lifestyle modifications for the prevention and management of hypertension andreas pittaras md
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Lifestyle Modifications for the Prevention and Management of
Hypertension
ANDREAS PITTARAS MD
Blood Pressure and CVD
• High BP is a strong, consistent and independent risk factor for CV events.
• The risk begins at BP 115/75 mm Hg and doubles with each incremental increase of 20/10 mm Hg.
•Vasan RS, et al. The Framingham Heart Study.JAMA 2002:287:1003-10 •Lewington S. Lancet 2002;360:1903-1913
JNC Goal:
Not Only Treat HTN, But Prevent it.
Does Increased Physical Activity Prevent or Attenuate
the Progression to HTN?
Physical Activity and BP
• Moderate increases in PA can prevent or at least attenuate the development of HTN.
• The RR for developing HTN is about 1.5 to 2.0 times higher in sedentary vs 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
115
125
135
145
Daytime 24-HR Nighttime
Ambulatory SBP and Fitness in Men
mm Hg
High-Fit
Mod-Fit
Low-FitN=407
Kokkinos P. Pittaras A, et al. Am J Hypertension 2006; 19(3):251-58
68
74
80
86
92
Daytime 24-HR Nighttime
Ambulatory DBP and Fitness in Men
mm Hg
High-Fit
Mod-Fit
Low-FitN=407
Kokkinos P. Pittaras A, et al. Am J Hypertension 2006; 19(3):251-58
120
130
140
150
Daytime 24-HR Nighttime
Ambulatory SBP and Fitness in Women
mm Hg
High-Fit
Mod-Fit
Low-FitN=243
Kokkinos P. Pittaras A, et al. Am J Hypertension 2006; 19(3):251-58
70
75
80
85
90
Daytime 24-HR Nighttime
Ambulatory DBP and Fitness in Women
mm Hg
High-Fit
Mod-Fit
Low-FitN=243
Kokkinos P. Pittaras A, et al. Am J Hypertension 2006; 19(3):251-58
LVMI and Fitness in Pre-Hypertensives
48
41 41
30
40
50
LOW-FIT MOD-FIT HIGH-FIT
g/m2.7
Kokkinos, P, Pittaras A, Manolis T. Hypertension 2007; 49:1-7
N=790
The Role of Physical Activity in the Management of
Hypertension
Kokkinos P., et al. Cardiology Clinics 2001;19(3):507-516
Average Reduction in BP: Active: 10.5/7.6 mm Hg Controls: 3.8/1.3 mm Hg
Exercise and BP
• How Much Exercise for changes? (intensity, Duration, Frequency)
• How Intense Should Exercise Be?
• How Soon Do We See Results?
• How Long Do the Changes Last?
Exercise Intensity and BP Reduction
-25
-20
-15
-10
-5
0
mm Hg
Low Intensity (53% VO2 max)
High Intensity (73% VO2 max)
Hagberg J., et al. Am J Cardiol 1989;64:348-53
SBP DBP SBP DBP
-12
-10
-8
-6
-4
-2
0
mm Hg
Low Intensity (50% VO2 max)
High Intensity (75% VO2 max)
Matsusaki M, et al. Clin Exp Pharm & Physiol 1992;19:471-9
SBP DBPSBP
DBP
Exercise Intensity and BP Reduction
BP Changes with Exercise in pts with Severe Hypertension (Stage 2 & 3)
-10
-8
-6
-4
-2
0
mm Hg
16 weeks 32 weeks
Kokkinos P, Pittaras A.et al. N Engl J Med 1995;333:1462-7
SBP
SBP
DBP
DBP
Wall Thickness at Baseline & 16 weeks
13.3
12.3
14.9
14
11
12
13
14
15
PW IVS
mm
*
*
Kokkinos P, Pittaras A et al. N Engl J Med 1995;333:1462-7
Baseline
Baseline
16 Wks
16 Wks
LVMI at Baseline and 16 Weeks
163
143
135
141
147
153
159
165
*
* p<0.05
Baseline 16 weeks
g/m2
Kokkinos P, Pittaras A et al. N Engl J Med 1995;333:1462-7
Exercise Intensity Implications
• Low-to-moderate exercise intensities carry a relatively lower risk.
• Patients with more severe HTN and other risk factors can exercise safely.
• Patients are more likely to participate and sustain Lo-intensity exercise programs.
Exercise and BP Reduction
How Soon Should We Expect
To Observe Changes in BP?
Time Course for Exercise and BP Reductions
• Acute changes occur immediately after cessation of activity. They last about 2-12 hours.
• Chronic changes?
BP Changes with Exercise
-12
-8
-4
0mm Hg
SBP DBP
2 Weeks
16 Weeks
16 Weeks
2 Weeks
2 Weeks
Kokkinos P., Pittaras A et al. N Engl J Med 1995;333:1462-7
Exercise and BP Reduction
How Long Do
These Changes Last?
SBP Response to Training & Detraining
124
128
132
136
140
Baseline 16 Wks 32 Wks 7 Days 14 Days 21 Days
33% Reduction in Meds
mm Hg
Exercise Training
Clinical Significance of Exercise-Induced BP
Reduction
Relative Risk of All-Cause Death and Exercise Capacity in Hypertensive Patients
1
1.3
2
0.2
0.7
1.2
1.7
2.2
>8 5-8 MET <5
RR of DeathMyers J. et al., N Engl J Med 1002;346:793-801
Exercise Capacity and Mortality in HTN Pts (VAMC Data (n=4,397)
1
1.3
2.82.9
0
1
2
3
10+ METs 7.1-10 METs 5-7 METs <5 METs
RR of Death
Exercise Capacity and Mortality in HTN+DM: VAMC DATA
1
1.5
3.3
3.6
0
1
2
3
4
10+ METs 7.1-10 METs 5-7 METs <5 METs
RR of Death
Exercise Capacity and Mortality in HTN + Obesity: VAMC DATA
1
2.1
4.8 4.9
0
1
2
3
4
5
10+METs 7.1-10 METs 5-7 METs <5 METs
RR of Death
Survival and Fitness Levels for HTNs
>10 MET; n=968
7-10 MET; n=1563 5-7 MET; n=1310<5 MET; n=578
>10 MET; n=1,000
7-10 MET; n=1558
5-7 MET; n=1286
<5 MET; n=524Log Rank=222; p<0.001
N=4,368
Exercise Recommendations for BP Control
American College of Sports Medicine
F: Frequency: 3-6 times/wk
I: Intensity: Moderate (Brisk walk)
T: Time: 20-60 min/session.
May split sessions (AM/PM)
T: Type: Type of Exercise: Aerobic
Exercise Intensity for Health Benefits
PMHR: 60% - 70% >85%
METs: < 4 – 5 7 10 +
Fast walk Running
6 km/hr 10 km/hr
500 - 1000 3000 Kcal
Body Weight and BP
• A direct association between excess body wt and HTN regardless of age, gender & race.
• 4.5 kg reduction in wt resulted in reduced BP.
• 60% of pts remained normotensive without pharmacologic therapy (DISH Trial)
• Better control of BP achieved when Wt reduction added to antihypertensive therapy.
• Waist circumference <85 cm for women and <98 cm Men and BMI<27 are recommended.
Exercise for HTNsive, Obese Patients
• Likely to have multiple risk factors
• ETT strongly recommended
• Tailor exercise to patient needs/abilities.
• Frequency: 3-6 days/week
• Low intensity exercises (HR ~95-100 bpm)
• Initial duration of 10 min/day
• Two sessions (am/pm), 5 min/secs if needed)
• Increase by 2 min/wk- Aim: 100-200 min/wk
Dietary Factors and
Blood Pressure
Salt Reduction and Blood Pressure
• Historically, the limitation of salt in food has been the primary dietary approach in the control of HTN.
• Over 50 studies have been concluded. Recent Meta analysis revealed a reduction of 5/2.7 mm Hg in BP for a reduction of ~ 1.8 g/d in urinary sodium for HTN pts.
He FJ, et al. J Hum Hypertns. 2002;16:761-70
Foods and Blood Pressure• Calcium and Magnesium:
–Small reductions. Insufficient data to recommend supplementation.
• Potassium: –Meta-analysis (33 trials): a modest reduction (3/2 mm Hg) in HTN pts receiving potassium supplements. Effects more AA and those with high sodium intake.
• Fish Oil: Not routinely recommend
• Fiber: Insufficient data.
• High CHO Intake : –High sugar intake is shown to increase BP. More studies necessary
• High Protein Intake: –Some evidence of lower BP, but may be due to lower CHO
Comprehensive Dietary Approaches for BP Control
It is becoming more evident that diets low in salt and fat and rich in other minerals are more effective in lowering BP than any one element alone. Such diets include the DASH Diet and the Mediterranean diet.
DASH Trial and Blood Pressure
• Control Diet: – Low in fruits, veggies and dairy products
and typical fat content.– Potassium, magnesium, calcium at 25th
percentile of US consumption.
• Fruits & Vegetables Diet:– More fruits & Vegetables – Potassium, magnesium, calcium at 75%
of US consumption. – Fat content similar to Control Diet.
Appel L, et al. N Engl J Med 1997;336:1117-24
DASH Trial and Blood Pressure
• Combination Diet:– Rich in fruits, vegetables, fiber,
protein, and low-fat dairy products– Reduced amounts of total fat,
saturated fat and cholesterol.
• Sodium content of each diet was similar- approximately 3 g per day.
Appel L, et al. N Engl J Med 1997;336:1117-24
Weekly SBP in the DASH Trial
122
124
126
128
130
132
Base 1 2 3 4 5 6 7 & 8
mm Hg Appel L, et al. N Engl J Med 1997;336:1117-24
Fruits + Vegetables
Control Group Diet
Fruits + Vegetables + Low Fat
Intervention Week
X=5.5 mm Hg
Weekly DBP in the DASH Trial
78
80
82
84
86
Base 1 2 3 4 5 6 7 & 8
mm Hg Appel L, et al. N Engl J Med 1997;336:1117-24
Fruits + Vegetables + Low Fat
Intervention Week
X=3 mm Hg
Control Group Diet
Fruits + Vegetables
SBP Changes & Sodium in the DASH Trial
120
125
130
135
High-Salt Mod-Salt Low-Salt
mm Hg Sacks FM, et al. N Engl J Med 2001;344:3-10
Control Group Diet
DASH Diet
-5.9
-5.0
-2.2
DBP Changes & Sodium in the DASH Trial
75
80
85
High-Salt Mod-Salt Low-Salt
mm Hg
Control Group Diet
DASH Diet
Sacks FM, et al. N Engl J Med 2001;344:3-10
DASH Trial and Blood Pressure
• Compelling evidence that adequate intake of minerals should be the focus of dietary recommendations in the control of BP.
• The DASH Diet in combination with reduced salt intake optimizes BP control.
Alcohol Consumption and BP
Panagiotakos D. et al J Hypertens 2003;21:1-7
Lifestyle Interventions for BP Control: Conclusions
• High intake of fruits, vegetables, nuts and low-fat dairy products
• Reduce total fat, saturated fats, TC, • Restrict salt intake, but increase
calcium potassium and magnesium• Control body wt / Reduce body fat• Limit alcohol intake to <2 drinks/day• Brisk walk 3-6 times a week; 20-60
min per session (100-200 min/Wk).