Current issuesCurrent issues !!! !!! NON-NON-PHARMACOLOGICAL PHARMACOLOGICAL MANAGEMENT OF MANAGEMENT OF

HYPERTENSION HYPERTENSION

Dr.Vinod K. RavaliyaDr.Vinod K. Ravaliya Cardiothoracic Cardiothoracic

PhysiotherapyPhysiotherapy

KMPIP,KARAMSADKMPIP,KARAMSAD

What is Hypertension?

Increase in the blood pressure Increase in the blood pressure above normal value is known as above normal value is known as hypertension or high blood hypertension or high blood pressurepressure..

British Hypertension society Classification of blood pressure

levels Category Systolic blood pressure

(mm Hg)Diastolic blood pressure

(mm Hg)

Blood pressureOptimalNormalHigh Normal

<120<130130 – 139

<80<8585 -89

HypertensionGrade 1 (mild)Grade 2 (moderate)Grade 3 (severe)

140 – 159160 – 179>180

90 – 99100 – 109>110

Isolated Systolic HypertensionGrade 1Grade 2

140 – 159>160

<90<90

It was estimated that almost 1/3It was estimated that almost 1/3rdrd of BP related of BP related deathsdeaths occurred in normotensive individuals with occurred in normotensive individuals with blood pressureblood pressure

SBP : 120 – 139SBP : 120 – 139

DBP : 80 – 89DBP : 80 – 89

Stamler J, Neaton JD et al. Arch. Of internal medicine, 1993 ; 153 : Stamler J, Neaton JD et al. Arch. Of internal medicine, 1993 ; 153 : 598 – 615.598 – 615.

Blood pressure, systolic and diastolic and cardiovascular Blood pressure, systolic and diastolic and cardiovascular risks : US population data. risks : US population data.

The Joint national committee VII report on The Joint national committee VII report on prevention, detection, evaluation and treatment prevention, detection, evaluation and treatment of high blood pressure.of high blood pressure.

Chobanian AV, Black HR et al.2003Chobanian AV, Black HR et al.2003

JNC VII Classification of blood JNC VII Classification of blood pressurepressure

BPClassification

SBP, mm Hg

DBP, mm Hg

Lifestyle modifications

Without Compelling Indications

Normal <120 And <80 Encourage   

Pre hypertension 120-139Or

80-89Yes

No antihypertensive drug indicated

Stage 1 Hypertension

140-159Or

90-99Yes

Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination

Stage 2 Hypertension

> 160 Or >100 Yes

Two-drug combination for most† (usually thiazide-type diuretic and ACEI or ARB or BB or CCB)

Indeed blood pressure is a continuum and any Indeed blood pressure is a continuum and any increase above normal value confers additional increase above normal value confers additional independent risk of coronary heart disease, independent risk of coronary heart disease, stroke, CHF, end stage renal disease, peripheral stroke, CHF, end stage renal disease, peripheral vascular disease. vascular disease. (McMahon S, Peto R et al.2002)(McMahon S, Peto R et al.2002)

3 mm Hg in SBP - 8% in stroke mortality3 mm Hg in SBP - 8% in stroke mortality - 5% in CAD mortality- 5% in CAD mortality

(National High blood pressure education programme working (National High blood pressure education programme working group report, 1993.)group report, 1993.)

The lifetime risk of developing hypertension The lifetime risk of developing hypertension is estimated to be 90% at the age of 55 years is estimated to be 90% at the age of 55 years (Vasan RS et al.2002, JAMA)(Vasan RS et al.2002, JAMA)

Each increment of 20mmHg (SBP) and Each increment of 20mmHg (SBP) and 10mmHg (DBP) doubles the risk of CVD 10mmHg (DBP) doubles the risk of CVD across the entire BP range from 115\75 to across the entire BP range from 115\75 to 185\115 mmHg 185\115 mmHg

What causes hypertension? What causes hypertension? Essential hypertension

Probable mechanisms :

• Rennin - angiotensin system

• Peripheral resistance vessels

• Overactivation of sympathetic nervous system

Secondary causes of hypertension:• Chronic steroid therapy • Reno vascular disease

• Chronic kidney disease

• Primary aldosteronism

• Pheochromocytoma

• Coarctation of aorta

• Thyroid \Parathyroid disease

Management of hypertension: Management of hypertension:

PharmacologicalPharmacological NonpharmacologicalNonpharmacological

Why not pharmacological exclusively? Failure of hypertension control point towards :

• non-compliance with treatment

• long term usage of drug

• increased risk of cardiovascular events

• economic-constraint

Is there any alternative?

Modifiable risk factors for Modifiable risk factors for Essential Hypertension :( JNC VII Essential Hypertension :( JNC VII

Guidelines)Guidelines) ObesityObesity

Physical inactivityPhysical inactivity

Alcohol consumptionAlcohol consumption

Diet Diet

Stress & anxietyStress & anxiety

Weight reduction Weight reduction

BMI (>/= 25kg/m2)BMI (>/= 25kg/m2) Essential hypertensionEssential hypertension

78%-in male78%-in male 65%-in female65%-in female

(Vasant RS, Larson MG et al, 2001)(Vasant RS, Larson MG et al, 2001)

Dolls, Bovet P et al, 2002

Confusion?

fasting exercise

surgery drugs

FastingFasting No energy input ensures negative No energy input ensures negative

energy balanceenergy balance

Weight loss is rapid but this is Weight loss is rapid but this is disadvantagedisadvantage

Disadvantage is a large portion of Disadvantage is a large portion of weight loss is from lean body mass.weight loss is from lean body mass.

Nutrient deficit occurNutrient deficit occur

ketogenicketogenic

SurgerySurgery

Alteration of gastrointestinal tract Alteration of gastrointestinal tract capacitycapacity

Advantage-Caloric restriction is less Advantage-Caloric restriction is less necessarynecessary

Disadvantage-risks of surgeryDisadvantage-risks of surgery

Exercise Exercise

Evidence supports that level of regular Evidence supports that level of regular physical activity is more effective than physical activity is more effective than dieting for long term weight control.dieting for long term weight control.

(French, S.A., et al. 1994)(French, S.A., et al. 1994)

Increased caloric expenditure through Increased caloric expenditure through aerobic type exercise is a significant aerobic type exercise is a significant option for unbalancing the energy option for unbalancing the energy equation to bring out both weight loss equation to bring out both weight loss and a favorable modification in body and a favorable modification in body composition.composition.

(Ballor, and Kessey et (Ballor, and Kessey et al.1994al.1994))

Calorie expenditure > Calorie intake by 10%Calorie expenditure > Calorie intake by 10%

Net 3500 kcal energy burning gives 0.45 kg body Net 3500 kcal energy burning gives 0.45 kg body fat loss.fat loss.

A meta analysis by staessen et al. showed that A meta analysis by staessen et al. showed that mean SBP & DBP reductions were 1.6/1.1 mmHg mean SBP & DBP reductions were 1.6/1.1 mmHg per kg of body weight by aerobic program.per kg of body weight by aerobic program.

18 month weight loss program associated with 18 month weight loss program associated with 77% reduction in incidence of hypertension.77% reduction in incidence of hypertension.

(He J, Whelton PK et al.2000)(He J, Whelton PK et al.2000)

The exact mechanism by which weight reduction The exact mechanism by which weight reduction lowers blood pressure is not known.lowers blood pressure is not known.

Probable mechanism:Probable mechanism:

- Decreased concentration of renin - Decreased concentration of renin and and

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

- Decrease in activity of - Decrease in activity of sympathetic sympathetic

nervous system.nervous system. (Esler M, Lambert G et al.2006) (Esler M, Lambert G et al.2006)

Physical Physical activityactivity

Physical activity

Endurance training

Resistance training

Isometric program

Endurance trainingEndurance training

Reduces blood pressure through:Reduces blood pressure through:

-Reduction in systemic vascular -Reduction in systemic vascular resistanceresistance

-decrease in renin - angiotensin -decrease in renin - angiotensin activityactivity

A meta analysis of RCTA meta analysis of RCT

Systolic Blood PressureDiastolic Blood Pressure

4.7 mm Hg3.1 mm Hg

Systemic VascularResistance

7.1%

Plasma noradrenaline 29%

Plasma rennin 20%

Body Weight 1.2 kg

Waist Circumference 2.8 cm

% Body Fat 1.4%

HDL 0.032 mmol/l

104 study groups involved

Intervention Duration – 4 weeks

Endurance Training program

Fagard RH et al, 2006, Sept.

A meta analysis of 54 RCTs showed net A meta analysis of 54 RCTs showed net reduction of 3.8 mm Hg (SBP) and 2.6 mm reduction of 3.8 mm Hg (SBP) and 2.6 mm Hg (DBP) in hypertensive individuals Hg (DBP) in hypertensive individuals performing aerobic exercise.performing aerobic exercise.

(Whelton SP, Chin A et al, (Whelton SP, Chin A et al, 2002)2002)

Recommended exercise protocol :Recommended exercise protocol :– Frequency :-Frequency :- > 3 sessions/week > 3 sessions/week– Intensity :-Intensity :- > 70% VO2 max > 70% VO2 max– Type :-Type :- aerobic exercise aerobic exercise– Time :-Time :- > 45 mins > 45 mins

More than these values have no added benefits

Halbert JA, Silagy CA et al, 1997

Resistance TrainingResistance Training

Strength exercise can even be used for Strength exercise can even be used for lowering blood pressure.lowering blood pressure.

The actual blood pressure response depends The actual blood pressure response depends on :on :

• isometric componentisometric component• exercise intensityexercise intensity• Muscle mass activatedMuscle mass activated• number of repetitionsnumber of repetitions• duration of contractionduration of contraction• involvement of valsalva maneuverinvolvement of valsalva maneuver

Bjarnason – Wehrens B, Mayer – Berger W et al, 2004

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

Kelley G et al, 1997Kelley G et al, 1997

Isometric ExerciseIsometric Exercise

Isometric exercise such as weight lifting can Isometric exercise such as weight lifting can have a pressor effect and therefore should be have a pressor effect and therefore should be avoided. Thus it is strictly contraindicated.avoided. Thus it is strictly contraindicated.

(Krousel(Krousel Wood MA, Muntner P et al, Wood MA, Muntner P et al, 2004)2004)

Moderation in alcohol Moderation in alcohol consumptionconsumption

Effects of alcohol reduction on BP showed a Effects of alcohol reduction on BP showed a dose dependent decline in BPdose dependent decline in BP

X in X, He J et al. 2001X in X, He J et al. 2001

Clinical Studies show that BP falls 4 to 5 mm Clinical Studies show that BP falls 4 to 5 mm Hg in days or weeks with abstinence from Hg in days or weeks with abstinence from alcoholalcohol

The JNC VII recommends that alcohol intake The JNC VII recommends that alcohol intake should be no more thanshould be no more than– 2 drinks/day (male)2 drinks/day (male)– 1 drink/day (female)1 drink/day (female)

For drinkersFor drinkers– < 20 – 30 gm/day (male)< 20 – 30 gm/day (male)

– < 10 – 20 gm/day (female< 10 – 20 gm/day (female))Puddey IB et al, Puddey IB et al,

1992.1992.

Dietary Modification

Reduce Salt Intake

Approximately 6 gm/day can prevent hypertension (trials of hypertension prevention collaborative research group, 1997)

Salt Intake reduction 6 gm/day.

7.11 mm Hg (SBP) & 3.88 mm Hg (DBP) in hypertensives.

Mac Gregor GA et al, 2002

Reduce Stroke Deaths by 14% and Coronary Reduce Stroke Deaths by 14% and Coronary deaths by 9% in hypertension.deaths by 9% in hypertension.

Consume foods low in salt (SRD)Consume foods low in salt (SRD) Avoid pickles, processed foods, chips and Avoid pickles, processed foods, chips and

chutneys.chutneys.

Increase potassium intakeIncrease potassium intake

High potassium intake – reduce blood High potassium intake – reduce blood pressurepressure

Consume foods such as fruits, vegetables Consume foods such as fruits, vegetables and especially coconut.and especially coconut.

Stress and Anxiety Stress and Anxiety ControlControl

Meditation was in one study to reduce SBP and Meditation was in one study to reduce SBP and DBP by 10.7 mm Hg and 6.4 mm Hg over a period DBP by 10.7 mm Hg and 6.4 mm Hg over a period of 3 monthsof 3 months

Schneider RH Alexander CN et al, 1995Schneider RH Alexander CN et al, 1995

Progressive muscle relaxation lower SBP by 4.7 Progressive muscle relaxation lower SBP by 4.7 mm Hg and DBP by 3.3mm Hg.mm Hg and DBP by 3.3mm Hg.

Yoga is also widely believed to reduce blood Yoga is also widely believed to reduce blood pressurepressure

Damodaran A, Patil N, Suryavanshi et al, 2002Damodaran A, Patil N, Suryavanshi et al, 2002

However, these interventions are with limited and However, these interventions are with limited and uncertain efficacy. Therefore more trials are uncertain efficacy. Therefore more trials are needed to confirm its effectneeded to confirm its effect..

conclusionconclusion Hypertension is a silent killer.Hypertension is a silent killer. Cardiopulmonary Physiotherapy is an Cardiopulmonary Physiotherapy is an

integral part of health service.integral part of health service. Evidence supports that exercise is the Evidence supports that exercise is the

cornerstone for hypertension control, cornerstone for hypertension control, then why it is not being utilized.then why it is not being utilized.

This is the time, physiotherapist must This is the time, physiotherapist must emerge and show their potential to beat emerge and show their potential to beat paramount disorder like hypertension paramount disorder like hypertension where even pharmacological where even pharmacological management fails.management fails.