NON-

PHARMACOLOGICAL
MANAGEMENT OF
HYPERTENSION

Dr Pringgodigdo Nugroho
Management of hypertension:

Non pharmacological
Pharmacological

Why not pharmacological exclusively?

Failure of hypertension control point towards :

non-compliance with treatment

long term usage of drug

increased risk of cardiovascular events

economic-constraint
Modifiable risk factors for Essential
Hypertension :( JNC VII Guidelines)
Obesity

Physical inactivity

Alcohol consumption

Diet

Stress & anxiety

Weight reduction
 BMI (>/= 25kg/m2)
Essential hypertension
78%-in male
65%-in female
(Vasant RS, Larson MG et al, 2001)
Dolls, Bovet P et al, 2002
fasting exercise

Confusion
?

surgery drugs
 Fasting
No energy input ensures negative energy balance

Weight loss is rapid but this is disadvantage

Disadvantage is a large portion of weight loss is from

lean body mass.

Nutrient deficit occur

ketogenic
 Surgery
Alteration of gastrointestinal tract capacity

Advantage-Caloric restriction is less necessary

Disadvantage-risks of surgery
 Exercise
Evidence supports that level of regular
physical activity is more effective than
dieting for long term weight control.
(French, S.A., et al. 1994)

Increased caloric expenditure through

aerobic type exercise is a significant
option for unbalancing the energy
equation to bring out both weight loss
and a favorable modification in body
composition.
(Ballor, and Kessey et al.1994)
 Calorie expenditure > Calorie intake by 10%

Net 3500 kcal energy burning gives 0.45 kg body fat

loss.

A meta analysis by staessen et al. showed that mean

SBP & DBP reductions were 1.6/1.1 mmHg per kg of
body weight by aerobic program.

18 month weight loss program associated with 77%

reduction in incidence of hypertension.
(He J, Whelton PK et al.2000)

The exact mechanism by which weight reduction

lowers blood pressure is not known.
Probable mechanism:

- Decreased concentration of renin and

aldosterone .
(Engel S, Sharma AM et al. 2001)

- Decrease in activity of sympathetic

nervous system.
(Esler M, Lambert G et al.2006)
 Body Weight and BP
A direct association between excess body wt
and HTN regardless of age, gender & race.
4.5 kg reduction in wt resulted in reduced BP.
60% of pts remained normotensive without
pharmacologic therapy (DISH Trial)
Better control of BP achieved when Wt
reduction added to antihypertensive therapy.
Waist circumference <85 cm for women and
<98 cm Men and BMI<27 are recommended.
Physical activity
The Role of Physical Activity
in the Management of
Hypertension
 Kokkinos P., et al.
Cardiology Clinics 2001;19(3):507-516

Average Reduction in BP:

Active: 10.5/7.6 mm Hg
Controls: 3.8/1.3 mm Hg
 Exercise and BP

How Much Exercise for changes?

(intensity, Duration, Frequency)
How Intense Should Exercise Be?

How Soon Do We See Results?

How Long Do the Changes Last?

 Exercise Intensity and BP Reduction
Hagberg J., et al. Am J Cardiol 1989;64:348-53
mm Hg

SBP DBP SBP DBP

High Intensity (73% VO2 max)

Low Intensity (53% VO2 max)

 Exercise Intensity and BP Reduction
Matsusaki M, et al. Clin Exp Pharm & Physiol 1992;19:471-9

mm Hg

SBP DBP DBP

SBP

High Intensity (75% VO2 max)

Low Intensity (50% VO2 max)

BP Changes with Exercise in pts with Severe
Hypertension (Stage 2 & 3)
Kokkinos P, Pittaras A.et al. N Engl J Med 1995;333:1462-7
mm Hg

DBP

DBP

SBP

SBP

16 weeks 32 weeks
Wall Thickness at Baseline & 16 weeks
Kokkinos P, Pittaras A et al. N Engl J Med 1995;333:1462-7
mm
14.9
15

Baseline *
14
14
13.3
16 Wks

13 Baseline *
12.3

12 16 Wks

11
PW IVS
 LVMI at Baseline and 16 Weeks
Kokkinos P, Pittaras A et al. N Engl J Med 1995;333:1462-7

g/m2
* p<0.05

Baseline 16 weeks
 Exercise Intensity Implications
Low-to-moderate exercise intensities
carry a relatively lower risk.
Patients with more severe HTN and
other risk factors can exercise safely.
Patients are more likely to participate
and sustain Lo-intensity exercise
programs.
Exercise and BP Reduction

How Soon Should We Expect

To Observe Changes in BP?
 Time Course for Exercise and
BP Reductions
Acute changes occur immediately
after cessation of activity. They last
about 2-12 hours.
Chronic changes?
 BP Changes with Exercise
Kokkinos P., Pittaras A et al. N Engl J Med 1995;333:1462-7

mm Hg

2 Weeks

2 Weeks

16 Weeks
16 Weeks

SBP DBP
Exercise and BP Reduction

How Long Do
These Changes Last?
SBP Response to Training & Detraining
mm Hg

33% Reduction in Meds

Exercise Training
Clinical Significance of
Exercise-Induced BP
Reduction
 Relative Risk of All-Cause Death and
Exercise Capacity in Hypertensive Patients
Myers J. et al., N Engl J Med 1002;346:793-801
RR of Death
 Exercise Capacity and Mortality in
HTN Pts (VAMC Data (n=4,397)
RR of Death
 Exercise Capacity and Mortality in
HTN+DM: VAMC DATA
RR of Death
 Exercise Capacity and Mortality in
HTN + Obesity: VAMC DATA
RR of Death
Survival and Fitness Levels for HTNs
N=4,368

>10 MET; n=968

>10 MET; n=1,000
7-10 MET;
7-10 n=1558
MET; n=1563 5-7 MET; n=1310
5-7<5
MET;
MET;
n=1286
n=578
Log Rank=222; p<0.001
<5 MET; n=524
Exercise Recommendations for BP Control
American College of Sports Medicine
F: Frequency: 3-6 times/wk
I: Intensity: Moderate (Brisk walk)
T: Time: 20-60 min/session.
May split sessions (AM/PM)
T: Type: Type of Exercise: Aerobic
 Exercise Intensity for Health Benefits

PMHR: 60% - 70% >85%

METs: <4 5 7 10 +
Fast walk Running
6 km/hr 10 km/hr
500 - 1000 3000 Kcal
 Exercise for HTNsive, Obese Patients
Likely to have multiple risk factors
ETT strongly recommended
Tailor exercise to patient needs/abilities.
Frequency: 3-6 days/week
Low intensity exercises (HR ~95-100 bpm)
Initial duration of 10 min/day
Two sessions (am/pm), 5 min/secs if needed)
Increase by 2 min/wk- Aim: 100-200 min/wk
 Physical activity

Endurance Resistance Isometric

training training program
 Endurance training
Reduces blood pressure through:
-Reduction in systemic vascular resistance
-decrease in renin - angiotensin activity
 A meta analysis of RCT
Systolic Blood Pressure 4.7 mm Hg 104 study groups involved
Diastolic Blood Pressure 3.1 mm Hg
Intervention Duration 4
Systemic Vascular 7.1% weeks
Resistance Endurance Training program
Plasma noradrenaline 29%

Plasma rennin 20%

Body Weight 1.2 kg

Waist Circumference 2.8 cm

% Body Fat 1.4%

HDL 0.032 mmol/l Fagard RH et al, 2006,

Sept.
A meta analysis of 54 RCTs showed net
reduction of 3.8 mm Hg (SBP) and 2.6 mm Hg
(DBP) in hypertensive individuals performing
aerobic exercise.
(Whelton SP, Chin A et al, 2002)

Recommended exercise protocol :

Frequency :- > 3 sessions/week
Intensity :- > 70% VO2 max More than these
Type :- aerobic exercise values have no
Time :- > 45 mins added benefits
Halbert JA, Silagy CA et al,
1997
 Resistance Training

Strength exercise can even be used for lowering

blood pressure.

The actual blood pressure response depends on :

isometric component
exercise intensity
Muscle mass activated
number of repetitions
duration of contraction
involvement of valsalva maneuver

Bjarnason Wehrens B, Mayer Berger W et al,

 However, a need exists for additional well
designed studies on this topic before a
recommendation can be made regarding the
efficacy of resistance exercise as a non
pharmacologic therapy for reducing the
resting blood pressure in hypertensive
individuals.

Kelley G et al, 1997

 Isometric Exercise

Isometric exercise such as weight lifting can have a

pressor effect and therefore should be avoided. Thus it is
strictly contraindicated.
(Krousel Wood MA, Muntner P et al, 2004)
Dietary Factors
and
Blood Pressure
 Salt Reduction and Blood Pressure
Historically, the limitation of salt in food
has been the primary dietary approach in
the control of HTN.
Over 50 studies have been concluded.
Recent Meta analysis revealed a
reduction of 5/2.7 mm Hg in BP for a
reduction of ~ 1.8 g/d in urinary sodium
for HTN pts.

He FJ, et al. J Hum Hypertns. 2002;16:761-70

 Foods and Blood Pressure
Calcium and Magnesium:
Small reductions. Insufficient data to recommend
supplementation.
Potassium:
Meta-analysis (33 trials): a modest reduction (3/2 mm Hg)
in HTN pts receiving potassium supplements. Effects more
AA and those with high sodium intake.
Fish Oil: Not routinely recommend
Fiber: Insufficient data.
High CHO Intake :
High sugar intake is shown to increase BP. More studies
necessary
High Protein Intake:
Some evidence of lower BP, but may be due to lower CHO
Comprehensive Dietary Approaches
for BP Control
It is becoming more evident that
diets low in salt and fat and rich in
other minerals are more effective in
lowering BP than any one element
alone. Such diets include the DASH
Diet and the Mediterranean diet.
 DASH Trial and Blood Pressure
Appel L, et al. N Engl J Med 1997;336:1117-24

Control Diet:
Low in fruits, veggies and dairy products
and typical fat content.
Potassium, magnesium, calcium at 25 th
percentile of US consumption.
Fruits & Vegetables Diet:
More fruits & Vegetables
Potassium, magnesium, calcium at 75%
of US consumption.
Fat content similar to Control Diet.
 DASH Trial and Blood Pressure
Appel L, et al. N Engl J Med 1997;336:1117-24

Combination Diet:
Rich in fruits, vegetables, fiber,
protein, and low-fat dairy products
Reduced amounts of total fat,
saturated fat and cholesterol.
Sodium content of each diet was
similar- approximately 3 g per day.
 Weekly SBP in the DASH Trial
mm Hg Appel L, et al. N Engl J Med 1997;336:1117-24

Control Group Diet

Fruits + Vegetables

X=5.5 mm Hg Fruits + Vegetables + Low Fat

Intervention Week
 Weekly DBP in the DASH Trial
mm Hg Appel L, et al. N Engl J Med 1997;336:1117-24

Control Group Diet

Fruits + Vegetables

X=3 mm Hg
Fruits + Vegetables + Low Fat

Intervention Week
 SBP Changes & Sodium in the DASH Trial
mm Hg Sacks FM, et al. N Engl J Med 2001;344:3-10

Con
trol
Gro
up D
-5.9 iet

-5.0

-2.2
DASH
Diet
 DBP Changes & Sodium in the DASH Trial
mm Hg Sacks FM, et al. N Engl J Med 2001;344:3-10

Con
Gro trol
up D
ie t

DAS
H Diet
 DASH Trial and Blood Pressure
Compelling evidence that adequate
intake of minerals should be the
focus of dietary recommendations
in the control of BP.
The DASH Diet in combination
with reduced salt intake optimizes
BP control.
Alcohol Consumption and BP
Panagiotakos D. et al J Hypertens 2003;21:1-7
Moderation in alcohol consumption

Effects of alcohol reduction on BP showed a

dose dependent decline in BP
X in X, He J et al. 2001
Clinical Studies show that BP falls 4 to 5 mm
Hg in days or weeks with abstinence from
alcohol

The JNC VII recommends that alcohol intake

should be no more than
2 drinks/day (male)
1 drink/day (female)
 Stress and Anxiety Control

Meditation was in one study to reduce SBP and DBP

by 10.7 mm Hg and 6.4 mm Hg over a period of 3
months
Schneider RH Alexander CN et al, 1995

Progressive muscle relaxation lower SBP by 4.7 mm

Hg and DBP by 3.3mm Hg.

Yoga is also widely believed to reduce blood pressure

Damodaran A, Patil N, Suryavanshi et al, 2002

However, these interventions are with limited and

uncertain efficacy. Therefore more trials are needed
to confirm its effect.
Lifestyle Interventions for BP Control:
Conclusions
High intake of fruits, vegetables, nuts
and low-fat dairy products
Reduce total fat, saturated fats, TC,
Restrict salt intake, but increase
calcium potassium and magnesium
Control body wt / Reduce body fat
Limit alcohol intake to <2 drinks/day
Brisk walk 3-6 times a week; 20-60
min per session (100-200 min/Wk).