1. Lifestyle Modifications for the Prevention and Management of Hypertension ANDREAS PITTARAS MD

2. Blood Pressure and CVD High BP is a strong, consistent and independent risk factor for CV events. The risk begins at BP 115/75 mm Hg and doubles with each incremental increase of 20/10 mm Hg. Vasan RS, et al. The Framingham Heart Study.JAMA 2002:287:1003-10 Lewington S. Lancet 2002;360:1903-1913

3. JNC Goal: Not Only Treat HTN, But Prevent it. Does Increased Physical Activity Prevent or Attenuate the Progression to HTN?

4. Physical Activity and BP Moderate increases in PA can prevent or at least attenuate the development of HTN. The RR for developing HTN is about 1.5 to 2.0 times higher in sedentary vs physically active individuals. Staessen, et al., ’94; Sawada S, et al. ’93; Reaven et al., ‘91 Blair S, et al., ‘84 ; Paffenbarger et al., ‘83

5. Ambulatory SBP and Fitness in Men mm Hg High-Fit Mod-Fit Low-FitN=407 Kokkinos P. Pittaras A, et al. Am J Hypertension 2006; 19(3):251-58

6. Ambulatory DBP and Fitness in Men mm Hg High-Fit Mod-Fit Low-FitN=407 Kokkinos P. Pittaras A, et al. Am J Hypertension 2006; 19(3):251-58

7. Ambulatory SBP and Fitness in Women mm Hg High-Fit Mod-Fit Low-FitN=243 Kokkinos P. Pittaras A, et al. Am J Hypertension 2006; 19(3):251-58

8. Ambulatory DBP and Fitness in Women mm Hg High-Fit Mod-Fit Low-Fit N=243 Kokkinos P. Pittaras A, et al. Am J Hypertension 2006; 19(3):251-58

9. LVMI and Fitness in Pre-Hypertensives g/m 2.7 Kokkinos, P, Pittaras A, Manolis T. Hypertension 2007; 49:1-7 N=790

10. The Role of Physical Activity in the Management of Hypertension

11. Kokkinos P., et al. Cardiology Clinics 2001;19(3):507-516 Average Reduction in BP: Active: 10.5/7.6 mm Hg Controls: 3.8/1.3 mm Hg

12. Exercise and BP How Much Exercise for changes? (intensity, Duration, Frequency) How Intense Should Exercise Be? How Soon Do We See Results? How Long Do the Changes Last?

13. Exercise Intensity and BP Reduction mm Hg Low Intensity (53% VO 2 max) High Intensity (73% VO 2 max) Hagberg J., et al. Am J Cardiol 1989;64:348-53 SBPDBPSBPDBP

14. mm Hg Low Intensity (50% VO 2 max) High Intensity (75% VO 2 max) Matsusaki M, et al. Clin Exp Pharm & Physiol 1992;19:471-9 SBPDBP SBP DBP Exercise Intensity and BP Reduction

15. BP Changes with Exercise in pts with Severe Hypertension (Stage 2 & 3) mm Hg 16 weeks32 weeks Kokkinos P, Pittaras A.et al. N Engl J Med 1995;333:1462-7 SBP DBP

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

17. LVMI at Baseline and 16 Weeks * * p<0.05 Baseline16 weeks g/m2 Kokkinos P, Pittaras A et al. N Engl J Med 1995;333:1462-7

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

19. Exercise and BP Reduction How Soon Should We Expect To Observe Changes in BP?

20. Time Course for Exercise and BP Reductions Acute changes occur immediately after cessation of activity. They last about 2-12 hours. Chronic changes?

21. BP Changes with Exercise mm Hg SBP DBP 2 Weeks 16 Weeks 2 Weeks Kokkinos P., Pittaras A et al. N Engl J Med 1995;333:1462-7

22. Exercise and BP Reduction How Long Do These Changes Last?

23. SBP Response to Training & Detraining 33% Reduction in Meds mm Hg Exercise Training

24. Clinical Significance of Exercise-Induced BP Reduction

25. Relative Risk of All-Cause Death and Exercise Capacity in Hypertensive Patients RR of Death Myers J. et al., N Engl J Med 1002;346:793-801

26. Exercise Capacity and Mortality in HTN Pts (VAMC Data (n=4,397) RR of Death

27. Exercise Capacity and Mortality in HTN+DM: VAMC DATA RR of Death

28. Exercise Capacity and Mortality in HTN + Obesity: VAMC DATA RR of Death

29. Survival and Fitness Levels for HTNs >10 MET; n=968 7-10 MET; n=15635-7 MET; n=1310 <5 MET; n=578 >10 MET; n=1,000 7-10 MET; n=1558 5-7 MET; n=1286 <5 MET; n=524 Log Rank=222; p<0.001 N=4,368

30. Exercise Recommendations for BP Control American College of Sports Medicine F: Frequency: 3-6 times/wk I: Intensity: Moderate (Brisk walk) T: Time: 20-60 min/session. May split sessions (AM/PM) T: Type: Type of Exercise: Aerobic

31. Exercise Intensity for Health Benefits PMHR: 60% - 70%>85% METs: < 4 – 5 7 10 + Fast walk Running 6 km/hr 10 km/hr 500 - 1000 3000 Kcal

32. Body Weight and BP A direct association between excess body wt and HTN regardless of age, gender & race. 4.5 kg reduction in wt resulted in reduced BP. 60% of pts remained normotensive without pharmacologic therapy (DISH Trial) Better control of BP achieved when Wt reduction added to antihypertensive therapy. Waist circumference <85 cm for women and <98 cm Men and BMI<27 are recommended.

33. Exercise for HTNsive, Obese Patients Likely to have multiple risk factors ETT strongly recommended Tailor exercise to patient needs/abilities. Frequency: 3-6 days/week Low intensity exercises (HR ~95-100 bpm) Initial duration of 10 min/day Two sessions (am/pm), 5 min/secs if needed) Increase by 2 min/wk- Aim: 100-200 min/wk

34. Dietary Factors and Blood Pressure

35. Salt Reduction and Blood Pressure Historically, the limitation of salt in food has been the primary dietary approach in the control of HTN. Over 50 studies have been concluded. Recent Meta analysis revealed a reduction of 5/2.7 mm Hg in BP for a reduction of ~ 1.8 g/d in urinary sodium for HTN pts. He FJ, et al. J Hum Hypertns. 2002;16:761-70

36. Foods and Blood Pressure Calcium and Magnesium: –Small reductions. Insufficient data to recommend supplementation. Potassium : –Meta-analysis (33 trials): a modest reduction (3/2 mm Hg) in HTN pts receiving potassium supplements. Effects more AA and those with high sodium intake. Fish Oil: Not routinely recommend Fiber: Insufficient data. High CHO Intake : –High sugar intake is shown to increase BP. More studies necessary High Protein Intake: –Some evidence of lower BP, but may be due to lower CHO

37. Comprehensive Dietary Approaches for BP Control It is becoming more evident that diets low in salt and fat and rich in other minerals are more effective in lowering BP than any one element alone. Such diets include the DASH Diet and the Mediterranean diet.

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

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

40. Weekly SBP in the DASH Trial mm Hg Appel L, et al. N Engl J Med 1997;336:1117-24 Fruits + Vegetables Control Group Diet Fruits + Vegetables + Low Fat Intervention Week X=5.5 mm Hg

41. Weekly DBP in the DASH Trial mm Hg Appel L, et al. N Engl J Med 1997;336:1117-24 Fruits + Vegetables + Low Fat Intervention Week X=3 mm Hg Control Group Diet Fruits + Vegetables

42. SBP Changes & Sodium in the DASH Trial mm Hg Sacks FM, et al. N Engl J Med 2001;344:3-10 Control Group Diet DASH Diet -5.9 -5.0 -2.2

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

44. DASH Trial and Blood Pressure Compelling evidence that adequate intake of minerals should be the focus of dietary recommendations in the control of BP. The DASH Diet in combination with reduced salt intake optimizes BP control.

45. Alcohol Consumption and BP Panagiotakos D. et al J Hypertens 2003;21:1-7

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