Lifestyle Lifestyle modifications modifications

in in HypertensionHypertension

Blood PressureBlood Pressure

The pressure in the arterial blood The pressure in the arterial blood vessels results from:vessels results from: flow of blood from the heartflow of blood from the heart resistance of the arterial blood vessel wallsresistance of the arterial blood vessel walls

The higher the blood pressure, the The higher the blood pressure, the harder the heart has to pump in harder the heart has to pump in order to supply the body with bloodorder to supply the body with blood

Blood Blood PressurePressure

Blood PressureBlood Pressure

The first (top) number is the The first (top) number is the systolic systolic blood pressureblood pressure (SBP) and indicates (SBP) and indicates the pressure in the artery when the the pressure in the artery when the heart is actively pumping bloodheart is actively pumping blood

The second (bottom) number is the The second (bottom) number is the diastolic blood pressurediastolic blood pressure (DBP) and (DBP) and indicates the pressure in the artery indicates the pressure in the artery when the heart is resting between when the heart is resting between beatsbeats

Measuring Measuring Blood Blood

PressurePressure

Measuring Measuring Blood PressureBlood Pressure

Blood pressure is measured in the sitting Blood pressure is measured in the sitting position after at least 5 minutes of restposition after at least 5 minutes of rest

The blood pressure cuff should be the The blood pressure cuff should be the correct size and should not be placed correct size and should not be placed over clothing over clothing

At least two blood pressure At least two blood pressure measurements should be made and measurements should be made and blood pressure categorized based on the blood pressure categorized based on the averageaverage

Blood Pressure Blood Pressure CategoriesCategories

CategoryCategory Systolic BPSystolic BP Diastolic BPDiastolic BP

Normal blood Normal blood pressurepressure

Less than 120Less than 120 Less than 80Less than 80

Pre-hypertensionPre-hypertension 120 to 139120 to 139 80 to 8980 to 89

Stage 1 Stage 1 hypertensionhypertension

140 to 159140 to 159 90 to 9990 to 99

Stage 2 Stage 2 hypertensionhypertension

160 or higher160 or higher 100 or higher100 or higher

Blood Pressure & AgingBlood Pressure & Aging

There is an age-related increase in There is an age-related increase in blood pressure due to: blood pressure due to: Increased arterial wall tensionIncreased arterial wall tension Increased peripheral resistanceIncreased peripheral resistance Increased arterial stiffnessIncreased arterial stiffness

This is not benign: The blood This is not benign: The blood pressure categories are pressure categories are notnot adjusted adjusted upwards to compensate for agingupwards to compensate for aging

Why Do Why Do We We

Worry Worry About About High High Blood Blood

PressurePressure??

Framingham Heart StudyFramingham Heart Study

Objective:Objective:“…“…identify the common factors or identify the common factors or

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

Framingham Framingham Heart Study: Heart Study:

Risks of Risks of HypertensionHypertension Cardiac diseaseCardiac disease

Heart attack and heart failureHeart attack and heart failure

Cerebrovascular diseaseCerebrovascular disease StrokeStroke

Peripheral vascular diseasePeripheral vascular disease Circulation in the extremitiesCirculation in the extremities

Microvascular diseaseMicrovascular disease Kidney and eye diseaseKidney and eye disease

Benefits of Benefits of Blood Pressure ControlBlood Pressure Control

Blood pressure control can reduce the Blood pressure control can reduce the risk of heart attack by 20% to 25%risk of heart attack by 20% to 25%

Blood pressure control can reduce the Blood pressure control can reduce the risk of heart failure by more than 50% risk of heart failure by more than 50%

Blood pressure control can reduce the Blood pressure control can reduce the risk of stroke by 35% to 40%risk of stroke by 35% to 40%

A 10mmHg drop in SBP lowers the risk of A 10mmHg drop in SBP lowers the risk of death from stroke by 50-60% and the risk death from stroke by 50-60% and the risk of death from heart attack by 40-50%of death from heart attack by 40-50%

Blood Pressure ControlBlood Pressure Control

Lowering Blood PressureLowering Blood Pressure

Lifestyle modificationLifestyle modification Smoking cessationSmoking cessation Increased physical activityIncreased physical activity Limitation of alcohol intakeLimitation of alcohol intake Maintenance of a healthy body weightMaintenance of a healthy body weight Diet comprised of healthy foodsDiet comprised of healthy foods

Pharmacotherapy (medications)Pharmacotherapy (medications)

Lifestyle ModificationLifestyle Modification

ModificationModification RecommendationRecommendation Approximate Approximate drop in SBPdrop in SBP

Weight Weight reductionreduction

Maintain normal body weightMaintain normal body weight 5-10 mmHg/5-10 mmHg/

10kg weight 10kg weight lossloss

DASH DASH eating planeating plan

Rich in fruits, vegetables, low fat Rich in fruits, vegetables, low fat dairy; reduced saturated & total dairy; reduced saturated & total fatfat

8-14 mmHg8-14 mmHg

Less dietary Less dietary sodiumsodium

No more than 2.4 g sodium/dayNo more than 2.4 g sodium/day 2-8 mmHg2-8 mmHg

Physical Physical activityactivity

Aerobic activity for 30 minutes at Aerobic activity for 30 minutes at least 5 days/weekleast 5 days/week

4-9 mmHg4-9 mmHg

Alcohol in Alcohol in moderationmoderation

No more than 2/day for menNo more than 2/day for men

No more than 1/day for womenNo more than 1/day for women2-4 mmHg2-4 mmHg

DietDiet

Diet & Blood PressureDiet & Blood Pressure

SaltSalt Excess can increase blood pressureExcess can increase blood pressure

PotassiumPotassium Insufficient can increase blood pressureInsufficient can increase blood pressure

WeightWeight Excess can increase blood pressureExcess can increase blood pressure

AlcoholAlcohol Excess can increase blood pressureExcess can increase blood pressure

Diet & Blood PressureDiet & Blood Pressure

Several research studies have shown Several research studies have shown beneficial effects of diets rich in beneficial effects of diets rich in magnesium, potassium, calcium, magnesium, potassium, calcium, fiber, and proteinfiber, and protein

Studies looking at supplementation Studies looking at supplementation of individual nutrients have not of individual nutrients have not shown much improvement in blood shown much improvement in blood pressurepressure

DASH Clinical TrialDASH Clinical Trial

Looked at the effect of dietary Looked at the effect of dietary patterns rather than individual patterns rather than individual nutrients for blood pressure nutrients for blood pressure loweringlowering

Studied three different diet patterns:Studied three different diet patterns: Control (typical) dietControl (typical) diet Fruits and vegetables dietFruits and vegetables diet Combination (DASH) dietCombination (DASH) diet

Control DietControl Diet

Potassium, magnesium, and calcium Potassium, magnesium, and calcium levels were close to 25levels were close to 25thth percentile of percentile of U.S. consumptionU.S. consumption

Macronutrients (carbohydrate, fat, Macronutrients (carbohydrate, fat, protein) and fiber were similar to protein) and fiber were similar to average U.S. consumptionaverage U.S. consumption

Typical “American” dietTypical “American” diet

Fruits & Vegetables DietFruits & Vegetables Diet

Potassium and magnesium close to Potassium and magnesium close to the 75the 75thth percentile of U.S. percentile of U.S. consumptionconsumption

High amount of fiberHigh amount of fiber More fruits and vegetables and More fruits and vegetables and

fewer snacks and sweets than fewer snacks and sweets than control diet, but was otherwise control diet, but was otherwise similarsimilar

Combination Combination (DASH) Diet(DASH) Diet

Potassium, magnesium, and calcium Potassium, magnesium, and calcium close to the 75close to the 75thth percentile of U.S. percentile of U.S. consumptionconsumption

High amounts of fiber and proteinHigh amounts of fiber and protein Rich in fruits, vegetables, and low Rich in fruits, vegetables, and low

fat dairy foodsfat dairy foods Reduced amount of saturated fat, Reduced amount of saturated fat,

total fat, and cholesteroltotal fat, and cholesterol

DASH Clinical TrialDASH Clinical Trial

Study subjects were provided with Study subjects were provided with meals that were prepared in meals that were prepared in research kitchensresearch kitchens

All diets contained approximately 3 All diets contained approximately 3 grams sodium per daygrams sodium per day

Each subject was given the Each subject was given the appropriate calories to maintain appropriate calories to maintain weight and diet was adjusted for weight and diet was adjusted for weight loss or weight gainweight loss or weight gain

Results Results (Change in (Change in

SBP/Change in SBP/Change in DBP)DBP)CategoryCategory DASH – DASH –

ControlControlDASH – DASH –

Fruits/VeFruits/Vegg

Fruits/Fruits/Veg – Veg –

Control Control

All All subjectssubjects

-5.5/-3.0-5.5/-3.0 -2.7/-1.9-2.7/-1.9 -2.8/-1.1-2.8/-1.1

MenMen -4.9/-3.3-4.9/-3.3 -1.6/-1.3-1.6/-1.3 -3.3/-2.0-3.3/-2.0

WomenWomen -6.2/-2.7-6.2/-2.7 -3.9/-2.5-3.9/-2.5 -2.3/-0.2-2.3/-0.2

HTNHTN -11.4/-5.5-11.4/-5.5 -4.1/-2.6-4.1/-2.6 -7.2/-2.8-7.2/-2.8

No HTNNo HTN -3.5/-2.1-3.5/-2.1 -2.7/-1.8-2.7/-1.8 -0.8/-0.3-0.8/-0.3

DASH ResultsDASH Results

120

122

124

126

128

130

132

134

0 1 2 3 4 5 6 7

Control

Fruits/Veg

DASH

Weeks

Sy

sto

lic B

loo

d P

res

sure

DASH Meal PlanDASH Meal Plan

Fruits: 4-5 servings/dayFruits: 4-5 servings/day 1 medium fruit; 6 ounces fruit juice1 medium fruit; 6 ounces fruit juice

Vegetables: 4-5 servings/dayVegetables: 4-5 servings/day 1 cup raw leafy; ½ cup cooked1 cup raw leafy; ½ cup cooked

Low fat dairy products: 2-3 servings/dayLow fat dairy products: 2-3 servings/day 8 ounces milk/yogurt; 1.5 ounces cheese8 ounces milk/yogurt; 1.5 ounces cheese

Grains: 7-8 servings/dayGrains: 7-8 servings/day 1 slice bread; ½ cup cereal, rice, pasta1 slice bread; ½ cup cereal, rice, pasta

Meat, Fish, Poultry: 2 or less servings/dayMeat, Fish, Poultry: 2 or less servings/day 3 ounces3 ounces

Nuts, Seeds, Dried Beans: 4-5 servings/weekNuts, Seeds, Dried Beans: 4-5 servings/week 1/3 cup nuts; 2 tablespoons seeds, ½ cup cooked beans1/3 cup nuts; 2 tablespoons seeds, ½ cup cooked beans

ExerciseExercise

Aerobic ActivityAerobic 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 MedicineAmerican Heart Association2007 Recommendations

Muscle-Strengthening Muscle-Strengthening ActivityActivity

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 MedicineAmerican Heart Association2007 Recommendations

PharmacothePharmacotherapyrapy

Antihypertensive Antihypertensive MedicationsMedications

All antihypertensive medications are All antihypertensive medications are effective at lowering blood pressureeffective at lowering blood pressure

Some provide additional benefitsSome provide additional benefits Newer medications are not necessarily Newer medications are not necessarily

better than older medicationsbetter than older medications Medications control hypertension, they Medications control hypertension, they

don’t cure itdon’t cure it Medications only work if they are taken Medications only work if they are taken

every dayevery day

AntihypertensiAntihypertensive Medicationsve Medications

ACE Inhibitors (ACEI)ACE Inhibitors (ACEI) Angiotensin receptor blockers Angiotensin receptor blockers

(ARB)(ARB) Diuretics Diuretics Beta blockers (BB)Beta blockers (BB) Calcium channel blockers (CCB)Calcium channel blockers (CCB) Alpha blockersAlpha blockers NitratesNitrates

TreatmentTreatmentRecommendationsRecommendations

Area of Area of ConcernConcern

BP BP TargetTarget

Lifestyle Lifestyle ModificatiModificati

onon

Specific Drug Specific Drug IndicationsIndications

General General CAD CAD PreventionPrevention

<140/<90<140/<90 YesYes Any effective BP Any effective BP drug or drug or combinationcombination

High CAD High CAD Risk*Risk*

<130/<80<130/<80 YesYes ACEI, ARB, CCB, ACEI, ARB, CCB, thiazide, or thiazide, or combinationcombination

Stable Stable AnginaAngina

<130/<80<130/<80 YesYes ΒΒ-blocker -blocker ANDAND ACEI or ARBACEI or ARB

*Diabetes, chronic kidney disease, known CAD or CAD equivalent, or 10y Framingham risk score >10%

Side EffectsSide Effects

Unintended effects of a medicationUnintended effects of a medication Many medications cause minor side Many medications cause minor side

effectseffects

All antihypertensive medications can All antihypertensive medications can cause you to feel dizzy if you stand cause you to feel dizzy if you stand up quickly, especially when you first up quickly, especially when you first start taking the medicationstart taking the medication

MonitoringMonitoring

Blood pressure should be rechecked Blood pressure should be rechecked within 2 to 4 weeks after starting a new within 2 to 4 weeks after starting a new blood pressure medicationblood pressure medication

Blood pressure can be monitored at home Blood pressure can be monitored at home or in the clinicor in the clinic

Some antihypertensive medications also Some antihypertensive medications also require laboratory or heart rate require laboratory or heart rate monitoring (ACEI, ARB, diuretic, BB, monitoring (ACEI, ARB, diuretic, BB, some CCBs)some CCBs)

Adherence to Adherence to TherapyTherapy

Medications won’t work if you don’t Medications won’t work if you don’t take them as prescribedtake them as prescribed

Medications must be taken daily to Medications must be taken daily to keep blood pressure under control keep blood pressure under control

Talk to your provider about any Talk to your provider about any problems that you have with taking problems that you have with taking your medicationyour medication

SummarySummary

High blood pressure increases risk High blood pressure increases risk of cardiovascular, kidney, and eye of cardiovascular, kidney, and eye diseasedisease

Lifestyle modification is an effective Lifestyle modification is an effective means of lowering blood pressuremeans of lowering blood pressure

Medications are needed to achieve Medications are needed to achieve optimal blood pressure levels in optimal blood pressure levels in many peoplemany people