Lifestyle modifications in Hypertension

1
Lifestyle modifications in Hypertension
2
Blood Pressure

• The pressure in the arterial blood vessels
  results from
• flow of blood from the heart
• resistance of the arterial blood vessel walls
• The higher the blood pressure, the harder the
  heart has to pump in order to supply the body
  with blood

3
Blood Pressure
4
Blood Pressure

• The first (top) number is the systolic blood
  pressure (SBP) and indicates the pressure in the
  artery when the heart is actively pumping blood
• The second (bottom) number is the diastolic blood
  pressure (DBP) and indicates the pressure in the
  artery when the heart is resting between beats

5
Measuring Blood Pressure
6
Measuring Blood Pressure

• Blood pressure is measured in the sitting
  position after at least 5 minutes of rest
• The blood pressure cuff should be the correct
  size and should not be placed over clothing
• At least two blood pressure measurements should
  be made and blood pressure categorized based on
  the average

7
Blood Pressure Categories
Category Systolic BP Diastolic BP
Normal blood pressure Less than 120 Less than 80
Pre-hypertension 120 to 139 80 to 89
Stage 1 hypertension 140 to 159 90 to 99
Stage 2 hypertension 160 or higher 100 or higher
8
Blood Pressure Aging

• There is an age-related increase in blood
  pressure due to
• Increased arterial wall tension
• Increased peripheral resistance
• Increased arterial stiffness
• This is not benign The blood pressure categories
  are not adjusted upwards to compensate for aging

9
Why Do We Worry About High Blood Pressure?
10
Framingham Heart Study

• Objective
• identify the common factors or characteristics
  that contribute to cardiovascular disease by
  following its development over a long period of
  time in a large group of participants who had not
  yet developed overt symptoms of cardiovascular
  disease or suffered a heart attack or stroke.

11
Framingham Heart Study Risks of Hypertension

• Cardiac disease
• Heart attack and heart failure
• Cerebrovascular disease
• Stroke
• Peripheral vascular disease
• Circulation in the extremities
• Microvascular disease
• Kidney and eye disease

12
Benefits of Blood Pressure Control

• Blood pressure control can reduce the risk of
  heart attack by 20 to 25
• Blood pressure control can reduce the risk of
  heart failure by more than 50
• Blood pressure control can reduce the risk of
  stroke by 35 to 40
• A 10mmHg drop in SBP lowers the risk of death
  from stroke by 50-60 and the risk of death from
  heart attack by 40-50

13
Blood Pressure Control
14
Lowering Blood Pressure

• Lifestyle modification
• Smoking cessation
• Increased physical activity
• Limitation of alcohol intake
• Maintenance of a healthy body weight
• Diet comprised of healthy foods
• Pharmacotherapy (medications)

15
Lifestyle Modification
Modification Recommendation Approximate drop in SBP
Weight reduction Maintain normal body weight 5-10 mmHg/ 10kg weight loss
DASH eating plan Rich in fruits, vegetables, low fat dairy reduced saturated total fat 8-14 mmHg
Less dietary sodium No more than 2.4 g sodium/day 2-8 mmHg
Physical activity Aerobic activity for 30 minutes at least 5 days/week 4-9 mmHg
Alcohol in moderation No more than 2/day for men No more than 1/day for women 2-4 mmHg
16
Diet
17
Diet Blood Pressure

• Salt
• Excess can increase blood pressure
• Potassium
• Insufficient can increase blood pressure
• Weight
• Excess can increase blood pressure
• Alcohol
• Excess can increase blood pressure

18
Diet Blood Pressure

• Several research studies have shown beneficial
  effects of diets rich in magnesium, potassium,
  calcium, fiber, and protein
• Studies looking at supplementation of individual
  nutrients have not shown much improvement in
  blood pressure

19
DASH Clinical Trial

• Looked at the effect of dietary patterns rather
  than individual nutrients for blood pressure
  lowering
• Studied three different diet patterns
• Control (typical) diet
• Fruits and vegetables diet
• Combination (DASH) diet

20
Control Diet

• Potassium, magnesium, and calcium levels were
  close to 25th percentile of U.S. consumption
• Macronutrients (carbohydrate, fat, protein) and
  fiber were similar to average U.S. consumption
• Typical American diet

21
Fruits Vegetables Diet

• Potassium and magnesium close to the 75th
  percentile of U.S. consumption
• High amount of fiber
• More fruits and vegetables and fewer snacks and
  sweets than control diet, but was otherwise
  similar

22
Combination (DASH) Diet

• Potassium, magnesium, and calcium close to the
  75th percentile of U.S. consumption
• High amounts of fiber and protein
• Rich in fruits, vegetables, and low fat dairy
  foods
• Reduced amount of saturated fat, total fat, and
  cholesterol

23
DASH Clinical Trial

• Study subjects were provided with meals that were
  prepared in research kitchens
• All diets contained approximately 3 grams sodium
  per day
• Each subject was given the appropriate calories
  to maintain weight and diet was adjusted for
  weight loss or weight gain

24
Results (Change in SBP/Change in DBP)
Category DASH Control DASH Fruits/Veg Fruits/Veg Control
All subjects -5.5/-3.0 -2.7/-1.9 -2.8/-1.1
Men -4.9/-3.3 -1.6/-1.3 -3.3/-2.0
Women -6.2/-2.7 -3.9/-2.5 -2.3/-0.2
HTN -11.4/-5.5 -4.1/-2.6 -7.2/-2.8
No HTN -3.5/-2.1 -2.7/-1.8 -0.8/-0.3
25
DASH Results
Systolic Blood Pressure
Weeks
26
DASH Meal Plan

• Fruits 4-5 servings/day
• 1 medium fruit 6 ounces fruit juice
• Vegetables 4-5 servings/day
• 1 cup raw leafy ½ cup cooked

• Low fat dairy products 2-3 servings/day
• 8 ounces milk/yogurt 1.5 ounces cheese
• Grains 7-8 servings/day
• 1 slice bread ½ cup cereal, rice, pasta
• Meat, Fish, Poultry 2 or less servings/day
• 3 ounces
• Nuts, Seeds, Dried Beans 4-5 servings/week
• 1/3 cup nuts 2 tablespoons seeds, ½ cup cooked
  beans

27
Exercise
28
Aerobic Activity
To promote and maintain health, all healthy
adults age 18-65 years need moderate-intensity
physical activity for a minimum of 30 minutes on
five days each week OR vigorous-intensity for a
minimum of 20 minutes on three days each week.
Also, combinations of moderate- and
vigorous-intensity activity can be performed to
meet this recommendation.
American College of Sports Medicine American
Heart Association 2007 Recommendations
29
Muscle-Strengthening Activity
To promote and maintain good health and physical
independence, adults will benefit from performing
activities that maintain or increase muscular
strength and endurance for a minimum of two days
each week. It is recommended that 8-10 exercises
be performed on two or more nonconsecutive days
each week using the major muscle groups.
American College of Sports Medicine American
Heart Association 2007 Recommendations
30
Pharmacotherapy

31
Antihypertensive Medications

• All antihypertensive medications are effective at
  lowering blood pressure
• Some provide additional benefits
• Newer medications are not necessarily better than
  older medications
• Medications control hypertension, they dont cure
  it
• Medications only work if they are taken every day

32
Antihypertensive Medications

• ACE Inhibitors (ACEI)
• Angiotensin receptor blockers (ARB)
• Diuretics
• Beta blockers (BB)
• Calcium channel blockers (CCB)
• Alpha blockers
• Nitrates

33
TreatmentRecommendations
Area of Concern BP Target Lifestyle Modification Specific Drug Indications
General CAD Prevention lt140/lt90 Yes Any effective BP drug or combination
High CAD Risk lt130/lt80 Yes ACEI, ARB, CCB, thiazide, or combination
Stable Angina lt130/lt80 Yes ?-blocker AND ACEI or ARB
Diabetes, chronic kidney disease, known CAD or
CAD equivalent, or 10y Framingham risk score gt10
34
Side Effects

• Unintended effects of a medication
• Many medications cause minor side effects
• All antihypertensive medications can cause you to
  feel dizzy if you stand up quickly, especially
  when you first start taking the medication

35
Monitoring

• Blood pressure should be rechecked within 2 to 4
  weeks after starting a new blood pressure
  medication
• Blood pressure can be monitored at home or in the
  clinic
• Some antihypertensive medications also require
  laboratory or heart rate monitoring (ACEI, ARB,
  diuretic, BB, some CCBs)

36
Adherence to Therapy

• Medications wont work if you dont take them as
  prescribed
• Medications must be taken daily to keep blood
  pressure under control
• Talk to your provider about any problems that you
  have with taking your medication

37
Summary

• High blood pressure increases risk of
  cardiovascular, kidney, and eye disease
• Lifestyle modification is an effective means of
  lowering blood pressure
• Medications are needed to achieve optimal blood
  pressure levels in many people