NON-NON-PHARMACOLOGICAL PHARMACOLOGICAL MANAGEMENT OF MANAGEMENT OF

HYPERTENSION HYPERTENSION

Overview of HypertensionOverview of Hypertension

High BP is a risk factor for stroke, High BP is a risk factor for stroke, CHF, angina, renal failure, …CHF, angina, renal failure, …

Hypertension clusters with Hypertension clusters with hyperlipidemia, diabetes and obesityhyperlipidemia, diabetes and obesity

Drugs have been effective in treating Drugs have been effective in treating high BP but because of their side high BP but because of their side effects and cost, non-pharmacologic effects and cost, non-pharmacologic alternatives are attractivealternatives are attractive

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Two types of high blood pressure Two types of high blood pressure

HypertensionHypertension

essential essential (primary) (primary) hypertension hypertension secondary secondary hypertension hypertension

Most common Most common (90%) and (90%) and dangerousdangerous

Treatable or Treatable or reversiblereversible

© 2004, 2002 Elsevier Inc. All rights reserved.

Treatment of Hypertension—CauseTreatment of Hypertension—Cause

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

British Hypertension society Classif ication of blood pressure

levels Category Systolic blood pressure

(mm Hg)Diastolic blood pressure

(mm Hg)

Blood pressureOptimalNormalHigh Normal

<120<130130 – 139

<80<8585 -89

HypertensionGrade 1 (mild)Grade 2 (moderate)Grade 3 (severe)

140 – 159160 – 179>180

90 – 99100 – 109>110

Isolated Systolic HypertensionGrade 1Grade 2

140 – 159>160

<90<90

Pathophysiology of HypertensionPathophysiology of Hypertension

High blood pressure is also associated with High blood pressure is also associated with obesity, salt intake, low potassium intake, obesity, salt intake, low potassium intake, physical inactivity, heavy alcohol use and physical inactivity, heavy alcohol use and psychological stress.psychological stress.

Intra-abdominal fat and hyperinsulinemia may Intra-abdominal fat and hyperinsulinemia may play a role in the pathogenesis of hypertension.play a role in the pathogenesis of hypertension.

3 mm Hg reduction in SBP results in 8% 3 mm Hg reduction in SBP results in 8% reduction in stroke mortality and 5% in CAD reduction in stroke mortality and 5% in CAD mortality.mortality.(National High blood pressure education programme working group report, (National High blood pressure education programme working group report, 1993.)1993.)

Modifiable risk factors for Essential Modifiable risk factors for Essential Hypertension :( JNC VII Guidelines)Hypertension :( JNC VII Guidelines)

ObesityObesity

Physical inactivityPhysical inactivity

Alcohol consumptionAlcohol consumption

Diet Diet

Stress & anxiety Stress & anxiety

Lifestyle interventions Recommends therapeutic l i festyle change for Recommends therapeutic l i festyle change for

most people with pre-hypertension as well as most people with pre-hypertension as well as for those with hypertension. for those with hypertension. Weight reductionWeight reduction DASH dietDASH diet Dietary sodium reductionDietary sodium reduction Physical ActivityPhysical Activity Moderate alcohol consumptionModerate alcohol consumption

http://www.nhlbi.nih.gov/guidelines/hypertension/http://www.nhlbi.nih.gov/guidelines/hypertension/

1-Body Weight and BP1-Body Weight and BP A direct associat ion between excess body wt and HTN regardless A direct associat ion between excess body wt and HTN regardless

of age, gender & race. of age, gender & race.

4.5 kg reduction in wt resulted in reduced BP.4.5 kg reduction in wt resulted in reduced BP.

60% of pts remained normotensive without pharmacologic therapy 60% of pts remained normotensive without pharmacologic therapy (DISH Trial) (DISH Trial)

Better control of BP achieved when Wt reduction added to Better control of BP achieved when Wt reduction added to antihypertensive therapy. antihypertensive therapy.

Waist circumference <85 cm for women and <98 cm Men and Waist circumference <85 cm for women and <98 cm Men and BMI<27 are recommended. BMI<27 are recommended.

lose weightlose weight

Calorie reduction; aim to maintain normal Calorie reduction; aim to maintain normal weight for adults (body mass index 20-25 weight for adults (body mass index 20-25 kg/m2)kg/m2)

Systolic BP can be lowered 5 - 20 Systolic BP can be lowered 5 - 20 mm Hg for every 10 kg weight lossmm Hg for every 10 kg weight loss

2-DASH Diet and High Blood 2-DASH Diet and High Blood PressurePressure

Dietary Approaches to Stop Hypertension. The diet is simple:Dietary Approaches to Stop Hypertension. The diet is simple: Eat more fruits, vegetables, and low-fat dairy foodsEat more fruits, vegetables, and low-fat dairy foods Cut back on foods that are high in saturated fat, Cut back on foods that are high in saturated fat,

cholesterol, and trans fatscholesterol, and trans fats Eat more whole-grain foods, fish, poultry, and nutsEat more whole-grain foods, fish, poultry, and nuts Limit sodium, sweets, sugary drinks, and red meatsLimit sodium, sweets, sugary drinks, and red meatsIn research studies, people who were on the DASH diet In research studies, people who were on the DASH diet

lowered their blood pressure within 2 weeks.lowered their blood pressure within 2 weeks.Another diet -- DASH-Sodium -- calls for cutting back sodium Another diet -- DASH-Sodium -- calls for cutting back sodium

to 1,500 mgm a day (about 2/3 teaspoon). Studies of to 1,500 mgm a day (about 2/3 teaspoon). Studies of people on the DASH-Sodium plan lowered their blood people on the DASH-Sodium plan lowered their blood pressure as well.pressure as well.

Foods and Blood PressureFoods and Blood Pressure

3-The Effect of Sodium Intake on BP Sodium intake is one of several dietary factors Sodium intake is one of several dietary factors

that increases blood pressure that increases blood pressure Sodium is the principal cation of the Sodium is the principal cation of the

extracellular f luid and functions as the osmotic extracellular f luid and functions as the osmotic determinant in regulating extracellular f luid determinant in regulating extracellular f luid volume and plasma volumevolume and plasma volume

Sodium is stored in the blood and in the f luid Sodium is stored in the blood and in the f luid surrounding the cells; kidneys control the body surrounding the cells; kidneys control the body sodium concentrat ion by clearing excess sodium concentrat ion by clearing excess sodium through urine sodium through urine

The Effect of Sodium Intake on BP Sodium affects blood pressure by changing Sodium affects blood pressure by changing

blood volumeblood volume Absorbed sodium remains in the extracellular Absorbed sodium remains in the extracellular

compartments, includingcompartments, including plasma (at [140 mmol/L]; interstitial fluid [145 mmol/L]; plasma plasma (at [140 mmol/L]; interstitial fluid [145 mmol/L]; plasma

water [150 mmol/L]; muscle tissue [3 mmol/L])water [150 mmol/L]; muscle tissue [3 mmol/L]) These levels maintain blood pressure in the These levels maintain blood pressure in the

normal rangenormal range Increased sodium intake =increased blood Increased sodium intake =increased blood

volume = higher blood pressure volume = higher blood pressure Sodium reduction = decreased blood volume = Sodium reduction = decreased blood volume =

lower blood pressure lower blood pressure Institute of Medicine. Dietary reference intakes for water, potassium, sodium chloride, and sulfate. Washington, DC: NationalInstitute of Medicine. Dietary reference intakes for water, potassium, sodium chloride, and sulfate. Washington, DC: NationalAcademies Press; 2004.Academies Press; 2004.

Sodium Reduction Benefits All Ranges of BP

Evidence supports a strong, direct relationship Evidence supports a strong, direct relationship between blood pressure and vascular mortali ty between blood pressure and vascular mortali ty

Average blood pressure was reduced by Average blood pressure was reduced by 22.7/9.1 mm Hg in patients with resistant 22.7/9.1 mm Hg in patients with resistant hypertension when switched from a high to low hypertension when switched from a high to low sodium diet sodium diet

In most individuals blood pressure is reduced In most individuals blood pressure is reduced within days to weeks of reducing sodium intakewithin days to weeks of reducing sodium intake

Salt Intake reduction 6 gm/day. lowers BP to Salt Intake reduction 6 gm/day. lowers BP to 7.11 mm Hg (SBP) & 3.88 mm Hg (DBP) in 7.11 mm Hg (SBP) & 3.88 mm Hg (DBP) in hypertensives.hypertensives.

Mac Gregor GA et al, 2002Mac Gregor GA et al, 2002Institute of Medicine. Dietary reference intakes for water, potassium, sodium chloride, and sulfate. Washington, DC: NationalInstitute of Medicine. Dietary reference intakes for water, potassium, sodium chloride, and sulfate. Washington, DC: NationalAcademies Press; 2004.Academies Press; 2004.Pimenta E, Gaddam KK, Oparil S, Aban I, Husain S, Dell'Italia J, Calhoun DA. Effects of dietary sodium reduction on bloodPimenta E, Gaddam KK, Oparil S, Aban I, Husain S, Dell'Italia J, Calhoun DA. Effects of dietary sodium reduction on bloodpressure in subjects with resistant hypertension: results from a randomized trial. pressure in subjects with resistant hypertension: results from a randomized trial. HypertensionHypertension. 2009; 54: 475 - 481. 2009; 54: 475 - 481

4-Physical Activity and BP4-Physical Activity and BP

Moderate increases in PA can prevent or Moderate increases in PA can prevent or at least attenuate the development of at least attenuate the development of HTN.HTN.

The RR for developing HTN is about 1.5 The RR for developing HTN is about 1.5 to 2.0 times higher in sedentary vs to 2.0 times higher in sedentary vs physically active individuals. physically active individuals.

Staessen, et al., ’94; Sawada S, et al. ’93; Reaven et al., ‘91 Blair S, et al., ‘84 ; Paffenbarger et al., ‘83

ExerciseExercise

Evidence supports that level of regular Evidence supports that level of regular physical activity is more effective than physical activity is more effective than dieting for long term weight control.dieting for long term weight control.

(French, S.A., et al. 1994)(French, S.A., et al. 1994)

Increased caloric expenditure through Increased caloric expenditure through aerobic type exercise is a signif icant option aerobic type exercise is a signif icant option for unbalancing the energy equation to for unbalancing the energy equation to bring out both weight loss and a favorable bring out both weight loss and a favorable modif ication in body composit ion.modif ication in body composit ion.

(Ballor, and Kessey et (Ballor, and Kessey et al.1994al.1994 ))

Net 3500 kcal energy burning gives 0.45 kg Net 3500 kcal energy burning gives 0.45 kg body fat loss.body fat loss.

A meta analysis by staessen et al. showed that A meta analysis by staessen et al. showed that mean SBP & DBP reductions were 1.6/1.1 mean SBP & DBP reductions were 1.6/1.1 mmHg per kg of body weight by aerobic mmHg per kg of body weight by aerobic program.program.

18 month weight loss program associated with 18 month weight loss program associated with 77% reduction in incidence of hypertension.77% reduction in incidence of hypertension.

(He J, Whelton PK et (He J, Whelton PK et al.2000)al.2000)

The exact mechanism by which weight The exact mechanism by which weight reduction lowers blood pressure is not known.reduction lowers blood pressure is not known.

ExerciseExercise

Probable mechanism:Probable mechanism:

- Decreased concentration of renin and - Decreased concentration of renin and aldosterone .aldosterone . (Engel S, Sharma AM et al. 2001)(Engel S, Sharma AM et al. 2001)

- Decrease in activity of sympathetic - Decrease in activity of sympathetic nervous system.nervous system. (Esler M, Lambert G et al.2006) (Esler M, Lambert G et al.2006)

Aerobic exercises

Aerobic exercises may play an important role in Aerobic exercises may play an important role in the treatment of blood pressure of hypertensive the treatment of blood pressure of hypertensive individuals treated in the long run.individuals treated in the long run.Moderate-intensity of aerobic exercise is Moderate-intensity of aerobic exercise is associated with a signif icant reduction of B.P. associated with a signif icant reduction of B.P. in hypertensive and normotensive part icipants in hypertensive and normotensive part icipants and in overweight, as well as normal-weight and in overweight, as well as normal-weight participants reducing :participants reducing :

1-regional sympathetic outf low,1-regional sympathetic outf low, 2- total peripheral resistance2- total peripheral resistance 3- heart rate. 3- heart rate.

ExerciseExercise

Regular aerobic exercise within the limits of the person’s cardiovascular status Regular aerobic exercise within the limits of the person’s cardiovascular status should be encouragedshould be encouraged

Not only is exercise helpful in controlling weight, but there is also evidence that Not only is exercise helpful in controlling weight, but there is also evidence that physical conditioning may:physical conditioning may:

1)1) lower arterial pressurelower arterial pressure 2)2) lower insulin levelslower insulin levels3)3) increase peripheral sensitivity to insulinincrease peripheral sensitivity to insulin4)4) decrease incidence of NIDDMdecrease incidence of NIDDM5)5) decrease sympathetic tone decrease sympathetic tone

Isotonic exercise (e.g., jogging) is better than isometric exercises (e.g., weight Isotonic exercise (e.g., jogging) is better than isometric exercises (e.g., weight lifting) since the latter may raise arterial pressurelifting) since the latter may raise arterial pressure

Isometric exercise such as weight lifting can have a pressor effect and Isometric exercise such as weight lifting can have a pressor effect and therefore should be avoided. Thus it is strictly contraindicated. therefore should be avoided. Thus it is strictly contraindicated.

(Krousel(Krousel Wood MA, Muntner P et al, 2004)Wood MA, Muntner P et al, 2004)

Take regular exerciseTake regular exercise

Engage in regular aerobic physical exercise (brisk Engage in regular aerobic physical exercise (brisk walking rather than weight lifting) for 30 minutes per walking rather than weight lifting) for 30 minutes per day, ideally on most of days of the week but at least day, ideally on most of days of the week but at least on three days of the week on three days of the week

Regular exercise decrease BP by 8-10 mmHgRegular exercise decrease BP by 8-10 mmHgAvoidance of elevators should be encouraged as toleratedAvoidance of elevators should be encouraged as tolerated

Exercise Recommendations for BP Control Exercise Recommendations for BP Control American College of Sports MedicineAmerican College of Sports Medicine

F:F: Frequency: Frequency: 3-6 t imes/wk3-6 times/wk

I:I: Intensity: Intensity: Moderate (Brisk walk)Moderate (Brisk walk)

T:T: Time: Time: 20-60 min/session. 20-60 min/session. May split sessions May split sessions

(AM/PM)(AM/PM)

T:T: Type: Type: Type of Exercise: AerobicType of Exercise: Aerobic

Regular alcohol intake in excess of 4 drinks per day (more than 100 g Regular alcohol intake in excess of 4 drinks per day (more than 100 g ethanol) increases BP in men and women even in normotensive ethanol) increases BP in men and women even in normotensive subjectssubjects

Reduction of alcohol decreases both systolic and diastolic BP Reduction of alcohol decreases both systolic and diastolic BP readings in hypertensive patientsreadings in hypertensive patients

Clinical Studies show that BP falls 4 to 5 mm Hg in days Clinical Studies show that BP falls 4 to 5 mm Hg in days or weeks with abstinence from alcoholor weeks with abstinence from alcohol

The JNC VII recommends that alcohol intake should be The JNC VII recommends that alcohol intake should be no more thanno more than– 2 drinks/day (male)2 drinks/day (male)– 1 drink/day (female)1 drink/day (female)

5-Alcohols consumption5-Alcohols consumption

Smoking cessationSmoking cessation

Cigarette smokingCigarette smoking is a powerful risk factor for cardiovascular is a powerful risk factor for cardiovascular disease and its multiple complications. disease and its multiple complications.

i l l icit drugs : i l l icit drugs : illicit drugs such as cocaine can illicit drugs such as cocaine can exacerbate hypertension and dangerously interact exacerbate hypertension and dangerously interact with antihypertensive medications. with antihypertensive medications.

© 2008, American Heart © 2008, American Heart Association. All rights Association. All rights reserved. reserved.

• Non-Narcotic Analgesics - Non-steroidal anti-inflammatory agents including aspirin - Selective COX-2 inhibitors• Sympathomimetic agents

- decongestants- diet pills- cocaine

• Stimulants -methylphenidate-dexmethylphenidate,-dextroamphetamine- amphetamine, methamphetamine-modafinil

Substances that Can Interfere with Blood Pressure Control

© 2008, American Heart © 2008, American Heart Association. All rights Association. All rights reserved. reserved.

Substances that Can Interfere with Blood Pressure Control

Oral contraceptivesOral contraceptives

CyclosporineCyclosporine

ErythropoietinErythropoietin

Natural licoriceNatural licorice

Herbal compoundsHerbal compounds -ephedra -ephedra - ma huang- ma huang

Relaxation TherapyRelaxation Therapy

Meditation was in one study to reduce SBP and DBP by Meditation was in one study to reduce SBP and DBP by 10.7 mm Hg and 6.4 mm Hg over a period of 3 months10.7 mm Hg and 6.4 mm Hg over a period of 3 months

Schneider RH Alexander CN et al, 1995Schneider RH Alexander CN et al, 1995

Progressive muscle relaxation lower SBP by 4.7 mm Hg Progressive muscle relaxation lower SBP by 4.7 mm Hg and DBP by 3.3mm Hg.and DBP by 3.3mm Hg.

Yoga is also widely believed to reduce blood pressureYoga is also widely believed to reduce blood pressure Damodaran A, Patil N, Suryavanshi et al, 2002Damodaran A, Patil N, Suryavanshi et al, 2002

However, these interventions are with l imited and However, these interventions are with l imited and uncertain eff icacy. Therefore more tr ials are needed to uncertain eff icacy. Therefore more tr ials are needed to confirm its effectconfirm its effect ..

ConclusionsConclusions

1.1. Lifestyle modifications are effective in preventing Lifestyle modifications are effective in preventing hypertension, treating hypertension and reducing hypertension, treating hypertension and reducing cardiovascular risk.cardiovascular risk.

2.2. Combinations of both lifestyle changes and drugs are Combinations of both lifestyle changes and drugs are generally necessary to achieve target blood generally necessary to achieve target blood pressures.pressures.

3.3. Weight control, alcohol moderation, regular aerobic exercise Weight control, alcohol moderation, regular aerobic exercise should be immediate goalsshould be immediate goals

4.4. Evidence supports that exercise is the cornerstone for Evidence supports that exercise is the cornerstone for hypertension control.hypertension control.

5.5. Fruit and vegetable intake, and reduction of salt and fat should be Fruit and vegetable intake, and reduction of salt and fat should be included in dietary interventionincluded in dietary intervention