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High Blood Pressure, Hypertension

physician assistant

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Introduction:

Hypertension, also known as high blood pressure, is a condition of higher than normal force of blood pushing against arterial vessel walls. The higher the blood pressure, the more difficult it is for the heart to pump. Hypertension is a major risk factor for coronary artery disease, heart failure, stroke, aneurysm, chronic kidney disease, and other diseases. Most hypertension is related to essential hypertension, and the cause is usually unknown, but when a cause is identified, the secondary cause results in a diagnosis of secondary hypertension. Examples include renal artery stenosis which lowers the rate of blood flow to the kidney and the kidney responds by secreting hormones to increase blood pressure and perfuse the kidneys or in pheochromocytoma, a condition in which an adrenal mass secretes excessive catecholamines resulting in severely elevated blood pressure. Obstructive sleep apnea and medications such as non-steroidal anti-inflammatory drugs may also result in secondary hypertension.

There are several factors that place patients at risk for essential hypertension which include 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. Treating hypertension is vitally important for reducing the risks mentioned above. High blood pressure may be treated medically, by changing lifestyle factors, or a combination of these methods. It is advantageous to discover hypertension early as it is slowly increasing, and then lifestyle modifications may be used to achieve control. Unfortunately, hypertension is usually discovered late after it has set in for some time at a point which requires control with medication. As lifestyle changes are established and begin working, blood pressure control will often improve with time, and medication may be weaned and hopefully eventually be discontinued. However, a large majority will continue to required medication for control.

Preventive Health Advisor will focus on important lifestyle changes which include losing weight, eating a healthful diet, reducing sodium intake, exercising regularly, quitting smoking, limiting alcohol consumption as well as Integrative natural medicine therapies. Therapy for hypertension will require close follow-up and support by the primary care physician who will oversee pharmacological therapy, support lifestyle changes, and offer Integrative and natural therapy which is often preferred by the modern patient.

 

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.

 

Blood pressure monitoring:

Blood pressure technique:

Blood pressure should be obtained in a quiet room while the patient is in a comfortable seated position after a few minutes. A proper sized cuff should be placed over the upper arm with the marker on the cuff positioned over the brachial artery. The cuff should have about 2-3 cm of space between the arm and the cuff.

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

 

Home blood pressure monitoring:

A quality home blood pressure monitor is vitally important for the patient to not only be directly involved with their self-care, but also to diagnose, follow improvement, or evaluate for lack of control of their blood pressure.

 

Screening recommendations for hypertension:

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) (4):

  1. Screen patients with a blood pressure of under 120/80 for hypertension every 2 years.
  2. Screen patients with a blood pressure of 120-139/80-90 every year

 

U.S. Preventive Services Task Force and hypertension:

The U.S. Preventive Services Task Force supports the JNC 7 and JNC 8 recommendations: See the following link for further information: http://www.uspreventiveservicestaskforce.org/uspstf07/hbp/hbpsum.pdf or http://www.uspreventiveservicestaskforce.org/

 

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)

 

Diagnosis of hypertension and stages of hypertension:

Normal blood pressure is a systolic blood pressure less than 120 mm Hg, and a diastolic blood pressure less than 80 mmHg. Many advocate for BP to be under 115/75 due to the research which has shown that a rise in BP over this range increases risk of heart disease. One who has a blood pressure of under 120/80 should be screened for hypertension every 2 years. If the blood pressure is 120-139/80-90, one should be screened every year and take action to lower blood pressure to 120/80. If blood pressure is 139/90 or higher for the upper or the lower number, consult a physician. There are some high BP emergencies: 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 (blurred vision, double vision or vision loss), or altered mental status (confusion). Seek emergent medical care for hypertensive urgency or malignant hypertension.Low blood pressure, or hypotension, is systolic BP generally under 90 mmHg and a diastolic BP generally under 60. Likewise, seek emergent medical care for low BP with symptoms of fever, lightheadedness, fainting, poor concentration, nausea, diarrhea, clamminess, and thirst.

 

 

Diagnosis of hypertension at home:

Hypertension is diagnosed by the following criteria at home using a home blood pressure monitor:

JNC 7 recommendations for hypertension:

Recommendations of The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) (4) include 1) reduce sodium (salt) consumption to less than 2.4 g/day. 2) Exercise at least 30 min/day, 4 days per week. 3) Consume no more than 2 alcoholic drinks per day for men and 1 drink or less per day for women. 4) Eat a diet rich in fruits, vegetables, potassium, calcium, magnesium and low in fat and salt. 5) A weight loss goal of 10 lb or 4.5 kg is recommended.

New HTN Guidelines: 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)

 

Evidence-based dietary approaches for hypertension:

Sodium intake for hypertension:

Individuals with high blood pressure should not add excess salt to any foods, and use an all-purpose spice flavoring such as Ms. Dash or other spices to flavor food instead of salt or salt substitutes. Salt substitutes often add potassium which may accumulate and cause hyperkalemia. Flavor enhancers such as monosodium glutamate are associated with adverse reactions. Patients should be able to follow sodium content in foods by the label and add to reach no more than a total of 2 grams per day. There are small amounts of natural sodium in whole non-processed foods. Avoid processed or pre-prepared foods with high sodium content such as canned foods/soups, lunch meats, snack foods, and frozen dinners with added salt.

DASH diet for patients with high blood pressure:

DASH stands for Dietary Approaches to Stop Hypertension. The DASH diet is a lifelong approach to healthy eating that’s designed to help treat or prevent high blood pressure. The following lists the food groups and suggested serving amounts for the DASH diet: a) Grains: 7-8 daily servings (such as sliced bread,1 oz dry cereal, 1/2 cup cooked rice, pasta, or cereal); b) Vegetables: 4-5 daily servings (1 cup raw leafy vegetable, 1/2 cup cut-up raw or cooked vegetable, 1/2 cup vegetable juice); c) 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); d) Low-fat or fat-free dairy products: 2-3 daily servings (1 cup milk or yogurt, 11/2 oz cheese); e) Meat, poultry, and fish: 6 or less servings daily (1 oz cooked meats, poultry, or fish, 1 egg); f) 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); g) Fats and oils: 2-3 daily servings (1 tsp soft margarine, 1 tsp vegetable oil, 1 Tbsp mayonnaise, 2 Tbsp salad dressing); h) 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). (6)

The DASH diet is consistent with the American Heart Association’s (AHA) 2006 Diet and Lifestyle Recommendations which may be accessed at : http://circ.ahajournals.org/content/114/1/82.full.pdf (6)

 

Evidence-based effectiveness of DASH:

As cited in “Your Guide To Lowering Your Blood Pressure With DASH” by the US Department of Health and Human Services, April 2006 (6): A study involved 459 adults (50% women, 60% African America) with systolic blood pressure less than 160 mmHg and diastolic pressure of 80-95 mmHg. The study compared 3 eating plans that all included a daily sodium intake of 3,000 mg: 1) a normal American diet; 2) a normal American diet plus more fruits and vegetables; 3) and the DASH eating plan. A reduction in blood pressure was reported among participants who followed both the plan that included more fruits and vegetables and the DASH diet. Overall, the DASH diet had the greatest effect with blood pressure reductions reported within 2 weeks of starting the diet. The benefits of the DASH diet were especially pronounced in those with high blood pressure.

The effect of the DASH diet or the normal American diet with different sodium levels (3,300, 2,300 or 1,500mg) was examined. Participants (n=412) were randomly assigned to one of the two eating plans and followed for a month at each of the 3 sodium levels. Although reducing salt intake lowered blood pressure for both eating plans, the results showed that the combined effect of a lower sodium intake with the DASH diet was greater than just the DASH diet or a low salt diet. The greatest effect was with the lower sodium intake of 1,500mg, particularly for those without hypertension.

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:

Obesity, high salt intake, and the consumption of alcohol are leading factors in high blood pressure. The effect of diet on blood pressure was put to the test. Research of 133 adults with hypertension and 326 without hypertension showed that a diet low in both saturated and unsaturated fats, yet rich in fruits and vegetables, can greatly lower bp. As a control, the subjects were first provided a typical American diet for 3 weeks with average fruit, vegetable and fat intake. Following a diet rich in fruits, vegetables, and low fat dairy products, bp in subjects without hypertension improved from an average bp of 131.3/84.7 at baseline to an average of 125.8/81.7. In those with hypertension (bp over 140/90), systolic and diastolic bp improved by 11.4 and 5.5 points respectively over the control diet. (7)

 

Benefits of the Pritikin diet:

The Pritikin Diet may help to reduce the risk of developing coronary heart disease (CHD) according to a study using 67 patients with metabolic syndrome to investigate the effects of Pritikin therapy for 12-15 days. Along with exercise the Pritikin encourages a diet very low in fat and sodium and high fiber. Findings from this study showed improvement in most heart disease risk factors, including body mass index (3% reduction), blood pressure, glucose and LDL cholesterol (10%-15% reduction), and triglycerides (36% reduction). HDL cholesterol decreased by 3%. Additionally, 37% of subjects no longer met the criteria for metabolic syndrome as determined by the National Cholesterol Education Program. (8)

 

Benefits of the Therapeutic Lifestyle Changes Diet:

This diet is consistent with the American Heart Association’s 2006 Diet and Lifestyle Recommendations which can reduce the risk of cardiovascular disease. The diet consists of cutting back sharply on saturated fat, which may elevate LDL cholesterol levels and increase the risk of heart attack and stroke. Intake of saturated fat is kept below 7% of the total calorie intake. Total fat intake should consist of 25-35% of daily total calories. Daily cholesterol intake should be kept below 200 milligrams. Sodium intake is limited to 2400 mg per day. Calorie intake should be kept to a level needed for maintaining healthy weight and reduce blood cholesterol level. (9,25)

 

Aerobic exercise and hypertension:

The recommendations of The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) includes exercise at least 30 min daily (49). 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. Aerobic exercise generally consists of mild to moderate intensity activity with rhythmic contraction of major muscle groups over an extended period of time. Examples include fast walking, jogging, cycling, Zumba, cross country skiing, and swimming. For the  physician or fitness professional, the following source is the most credible reference for initiation of exercise in patients: Walter R. Thompson, American College of Sports Medicine, Neil F. Gordon, Linda S. Pescatello. ACSM’s Guidelines for Exercise Testing and Prescription. Lippincott Williams & Wilkins, Feb 1, 2009. (10)

 

Benefits of aerobic exercise:

The many benefits of aerobic exercise in cardiopulmonary (heart and lung) conditioning include: 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).

 

Physical activity according to the World Health Organization:

The most benefit from physical activity is achieved with at least 2.5 hours of aerobic exercise of moderate intensity per week, which can be accumulated in 10-minute periods. At least 2 days/week vigorous intensity aerobic exercise and resistance exercises for muscle strengthening are recommended. Increased intensity, frequency and duration of exercise is associated with increased added health benefits. Regular exercise is recommended for not only all healthy individuals, but also those suffering from obesity, diabetes, hypertension, atherosclerotic cardiovascular disease and cancer. (18)

 

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 (19,20).

 

Exercise cardiac stress testing in patients before exercise:

Exercise cardiac stress testing should be conducted in patients with suspected or known coronary artery disease, typical and atypical angina or have had prior heart attack. In healthy people, without symptoms, those 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 occupation for example pilots, firefighters, law enforcement officers, and transit operators should undergo exercise stress testing. Stress testing is also recommend for 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 is also necessary. (21)

 

Aerobic exercise for hypertension:

Once approved by the primary physician for exercise, an adult patient suffering from 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)

 

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:

Yoga and degree of blood pressure control: Yoga may be used to control blood pressure. In a study of 34 hypertensive patients randomly assigned to 6 weeks of either yoga relaxation methods or to placebo (general relaxation) blood-pressure was reported to have significantly decreased (on average from 168/100 to 141/84 mm Hg in the yoga group and from 169/101 to 160/96 mm Hg in the placebo group). When the placebo group switched to yoga relaxation, their blood-pressure was further reduced. (23)

Yoga and may help control the amount of required blood pressure medication. Yoga may be have beneficial effects for those suffering from hypertension according to a study including 25 patients with hypertension. Study participants were taught Shavasana, which they practiced for 6 months. Individuals either received no antihypertensive drug treatment (n=20, Group A) or took antihypertensive drugs (n=5, Group B). The study showed both groups had a significant reduction in average systolic and diastolic blood pressure. In group B, there were significant reduction in the amount of antihypertensive drugs taken. In group A, 65% of patients’ blood pressure could be controlled with Shavasana without use of medication. Among those who stopped practising yoga, blood pressure rose significantly to pre-Shavasana levels. (24)

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):

The Therapeutic Lifestyle Changes Diet (9,25), plus 30 minutes of daily exercise at 50-75% of age-predicted maximum heart rate resulted in the following benefits (33):

  1. 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.
  2. 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.
  3. HDL cholesterol increased 2.6% on average (p=0.41).
  4. Women: 12.3% reduction in LDL cholesterol and an 11.4% increase in HDL cholesterol.
  5. Men: 7.9% reduction in LDL cholesterol and no change in HDL.
  6. Systolic and diastolic blood pressure (BP) decreased 9% (p<0.001) and 13%, respectively (p <0.0001).
  7. BP reductions were two-fold greater than in a DASH diet (Dietary Approaches to Stop Hypertension) diet.

 

The Pritikin Program

The Pritikin Program evidence-based benefits after 12-15 days improves most risk factors for coronary artery disease including hypertension (26,27,28):

  1. Body mass index, 3% reduction
  2. Blood pressure, glucose and LDL, all with 10%-15% reduction
  3. Triglycerides, 36% reduction
  4. 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.
  5. Usually program is done for 3-4 weeks allowing additional benefit as the patient continues the program.

 

Pritikin Program includes (27,28):

  1. Very low fat, less than 10% of calories.
  2. Low sodium and avoid salty foods.
  3. 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.
  4. Refined grain products (white flour, regular pasta, white rice) are limited to two servings daily.
  5. 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
  6. At least three servings of fruit, one of which can be fruit juice.
  7. Two servings daily of calcium-rich foods such as nonfat milk, nonfat yogurt or fortified and enriched soymilk.
  8. No more than one caffeinated drinks daily. Instead drink water, low-sodium vegetable juices, grain-based coffee substitutes or caffeine-free teas.
  9. 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.
  10. No more than seven egg whites per week.
  11. No more than 2 ounces (about 1/4 cup of nuts) daily.
  12. 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.
  13. Adapted to vegetarians by replacing animal protein with protein from soy products, beans, or lentils.
  14. 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.
  15. Eat frequently with three meals a day plus two snacks.
  16. Artificial sweeteners such as Splenda are okay.
  17. 45 minutes of moderate exercise daily such as walking.
  18. 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 (29-31):

The Dean Ornish Program for Reversing Heart Disease improves most risk factors for coronary artery disease including hypertension. The program includes the following benefits:

  1. Weight loss of 13.3 pounds in the first 12 weeks and 15.9 pounds after 1 year.
  2. Significant reductions in systolic blood pressure (BP), diastolic BP, total cholesterol, triglycerides, and LDL-cholesterol after 12 weeks were still significant after 1 year.
  3. Exercise capacity increased by 18% after 12 weeks and 24% after one year.
  4. Reductions in depression were still significant after 1 year.
  5. Hemoglobin A1C in diabetics continued to decrease after one year.
  6. Improvement in severity of angina after 1 year.

 

Ornish Program includes (29-31):

Patients are instructed to eat a plant-based, meatless diet, as well as practice meditation and perform regular exercise. Adherence to the program has been quoted 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:

A systematic review and meta-analysis of randomized controlled trials by Taylor et al found that exercise based cardiac rehabilitation reduces all cause and cardiac mortality and improves a number of cardiac risk factors in patients with coronary heart disease according to a meta-analysis of 48 randomized controlled trials (RCTs) (8940 patients, mean age 55 y). Intervention duration ranged from 0.25–30 months and follow up was between 6–72 months. Patients who received exercise-based cardiac rehab had a significant reduction in all-cause mortality of 20% and cardiac mortality of 26% than did patients who received usual care. Groups did not differ for rates of non-fatal heart attack (odds ratio [OR]= 0.79), coronary artery bypass grafting (OR=0.87), or percutaneous coronary intervention (OR=0.81). Cardiac rehabilitation was associated with significant reductions in total cholesterol of 0.37 mmol/L and triglyceride concentrations by 0.23 mmol/L; no significant differences were seen in low ‘bad’ or high-density ‘good’ lipoprotein concentrations. Systolic blood pressure was significantly reduced by 3.2 mm Hg. A significant 36% reduction in patient smoking was reported with cardiac rehabilitation. (14)

Silberman and colleagues reported the results of an analysis of patients (n=2974) participating in an intensive cardiac rehabilitation program. The authors 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)

 

Risks of smoking, caffeine and alcohol use by patients with high blood pressure:

Smoking and hypertension:

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, 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 cafeine 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 (31). 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 (31).

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 contains not only caffeine, but also theobromine which is known to act as a stimulant, vasodilator, and diuretic which may be responsible for some of the therapeutic action of cocoa (52). 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 higher doses of cocoa or chocolate for high blood pressure than typically found in foods.

 

Alcohol and blood pressure:

Alcohol is known to increase blood pressure at both rest and during physical activity (32). 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 (51).

 

Hyperlipidemia and hypertension:

Test for and treat hyperlipidemia if present. Many lifestyle modifications will benefit both hypertension and hyperlipidemia including dietary changes, exercise, foods and weight loss discussed here. 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 supplementation in overweight individuals with high blood pressure significantly reduced systolic and diastolic blood pressure (BP) in a 6-month study (n=141). Participants were administered either oral psyllium power or guar gum (3.5 grams 3 times daily). After administration, both supplements significantly improved body mass index, fasting plasma glucose, fasting plasma insulin, and LDL cholesterol. However, only psyllium significantly lowered systolic and diastolic BP. (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 significantly improved blood sugar control by 5.7% measured by fructosamine (a measurement of long term glucose control and 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:

 

Calcium and blood pressure:

Calcium intake precautions:

Preventive Health Advisor supports obtaining the RDA (recommended daily allowance) for calcium in adults to help maintain a normal blood pressure, but to avoid high calcium intake over 1400 mg per day including food sources and supplements. Patients should 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.

 

Expected blood pressure lowering with calcium:

A. meta-analysis of 40 trials (2,492 subjects with high blood pressure) showed significant reductions in systolic blood pressure of about -1.8 mmHg and reduction of diastolic blood pressure of -0.99 mmHg with an average calcium supplement dose of 1,200 mg daily. Among patients with a lower calcium intake on average of about 800 mg daily, an average 1200 mg calcium supplement reduced systolic blood pressure by -2.63 mmHg, and reduced diastolic blood pressure by -1.30 mmHg. (42)

 

Calcium plus vitamin D compared to calcium alone in hypertension:

A double-blind randomized controlled trial of 148 women with a mean age of 74 years was conducted to study the effects of calcium supplements on blood pressure. The study participants received 1200 mg calcium plus 800 IU vitamin D or only 1200 mg calcium daily for 8 weeks. At the end of the study, researchers found that supplementation with vitamin D and calcium resulted in a significant increase in vitamin-D levels by 72% and decreased parathyroid hormone (PTH) levels, which controls calcium, phosphorus, and vitamin D levels in the blood and bone, by 17% along with significant decreases in systolic blood pressure of 9.3% (p=0.02) and heart rate of 5.4% (p=0.02) compared with calcium supplementation alone. 81% of subjects in the vitamin D3 and calcium group compared with 47% in the calcium group showed a decrease in SBP of 5 mm Hg or more. The researchers concluded that short-term vitamin D and calcium supplements are more effective in reducing systolic blood pressure than calcium alone in elderly women. (43)

 

Vitamin D and blood pressure:

Vitamin D level and hypertension: A vitamin D level is recommended for patients suspected of vitamin D 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. Vitamin D supplements are known to lower blood pressure in patients with hypertension and low vitamin D levels. See the vitamin D section for further information.

Participants in a study received either standard antihypertensive drugs (n=100) or vitamin D3 (33,000 IU, every 2 weeks, for 3 months) in addition to standard therapy (n=100). After 3 months, results showed a reduction in systolic blood pressure (BP) of 7.5 mmHg with Vitamin D supplementation compared to a 3.6 mmHg reduction in the standard therapy group. Diastolic BP in both the Vitamin D group and non-Vitamin D group increased by 2.1 mmHg and 1.3 mmHg, respectively. Additionally, Vitamin D supplementation showed a significant increase in blood calcium levels as well as albumin-corrected calcium with a decrease in phosphorous. (44)

 

Coenzyme Q10 (CoQ10) and hypertension:

Coenzyme Q10 (CoQ10) is a natural antioxidant synthesized by the body, found in many foods, and commonly available as a supplement.

 

Effectiveness of coenzyme Q10 in hypertension:

A systematic review on effectiveness of Coenzyme Q10 in hypertension: In a systematic review done by Rosenfeldt, F L et al, CoQ10 supplementation in 8 trials showed an average decrease in systolic blood pressure of 16 mmHg and a10 mm Hg average decrease in diastolic blood pressure. (45)

 

A review of trials with coenzyme Q10 (CoQ10) for hypertension:

A review of published trials of coenzyme Q10 (CoQ10) for high blood pressure (hypertension) was conducted and resulted in a meta-analysis including 12 clinical trials (3 randomized controlled trials [RTCs, n=120], 1 crossover study [n=18], and 8 open label studies [n=214]). These trials compared CoQ10 with placebo. In the RTCs, CoQ10 resulted in average decreases of SBP by 16.6 mmHg and DBP by 8.2 mmHg more than placebo. SBP decreased by 11 mmHg and DBP by 8 mmHg in the crossover study with CoQ10 administration, with no significant change reported with placebo. In the open label studies CoQ10 resulted in average decreases of SBP by 13.5 mmHg and DBP by 10.3 mmHg more than placebo. (46)

 

Coenzyme Q10 in patients with hypertension and coronary artery disease:

Fifty-nine patients who had coronary artery disease and who had been on antihypertensive drugs receive oral administration of either B-complex vitamins or coenzyme Q10 60 mg/d. After 8 weeks of therapy, the coenzyme Q10 group had significantly lower systolic and diastolic blood pressure than the placebo group. HDL cholesterol, vitamins A, C, E and beta-carotene showed a significant increase after use of Q10. B-vitamin complex only increased vitamin C and beta-carotene. (47)

 

Coenzyme Q10, blood pressure, and cholesterol:

Coenzyme Q10 (CoQ10) may be effective in reducing blood pressure and cholesterol. In this study 26 individuals with high blood pressure were supplemented with CoQ10 at a dose of 50 mg twice daily for 10 weeks. At the end of the treatment with CoQ10, CoQ10 levels increased by 0.94 mcg per ml, systolic blood pressure decreased 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. Average total cholesterol decreased slightly, from 222 mg/dL to 213 mg/dL, while there was no significant change in HDL cholesterol levels (41.1 mg/dL to 43.1 mg/dL). (48)

 

Small study on effects of coenzyme Q10 taken by healthy patients:

A study that included 26 healthy individuals (average age, 24 years), found that coenzyme Q10 (Q10) supplementation (50 mg) had no effect on results of an electrocardiographic (ECG), which checks the heart’s electrical activity, but slightly increased systolic blood pressure (SBP) by 2 mmHg. This increase only lasted a short time. (49)

 

Coenzyme Q10 (CoQ10) for hypertension, dose, and monitoring requirements:

Based on a review of published studies on coenzyme Q10 (CoQ10) for hypertension researchers found that CoQ10 lowered systolic blood pressure by up to 17 mm Hg and diastolic blood pressure by up to 10 mm Hg. Additionally, CoQ10 doses have increased from 34 mg/day in the early trials to 225 mg/day in the later ones. In a large study, control of blood pressure was achieved gradually over many months and required different doses that ranged from 75–360 mg daily to attain a therapeutic blood level of CoQ10 (>2.0 mcg per ml).  Since absorption of CoQ10 varies with the preparation used and patient response varies, monitoring CoQ10 levels in the blood to guide dosage is desirable. Another factor complicating CoQ10 therapy is the use of statins which are a class of drugs used to lower cholesterol levels. Statins inhibit the synthesis of cholesterol and CoQ10 through the same mechanism. In conclusion, CoQ10 lowers blood pressure and optimal dose can be patient dependent. (50)

 

Coenzyme Q10 and isolated systolic hypertension:

Burke et al. conducted a 12-week randomized, double-blind, placebo-controlled study, consisting of 46 men and 37 women with isolated systolic hypertension. Participants received a twice-daily administration of 60 mg of oral coenzyme Q10 (CoQ10). Blood pressures were monitored twice weekly. The average reduction in systolic blood pressure (SBP) in the isolated systolic hypertension CoQ10 group after 12 weeks of treatment was 17.8 mm Hg. There were no significant orthostatic changes in SBP (refers to blood pressure change when standing up or stretching) in any of the patients. These findings suggest that CoQ10 may be a safe alternative treatment option for hypertensive individuals. (51)

 

Oral coenzyme Q10 in chronic heart failure:

Oral coenzyme Q10 (CoQ10) supplementation was analyzed in double-blind trials and was found to have positive clinical and hemodynamic effects including improvement in blood pressure and heart rate, especially in chronic heart failure. Experiments using daily supplements of up to 200 mg CoQ10 for 6-12 months and 100 mg/d for up to 6 years have reported no major adverse effects. (52)

 

Omega-3 fatty acids and high blood pressure:

Omega-3 fatty acid effectiveness and hypertension: In a meta-analysis of 31 controlled trials (n=1356), treatment with omega-3 (n−3) fatty acids supplementation lowered systolic and diastolic blood pressure in hypertensive patients. Researchers found that fish oil supplementation (mean dose of 5.6 grams/day) lowers systolic blood pressure by an average of 3.4 mm Hg and diastolic pressure by an average of 2.0 mm Hg. The effect was found to be highly 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. (53)

 

Omega-3 fatty acids in subjects with untreated hypertension:

Evidence suggests that supplementation with omega-3 polyunsaturated fatty acids (omega-3 PUFA) may reduce blood pressure (BP). Appel, LJ et al reviewed research on omega-3 oils and hypertension. Of 11 trials that enrolled people with normal blood pressure (n=728), 2 found a reduction in systolic pressure (SBP) and 1 in diastolic pressure (DBP). Of 6 trials that enrolled untreated hypertensive subjects (n=291), 2 found significant reductions in SBP and 4 in DBP. Including all trials, average SBP and DBP reductions (mmHg) were -1.0 and -0.5 in the trials including normal blood pressure subjects, and -5.5 and -3.5 in the trials of untreated high blood pressure. The duration of 13 of these 17 trials was less than 3 months and generally omega-3 dose exceeded 3 g/day. Reduction of BP was greatest when BP was high but was not significantly associated with dose of fish oil. The authors conclude that supplementation with omega-3 fatty acids can produce clinically relevant BP reductions in subjects with untreated hypertension. (54)

 

Omega 3 fatty acids, blood pressure, and cognitive ability:

A randomized, controlled, cross-over study involving 40 healthy adults, ages 51-72 years old, found that omega-3 fatty acids improved cognitive function and cardio-metabolic risk factors after 5 weeks of supplementation. Subjects received either 3g daily fish oil or placebo for 5 weeks, separated by a 5-week washout period. Results showed subjects performed better on working memory tests and had lowered blood pressure and plasma triglyceride levels with omega-3 compared to placebo. Systolic blood pressure, f-glucose, and s-TNF-alpha, were inversely related to the performance in cognitive tests. The results from this study suggest that omega-3 fatty acids may improve cognitive performance in healthy subjects after only five weeks and may help prevent or delay onset of metabolic disorders and the associated cognitive decline. (55)

 

Green tea and hypertension:

Green tea is rich in the class of antioxidant polyphenol compounds known as catechins. 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 of 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 11-48mg) 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 at the physician’s discretion due to high a 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. Patients should be advised to avoid drugs metabolized by the liver such as acetaminophen when taking over 3 cups per day of green tea.

 

Green tea extract effect on blood pressure and other health parameters:

Daily supplementation with 379 mg of green tea extract (GTE) was found to be associated with beneficial effects on blood pressure, insulin resistance, inflammation and oxidative stress, and cholesterol in 56 patients with obesity-related hypertension. At the end of the 3-month study both systolic and diastolic blood pressures significantly decreased in the GTE group when compared to the placebo group (p < .01). Additionally, compared to the placebo group, significant (p < .01) reductions in glucose and insulin levels and insulin resistance were observed in the GTE group. Serum tumor necrosis factor α and C-reactive protein were significantly lower, whereas total antioxidant status increased in the GTE group compared with the placebo (p < .05). Supplementation also contributed to statistically significant decreases in the total cholesterol, LDL cholesterol and triglycerides. There was also an increase in HDL cholesterol observed. Following 3 months of treatment, systolic blood pressure dropped about 4 mmHg and diastolic bp dropped about 2 mmHg on average. LDL improved from 3.5 to 3.1 mmol/L, HDL from 1.2 to 1.4 mmol/L, triglycerides 1.4 to 1.1 mmol/L, total cholesterol 5.4 to 5.0 mmol/L, C-reactive protein from 3.4 to 2.5 mg/L and tumor necrosis factor 5.4 to 4.7 ng/L. (56)

 

Green tea extract, weight loss, body composition, and blood pressure:

A randomized double-blind, controlled parallel multi-center trial consisting of a 2-week run-in period and a 12-week treatment period was conducted to investigate the effects of green tea extract (GTE) high in catechins on body fat reduction and reduction in the risks for cardiovascular disease in obese individuals. Data consisted of 240 subjects 25 to 55 years of age (catechin group; n = 123, control group; n = 117). Participants in the treatment group had an intake of 583 mg catechin (equivalent of about 4-5 cups of green tea), while those in the control group had an intake of 96 mg catechin. Decreases in body weight, body mass index, body fat ratio, body fat mass, waist circumference, hip circumference, visceral fat area, and subcutaneous fat area were found to be greater in the catechin group than in the control group. Those in the treatment group experienced a loss of about 4 pounds after 12 weeks. A greater decrease in systolic blood pressure (SBP) was found in the catechin group compared with the control group for subjects whose initial SBP was 130 mm Hg or higher.  A reduction of 9.0 mm Hg vs 2.9 mm Hg was seen. Low-density lipoprotein (LDL) cholesterol was also decreased to a greater extent in the catechin group. No adverse effect was found. In conclusion, catechins, especially in high amounts, reduce body fat, cholesterol levels, and blood pressure in women and men. (57)

 

Green tea plus inulin and hypertension:

The effect of green tea plus inulin (a type of dietary soluble fiber) on body weight and fat mass in overweight adults was examined. 30 subjects were divided into a control group and an experimental group who received 650 ml (about 3-4 cups) of regular tea or catechin-rich green tea plus inulin (534 mg catechins and 11.7 g inulin). A reduction in body weight of approximately 4-5 pounds and an improvement by 7-8 points in systolic blood pressure among those drinking catechin-rich green tea plus inulin was found after 6 weeks, and no adverse effects were observed. In conclusion, sustained intake of catechin-rich green tea in combination with inulin for more than 3 weeks may contribute to weight loss and lower blood pressure. (58)

 

Green tea interactions and adverse reactions:

 

Chocolate or cocoa consumption and blood pressure:

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 2 days after stopping chocolate intake (68).

 

Dark chocolate and hypertension:

In a study involving 14,310 adults from various regions of Jordan, higher intake of dark chocolate was found to be associated with lower blood pressure. No particular effects on heart rate were found. Subjects were divided into 3 categories according to dark chocolate intake: 1) mild (1-2 bars/wk); 2) moderate (3-4 bars/wk); and 3) high (more than 4 bars/wk), and results showed that higher intakes of dark chocolate were associated with lower systolic and diastolic blood pressure, regardless of age or family history of hypertension. These results suggest that intake of dark chocolate may be associated with lower blood pressure. (66)

A study looked at the effects of dark chocolate for fifteen days on Nitric oxide (NO) with regards to blood pressure in people with prehypertension. Thirty-two individuals were recruited and divided into 2 groups of 16 each. The treatment group received 30 g/day of dark chocolate daily (containing 70% cocoa) and dietary counseling. Those in the placebo group received 25 g/day of white chocolate daily and dietary counseling. After 15 days, dark chocolate increased NO blood levels compared to placebo (7.70 vs 1.92, respectively) and decreased systolic blood pressure (120.64 vs 131.19). (67)

Cocoa-rich foods may reduce blood pressure. For 2 weeks, participants (n=13) were randomly assigned to receive 480 kcal bars containing either 100-g dark polyphenol-rich chocolate (PRC) bars per day containing 500 mg of polyphenols or 90-g white chocolate (polyphenol-free chocolate [PFC]). At the end of the study, when compared to the PFC group, those in the PRC group experience an average decrease in systolic and diastolic blood pressure (BP) of 5.1 mmHg and 1.8 mmHg, respectively. After the intervention was stopped, BP returned to pre-study values within 2 days. (68)

In an 18-week study researches looked at relationship between polyphenol-rich dark chocolate and blood pressure. Polyphenol are thought to act as antioxidants and are known to protect cells against damage. Between January 2005 and December 2006, 44 participants (24 women, 20 men) aged 56 through 73 years in Germany with untreated upper-range prehypertension or stage 1 hypertension received 6.3 g of dark chocolate containing 30 mg of polyphenols or matching polyphenol-free white chocolate per day. At the end of the study, researches saw a drop in systolic blood pressure by -2.9 (1.6) mm Hg (P < .001) and diastolic BP by -1.9 (1.0) mm Hg (P < .001) among participants consuming dark chocolate. The proportion of subjects with hypertension decreased from 86% to 68%. (69)

 

Cocoa and hypertension:

In a study, 15 healthy adults under the age of 50 and 19 healthy adults over the age of 50 drank 920 mls of Cocoapro from Mars Inc., Hackettstown, New Jersey, USA divided into 4 doses daily with a total of 821 mg of flavonols daily for 4-6 days. Flavonols naturally occur in plants and possess antioxidant characteristics. Blood pressure and peripheral arterial responses were recorded. The results showed blood vessel function improved among both younger and older adults after the cocoa phase. However, improvements were more significant in the older group. (70)

 

Oats, β-glucan, and 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 the following results: 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%; and trend toward improved insulin sensitivity. (71)

 

Garlic and 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. Garlic was associated with blood pressure (BP) reductions only in patients with an elevated systolic blood pressure (SBP) and not in patients without elevated SBP in a review of 10 randomized controlled trials. In patients with elevated SBP, garlic reduced SBP by -16.3 mmHg and diastolic blood pressure (DBP) by -9.3mmHg in comparison with placebo. In participants without elevated SBP, there were no significant differences between garlic and placebo for SBP or DBP. (72)

Findings by Ried, K et al on garlic and hypertension: A meta-analysis that including 11 trials found that garlic supplements can significantly reduce blood pressure (BP) in people who have high BP. In most of the included studies, participants took garlic in powdered form, in doses ranging from 600 mg to 900 mg/day for 12 to 23 weeks. Results showed that garlic reduced systolic BP by an average of 4.6 mmHg. In people with high BP, the average reduction in BP was 8.4 mmHg systolic and 7.3 mmHg diastolic. The higher the person’s BP at the beginning of the study, the more their BP was reduced. (73)

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:

Eighteen overweight and hypertensive men and women consumed 6-8 small microwaved purple potatoes twice a day, or no potatoes, for four weeks; then switch to the opposite regimen for another four weeks.  The researchers monitored the volunteer’s blood pressure during the same period and found that the average diastolic blood pressure dropped by 4.3% and the average systolic dropped by 3.5%. None of the study participants gained weight during the study period. The study authors concluded that purple potato consumption may control blood pressure, reduce the risk of heart disease, and decrease stroke risk while not causing weight gain. (74)

 

Beet juice and blood pressure:

Effect of beetroot juice on blood pressure: Researchers used 14 healthy volunteers aged 18-45 in an open-label crossover design study to examine the effect of taking 500 mL of beet juice on dietary nitrate levels. Systolic blood pressure (BP) approximately 3 hours after ingestion dropped by 10.4±3.0 mm Hg (p<0.01) while diastolic BP dropped 8.1±2.1 mm Hg. This drop in BP signaled an increase in nitric acid in the blood.  The beneficial effects of a drop in BP lasted 24 hours. In conclusion, dietary nitrate may lower blood pressure among healthy individuals. (75)

 

Beetroot juice interactions and adverse reactions:

Caution in patients already taking prescribed nitrates or blood pressure lowering medication since beet juice may potentiate lowering of blood pressure. Beet juice increases plasma nitrate levels and dangerous drop in blood pressure may occur if taken with other nitrate medications such as sublingual nitroglycerin, nitroglycerin paste, nitroglycerin patches, Imdur, Isordil, and Viagra.

 

Grape juice and blood pressure:

A double-blinded, placebo controlled study by Park et al. of 40 hypertensive adult Korean men with elevated blood pressure (BP), found that daily consumption of Concord grape juice (CGJ) for 8 weeks (5.5 mL/kg/d) resulted in lower systolic and diastolic blood pressure versus baseline. Participants were assigned to treatment with grape juice or placebo. At the end of the study, compared to baseline, those in the CGJ group experienced a mean systolic BP reduction of 7.2 mm Hg (p = 0.005) and mean diastolic BP reduction of 6.2 mm Hg (p = 0.001). Comparable changes in the group getting the placebo product were -3.5 mm Hg (NS) and -3.2 mm Hg (p = 0.05). The authors conclude that consuming Concord grape juice, which is high in polyphenolic compounds (antioxidants), might positively affect BP in hypertensive individuals. (76)

 

Sodium-bicarbonated mineral water and blood pressure, cholesterol:

A study examined the effects of drinking sodium-bicarbonated mineral water on cardiovascular risk among 18 young volunteers in two 8-week intervention periods. In addition to their normal diet, participants took 1 L/day control low mineral water, followed by 1 L/day bicarbonate water which was the equivalent of ¾ teaspoon of sodium bicarbonate in 1 quart of water. Results indicate that dietary intake, body weight and body mass index were not significantly affected. Systolic blood pressure decreased significantly after 4 weeks of bicarbonated water consumption, though no significant differences between Weeks 4 and 8 were demonstrated. Consumption of bicarbonated water was shown to significantly reduce total cholesterol by 6.3% and reduced LDL (bad) cholesterol by 10%. This study suggests that supplementing dietary intake with bicarbonate water may reduce cardiovascular risk. (77)

 

Pycnogenol, and blood pressure:

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 effect upon platelet aggregation. 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).

Pycnogenol at a dose of 50 mg 3 times daily added to Ramipril at a dose of 5mg twice daily 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). 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). The group taking Pycnogenol also had a significant weight loss from average BMI 26.5 to 25.0 kg/meters squared and lowered fasting blood glucose levels after 6 months (79).

 

Hawthorn and blood pressure:

The effect of hawthorn for hypertension (high blood pressure) in patients with type 2-diabetes taking on average about 4.4 prescription drugs for diabetes and hypertension was examined in a randomized controlled trial. Patients (n=79) received 1200 mg of hawthorn extract or placebo daily for 16 weeks. At the end of the study, there was a significant group difference in average diastolic blood pressure (BP) reductions with the hawthorn group showing greater reductions than the placebo group (85.6 to 83.0 mmHg vs 84.5 to 85 mmHg). There was no significant difference in systolic BP reduction between the two groups. (87)

 

Homocysteine and risk of heart attack:

A statistically significant positive association between elevated homocysteine (Hcy), an amino acid, and risk of heart attack (myocardial infarction) and stroke has been found in a cohort study of 7,983 individuals. It was estimated that each 1 mmol/L increase in plasma Hcy concentrations were associated with a 6%–7% increase in the risk of stroke. Additionally, participants with total Hcy levels above 18.6 micromol/L were at significantly increased risk for heart attack (odds ratio [OR]=2.43) and stroke (OR=2.53). Those with hypertension also faired worse. (88)

 

ACE inhibitors and cough:

Iron supplements may reduce the cough symptom associated with a widely used drug, angiotensin-converting enzyme (ACE) inhibitor. ACE inhibitors are widely prescribed for the treatment of high blood pressure, heart failure and other cardiac conditions. In this study, after a 2-week observation period, participants (n=19) were randomized to receive either a daily morning dose of 256 mg ferrous sulfate (iron) or placebo for 4 weeks. Subjects kept a daily diary, scoring their cough twice per day on a scale of 0 to 4. Results showed that use of ferrous sulfate significantly reduced average daily cough scores (from 3.07 to 1.69) as compared to placebo (from 2.57 to 2.35). (89)

Researchers investigated the effect of oral iron and anti-oxidants on cough symptoms associated with a widely used drug, angiotensin-converting enzyme (ACE) inhibitor and nitric oxide levels. ACE inhibitors are widely prescribed for the treatment of high blood pressure, heart failure and other cardiac conditions. In this study, after a 2-week observation period, participants received 200 mg ferrous sulphate (iron) (n=11), 200 mg vitamin E and 150 mg vitamin C (n=8), or placebo (n=9) for 4 weeks. At the end of the study, cough scores, nitric oxide and malondialdehyde (MDA) level (measures cell damage) had significantly decreased in the iron group. Only cough scores and MDA level had significantly decreased in the anti-oxidant group. NO levels were found to increase significantly in patients who developed a cough compared to those that did not. No changes were recorded for the placebo group. (90)

 

Melatonin use in patients suffering from high blood pressure:

A nightly 2.5mg melatonin supplement in 16 individuals with high blood pressure who were taking beta-blockers suggested that melatonin supplementation increases sleep quality. After 3 weeks, individuals on melatonin significantly increased total sleep time by 36 minutes, sleep efficiency by 7%, time to reach a light sleep (stage 2) decreased by14 minutes, and time spent in Stage 2 sleep increased by 41 minutes when compared to the placebo group. A significantly reduced time to reach a light sleep (-25 minutes) continued for a day after supplementation stopped suggesting the benefit of melatonin may have still been present. (91)

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References :

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2.Rosendorff C, Black HR, Cannon CP, Gersh BJ, Gore J, Izzo JL Jr, Kaplan NM, O’Connor CM, O’Gara PT, Oparil S; American Heart Association Council for High Blood Pressure Research; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Epidemiology and Prevention. Treatment of hypertension in the prevention and management of ischemic heart disease: a scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention. Circulation. 2007 May 29;115(21):2761-88. Epub 2007 May 14. http://www.ncbi.nlm.nih.gov/pubmed/17502569

 

3.Atherosclerosis, Hypertension, and Obesity in the Young Committee of the American Heart Association Council on Cardiovascular Disease in the Young, Alpert B, McCrindle B, Daniels S, Dennison B, Hayman L, Jacobson M, Mahoney L, Rocchini A, Steinberger J, Urbina E, Williams R. Recommendations for blood pressure measurement in human and experimental animals; part 1: blood pressure measurement in humans. Hypertension. 2006 Jul;48(1):e3; author reply e5. Epub 2006 Jun 12. http://www.ncbi.nlm.nih.gov/pubmed/16769991

 

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12.Barnard , James R., Tung H. Ngo, Pak-Shan Leung, William J. Aronson, and Lawrence A. Golding. A Low-Fat Diet and/or Strenuous Exercise Alters the IGF Axis In Vivo and Reduces Prostate Tumor Cell Growth In Vitro. The Prostate 56:201-206 May 2003. http://www.ncbi.nlm.nih.gov/pubmed/12772189

 

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14.Taylor, RS, Allan Brown, Shah Ebrahim, Judith Jolliffe, Hussein Noorani, Karen Rees, Becky Skidmore, James A. Stone, David R. Thompson, Neil Oldridge. Exercise-Based Rehabilitation for Patients with Coronary Heart Disease: Systematic Review and Meta-analysis of Randomized Controlled Trials. Am J Med. 2004;116:682– 692. http://www.ncbi.nlm.nih.gov/pubmed/15121495

http://exerciseprescription.wiki.umt.edu/file/view/Taylor+et+al,+2004.pdf

 

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19.American College of Sports Medicine (ACSM)

 

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