DBP by 7 or 9 mmHg.8,9 Aim to consume 2-5 g/d fresh or 480-960 mg/d aged garlic extract standardised to S-allylcysteine 4.8 mg/d7

Contact education@blackmoresinstitute.org Healthcare Professional Advisory Service 1800 151 493 Website blackmoresinstitute.org