CHAPTER I

THE PROBLEM AND ITS BACKGROUND

Rationale of the Study

Hypertension is one of the major health concerns among Filipinos. In the latest data of

Philippine National and Nutrition Health Survey, it is found that seven million Filipinos suffers

from hypertension and according to Department of Health only 13.6% of the hypertensives are

aware of their condition since hypertension causes minimal or no symptoms at all. By the year

2020, annual deaths resulting from heart disease and stroke could go high as 20 million

worldwide; this was according to the World Health organization. These disturbing trends

indicate the need for increased attention in the battle against the disease.

Hypertension related morbidity and mortality rates will not significantly decrease until

comprehensive management program is created, proper information dissemination and

reinforcement of compliance to lifestyle modification, and medication adherence among

hypertensive patients.

Hypertension is characterized by type, cause and severity. However, regardless of type,

hypertension results from array of genetic and environmental factors. These factors are called

risk factors and they are divided into two, the modifiable risk factors which are the things that

you can control such as lifestyle and dietary patterns on the other hand the non-modifiable risk

factors are those you cannot control such as age, family history of hypertension and race. It is

possible to develop hypertension with or without the risk factors. However the more risk factors

you have ,the greater your likelihood of developing the disease.

 Strong research evidence has illustrated conclusively that lifestyle modifications are

effective in lowering blood pressure and reducing cardiovascular risk factors at a little over cost

and with minimal risk. According to the Seventh Report of the Joint Committee on Detection,

Evaluation and Treatment of High Blood Pressure last 2003, lifestyle modifications are

suggested as definitive first line therapy for some clients. Lifestyle modification is also strongly

encouraged for all clients with hypertension who are receiving pharmacologic therapy.

Continued healthy lifestyle practices along with pharmacologic therapy can reduce the number

and dosage of anti-hypertensive medication needed to manage the condition. Hypertension is

known as silent killer because it doesn’t produce any symptoms at least none that most people

are aware of it until considerable damage has already been done. Specific lifestyle factors that

could put you on risk for hypertension includes excessive drinking of alcohol, consumption of 1

ounce of alcohol per day is associated with a higher incidence of hypertension. Lack of exercise

is another example of modifiable risk factors of hypertension. Moderate to intense exercise,

done regularly helps improve heart function and promotes healthy arteries. Stress could also be

associated in hypertension. Hormones released by the body when under stress can increase the

blood pressure. This may aggravate high blood pressure in genetically susceptible individuals.

Excess dietary sodium is also associated to hypertension, at least 40% of clients who eventually

develops hypertension are salt sensitive. Too little vitamin D in diet can also lead to high blood

pressure. Researchers think that vitamin D may affect an enzyme produced by kidneys that affect

blood pressure. The degree to which hypertension can be prevented depends on a number of

features including current blood pressure level, sodium/potassium balance, detection and

omission of environmental toxins, changes in end/target organs (retina, kidney, heart, among

others), risk factors for cardiovascular diseases and the age at diagnosis of prehypertenion or at
risk for hypertension. A prolonged assessment in which repeated measurements of blood

pressure are taken provides the most accurate assessment of blood pressure levels. Following

this, lifestyle changes are recommended to lower blood pressure, before the initiation of

prescription drug therapy. The process of managing prehypertension according the guidelines of

the British Hypertension Society suggest the following lifestyle changes:

• Weight reduction and regular aerobic exercise (e.g., walking): Regular exercise improves

blood flow and helps to reduce the resting heart rate and blood pressure.

• Reducing dietary sugar.

• Reducing sodium (salt) in the diet: This step decreases blood pressure in about 33% of

people (see above). Many people use a salt substitute to reduce their salt intake

• Additional dietary changes beneficial to reducing blood pressure include the DASH diet

(dietary approaches to stop hypertension) which is rich in fruits and vegetables and low-fat or

fat-free dairy products. This diet has been shown to be effective based on research sponsored by

the National Heart, Lung, and Blood Institute. In addition, an increase in dietary potassium,

which offsets the effect of sodium has been shown to be highly effective in reducing blood

pressure.

• Discontinuing tobacco use and alcohol consumption has been shown to lower blood

pressure. The exact mechanisms are not fully understood, but blood pressure (especially systolic)

always transiently increases following alcohol or nicotine consumption. Abstaining from

cigarette smoking reduces the risk of stroke and heart attack which are associated with

hypertension.

• Reducing stress, for example with relaxation therapy, such as meditation and other

mindbody relaxation techniques, by reducing environmental stress such as high sound levels and
over-illumination can also lower blood pressure. Jacobson's Progressive Muscle Relaxation and

biofeedback are also beneficial, such as device-guided paced breathing, although meta-analysis

suggests it is not effective unless combined with other relaxation techniques.

Hypertension is the most important risk factor for death in industrialized countries. It

increases hardening of the arteries thus predisposes individuals to heart disease, peripheral

vascular disease, and strokes. Types of heart disease that may occur include: myocardial

infarction, heart failure and left ventricular hypertrophy Other complications include:

Hypertensive retinopathy, Hypertensive nephropathy and if blood pressure is very high

hypertensive encephalopathy may result.

In the year 2000 it is estimated that nearly one billion people or ~26% of the adult

population have hypertension worldwide. It was common in both developed (333 million ) and

undeveloped (639 million) countries. However rates vary markedly in different regions with

rates as low as 3.4% (men) and 6.8% (women) in rural India and as high as 68.9% (men) and

72.5% (women) in Poland.

In 1995 it is estimated that 43 million people in the United States had hypertension or

were taking antihypertensive medication, almost 24% of the adult population. The prevalence of

hypertension in the United States is increasing and reached 29% in 2004. It is more common in

blacks and less in whites and Mexican Americans, rates increase with age, and is greater in the

southeastern United States. Hypertension is more prevalent in men (though menopause tends

decrease this difference) and those of low socioeconomic status.

Over 90–95% of adult hypertension is essential hypertension. The most common cause of

secondary hypertension is primary aldosteronism. The incidence of exercise hypertension is

reported to range from 1–10%.

Conceptual Framework

The Health Belief model that was developed by Irvin Rosenstock will be the basis of the

study. It is defined as a psychological model that attempts to explain and predict behaviors. This

is done by focusing on the attitude,activities and beliefs of the individuals . Originally the model

was designed to predict behavioral response to the treatment received by acutely or chronically

ill patients, but in more recent years the model has been used to predict more general health

behaviors. The health belief model was spelled out in terms of four constructs representing the

perceived threats and net benefits:perceived susceptibility , perceived severity, perceived benefits

and perceived barriers. These concepts were proposed as accounting for peoples’ s readiness to

act. An added concept, cues to action would activate that readiness and stimulate overt behavior.

A recent addition to the health Belief model is the concept of self-efficacy, or one’s confidence

in the ability to successfully perform an action . This concept was added by Rosenstock and his

colleagues in 1988 to help the health Belief Model better fit challenges of changing habitual

unhealthy behaviors such as being sedentary , smoking or overeating. The health belief Model is

based on the understanding that a person will take a health related action(i.e Lifestyle

modification) if that person: (1) Feels that a negative health condition (complications of

hypertension) can be avoided (2).has a positive expectation that by taking a recommended action

he/she will avoid a negative health condition(i.e. adopting a healthy lifestyle such as regular

execise and reducing excessive salt intake will be effective at preventing hypertension and ist
complications) and (3) believes that he/she can successfully take a recommended health

action(i.e. he/she can adhere with the lifestyle modifications suggested by health experts).

To further understand the health belief model here is the diagram:

 Perceived susceptibility (an individual's assessment of their risk of getting the condition)
 Perceived severity (an individual's assessment of the seriousness of the condition, and its
potential consequences)
 Perceived barriers (an individual's assessment of the influences that facilitate or
discourage adoption of the promoted behavior)
 Perceived benefits (an individual's assessment of the positive consequences of adopting
the behavior).

With the above mentioned theory,it is said that knowing and analyzing the activities of

hypertensive patients relative to the modifiable cause of hypertension,the result of the study

might further reduce the occurrence and complications of the disease.

Figure 1.
 INPUT PROCESS OUTPUT

1. Description of Analysis of: Appropriate measures to

respondents in improve further the
1. The description of the
terms of : activities of the
A. Age respondents respondents in their
2. Activities undertaken
B. Gender lifestyle,diet and
C. Highest by the respondents on medication
the modifiable risk
educational
attainment factors of hypertension
under the area of;
D. Main
occupation A. Lifestyle
B. Diet
E. Family history
of hypertension C. Medication
2.1. The extent of the
2. Activities
undertaken by the activities being done.
respondents in the
area of:
A. Lifestyle
B. Diet
C. Medication
2.1. The extent of the
activites being
done

The research paradigm as shown in figure 1 makes use of the input , process and output model.

The input box consists of the description of the respondents in terms of : age, gender,

highest educational attainment, main occupation, and family history of hypertension. Also

activities undertaken by the respondents in the area of : lifestyle, diet, medication and the extent

of the activities being done.

 The process box includes the analysis of the respondents’ characteristics and the activities

of the respondents on the modifiable risk factors of hypertension in the area of lifestyle , diet and

medication and the extent of activities being done.

The output box contains appropriate measures that will be formulated to improve the

activities of the patients in the area of lifestyle, diet and medication.

Statement of the Problem

The study will determine the activities done by the hypertensive patients on the

modifiable risk factors of hypertension. Results of the study will serve in developing appropriate

hints for hypertensive patients.

Specific Problems:

Specifically the study will seek to answer the following questions:

1. How are the respondents described in terms of:

1.1. Age

1.2. Gender

1.3. Highest educational attainment

1.4. Main occupation

1.5. Family history of hypertension

2. What activities are undertaken by the respondents under the area of:

A. Lifestyle

B. Dietary pattern

C. Medications

2.1. To what extent are the activities are being done?

3. What appropriate measures could be formulated to improve the lifestyle,dietary patterns

and medications of the hypertensive patients?

Assumptions of the Study:

The research is premised on the following assumptions:

1. The data that will be solicited from hypertensive patients in the selected barangays of

Bugallon are true and objective.

2. The interview schedule given to respondents from the selected barangay of Bugallon are

valid and reliable.

3. The appropriate measures that will be suggested can be used by the hypertensive patients

to further improve the lifestyle, dietary patterns and medication adherence.

Scope and Delimitations

The study will be focusing on activities of the identified patients on the modifiable risk

factors of hypertension. It will be community based and will be conducted in ten(10) selected

barangays of Bugallon where there is high incidence of hypertension. In order to select the

qualified barangays,there will be proper coordination with the Municipal Health Officers in order

to get the accurate statistical data. The barangay officials and barangay health workers plays an

important role in finding the respondents needed in the study to be conducted.

Significance of the Study:

The result of the study will serve as a guidepost and starting point in facilitating the

improvement on the activities of hypertensive patients on the modifiable risk factors of

hypertension especially on the lifestyle ,dietary patterns and medication adherence.

 Specifically, it will be great significance to the following:

Hypertensive patients. Findings of the study will serve as an eye opener for

hypertensive patients specifically in providing appropriate hints or measures to understand more

the modifiable risk factors of hypertension.

Municipal Health Office/Barangay Officials. Results of this study will help guide the

officials of Bugallon in developing actions that will improve further the activities of hypertensive

patients on the modifiable risk factors of hypertension.

Resident of Barangays. The residents of the barangays will be greatly guided by this

study and can prevent the complications of hypertension and can reduce the mortality and

morbidity of the disease.

Future Researchers. Future researchers will have an increase motivation in pursuing

related studies to hypertension. This study can serve as their guideline in conducting another

studies in the future.

Definition of Terms

To give the readers a better understanding and interpretation of the following terms are

theoretically and operationally defined:

Hypertension. is a chronic medical condition in which the systemic arterial blood

pressure is elevated. It is the opposite of hypotension. It is classified as either primary (essential)

or secondary. About 90–95% of cases are termed "primary hypertension", which refers to high

blood pressure for which no medical cause can be found. The remaining 5–10% of cases

(Secondary hypertension) are caused by other conditions that affect the kidneys, arteries, heart,

or endocrine system.
Persistent hypertension is one of the risk factors for stroke, myocardial infarction, heart failure

and arterial aneurysm, and is a leading cause of chronic kidney failure. Moderate elevation of

arterial blood pressure leads to shortened life expectancy. Dietary and lifestyle changes can

improve blood pressure control and decrease the risk of associated health complications,

although drug treatment may prove necessary in patients for whom lifestyle changes prove

ineffective or insufficient. Blood pressure is usually classified based on the systolic and diastolic

blood pressures. Systolic blood pressure is the blood pressure in vessels during a heart beat.

Diastolic blood pressure is the pressure between heartbeats. A systolic or the diastolic blood

pressure measurement higher than the accepted normal values for the age of the individual is

classified as prehypertension or hypertension.

Hypertension has several sub-classifications including, hypertension stage I, hypertension

stage II, and isolated systolic hypertension. Isolated systolic hypertension refers to elevated

systolic pressure with normal diastolic pressure and is common in the elderly. These

classifications are made after averaging a patient's resting blood pressure readings taken on two

or more office visits. Individuals older than 50 years are classified as having hypertension if their

blood pressure is consistently at least 140 mmHg systolic or 90 mmHg diastolic. Patients with

blood pressures higher than 130/80 mmHg with concomitant presence of diabetes mellitus or

kidney disease require further treatment.Hypertension is also classified as resistant if medications

do not reduce blood pressure to normal levels. Exercise hypertension is an excessively high

elevation in blood pressure during exerciseThe range considered normal for systolic values

during exercise is between 200 and 230 mm Hg. Exercise hypertension may indicate that an

individual is at risk for developing hypertension at rest.

 Risk Factors. These are synonymous to causes, which are contributory factors to

hypertension. It is something that increases your likelihood in getting the disease or condition.

Patients with high risk factors of hypertension should be vigilant and careful in their health to

prevent the further dangerous complications of the disease.

Modifiable Risk Factors. These are the contributory factors of hypertension that you can

control. Examples are diet, exercise, vices, stress,certain chronic conditions and being

overweight.

Non- Modifiable Risk factors. These are the risk factors that you cannot change or

control. These are certain unalterable conditions that puts a person at greater risk for developing

hypertension such as heredity, race, and age.

Selected Barangays of Bugallon. It refers to the barangays selected to be part of the

study. These barangays have their own respective barangay councils, center for recreation,

educational, spiritual and other social activities.

Suggested Appropriate Measures/Guidelines. It refers to necessary information that

will help the hypertensive patients to guide them with their different activities in relation to the

modifiable risk factors of hypertension.

 CHAPTER II

REVIEW OF RELATED LITERATURE

This chapter presents the related studies and literature reviewed by the researcher to

guide him in conducting the study.

Conceptual Literatures

Modifiable Risk Factors of Hypertension

Diabetes. Hypertension has been shown to be more than twice as prevalent in diabetic

clients. Diabetes accelerates atherosclerosis and leads to hypertension from damage to the large

vessels. Therefore hypertension will become a prevalent diagnosis in diabetics, even if diabetes

is well controlled. When diabetic client is diagnosed with hypertension,treatment decisions and

follow-up care must be totally individualized and aggressive.

Stress. Stress increases peripheral resistance and cardiac output and stimulates

symphatetic nervous system activity. Over time hypertension can develop. Stressors can be many

things, and noise, infection, inflammmatiom, pain, decreased oxygen supply, heat , cold, trauma,

prolonged exertion,responses to life events, obesity, diseas, surgery and medical treatment can

elicit the stress response. These noxious stimuli are perceived by a person as a threat or as

capable of causing harm; subsequently , a psychophysiologic fight or flight response is initiated

in the body. If stress responses become excessive or prolonged target organ dysfunction or

disease will result. A report from the American Institute of Stress estimates that 60-90% of all

primary care visits involves stress related complaints.

 Obesity. Obesity , especially in the upper body(giving an apple shape), with increased

amounts of fat about the midriff,waist, abdomen, is associated with subsequent development of

hypertension. People who atre overweight but carry most of the excess weight in the buttocks ,

hips, and thighs(giving them a pear shape) are far less risk for development of hypertension

secondary to increased weight alone. The combination of obesity with other factors can be

labeled as metabolic syndrome, which also increases the risk of hypertension.

Nutrients. Sodium consumption can be an important factor in the development of

essential hypertension. At least 40% of the clients who develop hypertension are salt sensitive

and the excess salt may be the precipitating cause of hypertension in these individuals. A high

salt diet may induce excessive release of natriuretic hormone, which may indirectly increase

blood pressure. Sodium loading also stimulates vasopressor mechanisms within the central

nervous system. Studies also show that low dietary intake of calcium, potassium and magnesium

can contribute to the development of hypertension.

Substance abuse. Cigarette smoking, heavy alcohol consumption and some illicit drug

use are all risk factors of hypertension. The nicotine in cigarette smoke and drugs such as

cocaine cause an immediate rise in blood pressure that is dose dependent; however , habitual use

of these substances has been implicated in an increased incidence of hypertension over time. The

incidence of the hypertension is also higher among people who drink more than 3 ounces of

ethanol per day. The impact of caffeine is controversial. Caffeine raises blood pressure acutely

but does not produce sustained effects.

 Non Modifiable Risk factors

Family History. Hypertension is thought to be polygenic and multifactorial- that

is, in any person with a family history of hypertension, several genes may interact with each

other and the environment to cause the blood pressure to elevate over time. The genetic

predisposition that makes certain families to be more susceptible to hypertension may be related

to an elevation in the intracellular sodium levels and to lowered potassium-to-sodium ratios,

which are found more often in blacks than in other groups. Clients with parents who have

hypertension are at greater risk for hypertension at young age.

Age. Primary hypertension typically appears between the ages of 30 and 50 years. The

incidence of hypertension increases with age; 50% to 60% of clients older than 60 years have a

blood pressure over 140/90 mm/ Hg. Epidemiologic studies , however, have shown a poorer

prognosis in clients whose hypertension began at young age. Isolated systolic hypertension

occurs primarily in people older than 50 years , with almost 24% of all people affected by age 80

years. Among older adults, SBP readings are better predictor of possible future events such as

coronary heart disease , stroke, heart failure, and renal disease than in diastolic BP readings.

Gender. The over all incidence of hypertension is higher in men than in women until

about age 55 years. Between the ages of 55 and 74 years, the rsik in men and that in women are

almost equal; then, after age 74 years, women are at greater risk.

Ethnicity. Mortality statistics indicate that the death rate for adults with hypertension is

lowest for white women at 4.7%, white men have the next lowest rate at 6.3% and the black men

have next lowest at 22.55, the death rate is highest for black women at 29.3%. the reason for the

increased prevalence of hypertension among blacks is unclear, but the increase has been
attributed to lower rennin levels , greater ensitivity to vasopressin, higher salt intake, and greater

environmental stress.

Activities Preventing Risk For Hypertension

Lifestyle Modification. Strong research evidence has illustrated conclusively that

lifestyle modifications are effective in lowering blood pressure and reducing cardiovascular risk

factors at little over all cost. Lifestyle modification is also strongly encouraged as adjunctive

therapy for all clients with hypertension who are receiving pharmacologic therapy. Continued

healthy lifestyle practices, along with pharmacologic therapy can reduce the number and dosage

of antihypertensive medications needed to manage their condition.

Weight Reduction. Excess body weight , exhibited by a body mass index (BMI)- weigth

in kilograms in divide by height in meters squared –of 27 or greater , correlates closely with

elevated blood pressure. Also excess body fat accumulated in the torso with a waist

circumference of 35 inches or greater in women and 40 inches or greater in men has benn

associated with an increased risk for hypertension. For many people with hypertension whose

body weight is more than 10% greater than ideal weight reduction of as little as ten pounds can

lower blood pressure up to 10 mmHg . Weight reduction also enhances the effectives of

antihypertensive medications.

Sodium Restriction. Most hypertensive people are sensitive to sodium, showing rises in

blood pressure after sodium intake. Therefore, a moderate restriction of sodium intake to 2 or 3 g

of sodium can be used to lower blood pressure. The amount of medication otherwise needed may
decreased if sodium if sodium intake is lowered. In addition, this moderate sodium restriction

may reduce the degree of potassium depletion that often accompanies diuretic therapy.

Dietary Fat Modification. Modification of dietary intake of fat by decreasing the

fraction of saturated fat and increasing that of polyunsaturated fat has little any, effect on

decreasing blood pressure but can decreased the cholesterol level significantly. Because

dyslipidemia is a major risk factor of atherosclerosis, diet therapy aimed at reducing lipids is an

important adjunct to any total dietary regimen. In addition to the usual recommendations for

sensible eating following the food pyramid, the Dietary approaches to stop hypertension or the

DASH diet, which is rich in fruits, vegetables, nuts, and low-fat dairy products with reduced

saturated and total fats, should be recommend for clients who need a more structured, fat-limited

dietary intervention.

Exercise. A regular program of aerobic exercise adequate to achieve at least moderate

level of physical fitness facilitates cardiovascular conditioning and can aid the obese

hypertensive client in weight reduction and reduce the risk of cardiovascular disease and all-

cause mortality. Blood pressure can be reduced with moderate-intensity(as low as 40% to 60% of

maximum oxygen consumption) physical activity , such as a brisk walk(about 2.5 to 3 mph) for

30 to 45 minutes most days of the week. Weight training using light weights is a positive

addition to any exercise regimen; however, lifting heavy weights can be harmful because blood

pressure rises, sometimes to high levels, with the vasovagal response that occurs during an

intense isometric muscle contraction. Hypertensive clients are advise to initiate exercise

programs gradually, slowly increasing the intensity and duration of activity as the body adjusts

and becomes more conditioned with the ongoing professional surveillance.

 Alcohol Restriction. The consumption of more than 1 ounce of alcohol per day is

associated with a higher prevalence of hypertension, poor adherence to antihypertensive therapy ,

and occasionally refractory hypertension. It is advise that clients should a moderation intake of

alcohol.(i.e., no more than 1 ounce of ethanol per day for men and 0.5 ounce for women). There

is 1 ounce(30 ml) of ethanol in 2 ounces of 100-proof whiskey, in 10 ounces of wine, or in 24

ounces of beer.

Caffeine Restriction. Acute ingestion of caffeine may raise blood pressure.

Relaxation Techniques. A variety of relaxation therapies , including transcendental

meditation, yoga, biofeedback, progressive muscle relaxation, and psychotherapy, can reduce

blood pressure in hypertensive patients, at least transiently. Although each modality has its

advocates, none has been conclusively shown to be either practical for majority of hypertensive

patients or effective in maintaining a significant long term effect.

Smoking Cessation. Although smoking has not been statistically linked to the

development of hypertension, nicotine definitely increases the heart rate and produces peripheral

vasoconstriction which does raise arterial blood pressure for a short time during and after

smoking. Smoking cessation is strongly recommended, however, to reduce the client’s risk for

cancer,pulmonary disease and cardiovascular disease. Smokers appear to have a higher

frequency of malignant hypertension and subarachnoid hemorrhage. In addition, risk reduction

brought about by antihypertensive therapy may not be as great in smokers as in non- smokers.
 Potassium Supplementation. The high ratio of sodium to potassium in the modern diet

has been held responsible for the development of hypertension; however, even though potassium

supplements may lower blood pressure, they are too costlty and potentially too hazardous for

routine use. A reduction in the consumption of high sodium, low potassium processed foods with

an increase in the consumption of low-sodium,high potassium natural foods may be all that is

needed for maximum benefits.

Pharmacologic Interventions. Once a decision has been made to use pharmacologic

intervention, any one of several drugs from seven major drug classes can be used. Prevention-

based healthy lifestyle change with the addition of pharmacologic therapy as indicated is the

preferred treatment for those patients in stages 1 and 2. If the therapy is chosen carefully, more

than half of those with mild hypertension caes can be controlled with one or two drugs. Most

clients, however, will require two or more drugs to achieve goal of blood pressure.(Medical-

Surgical Nursing Clinical Management For Positive Outcome 8th edition vol2.; Black, Joyce)
 Hypertension and its Nature

Hypertension is a major health problem, especially because it has no symptoms. Many

people have hypertension without knowing it. In the United States, about 50 million people age

six and older have high blood pressure. Hypertension is more common in men than women and

in people over the age of 65 than in younger persons. More than half of all Americans over the

age of 65 have hypertension. It also is more common in African-Americans than in white

Americans.

Hypertension is serious because people with the condition have a higher risk for heart

disease and other medical problems than people with normal blood pressure. Serious

complications can be avoided by getting regular blood pressure checks and treating hypertension

as soon as it is diagnosed.

If left untreated, hypertension can lead to the following medical conditions:

• arteriosclerosis, also called atherosclerosis

• heart attack

• stroke

• enlarged heart

• kidney damage.

Arteriosclerosis is hardening of the arteries. The walls of arteries have a layer of muscle

and elastic tissue that makes them flexible and able to dilate and constrict as blood flows through

them. High blood pressure can make the artery walls thicken and harden. When artery walls

thicken, the inside of the blood vessel narrows. Cholesterol and fats are more likely to build up
on the walls of damaged arteries, making them even narrower. Blood clots also can get trapped

in narrowed arteries, blocking the flow of blood.

Arteries narrowed by arteriosclerosis may not deliver enough blood to organs and other

tissues. Reduced or blocked blood flow to the heart can cause a heart attack. If an artery to the

brain is blocked, a stroke can result.

Hypertension makes the heart work harder to pump blood through the body. The extra

workload can make the heart muscle thicken and stretch. When the heart becomes too enlarged it

cannot pump enough blood. If the hypertension is not treated, the heart may fail.

The kidneys remove the body's wastes from the blood. If hypertension thickens the

arteries to the kidneys, less waste can be filtered from the blood. As the condition worsens, the

kidneys fail and wastes build up in the blood. Dialysis or a kidney transplant are needed when

the kidneys fail. About 25% of people who receive kidney dialysis have kidney failure caused by

hypertension.

Causes and symptoms

Many different actions or situations can normally raise blood pressure. Physical activity

can temporarily raise blood pressure. Stressful situations can make blood pressure go up. When

the stress goes away, blood pressure usually returns to normal. These temporary increases in

blood pressure are not considered hypertension. A diagnosis of hypertension is made only when

a person has multiple high blood pressure readings over a period of time.

The cause of hypertension is not known in 90 to 95 percent of the people who have it.

Hypertension without a known cause is called primary or essential hypertension.

When a person has hypertension caused by another medical condition, it is called

secondary hypertension. Secondary hypertension can be caused by a number of different

illnesses. Many people with kidney disorders have secondary hypertension. The kidneys regulate

the balance of salt and water in the body. If the kidneys cannot rid the body of excess salt and

water, blood pressure goes up. Kidney infections, a narrowing of the arteries that carry blood to

the kidneys, called renal artery stenosis, and other kidney disorders can disturb the salt and water

balance.

Cushing's syndrome and tumors of the pituitary and adrenal glands often increase levels

of the adrenal gland hormones cortisol, adrenalin, and aldosterone, which can cause

hypertension. Other conditions that can cause hypertension are blood vessel diseases, thyroid

gland disorders, some prescribed drugs, alcoholism, and pregnancy.

Even though the cause of most hypertension is not known, some people have risk factors

that give them a greater chance of getting hypertension. Many of these risk factors can be

changed to lower the chance of developing hypertension or as part of a treatment program to

lower blood pressure.

Risk factors for hypertension include:

• age over 60

• male sex

• race

• heredity

• salt sensitivity

• obesity

• inactive lifestyle

• heavy alcohol consumption

• use of oral contraceptives

 Some risk factors for getting hypertension can be changed, while others cannot. Age,

male sex, and race are risk factors that a person can't do anything about. Some people inherit a

tendency to get hypertension. People with family members who have hypertension are more

likely to develop it than those whose relatives are not hypertensive. People with these risk factors

can avoid or eliminate the other risk factors to lower their chance of developing hypertension. A

2003 report found that the rise in incidence of high blood pressure among children is most likely

due to an increase in the number of overweight and obese children and adolescents.

Because hypertension doesn't cause symptoms, it is important to have blood pressure

checked regularly. Blood pressure is measured with an instrument called a sphygmomanometer.

A cloth-covered rubber cuff is wrapped around the upper arm and inflated. When the cuff is

inflated, an artery in the arm is squeezed to momentarily stop the flow of blood. Then, the air is

let out of the cuff while a stethoscope placed over the artery is used to detect the sound of the

blood spurting back through the artery. This first sound is the systolic pressure, the pressure

when the heart beats. The last sound heard as the rest of the air is released is the diastolic

pressure, the pressure between heart beats. Both sounds are recorded on the mercury gauge on

the sphygmomanometer.

Normal blood pressure is defined by a range of values. Blood pressure lower than 120/80

mm Hg is considered normal. A number of factors such as pain, stress or anxiety can cause a

temporary increase in blood pressure. For this reason, hypertension is not diagnosed on one high

blood pressure reading. If a blood pressure reading is 120/80 or higher for the first time, the

physician will have the person return for another blood pressure check. Diagnosis of

hypertension usually is made based on two or more readings after the first visit.
 Systolic hypertension of the elderly is common and is diagnosed when the diastolic

pressure is normal or low, but the systolic is elevated, e.g.170/70 mm Hg. This condition usually

co-exists with hardening of the arteries (atherosclerosis).

Blood pressure measurements are classified in stages, according to severity:

• normal blood pressure: less than less than 120/80 mm Hg

• pre-hypertension: 120-129/80-89 mm Hg

• Stage 1 hypertension: 140-159/90-99 mm Hg

• Stage 2 hypertension: at or greater than 160-179/100-109 mm Hg

A typical physical examination to evaluate hypertension includes:

• medical and family history

• physical examination

• ophthalmoscopy: Examination of the blood vessels in the eye

• chest x ray

• electrocardiograph (ECG)

• blood and urine tests.

The medical and family history help the physician determine if the patient has any

conditions or disorders that might contribute to or cause the hypertension. A family history of

hypertension might suggest a genetic predisposition for hypertension.

The physical exam may include several blood pressure readings at different times and in

different positions. The physician uses a stethoscope to listen to sounds made by the heart and

blood flowing through the arteries. The pulse, reflexes, and height and weight are checked and

recorded. Internal organs are palpated, or felt, to determine if they are enlarged.
 Because hypertension can cause damage to the blood vessels in the eyes, the eyes may be

checked with a instrument called an ophthalmoscope. The physician will look for thickening,

narrowing, or hemorrhages in the blood vessels.

A chest x ray can detect an enlarged heart, other vascular (heart) abnormalities, or lung

disease.

An electrocardiogram (ECG) measures the electrical activity of the heart. It can detect if

the heart muscle is enlarged and if there is damage to the heart muscle from blocked arteries.

Urine and blood tests may be done to evaluate health and to detect the presence of

disorders that might cause hypertension.

Diagnosis

Hypertension is generally diagnosed on the basis of a persistently high blood pressure.

Usually this requires three separate sphygmomanometer (see figure) measurements at least one

week apart. Initial assessment of the hypertensive patient should include a complete history and

physical examination. Exceptionally, if the elevation is extreme, or if symptoms of organ damage

are present then the diagnosis may be given and treatment started immediately.

Once the diagnosis of hypertension has been made, physicians will attempt to identify the

underlying cause based on risk factors and other symptoms, if present. Secondary hypertension is

more common in preadolescent children, with most cases caused by renal disease. Primary or

essential hypertension is more common in adolescents and has multiple risk factors, including

obesity and a family history of hypertension. Laboratory tests can also be performed to identify

possible causes of secondary hypertension, and determine if hypertension has caused damage to

the heart, eyes, and kidneys. Additional tests for Diabetes and high cholesterol levels are also

usually performed because they are additional risk factors for the development of heart disease
require treatment.Tests typically performed are classified as follows: Creatinine (renal function)

testing is done to determine if kidney disease is present, which can be either the cause or result of

hypertension. In addition, it provides a baseline measurement of kidney function that can be used

to monitor for side-effects of certain antihypertensive drugs on kidney function. Additionally,

testing of urine samples for protein is used as a secondary indicator of kidney disease. Glucose

testing is done to determine if diabetes mellitus is present. Electrocardiogram (EKG/ECG)

testing is done to check for evidence of the heart being under strain from high blood pressure. It

may also show if there is thickening of the heart muscle (left ventricular hypertrophy) or has

experienced a prior minor heart distubance such as a silent heart attack. A chest X-ray may be

performed to look for signs of heart enlargement or damage to heart tissue.

Prevention

The degree to which hypertension can be prevented depends on a number of features

including current blood pressure level, sodium/potassium balance, detection and omission of

environmental toxins, changes in end/target organs (retina, kidney, heart, among others), risk

factors for cardiovascular diseases and the age at diagnosis of prehypertenion or at risk for

hypertension. A prolonged assessment in which repeated measurements of blood pressure are

taken provides the most accurate assessment of blood pressure levels. Following this, lifestyle

changes are recommended to lower blood pressure, before the initiation of prescription drug

therapy. The process of managing prehypertension according the guidelines of the British

Hypertension Society suggest the following lifestyle changes:

• Weight reduction and regular aerobic exercise (e.g., walking): Regular exercise

improves blood flow and helps to reduce the resting heart rate and blood pressure

• Reducing dietary sugar.

 • Reducing sodium (salt) in the diet: This step decreases blood pressure in about

33% of people (see above). Many people use a salt substitute to reduce their salt intake.

• Additional dietary changes beneficial to reducing blood pressure include the

DASH diet (dietary approaches to stop hypertension) which is rich in fruits and vegetables and

low-fat or fat-free dairy products. This diet has been shown to be effective based on research

sponsored by the National Heart, Lung, and Blood Institute. In addition, an increase in dietary

potassium, which offsets the effect of sodium has been shown to be highly effective in reducing

blood pressure

• Discontinuing tobacco use and alcohol consumption has been shown to lower

blood pressure. The exact mechanisms are not fully understood, but blood pressure (especially

systolic) always transiently increases following alcohol or nicotine consumption. Abstaining

from cigarette smoking reduces the risk of stroke and heart attack which are associated with

hypertension.

• Reducing stress, for example with relaxation therapy, such as meditation and

other mindbody relaxation techniques, by reducing environmental stress such as high sound

levels and over-illumination can also lower blood pressure. Jacobson's Progressive Muscle

Relaxation and biofeedback are also beneficial, such as device-guided paced breathing, although

meta-analysis suggests it is not effective unless combined with other relaxation techniques.

(www.wikipedia.com)
 RESEARCH LITERATURE

Modifiable Risk Factors

Waist Size Tied to Hypertension Risk

Marginally increased waist circumference is strongly associated with prevalent

hypertension in normal-weight and overweight adults, according to data from a large National

Institute of Neurological Disorders and Stroke-sponsored study.

The finding is likely to change both clinical practice and guidelines, Dr. Deborah A.

Levine predicted in reporting the results at a conference of the American Heart Association.

“As a practicing general internist, I do not routinely measure waist circumference as well as I

should,” conceded Dr. Levine of Ohio State University, Columbus. “And I certainly don't do it in

persons with normal [body mass index] at this time. But these data have prompted me to

reconsider that practice.”

Moreover, the new data indicate a need to revise current U.S. guidelines regarding how

waist circumference measurement is used as a cardiovascular risk assessment tool.

Current National Institutes of Health guidelines include a less-than-forceful recommendation to

consider measuring waist circumference—a guide to central adiposity—in individuals with

normal BMIs. But the new data presented by Dr. Levine indicate that waist circumference

measurement is a valuable indicator of cardiovascular risk in patients with normal BMIs.

The U.S. guidelines define normal waist circumference as less than 80 cm in women and 94 cm

in men, and elevated waist circumference as more than 88 and 102 cm, respectively. The middle

zone of marginally elevated values—80–88 cm in women and 94–102 cm in men—is a gray area
that's largely disregarded by physicians and researchers alike. But this needs to change, Dr.

Levine said.

“Our data suggest that we should be treating waist circumference as a continuous risk factor and

not a categorical variable where the middle category is actually ignored in practice and in

studies,” she said.

In light of the new findings, she said, the current International Diabetes Federation guidelines

make far more sense.

In the IDF guidelines on metabolic syndrome, the group defines any waist circumference that's

above normal as elevated, period.

Dr. Levine presented an analysis of waist circumference and prevalent hypertension in 21,351

black and white adult community-dwelling participants in the Reasons for Geographic and

Racial Differences in Stroke (REGARDS) study, a population-based study whose primary goal is

to identify explanations for the excess stroke mortality in the so-called “stroke belt” in the

southeastern United States. The prevalence of baseline hypertension was found to be 45% among

the participants with a normal body mass index, 56% in those who were overweight, and 66% in

the subjects with class I obesity.

After adjustment for numerous demographic factors as well as for alcohol and tobacco

use, physical activity, and glomerular filtration rate, a marginally increased waist circumference

—that is, 80–88 cm in women and 94–102 cm in men—was independently associated with a

58% higher hypertension prevalence in normal-weight individuals and a 31% higher

hypertension prevalence in those who were overweight, compared with the participants who had

comparable BMI values but normal waist circumference. An elevated waist circumference was

associated with a 2.1-fold increased hypertension prevalence in normal-weight subjects, a 1.6-

fold increase in those who were overweight, and a 48% increase in the REGARDS participants

who were obese class I.

As the researchers expected, a marginally increased waist circumference did not confer a

significantly increased risk of hypertension in obese subjects. It has been previously shown that

waist circumference has a diminished ability to independently predict cardiovascular risk factors

and morbidity in obese individuals. (http://www.internalmedicinenews.com/BRUCE

JANCIN05/01/08)

Lifestyle modifications.

The first line of treatment for hypertension is the same as the recommended preventative lifestyle

changes such as the dietary changes, physical exercise, and weight loss, which have all been

shown to significantly reduce blood pressure in people with hypertension. If hypertension is high

enough to justify immediate use of medications, lifestyle changes are still recommended in

conjunction with medication. Drug prescription should take into account the patient's absolute

cardiovascular risk (including risk myocardial infarction and stroke) as well as blood pressure

readings, in order to gain a more accurate picture of the patient's cardiovascular profile.Different

programs aimed to reduce psychological stress such as biofeedback, relaxation or meditation are

advertised to reduce hypertension. However, in general claims of efficacy are not supported by

scientific studies, which have been in general of low quality.Regarding dietary changes, a low

sodium diet is beneficial; A Cochrane review published in 2008 concluded that a long term

(more than 4 weeks) low sodium diet in Caucasians has a useful effect to reduce blood pressure,

both in people with hypertension and in people with normal blood pressure. Also, the DASH diet

(Dietary Approaches to Stop Hypertension) is a diet promoted by the National Heart, Lung, and
Blood Institute (part of the NIH, a United States government organization) to control

hypertension. A major feature of the plan is limiting intake of sodium, and it also generally

encourages the consumption of nuts, whole grains, fish, poultry, fruits and vegetables while

lowering the consumption of red meats, sweets, and sugar. It is also "rich in potassium,

magnesium, and calcium, as well as protein.

(http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash)

Most physicians believe in urging hypertensive patients to alter their lifestyle in

beneficial ways, even though this seldom comes to pass, Norman Kaplan, M.D., said at the

annual meeting of the American Society of Hypertension.

“I'm not sure that we're going to be depending as much on lifestyle modifications as we have in

the past” because of the recognition that high blood pressures need to be lowered quickly, said

Dr. Kaplan, professor of medicine at the University of Texas, Dallas.

He described lifestyle modifications that do and don't work in treating hypertension:

Smoking cessation. Usually found at the bottom of lists of lifestyle modifications for

treating hypertension, smoking cessation deserves first mention because it is the major reversible

cardiovascular risk factor in hypertensive smokers. Until recently, physicians didn't recognize the

pressor effects of nicotine because patients weren't allowed to smoke during blood pressure

measurements. Ambulatory monitoring consistently shows higher BPs while smoking.

Advise patients repeatedly to stop smoking, and explain or show to them the pressor effect of

smoking, Dr. Kaplan said. Nicotine replacement products such as patches should not have

persistent pressor effects, but advise patients to check their BP on these products anyway

because some people may be particularly sensitive.

 Weight loss. Significant weight loss reduces blood pressure, but most dieters put the

pounds back on in a short amount of time. Studies comparing weight loss diets suggest that the

cheapest and “probably the most logical” method—Weight Watchers—may be the best diet

strategy, he said.

For morbidly obese people (body mass index greater than 40 kg/m

Gastric banding surgeries have been less successful in morbidly obese patients. It appears that

enough food is forced past the banded stomach over time that the patient regains the weight

initially lost after surgery.

Physical Activity. Unhealthy diets and physical inactivity share the blame equally for

Americans' march toward morbid obesity.

Duration is more important than intensity of physical activity for lowering BP, studies have

shown. Thirty minutes on a treadmill exercising at 50%–75% of maximal heart rate significantly

reduced BP and the effects persisted over 24 hours, one study found.

A metaanalysis of studies on diabetic patients found that walking as little as 2 hours each week

reduced mortality by about 40%, compared with less active patients, Dr. Kaplan said.

Sodium Reduction. Patients who reduce their sodium intake typically return to old

habits over time. The result is that no difference is seen after 5 years, according to an analysis of

about 30 studies.

People are surrounded by high-sodium foods in U.S. culture: Some fast food items pack 1,000–

3,000 mg sodium each. “Most people have no perception of what they're eating when they eat

this kind of food,” he said.

Moderation of Alcohol. Drinking modest amounts of alcohol while eating food does not

increase the risk of hypertension and may even provide some cardiovascular benefits, he said.
Consuming alcohol without food or having more than three drinks per day increases the risk for

hypertension and other health problems.

▸ Increasing potassium. Hypertensive patients can reduce their BP by taking 40–80 mmol/day

of supplemental potassium, but it's better to recommend that patients eat more fruits and

vegetables to boost their potassium intake. One reason the Dietary Approaches to Stop

Hypertension diet works is that it triples the typical potassium intake, Dr. Kaplan noted.

(http://www.internalmedicinenews.com/)

Medications

Antihypertensive Drug

Several classes of medications, collectively referred to as antihypertensive drugs, are

currently available for treating hypertension. Agents within a particular class generally share a

similar pharmacologic mechanism of action, and in many cases have an affinity for similar

cellular receptors. An exception to this rule is the diuretics, which are grouped together for the

sake of simplicity but actually exert their effects by a number of different mechanisms.Reduction

of the blood pressure by 5 mmHg can decrease the risk of stroke by 34%, of ischaemic heart

disease by 21%, and reduce the likelihood of dementia, heart failure, and mortality from

cardiovascular disease. The aim of treatment should be reduce blood pressure to <140/90 mmHg

for most individuals, and lower for individuals with diabetes or kidney disease (some medical

professionals recommend keeping levels below 120/80 mmHg).Comorbidity also plays a role in

determining target blood pressure, with lower BP targets applying to patients with end-organ

damage or proteinuria. Often multiple drugs are combined to achieve the goal blood pressure.

Commonly used prescription drugs include:

 • ACE inhibitors (e.g., captopril)

• Alpha blockers (e.g., prazosin)

• Angiotensin II receptor antagonists (e.g., losartan)

• Beta blockers (e.g.,propranolol)

• Calcium channel blockers (e.g., verapamil)

• Diuretics (e.g. hydrochlorothiazide)

• Direct renin inhibitors (e.g., aliskiren)

Some examples of common combined prescription drug treatments include:

• A fixed combination of an ACE inhibitor and a calcium channel blocker. One

example of this is the combination of perindopril and amlodipine, the efficacy of which has been

demonstrated in individuals with glucose intolerance or metabolic syndrome.[61]

• A fixed combination of an ACE inhibitor and a calcium channel blocker.

• A fixed combination of a diuretic and an ARB.

Society and culture

Economics

The National Heart, Lung, and Blood Institute (NHLBI) estimated in 2002 that

hypertension cost the United States $47.2 billion.

High blood pressure is the most common chronic medical problem prompting visits to

primary health care providers, yet it is estimated that only 34% of the 50 million American adults

with hypertension have their blood pressure controlled to a level of <140/90 mm Hg[citation

needed]. Thus, about two thirds of Americans with hypertension are at increased risk for heart

disease. The medical, economic, and human costs of untreated and inadequately controlled high
blood pressure are enormous. Adequate management of hypertension can be hampered by

inadequacies in the diagnosis, treatment, and/or control of high blood pressure.[87] Health care

providers face many obstacles to achieving blood pressure control from their patients, including

resistance to taking multiple medications to reach blood pressure goals. Patients also face the

challenges of adhering to medicine schedules and making lifestyle changes. Nonetheless, the

achievement of blood pressure goals is possible, and most importantly, lowering blood pressure

significantly reduces the risk of death due to heart disease, the development of other debilitating

conditions, and the cost associated with advanced medical care.,(www.wikipedia.com)

Awareness

The World Health Organization attributes hypertension, or high blood pressure, as the

leading cause of cardiovascular mortality. The World Hypertension League (WHL), an umbrella

organization of 85 national hypertension societies and leagues, recognized that more than 50% of

the hypertensive population worldwide are unaware of their condition. To address this problem,

the WHL initiated a global awareness campaign on hypertension in 2005 and dedicated May 17

of each year as World Hypertension Day (WHD). Over the past three years, more national

societies have been engaging in WHD and have been innovative in their activities to get the

message to the public. In 2007, there was record participation from 47 member countries of the

WHL. During the week of WHD, all these countries – in partnership with their local

governments, professional societies, nongovernmental organizations and private industries –

promoted hypertension awareness among the public through several media and public rallies.

Using mass media such as Internet and television, the message reached more than 250 million

people. As the momentum picks up year after year, the WHL is confident that almost all the
estimated 1.5 billion people affected by elevated blood pressure can be reached. ("What is

Hypertension? - WrongDiagnosis.com". http://www.wrongdiagnosis.com/h/hypertension/basics.htm.)

Activities in Relation to Prevent/Manage hypertension

Home/self measurement of BP

* Home/self BP readings can be used in the diagnosis of hypertension (Grade C).

* The use of home/self BP monitoring on a regular basis should be considered for patients with

hypertension (Grade D), particularly those with:

o diabetes mellitus;

o chronic kidney disease;

o suspected nonadherence;

o demonstrated white coat effect; and

o BP controlled in the office but not at home (masked hypertension).

* When white coat hypertension is suggested by home/self monitoring, its presence

should be confirmed with ABPM before making treatment decisions (Grade D).

* Patients should be advised to purchase and use only home/self BP monitoring

devices that are appropriate for the individual and have met the current standards of the

Association for the Advancement of Medical Instrumentation, the British Hypertension Society

protocol or the International Protocol for validation of automated BP measuring devices. Patients

should be encouraged to use devices with data recording capabilities or automatic data

transmission to increase the reliability of reported home/self BP values (Grade D).

* Health care professionals should ensure that patients who measure their BP at home

have adequate training, and if necessary, repeat training in measuring their BP. Patients should
be observed to ensure that they measure BP correctly and should be given adequate information

about interpreting these readings (Grade D).

* The accuracy of all individual patients’ validated devices (including electronic

devices) must be regularly checked against a device of known calibration (Grade D).

* Home/self BP values for assessing white coat hypertension or sustained hypertension

should be based on duplicate measures, morning and evening, for an initial seven-day period.

First-day home/self BP values should not be considered (Grade D).The use of home/self BP

monitoring was first expanded in the 2005 recommendations. The addition of BP assessment

outside the office setting has resulted in the recognition of the phenomenon of ‘masked

hypertension’, in which subjects with hypertension have normal BP with office measurements

but elevated BP in the home setting . The Self measurement of blood pressure at Home in the

Elderly: Assessment and Follow-up (SHEAF) study has provided evidence as to the clinical

significance of masked hypertension . In this prospective study of 4939 treated elderly

hypertensive subjects, followed for a mean of 3.2 years, the incidence of cardiovascular events in

subjects with masked hypertension was similar to that of subjects with uncontrolled hypertension

(ie, BP elevated both in the office and at home) at 30.6 cases (95% CI 21.2 to 39.9) and 25.6

cases (95% CI 22.4 to 28.9) per 1000 patient-years, respectively. Although the CHEP

Recommendations Task Force recognized that additional evidence is required before

recommendations regarding diagnosis and management of masked hypertension can be

developed, the compelling evidence from the SHEAF study regarding the clinical implications of

masked hypertension resulted in the new recommendation for 2006 that continued home/self BP

monitoring be considered for treated hypertensive patients with BP controlled in the office but

not at home (masked hypertension). The use of ABPM has also been used in the assessment of
masked hypertension and will be discussed in upcoming iterations of the CHEP guidelines as

evidence from ongoing studies becomes available. The CHEP Recommendations Task Force felt

it important to emphasize that adequate patient training is required to ensure accurate BP results

from home/self BP monitoring. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2560864/)

Research Review Finds Yoga Beneficial In Reducing Hypertension

Hypertension, or high blood pressure, remains the most common reason for office visits

to physicians for non-pregnant adults in the United States. Some 50 million Americans are

believed to have hypertension. Despite its prevalence and the complications associated with it,

control of the disease is far from adequate. As a result, hypertension will likely remain the most

common risk factor for stroke, heart failure, and kidney disease for years to come.

At the same time, some 42 percent of Americans have used complementary and

alternative medicine (CAM) approaches to meet their health care needs, spending more out-of-

pocket for CAM than the amount projected for expenditures in 1997 for all U.S. physician

services. Nearly three million people are estimated to have tried mind-body techniques to treat

their hypertension; approximately eight percent of the hypertensive population.

Mind-Body medicine, one of five major branches of CAM therapeutics, uses behavioral

techniques to augment the mind's capacity to affect bodily function and symptoms, utilizing

varied approaches such as meditation, prayer, mental healing, and therapies that use creative

outlets such as art, music, or dance. The 2002 National Health Interview Survey (NHIS) found

nearly 30 million users of relaxation techniques including meditation and yoga, and 10 million
users of yoga therapies. One-fourth of those who used mind-body therapies rated them "very

helpful."

There has been little quality research to discriminate between positive anecdotal

evidence, marketing schemes, and practices that are consistently effective and safe. As a result, a

team of researchers conducted a systematic review aims to assess the efficacy of mind-body

therapies (MBT) versus placebo or active control in the treatment of hypertension. The main

outcome measures include change in systolic and diastolic blood pressure pre- and post-

intervention period.

The team reviewed randomized, or quasi-randomized, controlled trials comparing mind-

body techniques (meditation, yoga, and guided imagery) alone or in combination with

conventional treatment to conventional treatment alone or no intervention/waiting list control.

Relevant trials were identified in the register of trials maintained by the Cochrane

Complementary Medicine Field Registry, The Cochrane Central Register of Controlled Trials,

Medline, EMBASE, PsycInfo, and CINAHL.

Participants in these trials were men and non-pregnant women, greater than 18 years of

age with hypertension defined as a systolic blood pressure of >140 mm Hg and/or diastolic blood

pressure >90 mm Hg. (Normal is defined as systolic >140 and/or diastolic >90 mmHg). The

types of intervention undertaken by the study participants were mind-body techniques with the

greatest rates of utilization (>3.5 percent prevalence of use in the general population) being

meditation, yoga, and guided imagery techniques. A description of each follows:

Meditation: A systematic mental focus on particular aspects of inner or outer experience

involving engaging in an activity that directs the mind to single point of focus, using breathing

techniques, or imagery in order to feel a state of calmness.

 Yoga: The Sanskrit word yoga connotes "the joining of the lower human nature to the

higher." Yoga techniques comprise a series of body positions and movements developed in order

to help relax the body and calm the mind. It involves breath control, physical exercises and

meditation.

Imagery: The generation (either by oneself or guided by a practitioner) of different

mental images. Using the capacities of visualization and imagination, individuals evoke images,

usually either sensory or affective. These images are typically visualized with the goal of

evoking a psychophysiological state of relaxation or with some specific outcome in mind.

The review and synthesis of 12 published randomized trials found largely favorable

effects of the most popular mind-body therapies on systolic and diastolic blood pressure. Mind-

Body Therapies (MBT) significantly reduced systolic blood pressure (SBP) by a mean 11.52 mm

Hg and diastolic blood pressure (DBP) by 6.83 mm Hg. Of the three MBT analyzed, yoga

therapies demonstrated results of the greatest magnitude, with mean SBP reductions of 19.07

mm Hg and DBP by 13.13 mm Hg. Significant results were seen in SBP reductions by yoga and

meditation therapy, while only yoga therapies demonstrated significant reductions in DBP.

The absolute reductions in blood pressure were comparable to pharmacologic

monotherapy in both effect size and temporality. Additionally, reductions in systolic and

diastolic blood pressure to the degree found in yoga interventions were associated with

reductions in vascular death rates as well as decreased overall cardiac risk.

According to Dr. Ali, the lead author, "This review shows that there is some high quality

scientific literature supporting the use of mind-body therapies as a treatment for hypertension,

and the magnitude of effect is clinically significant." Despite the limitations of a review, he

suggests mind-body interventions may be prudent choices for adjunctive treatment for motivated
patients.(http://www.medicalnewstoday.com/articles/80402.php Article Date: 24 Aug 2007 -

0:00 PDT)

Medications

ATLANTA — A first baby step toward drug therapy for prehypertension was taken with

the presentation of the Trial of Preventing Hypertension results at the annual meeting of the

American College of Cardiology.

TROPHY, a 4-year, 772-patient trial, showed that 2 years of treatment with the angiotensin II

receptor blocker candesartan delayed the otherwise nearly inexorable transition from

prehypertension to stage 1 hypertension.

But the TROPHY investigators and other observers were quick to emphasize that key questions

remain to be answered by future studies before a policy shift from lifestyle modification to

medication as first-line therapy can be seriously considered.

Dr. Stevo Julius, chair of the TROPHY executive committee, said the researchers were unwilling

to make major treatment recommendations based on this one study. Their sole strong new

recommendation based on TROPHY, he added, is that prehypertensive patients deserve closer

follow-up than what is now the norm. That's because nearly two-thirds of those on placebo

converted to stage 1 hypertension in 4 years.

“Since there was a very high rate of transition, we are rather confident in recommending that

once you have diagnosed prehypertension, these patients should be followed more frequently

than they are followed now in order to then detect the development of stage 1 hypertension—and

we think that follow-up at 3-month intervals is reasonable,” said Dr. Julius, professor emeritus of

medicine and physiology at the University of Michigan, Ann Arbor.

TROPHY participants had to have baseline prehypertension as defined by repeated automated

blood pressure readings of either 130–139 mm Hg systolic and 89 mm Hg or lower diastolic, or a

systolic pressure of 139 mm Hg or lower plus a diastolic value of 85–89 mm Hg. Their mean age

was 48 years. That's far younger than the patients in other hypertension trials, but Dr. Julius

expressed regret that they weren't even younger, since that might have enabled TROPHY to

show whether a brief drug intervention, given early enough, could permanently arrest the

hypertensive process.

TROPHY participants were randomized to 2 years of double-blind candesartan (Atacand) at 16

mg once daily or placebo, followed by 2 years in which all participants received placebo.

At the 2-year mark, clinical hypertension—the primary end point—had developed in 14% of the

candesartan group and 40% of the placebo group, for a 66% relative risk reduction. Blood

pressure began to climb soon after drug therapy stopped; at 4 years, stage 1 hypertension was

present in 53% of the candesartan arm and 63% of the placebo arm, for a still significant 16%

relative reduction. Drug side effects were mild and similar to those seen with placebo.

It has been estimated that up to 70 million Americans have prehypertension, as defined by blood

pressures of 120–139 mm Hg systolic or 80–89 mm Hg diastolic. Why consider redefining this

vast group as having a condition warranting drug therapy?

Because prehypertension—previously called transient hypertension, borderline hypertension, and

high-normal blood pressure—is an established precursor of clinical hypertension and is tied to

increased cardiovascular morbidity and mortality. Also, hypertension is a self-accelerating

condition, and animal studies have suggested that relatively brief drug therapy during the

prehypertensive phase might favorably alter the natural history by reversing the arteriolar
hypertrophy and endothelial dysfunction that define prehypertension—thereby not just delaying,

but preventing, clinical hypertension.

Also, guideline-recommended lifestyle modifications have failed badly. “Although

nonpharmacologic therapy has been recommended first as a population strategy, it hasn't

worked,” Dr. Julius said. With rising rates of obesity and diabetes, “the time has come to look at

this problem in a different way with some large-scale research.”

He noted that the best-ever performance of lifestyle modification, seen in the Trials of

Hypertension Prevention, showed an absolute 8% reduction in new-onset hypertension over 2

years (Arch. Intern. Med. 1997;157:657–67), versus 27% with candesartan in TROPHY.

During the discussion, Dr. William J. Elliott expressed concern that the slope of the curve of

new-onset hypertension in the candesartan arm during years 2–4 appeared to be the same as in

years 0–2 in the placebo arm. This suggests, disappointingly, that drug therapy didn't halt the

hypertensive express train and prehypertensive individuals might need to take drugs for their

entire lives to benefit.

Lowering the traditional threshold for drug therapy from 140/90 mm Hg to encompass some

portion of the 70 million Americans with prehypertension could be a health care budget buster,

added Dr. Elliott, professor of preventive medicine, internal medicine, and pharmacology at

Rush Medical College, Chicago.Dr. Julius receives grant support from AstraZeneca, which

funded TROPHY. (http://www.internalmedicinenews.com/ BRUCE JANCIN/04/01/06)

Biggest Hypertension Problem Is That Patients Do Not Continue Taking Their Medications

Article Date: 18 Aug 2007 - 16:00 PDT (http://www.lancet.com)

The largest problem for controlling high blood pressure (hypertension) is compliance

with treatment, according to an Editorial in this week's issue of The Lancet, Cardiology Special

Edition .

The editorial states "Despite very effective and cost-effective treatments, target blood

pressure levels are very rarely reached, even in countries where cost of medication is not an

issue. Many patients still believe that hypertension is a disease that can be cured, and stop or

reduce medication when blood pressure levels fall."

The Editorial mentions that a person's risk of becoming hypertensive in the developed

world is over 90%. As more and more people suffer from hypertension, obesity, diabetes and

hyperlipidaemia, their risk of developing cardiovascular disease, stroke, renal failure, and

ultimately death grows significantly.

In the years to come the burden of hypertension is expected to rise enormously. There

were approximately 972 million people living with high blood pressure in the world in the year

2000, compared to an estimated 1.56 billion in 2025.

"Lifestyle factors, such as physical inactivity, a salt-rich diet with high processed and

fatty foods, and alcohol and tobacco use, are at the heart of this increased disease burden, which

is spreading at an alarming rate from developed countries to emerging economies, such as India

and China," writes the Editorial.

"Physicians need to convey the message that hypertension is the first, and easily

measurable, irreversible sign that many organs in the body are under attack. Perhaps this
message will make people think more carefully about the consequences of an unhealthy lifestyle

and give preventative measures a real chance," the Editorial concludes.

Diet

Increased intake of soybean protein may provide an important means of preventing and

treating hypertension, Jiang He, M.D., declared at a meeting sponsored by the International

Academy of Cardiology.

He presented results from a multicenter, double-blind, randomized, controlled trial of soybean

protein in 302 Chinese adults with prehypertension or stage 1 hypertension. Participants in the

12-week trial ate cookies containing either 40 g/day of isolated soybean protein or 40 g of

complex carbohydrates from wheat. The cookies were identical in taste and appearance. Most

subjects ate them in lieu of their usual breakfast. Adherence was excellent, with 93% of all

cookies in both groups being eaten.

Baseline mean blood pressure was 135.0/84.7 mm Hg.

The main study finding was a highly significant net blood pressure reduction of 4.3 mm Hg for

systolic and 2.8 mm Hg for diastolic in the soy arm, compared with the control group.

This effect was larger than was found in studies of currently recommended lifestyle

modifications, with the single notable exception of the National Heart, Lung, and Blood

Institute-sponsored Dietary Approaches to Stop Hypertension (DASH) diet, noted Dr. He of

Tulane University, New Orleans.

The blood pressure reduction was greater in subjects with stage 1 hypertension than in those who

were prehypertensive.
Indeed, stage 1 hypertensives experienced a net reduction of 7.9/5.3 mm Hg in response to

soybean protein supplementation. The 2.4/1.3 mm Hg reduction in prehypertensive subjects

didn't achieve statistical significance; however, the study wasn't powered for subgroup analysis,

according to the physician.

In addition, it's worth noting that soybean protein has ancillary health benefits, Dr. He added. It

has been shown in randomized controlled trials to significantly reduce serum LDL, total

cholesterol, and triglycerides.

Session cochair Martha L. Daviglus, M.D., of Northwestern University, Chicago, noted that the

observational International Study on Macronutrients and Blood Pressure, in which she was an

investigator, found an association between greater consumption of vegetable protein—but not

animal protein—and lower blood pressure. This raises the question of whether the blood

pressure-lowering effect documented in Dr. He's study is unique to soy protein or might be

achievable with a diet enriched with mixed vegetable protein.

The daily portion of soy cookies contained 76 mg of total isoflavones, including 45 mg of

genistein and 27 mg of daidzein.The study was funded by Tulane University; the National Heart,

Lung, and Blood Institute; and the Ministry of Science and Technology of the People's Republic

of China. (http://www.internalmedicinenews.com/ BRUCE JANCIN/04/01/06)