file:///A|/STEPDOWN.

HTM

"STEP DOWN" CARE FOR THE LONG TERM TREATMENT

OF ESSENTIAL HYPERTENSION
P. Mahoney, Ph.D., L. Fehmi, Ph.D., S. Shor, C.S.W.

Does step-care treatment of hypertension increase cardiovascular risk and mortality?

Standard step-care has proven effective in lowering blood pressure and in reducing the incidence of stroke.
However, evidence from numerous large scale trials has raised concern that long term treatment with diuretic and
beta-blocking anti-hypertensive medications has actually increased patient risk for Coronary Heart Disease (CHD).1
These findings have spurred both the World Health Organization and the Joint National Committee on Detection,
Evaluation, and Treatment of High Blood Pressure (JNC) to initiate substantial revision in guidelines for treatment of
mild and moderate hypertension. Initial revisions call for `step-down' care, the control of blood pressure by
non-pharmacological means.

This has created a dilemma for the primary care physician. Recognition of the risks associated with hypertension
has increased the pressure to treat mild and moderate levels. Recently available and promising alternative drugs
such as alpha-blockers, calcium channel blockers and angiotensin converting enzyme inhibitors have not been
evaluated in long term trials for their effectiveness and side-effects. JNC recommendations for their use are not
expected until mid or late 1988 at the earliest. Moreover, non-pharmacological approaches such as salt and alcohol
restriction, exercise, and weight loss too often do not produce large enough reductions by themselves and they can
present frustrating problems with compliance.

However, two recent NIH funded studies have established the effectiveness of a biofeedback protocol developed by
a group at the Menninger Foundation. Their multimodal biofeedback treatment, involving training in hand and foot
warming and diaphragmatic breathing, reduces sympathetic arousal and results in both a lowering of cardiac output
and in increased peripheral vasodilation.2, 3

The Menninger group recently reported that 93% of the medicated hypertensive patients they treated were able to
significantly reduce their medicatIon (by 1/2 or more) while lowering and maintaining their pressure to a safe level
(140/90 mmg.). 58% were able to withdraw from medication completely. More importantly, follow-up data,
averaging three years per patient, showed almost all maintained their gains.3 Treatment varied from ten to fifty
weekly group sessions.

Biofeedback has much to recommend it as a treatment to withdraw patients from long term use of diuretic and
beta-blocking anti-hypertensive medication and to reduce the cardiovascular risks attendant to long term drug use:

(a) It is cost effective. The Menninger Study estimated that the savings in medication costs alone can
exceed $30,000 per patient life span.

(b) Compliance with biofeedback treatment is high, much higher than with many other behavioral
interventions.

(c) The self-regulation skills they learn transfer to other aspects of their life and health, and
patients experience an overall reduction in stress.

1. Zusman, R. (1986). "Alternatives to Traditional Antihypertensive Therapy," Editorial, Hypertension, 8, pp.

837-841.

2. Blanchard, E., et. al. (1986). "A Controlled Comparison of Thermal Biofeedback and Relaxation Training in the
Treatment of Essential Hypertension," Behavior Therapy, and Relaxation Training in the Treatment of Essential
Hypertension," Behavior Therapy, 17, pp. 563-579.

3. Fahrion, S., et. al. (1987). "Biobehavioral Treatment of Essential Hypertension: a Group Outcome Study,"
Biofeedback and Self-Regulation, 4, pp. 6-14.

BIOFEEDBACK CAN BE A BENEFICIAL ADJUNCTIVE TREATMENT IN THE LONG TERM CARE OF YOUR

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HYPERTENSIVE PATIENTS. THE PRINCETON AFFILIATED CLINICS PROVIDE BIOFEEDBACK IN THE

CONTEXT OF A PATIENT'S OVERALL MEDICAL CARE AND ONLY WITH CLOSE MONITORING AND
CONTINUED FOLLOW-UP BY HIS PRIMARY CARE PHYSICIAN. IF YOU WOULD LIKE REPRINTS OF
RELEVANT STUDIES OR MORE INFORMATION REGARDING OUR SERVICES, PLEASE GIVE US A CALL.

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