High Blood Pressure, Hypertension

Licorice affects blood pressure:

It is important for the patient and physician to understand that consumption of over 50 grams of licorice per day can result in an excess of mineralocorticoids (an adrenal hormone responsible for electrolyte balance) and lead to hypokalemia, (low blood potassium). This may lead to an elevation in blood pressure.  Low potassium concentrations have also been linked to occasional cardiac arrhythmias, muscular weakness, muscle cramps and constipation. (86)

Assessment and Plan: High Blood Pressure

• Patients with the following characteristics have an increased risk of hypertension: smoking, obesity, diabetes, lack of physical activity, family history of hypertension, stress, male gender, African American race, alcohol intake, vitamin D deficiency, dyslipidemia, and high salt intake.

• The main goal of treatment for stable essential hypertension is to achieve a normal blood pressure and maintain blood pressure control.

• Importance of treating high blood pressure: Hypertension is a major risk factor for coronary artery disease, heart failure, stroke, aneurysm, chronic kidney disease, and other diseases. According to the AHA, the lifetime risk of hypertension is about 90% and any elevation above a normal blood pressure of 120 systolic over 80 diastolic increases risk of coronary heart disease even if elevated into pre-hypertensive levels. It was determined by Lewington, S et al (1), (as cited by Rosendorff, Clive et al)(2) that for every 20 mmHg increase of systolic blood pressure or for every 10 mmHg increase in diastolic blood pressure over 115/75 to 185/115 mmHg, the risk of mortality from ischemic heart disease or stroke approximately doubles.

• For blood pressure measurement technique, please see the American Heart Association resource: http://hyper.ahajournals.org/content/45/1/142.full (3).

• Home blood pressure monitoring is vitally important for diagnosis, following improvement, or evaluating for lack of blood pressure control.

• The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) (4):
  • Screen patients with a blood pressure of under 120/80 for hypertension every 2 years.
  • Screen patients with a blood pressure of 120-139/80-90 every year

• The U.S. Preventive Services Task Force supports the JNC 7 recommendations: See the following link for further information: http://www.uspreventiveservicestaskforce.org/uspstf07/hbp/hbpsum.pdf  or http://www.uspreventiveservicestaskforce.org/

• New HTN Guidelines per the Eighth Joint National Committee (JNC 8) for Use of Medication as of Feb of 2014: Based on new research, JNC 8 advised healthcare providers to use HTN medication less aggressively. This allows patients more flexibility in adopting lifestyle changes, weight loss and supplements to reduce the potential need for BP medication. JNC 8 advised medication for a systolic BP over 140 or diastolic BP over 90 in patients < 60 years of age, or for any age patient with diabetes or chronic kidney disease. For patients > 60 years of age, JNC advised medication for a systolic BP over 150 or diastolic BP over 90 in patients > 60 years old. (95)

• Screening for type-2 diabetes in patients with hypertension: According to the U.S. Preventive Services Task Force (USPSTF), adults without any symptoms but with sustained blood pressure greater than 135/80 mm Hg (treated or untreated) are recommended to have screening for type 2 diabetes. (5)

• Hypertension diagnosis and stages of hypertension:
  • Prehypertension falls in the range between normal blood pressure and stage 1 hypertension.
  • Stage 1 hypertension is a systolic of 140 to 159 mmHg or diastolic of 80-89 mmHg.
  • Stage 2 hypertension is a systolic of 160 mmHg or higher, or a diastolic of 100 mmHg or higher.
  • Isolated systolic hypertension is a systolic blood pressure or 140 mmHg or higher but with a diastolic blood pressure in normal or prehypertension range.
  • Isolated diastolic hypertension is a diastolic blood pressure of 90 mmHg or higher but with a systolic blood pressure in normal or prehypertension range.
  • Hypertensive urgency is a diastolic blood pressure of 120 mmHg or higher which is not causing any symptoms or damage to organs.
  • Malignant hypertension is characterized by a diastolic blood pressure over 100 mmHg with visual changes or altered mental status. The patient may have swelling of the optic disc from elevated intracranial pressure, retinal hemorrhage, or hypertension related encephalopathy.

• Hypertension is diagnosed by the following criteria at home using a home blood pressure monitor:
  • Average blood pressure elevation of 135/85 mm Hg for over 24 hours.
  • Average blood pressure while asleep overnight over 125/75 mmHg.
  • Average blood pressure during the day over 140/90 mmHg while awake.

• Recommendations of The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) (4) :
  • reduce sodium (salt) consumption to less than 2.4 g/day.
  • Exercise at least 30 min/day, 4 days per week.
  • Consume no more than 2 alcoholic drinks per day for men and 1 drink or less per day for women.
  • Eat a diet rich in fruits, vegetables, potassium, calcium, magnesium and low in fat and salt.
  • A weight loss goal of 10 lb or 4.5 kg is recommended.

• Evidence-based dietary approaches for hypertension:
  • Instruct patients not to add excess salt to any foods, use an all-purpose spice flavoring instead, and follow sodium content in foods by the label and add to reach no more than a total of 2 grams per day.
  • DASH diet for patients with high blood pressure: DASH stands for Dietary Approaches to Stop Hypertension.
    • Grains: 7-8 daily servings (such as sliced bread,1 oz dry cereal, 1/2 cup cooked rice, pasta, or cereal)
    • Vegetables: 4-5 daily servings (1 cup raw leafy vegetable, 1/2 cup cut-up raw or cooked vegetable, 1/2 cup vegetable juice)
    • Fruits: 4-5 daily servings (1 medium fruit, 1/4 cup dried fruit, 1/2 cup fresh, frozen, or canned fruit, 1/2 cup fruit juice)
    • Low-fat or fat-free dairy products: 2-3 daily servings (1 cup milk or yogurt, 11/2 oz cheese)
    • Meat, poultry, and fish: 6 or less servings daily (1 oz cooked meats, poultry, or fish, 1 egg)
    • Nuts, seeds, and dry beans: 4-5 servings per week (1/3 cup or 11/2 oz nuts, 2 Tbsp peanut butter, 2 Tbsp or 1/2 oz seeds, 1/2 cup cooked legumes (dry beans and peas)
    • Fats and oils: 2-3 daily servings (1 tsp soft margarine, 1 tsp vegetable oil, 1 Tbsp mayonnaise, 2 Tbsp salad dressing)
    • Sweets: try to limit to less than 5 servings per week (1 Tbsp sugar, 1 Tbsp jelly or jam, 1/2 cup sorbet, gelatin, 1 cup lemonade).
    • The DASH diet is consistent with the American Heart Association’s (AHA) 2006 Diet and Lifestyle Recommendations available at : http://circ.ahajournals.org/content/114/1/82.full.pdf (6)
    • Evidence-based effectiveness of DASH: The combined effect of a lower sodium intake with the DASH diet was greater than just the DASH diet or a low salt diet alone (6). The DASH diet resulted in the greatest blood pressure lowering effect when it was combined with a low sodium intake (6), and with fruits and vegetables. Significant blood pressure reductions were reported within as little as 2 weeks after starting DASH.
    • DASH diet patient education brochure: Please see here for a detailed patient education brochure for the DASH diet: http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf
  • Diet and its effect on blood pressure: An American diet for 3 weeks followed by a diet rich in fruits, vegetables, and low fat dairy products showed improvement of bp from 131.3/84.7 at baseline to an average of 125.8/81 in pre-hypertensive subjects and an improvement of systolic and diastolic bp in hypertensive subjects by 11.4 and 5.5 points respectively over a control diet (7).
  • The Pritikin Diet Program modifies most risk factors for coronary artery disease including blood pressure improvement (8). This program is described in better detail in the sections on hyperlipidemia and coronary artery disease.
  • Therapeutic Lifestyle Changes Diet (TLC) consists of the following to help improve coronary artery disease risk factors (9,25):
    • Saturated fat below 7% of the total calories.
    • Total fat intake 25-35% of daily total calories.
    • Cholesterol intake below 200 milligrams each day.
    • Sodium intake under 2400 mg per day.
    • Calorie intake should be kept to a level needed for maintaining healthy weight but reduce blood cholesterol level.

• Aerobic exercise and hypertension:
  • The recommendations of the JNC 7 include exercise for at least 30 min daily (4). Once approved by the primary physician for exercise, an adult patient with hypertension should start slowly and work up gradually in frequency, intensity, and duration of exercise. The patient’s goal is a moderate-intensity (40-59% of peak oxygen uptake) aerobic activity for 30-60 minutes (can be achieved in short 10 minute sessions) preferably 7 days a week. (22)
  • For more information, please see the aerobic exercise section in Preventive Health Advisor.
  • Preventive Health Advisor recommends a combined aerobic and resistance exercise program for all ages, but patients should seek approval by the primary physician prior to starting an exercise program.

• Benefits of aerobic exercise: Individuals of all ages capable of aerobic exercise should do so most days of the week for the following benefits: improved pumping efficiency of the heart, improved circulatory system (11), weight control (12), cholesterol reduction (12,13), triglyceride lowering (12), lowering of blood pressure (14), lower rate of smoking (17),  and control of diabetes (15,16). Aerobic exercise results in reduction of cardiac mortality and all-cause mortality (17).

• Starting exercise in healthy adults to help prevent hypertension: According to the American College of Sports Medicine (ACSM) and the American Heart Association (AHA), older adults need moderate-intensity (between 5-6 on a 10-point scale) aerobic endurance activity for a minimum of 30 min which can be achieved in short 10 minute sessions on five days each week or vigorous-intensity aerobic, (rated a 7-8 on a 10-point scale) activity for a minimum of 20 min on 3 days each week.

• Exercise cardiac stress testing referral is required in patients with (21):
  • Patients with suspected or known coronary artery disease, typical and atypical angina or prior heart attack.
  • Healthy patients without symptoms with multiple heart risk factors (high cholesterol, high blood pressure, family history, obese, diabetes mellitus) or concurrent chronic diseases or those in a high-risk stressful occupations
  • Men over age 40 and women over age 50 who have been inactive but plan to start vigorous exercise.
  • Evaluation of exercise capacity in patients with heart disease involving one or more of the valves of the heart, those with heart rhythm disorders, and those with pacemakers.

• Resistance training for hypertension: Please see the resistance training section for more information. Once approved by the primary physician for exercise, the patient with hypertension should also include resistance training within their exercise program. In addition to aerobic exercise, muscle-training exercises should be performed 2-3 days each week using a variety of exercises (8-10 exercises involving the major muscle groups), and for each exercise, 1 set of 8-15 repetitions is recommended to improve strength (22).

• Yoga and hypertension:
  • 65% of patients with hypertension who performed yoga for 6 months were able to control their bp with Shavasana without using of medication but the high bp returned after yoga was stopped. (24)
  • Blood-pressure was reduced from 168/100 to 141/84 mm Hg on average in a study with 34 patients doing yoga for 6 weeks. (23)
  • Siu PM, et al randomly assigned 182 patients with metabolic syndrome an average of 56 years old to 1 year of yoga or a control group. The intervention was found to reduce central obesity and showed a trend towards lower BP. (93)
  • Wolf, M et al randomly assigned Kundalini yoga to 95 hypertensive patients to be done at home for 15 min twice daily for 12 weeks and compared to a control group. A reduction was seen in both the systolic and diastolic BP for both groups (-3.8/-1.7 mm Hg for yoga and -4.5/-3.0 mm Hg for control groups, respectively). The reduction of BP was not significantly different than control, but it is unclear in the amount of BP medication used and how compliant the patient reporting was. (94)

• Evidence-based diet plus exercise programs for hypertension and coronary artery disease: Preventive Health Advisor views both dietary changes and an exercise program of vital importance as part of comprehensive treatment for hypertension. We believe that striving for an ideal diet alone will have a greater health benefit than exercise alone, but if both aspects are combined, then health benefits will be greatly potentiated.
  • Therapeutic Lifestyle Changes Diet (TLC), http://www.nhlbi.nih.gov/health/public/heart/chol/chol_tlc.pdf (9,25) plus 30 minutes of daily exercise at 50-75% of age-predicted maximum heart rate resulted in the following benefits (33):
    • 89% of participants reached an LDL cholesterol goal of under 130 mg/dL without lowering HDL levels or needing to add or increase lipid lowering therapy.
    • Mean total cholesterol, LDL cholesterol and triglycerides decreased by 9.2% (p=0.08), 9.3% (p<0.018), and 18.8% (p<0.05), on average respectively.
    • HDL cholesterol increased 2.6% on average (p=0.41).
    • Women: 12.3% reduction in LDL cholesterol and an 11.4% increase in HDL cholesterol.
    • Men: 7.9% reduction in LDL cholesterol and no change in HDL.
    • Systolic and diastolic blood pressure (BP) decreased 9% (p<0.001) and 13%, respectively (p <0.0001).
    • BP reductions were two-fold greater than in a DASH diet (Dietary Approaches to Stop Hypertension) diet.
  • The Pritikin Program evidence-based benefits after 12-15 days improves most risk factors for coronary artery disease including hypertension (26,27,28):
    • Body mass index, 3% reduction
    • Blood pressure, glucose and LDL, all with 10%-15% reduction
    • Triglycerides, 36% reduction
    • Slowed or reversed progression of coronary heart disease and reduce the need for coronary artery bypass grafts (CABG), rates of angioplasty procedures and percutaneous interventions.
    • Usually program is done for 3-4 weeks allowing additional benefit.
  • Pritikin Program includes (27,28):
    • Very low fat, less than 10% of calories.
    • Low sodium and avoid salty foods.
    • High fiber with at least five ½-cup servings of whole grains daily (wheat, oats, and brown rice or starch vegetables such as potatoes, and dried beans and peas.
    • Refined grain products (white flour, regular pasta, white rice) are limited to two servings daily.
    • At least four 1-cup servings of raw vegetables daily or ½-cup servings of cooked vegetables. Dark green, leafy, and orange or yellow vegetables are preferred
    • At least three servings of fruit, one of which can be fruit juice.
    • Two servings daily of calcium-rich foods such as nonfat milk, nonfat yogurt or fortified and enriched soymilk.
    • No more than one caffeinated drinks daily. Instead drink water, low-sodium vegetable juices, grain-based coffee substitutes or caffeine-free teas.
    • No more than four alcoholic drinks per week for women and no more than seven for men, with red wine preferred over beer or distilled spirits.
    • No more than seven egg whites per week.
    • No more than 2 ounces (about 1/4 cup of nuts) daily.
    • Moderate amounts of fish, nonfat dairy, and lean meat with no more than one 3.5 cooked serving of animal protein per day with fish and shellfish are preferred. Lean poultry should optimally be limited to once a week and lean beef to once a month.
    • Adapted to vegetarians by replacing animal protein with protein from soy products, beans, or lentils.
    • Avoid fried foods, dressing with fat, and fatty sauces, animal fats, processed meat, dairy products not made with non-rat milk, egg yolks, salty snacks, cakes, cookies, and similar high-calorie choices.
    • Eat frequently with three meals a day plus two snacks.
    • Artificial sweeteners such as Splenda are okay.
    • 45 minutes of moderate exercise daily such as walking.
    • Medicare may approve coverage for qualifying individuals with a history or risk of cardiovascular events. The program has been approved for coverage under Part B of Medicare. Medicare will reimburse eligible beneficiaries for up to 72 one-hour ICR sessions, up to 6 sessions per day, at the Pritikin Longevity Center & Spa.
  • The Dean Ornish Program for Reversing Heart Disease improves most risk factors for coronary artery disease including hypertension (29-31.):
    • The Ornish program evidence-based benefits:
    • Weight loss of 13.3 pounds in the first 12 weeks and 15.9 pounds after 1 year.
    • Significant reductions in systolic blood pressure (BP), diastolic BP, total cholesterol, triglycerides, and LDL-cholesterol after 12 weeks were still significant after 1 year.
    • Exercise capacity increased by 18% after 12 weeks and 24% after one year.
    • Reductions in depression were still significant after 1 year.
    • Hemoglobin A1C in diabetics continued to decrease after one year.
    • Improvement in severity of angina after 1 year.
  • Ornish Program includes (29-31):
    • Plant-based, meatless diet, meditation, and regular exercise with adherence to the program between 85 to 90% after one year in hospitals and clinics that have offered it.
    • Medicare Part B covers The Dean Ornish Program for Reversing Heart Disease, under Intensive Cardiac Rehabilitation (ICR). Eligibility includes acute myocardial infarction within the preceding 12 months, a coronary artery bypass surgery, current stable angina pectoris, heart valve repair or replacement, percutaneous transluminal coronary angioplasty or coronary stenting, a heart or heart-lung transplant, or other cardiac conditions as specified through a national coverage determination.
• Cardiac Rehab Programs:
  • Silberman and colleagues reported that 2974 patients participating in an intensive cardiac rehabilitation program reported significant improvements in body mass index (BMI), triglycerides, low density lipoprotein cholesterol, total cholesterol, hemoglobin A1c, systolic blood pressure, diastolic blood pressure, depression, hostility, exercise, and functional capacity at 12 weeks and 1 year (32).
  • A systematic review and meta-analysis of randomized controlled trials by Taylor et al found that exercise based cardiac rehabilitation for a duration of 0.25–30 months reduces risk of all cause and cardiac mortality by 20% amd 26% respectively, and improves a number of cardiac risk factors in patients with coronary heart disease (31).

• Hypertension and hyperlipidemia: Test for and treat hyperlipidemia if present. For more information, see the section on hyperlipidemia.

• Fiber supplements and hypertension: Increasing the amount of daily soluble and insoluble fiber intake is recommended by incorporating a variety of at least 5 whole fruits and vegetables per day. Psyllium husk fiber (in pharmacies as brand name Metamucil and other generic brands) and glucomannan are reliable sources of daily soluble fiber intake. These 2 types of fiber are effective for improving the lipid profile, weight loss, and improvement of glucose control in diabetics. Psyllium is more effective than glucomannan for lowering blood pressure.

• Psyllium and hypertension:
  • Psyllium fiber at a dose of 3.5 grams oral 3 times daily was compared to glucomannan in overweight individuals with high blood pressure significantly reduced systolic and diastolic blood pressure in a 6-month study (n=141) as well as improved body mass index, fasting plasma glucose, fasting plasma insulin, and LDL cholesterol (39). Guar gum was not effective for blood pressure (39).
  • Psyllium fiber also lowers total cholesterol, lowers LDL cholesterol, may slightly increase or decrease HDL cholesterol, has also shown significant reductions in fasting blood glucose, and lowers HbA1c. See the sections on hyperlipidemia and diabetes mellitus.

• Glucomannan and blood pressure:
  • Glucomannan-enriched biscuits (0.7 g/412 kJ [100 kcal] of glucomannan) or placebo of wheat bran fiber biscuits taken by subjects on medication and a low cholesterol diet every day for three weeks lowered systolic blood pressure by 6.9% but body weight, HDL, LDL, and total cholesterol, triglycerides, glucose, insulin, and diastolic blood pressure were not affected (40). It may be difficult to sort out in this study whether the benefit was due to diet, medication or glucomannan.
  • Other studies did not show any benefit of glucomannan in lowering blood pressure (41).

• Fiber adverse reactions and interactions.
  • Dry powdered fibers are generally safe when mixed with adequate water or another liquid, but are not without health risks. They should not be taken before bed.
  • At least 8 ounces of fluid is recommended when taking dry fibers such as glucomannan, Konjac root, guar gum, Citrucel, and psyllium (Metamucil).
  • Fibers may also bind medications and interfere with absorption resulting in a reduction in the desired effect of the medication. Therefore, medications should be taken at least 2 hours before or after the fiber.

• Calcium and blood pressure:
  • Preventive Health Advisor supports obtaining the RDA (recommended daily allowance) for calcium to help maintain a normal blood pressure, but to avoid high calcium intake over 1400 mg per day including food sources and supplements. Instead, attempt to increase calcium intake by food sources to the RDA instead of supplements unless required to replace a deficiency gap in the recommended intake. Compared with dietary calcium intakes of 600 to 1000 mg daily, higher daily intakes of over 1400 mg of calcium was associated with significantly higher rates of death from all causes, cardiovascular disease, and ischemic heart disease as well as a higher rate of prostate cancer in men. See the section on calcium for more information.
  • Calcium alone at an average supplement dose of 1,200 mg daily may reduce systolic blood pressure by about -1.8 mmHg and diastolic blood pressure by about -0.99 mmHg, but greater reductions may be seen in systolic blood pressure by -2.63 mmHg, and diastolic blood pressure by -1.30 mmHg if a lower baseline dietary calcium intake of about 800 mg is present (42).
  • It was determined that 8 weeks of vitamin D added to a calcium supplement was more effective in elderly women for lowering blood pressure than calcium alone. A 1200 mg calcium supplement plus 800 IU vitamin D daily for 8 weeks resulted in significant decreases in systolic blood pressure of 9.3% (p=0.02) and heart rate by 5.4% (p=0.02) vs. calcium alone (43).

• Vitamin D and blood pressure:
  • Vitamin D supplements are known to lower blood pressure in patients with hypertension and low vitamin D levels. A vitamin D level is recommended for patients suspected of vitamin D insufficiency or deficiency which is assessed by using a blood test for the concentration of the compound 25(OH)D, and if vitamin D insufficient or deficient, a patient should obtain adequate vitamin D using a vitamin D3 supplement. See the vitamin D section for further information.
  • Goel RK found that subjects taking 33,000 IU of vitamin D every 2 weeks for 3 months plus standard therapy were noted to have a reduction in systolic blood pressure (BP) of 7.5 mm Hg compared to a 3.6 mmHg reduction in the standard therapy group, but diastolic BP in both groups increased by 2.1 mmHg and 1.3 mmHg, respectively (44).

• Risks of smoking, caffeine and alcohol use by patients with high blood pressure: Patients should be counseled to quit smoking to reduce the risk of cardiovascular disease. If they don’t smoke, they should be counseled not to start. Quit tobacco by using a combination of several methods to assist in cessation. For instance, combine nicotine replacement with at least one additional method such as an exercise program, medication, hypnosis, electronic cigarettes, or formal counseling such as support groups. The recommendation to counsel patients to stop smoking, stop using tobacco products, and provide methods of cessation is reinforced by the USPSTF (34). Many resources are available to assist in smoking cessation such as the online sites http://smokefree.gov/ , http://www.cdc.gov/tobacco/campaign/tips/quit-smoking/, and the phone number for free help 1-800-QUIT-NOW.

• Caffeine risks and adverse reactions in hypertension:
  • Teas, coffee, cocoa and chocolate contains caffeine. Caffeine intake up to 300 mg per day is generally safe for healthy adults. Older patients or those with hypertension, cardiovascular disease, or cerebrovascular disease should avoid more than 1-2 cups of caffeinated beverages per day (no more than 100-200 mg of caffeine intake per day).
  • One cup of coffee contains on average, about 100 mg of caffeine. Each standard sized milk chocolate bar such as Hershey’s contains about 10 mg of caffeine, and each standard size dark chocolate bar contains about 31 mg of caffeine.
  • According to James J. E., caffeine, through its daily consumption from a variety of sources (coffee, teas, soft drinks, chocolate and medicines), may have an impact on cardiovascular risk due to caffeine’s ability to increase resting blood pressure (BP) in adults by about 4/2 mmHg (35). According to this author, this increase in BP may be responsible for a percentage of premature deaths, possibly as much as 14% for coronary heart disease and 20% for stroke (35).
  • Standard caffeine intake is generally recognized as safe by the FDA and AMA but can be dangerous with adverse effects such as high bp, stroke, and arrythmias reported. If more than 1-2 cups of caffeinated beverages are consumed per day, it is prudent to seek physician and/or pharmacist approval of caffeine consumption with any medications or supplements. Please see caffeine section for more detail.

• Cocoa and chocolate also contains theobromine which is known to act as a stimulant, vasodilator, and diuretic which may be responsible for some of the therapeutic action of cocoa (36). Theobromine and cocoa may intensify the blood pressure lowering effects of any blood pressure medications. Therefore a physician should oversee the care of a patient taking cocoa or chocolate for high blood pressure.

• Alcohol and blood pressure: Alcohol is known to increase blood pressure at both rest and during physical activity (37). Chronic alcohol drinkers have an increase in systolic blood pressure of about 9 mmHg and a diastolic blood pressure of about 6 mmHg compared to non-drinkers of alcohol (38).

• Coenzyme Q10 and hypertension:
  • Coenzyme Q10 at variable doses between 60 mg daily and 360 mg daily studied in randomized controlled trials, systematic reviews, and open label studies suggest that it is effective for hypertension. Within the research reviewed, systolic blood pressure decreased by 11-17 mmHg on average, and diastolic blood pressure decreased by 8-10.3 mmHg on average more than placebo (45,46,50,51).
  • Coenzyme Q10 60 mg daily was given to patients on anti-hypertensive medications, which further improved bp control after 8 weeks of therapy (47).
  • Coenzyme Q10 at 50 mg twice daily for 10 weeks decreased systolic blood pressure from an average of 164.5 mmHg to 146.7 mmHg, and diastolic blood pressure decreased from an average of 98.1 mmHg to 86.1 mmHg (48).
  • One small study on healthy patients showed that Coenzyme Q10 at 50 mg daily slightly increased systolic blood pressure by 2 mmHg (49).
  • Coenzyme Q10 levels should be monitored to achieve desired therapeutic level while monitoring for response.
  • Although there is no standard for co-enzyme Q10 replacement, and monitoring, we recommend a co-enzyme Q10 supplement with statin medications to keep the level over 0.70 micromol/L, closer to healthy controls.
  • Rosenfeldt FL et al expressed that co-enzyme Q10 levels are patient dependent based on variable absorption, use of other medications, and patient response. The authors noted that a large trial used co-enzyme Q10 to control blood pressure gradually over months by using doses of 75–360 mg daily to attain a therapeutic level of CoQ10 over 2.0 mcg/ml. (50)

• Omega-3 fish oil and hypertension: Omega-3 fish oil is effective at lowering bp
  • Morris, MC et al reviewed 31 controlled trials, and noted that fish oil at an average dose of 5.6 grams daily resulted in the following (53):
    • Lowered systolic blood pressure by an average of 3.4 mm Hg.
    • Decreased diastolic pressure by an average of 2.0 mm Hg.
    • Blood pressure lowering was dose-dependent with 1 gram/day of fish oil lowering systolic pressure by an average of 0.66 mm Hg and diastolic pressure by an average of 0.35 mm Hg.

• Appel LJ, et al reviewed trials on omega-3 oils and hypertension and found (54):
  • In subjects with untreated hypertension, omega-3 fatty acid reduced systolic blood pressure by about 5.5 mmHg, and diastolic blood pressure by about 3.5 mmHg.
  • In subjects with normal blood pressure, omega-3 fatty acid reduced systolic blood pressure by about 1 mmHg, and diastolic blood pressure by about 0.5 mmHg.
  • 13 of 17 trials were less than 3 months in duration and most used doses of omega-3 at a dose of over 3 grams daily.
  • A dose of 3 grams of fish oil daily for 5 weeks, separated by a 5-week washout period showed subjects performed better on working memory tests, lowered blood pressure, and lowered plasma triglyceride levels compared to placebo (55).

• Omega-3 fish oil adverse reactions and interactions:
  • A total of 10 studies were reviewed by Villani AM et al to determine potential serious adverse effects of fish oil at a dose of under 1.86 grams per day (81). It was found that there were no serious adverse effects reported in 994 adults over 59 years of age and other non-serious adverse effects were not significantly different from placebo (81).
  • Fish oil has been reported to affect platelet aggregation, reduce vitamin K dependent factors which may be associated with an increased anticoagulation (reduce blood clotting) effect. Consumption should be avoided when taking anticoagulants like aspirin, warfarin, or ticlopidine because of the potential increased risk of bleeding (82).
  • A case of a 67-year old woman taking warfarin (1.5 mg/day), an increase in her fish oil intake from 1 g/day to 2 g/day was associated with an increase in time for blood to clot as measured by the international normalized ratio (INR) which went from 2.8 to 4.3 within 1month, and decreased to 1.6 after the fish oil dose was reduced (83).
  • An intake of 6 grams per day of docosahexaenoic acid (DHA) found no significant difference found in blood coagulation, platelet function, or thrombotic parameters including prothrombin time, activated partial thromboplastin time, antithrombin-III levels, and platelet aggregation (84).
  • Fish oil may contain harmful contaminants such as heavy metals including mercury, dioxins, and polychlorinated biphenyls (PCBs) (85). This risk can be reduced by purchasing fish oil that has undergone a purification process specified on the label to remove these contaminants.

• Green tea and hypertension:
  • Green tea has numerous health benefits cited in research. Green tea has been consumed for centuries by Asian countries and has been cited as generally safe, but adverse reports on the use of green tea has been reported. Green tea has been quoted by multiple sources to contain a range of 120 to 160 mg of catechins per cup and an average of 23 mg of caffeine per cup (range of 11-48) but with high variability. Preventive Health Advisor recommends that liver function tests be obtained for green tea consumption of 4 cups per day or greater at baseline, after 3 months, at 6 months, and then yearly due to high variability in green tea catechin content. Brewed green tea is recommended in place of green tea extract supplements. Green tea extract is not recommended due to increased risk of hepatotoxicity with a higher concentration of catechins which it provides. See adverse reactions and interactions below.
  • Green tea extract at a daily dose of 370 mg was found to have the following effects vs. placebo after 3 months: (56):
    • Systolic blood pressure decreased by 4 mmHg
    • Diastolic bp decreased by about 2 mmHg on average.
    • LDL improved from 3.5 to 3.1 mmol/L
    • HDL improved from 1.2 to 1.4 mmol/L
    • Triglycerides lowered from 1.4 to 1.1 mmol/L
    • Total cholesterol decreased from 5.4 to 5.0 mmol/L
    • C-reactive protein decreased from 3.4 to 2.5 mg/L
    • Tumor necrosis factor lowered from 5.4 to 4.7 ng/L.
  • A 12-week RCT on subjects taking 583 mg of catechins plus about 39 mg of caffeine in the form of green tea extract vs, 96 mg for controls, on 240 subjects 25 to 55 years of age experienced the following (57):
    • Loss of about 4 pounds after 12 weeks.
    • Decrease in systolic blood pressure (SBP) in the catechin group for subjects with initial SBP of 130 mm Hg or higher with a reduction of 9.0 mm Hg in treatment vs 2.9 mm Hg in the control group.
    • Low-density lipoprotein (LDL) cholesterol decreased.
  • The effect of green tea plus inulin (a type of dietary soluble fiber) who received 650 ml-about 3-4 cups of green tea with 534 mg catechins plus 11.7 g inulin had the following results after 6 weeks (58):
    • Reduction in body weight of approximately 4-5 pounds.
    • 7-8 point reduction in systolic blood pressure.
    • No adverse effects were observed.
  • Green tea interactions and adverse reactions:
    • While drinking over 3 cups of green tea daily, patients should be advised to avoid drugs metabolized by the liver such as acetaminophen.
    • According to Schönthal, the following adverse reactions have been reported (59): 34 case reports of hepatotoxicity, tremor, headache, pain, paresthesias, insomnia, palpitations, nausea, dysphagia, flatulence, and bloating.
    • According to Schönthal the following interactions have been reported (59):
    • Green tea may reduce absorption of iron supplements, pseudoephedrine, theophylline, aminophylline, warfarin, codeine, atropine, ephedrine, carbinoxamine, dextromethorphan, Lomotil®, and Lonox.
    • Green tea may increase the action of ephedrine, pseudoephedrine, theophylline, aminophylline, and reduce the effectiveness of adenosine, bortezomib, and sunitinib.
    • Green tea contains caffeine which is generally recognized as safe by the FDA and AMA but can be dangerous with adverse effects such as high bp, stroke, and arrythmias reported. If more than 1-2 cups of caffeinated beverages are consumed per day, it is prudent to seek physician and/or pharmacist approval of caffeine consumption with any medications or supplements.
    • Caution use of whole green tea leaves or powder in patients taking warfarin which may make achievement of therapeutic PTINR difficult. When green tea is consumed in the form of whole leaves, or if it is steeped long enough to contain tannins, vitamin K is generally present in amounts significant enough to counteract the effects of warfarin (60,61), but if green tea is steeped for a short time, and the leaves are not consumed, green tea has very low concentrations of vitamin K (63). Vitamin K levels in coffee and tea were obtained by Booth, SL et al, and vitamin K concentrations were about 0.03 μg/100 mL or less, and according to this source, brewed tea or coffee contains extremely small amounts of vitamin K and is not a dietary source (63).
    • Consumption of green tea at a dose of 4-6 cups daily for 6 months (480-960 mg of green tea catechins) has resulted in occasional episodes of toxic hepatitis, and the risk appeared to increase with chronic use (64). Caution use of green tea in patients with other forms of hepatitis, liver dysfunction, use of other medications cleared by the liver such as acetaminophen.
    • No adverse effect of green tea was found in a 12 week RCT by Nagao, T et al (57). Both the study group and the control group had a low incidence of elevated liver function tests (57).

• Cocoa, chocolate, and hypertension: Dark chocolate at a dose of 6.3 to 100 grams daily or equivalent cocoa supplement lowers systolic blood pressure about 2-11 mmHg, and diastolic blood pressure about 1-2 mmHg (66-68,69). The effect of blood pressure lowering wears off within 2 days after stopping chocolate intake (68).
  • Higher intakes of dark chocolate were associated with lower systolic and diastolic blood pressure, regardless of age or family history of hypertension (66).
  • Sudarma V et al found that 30 g/day of dark chocolate daily (containing 70% cocoa) plus dietary counseling for 15 days resulted in increased nitric oxide blood levels over placebo (7.70 vs 1.92, respectively) and decreased systolic blood pressure (120.64 vs. 131.19) (67).
  • A 100-g dark polyphenol-rich chocolate bar once per day containing 500 mg of polyphenols showed an average decrease in systolic and diastolic blood pressure (BP) of -5.1 mmHg and -1.8 mmHg compared to white chocolate, respectively, but after the intervention was stopped, BP returned to pre-study values within 2 days (68).
  • Over 18-weeks, subjects with untreated upper-range prehypertension who took 6.3 grams of dark chocolate daily saw a drop in average systolic blood pressure by -2.9 mm Hg (P < .001) and decrease in average diastolic blood pressure by -1.9 mm Hg (P < .001) among the dark chocolate group compared to a white chocolate placebo group (69). The proportion of subjects with hypertension decreased from 86% to 68% (69).
  • Healthy adults drank 920 ml daily of a flavanol-rich cocoa drink (Cocoapro; Mars Inc., Hackettstown, New Jersey, USA), divided into 4 doses daily with a total of 821 mg of flavanols daily for 4-6 days, and improvements in endothelial function were greater in older adults than in the younger adults (70).

• Oats, β-glucan, and high blood pressure: Whole grain oats may reduce cholesterol and improve high blood pressure a significant amount if consumed daily. Oat consumption has allowed patients to improve blood pressure control while at the same time, promote a significant reduction in blood pressure medications (65).
  • A 6-week randomized controlled trial on hypertensive and hyperinsulinemic subjects by Keenan et al, compared an oat cereal group eating 5.52 grams daily of β-glucan to a low-fiber cereal group and found these results (71):
    • Systolic blood pressure decrease of 7.5 points and a diastolic pressure reduction of 5.5 points.
    • Decrease in both total cholesterol of 9% and LDL cholesterol of 14%.
    • Trend toward improved insulin sensitivity.

• Garlic and high blood pressure: Garlic capsules may obtained in a 400 mg in oral capsule which may be taken 2 – 3 times daily or may be simply be added into food.
  • Compared to placebo, garlic intake of about 600-900 mg daily for 3-6 months resulted in a significant improvement of blood pressure in patients with hypertension but did not have a blood pressure lowering effect in patients without hypertension (72,73).
  • Ried, K et al reported an average reduction in systolic bp by -8.4 mmHg, and diastolic bp by -7.3 mmHg across 11 trials (73).
  • Reinhart, KM et al reported an average reduction in systolic bp by -16.3 mmHg, and diastolic bp by -9.3mmHg across 10 trials (72).
  • Wexler and Aukerman reported a significant dose dependent BP lowering effect when comparing doses of 300 mg all the way up to 1500 mg in divided doses daily (92)

• Purple potatoes and hypertension: 6-8 small microwaved purple potatoes twice a day for four weeks dropped average diastolic blood pressure by 4.3% and average systolic blood pressure by 3.5% in overweight hypertensive subjects (74).

• Beet juice and blood pressure:
  • In healthy subjects, 500 mL of beet juice 3 hours after ingestion dropped systolic bp by -10.4±3.0 mm Hg (p<0.01) and diastolic BP by -8.1±2.1 mm Hg with the effect lasting 24 hours (75).
  • Beet juice contains high levels of nitrates, and most likely the same effect will occur in subjects with hypertension. Caution in patients already taking prescribed nitrates or blood pressure lowering medication since beet juice may potentiate lowering of blood pressure.

• Grape juice and blood pressure: Daily consumption of Concord grape juice by hypertensive Korean men for 8 weeks at a dose of 5.5 mL per kg daily resulted in a mean systolic bp lowering of -7.2 mm Hg (p = 0.005) and mean diastolic BP reduction of -6.2 mm Hg (p = 0.001) compared to baseline. Of note, the placebo group also had mean systolic and diastolic bp reductions of -3.5 mm Hg and -3.2 mm Hg (p = 0.05)(76).

• Sodium-bicarbonated mineral water, blood pressure, and cholesterol: 1 L daily of bicarbonate water (the approximate equivalent of about ¾ teaspoon of sodium bicarbonate in 1 quart of water) resulted in an average bp of 120/71 in controls, average bp of 111/68 after 4 weeks on bicarbonate, and average bp of 115/72 after 8 weeks on bicarbonate (77).

• Pycnogenol, and hypertension: Pycnogenol is maritime pine bark extract which contains the anti-oxidant compound procyanidolic oligomers used in research at doses between 100 – 300 mg daily. Caution in the use of pycnogenol due to its platelet aggregation effects. Pycnogenol may increase the risk of bleeding when taken with aspirin, non-steroidal anti-inflammatory drugs, other anti-platelet agents, and anti-coagulants such as heparin or warfarin (78).

• Stuard S, et al found that Pycnogenol at a dose of 50 mg 3 times daily added to Ramipril at a dose of 5mg twice daily had the following results (79):
  • Significantly lowered systolic and diastolic blood pressure -6 mmHg and -4.9 mmHg more respectively after 6 months compared to a group taking Ramipril alone (79).
  • The group taking Pycnogenol had a significant weight loss from an average BMI of 26.5 to 25.0 kg/meters squared and lowered fasting blood glucose levels after 6 months (79).
  • With Ramipril alone, urinary protein decreased by 23% but with the addition of Pycnogenol it decreased by 52.7%, and lowered creatinine with statistical significance (80).

• Hawthorn and high blood pressure: Patients who received 1200 mg of hawthorn extract daily for 16 weeks plus an average number of 4.4 prescription drugs for diabetes and hypertension were found to have a significant lower average diastolic bp reduction of 85.6 to 83.0 mmHg vs 84.5 to 85 mmHg with placebo, but no significant change in systolic bp was seen (87).

• Homocysteine and hypertension: Homocysteine levels should be monitored and treated as necessary by the primary care physician: The Rotterdam study found that patients with total homocysteine levels above 18.6 micromoles per liter are at a significantly elevated risk for heart attack (odds ratio [OR]=2.43), stroke (OR=2.53), and a history of hypertension further increases this risk (88).

• Cough related to angiotensin-converting enzyme (ACE) inhibitors: Patients experiencing symptoms of cough associated with widely used angiotensin-converting enzyme (ACE) inhibitors such as lisinopril and enalapril may experience a significant amount of relief from the use of a daily morning iron supplement dose of about 200-256 mg of iron sulfate (89,90). A mild amount of relief from ACE inhibitor cough was seen with the combination of 200 mg vitamin E with 150 mg vitamin C daily (90).

• Insomnia in patients taking beta-blockers: In patients experiencing insomnia while taking beta-blockers, a melatonin supplement at a dose of 2.5 mg nightly for 3 weeks increased total sleep time by 36 minutes, improved sleep efficiency by 7%, reduced time to reach a light sleep by14 minutes, and increased time spent in Stage 2 sleep by 41 minutes when compared to the placebo group (91).

• Licorice and high blood pressure: Licorice consumption should be limited to under 50 grams per day because it may result in an excess of mineralocorticoids leading to hypokalemia, high blood pressure, and other complications (86).