1. Lifestyle modifications in Hypertension

2. Blood Pressure The pressure in the arterial blood vessels results from: The pressure in the arterial blood vessels results from: flow of blood from the heart flow of blood from the heart resistance of the arterial blood vessel walls resistance of the arterial blood vessel walls The higher the blood pressure, the harder the heart has to pump in order to supply the body with blood The higher the blood pressure, the harder the heart has to pump in order to supply the body with blood

3. Blood Pressure

4. The first (top) number is the systolic blood pressure (SBP) and indicates the pressure in the artery when the heart is actively pumping blood The first (top) number is the systolic blood pressure (SBP) and indicates the pressure in the artery when the heart is actively pumping blood The second (bottom) number is the diastolic blood pressure (DBP) and indicates the pressure in the artery when the heart is resting between beats The second (bottom) number is the diastolic blood pressure (DBP) and indicates the pressure in the artery when the heart is resting between beats

5. Measuring Blood Pressure

6. Blood pressure is measured in the sitting position after at least 5 minutes of rest Blood pressure is measured in the sitting position after at least 5 minutes of rest The blood pressure cuff should be the correct size and should not be placed over clothing The blood pressure cuff should be the correct size and should not be placed over clothing At least two blood pressure measurements should be made and blood pressure categorized based on the average At least two blood pressure measurements should be made and blood pressure categorized based on the average

7. Blood Pressure Categories Category Systolic BP Diastolic BP Normal blood pressure Less than 120 Less than 80 Pre-hypertension 120 to 139 80 to 89 Stage 1 hypertension 140 to 159 90 to 99 Stage 2 hypertension 160 or higher 100 or higher

8. Blood Pressure & Aging There is an age-related increase in blood pressure due to: There is an age-related increase in blood pressure due to: Increased arterial wall tension Increased arterial wall tension Increased peripheral resistance Increased peripheral resistance Increased arterial stiffness Increased arterial stiffness This is not benign: The blood pressure categories are not adjusted upwards to compensate for aging This is not benign: The blood pressure categories are not adjusted upwards to compensate for aging

9. Why Do We Worry About High Blood Pressure?

10. Framingham Heart Study Objective: “…identify the common factors or characteristics that contribute to cardiovascular disease by following its development over a long period of time in a large group of participants who had not yet developed overt symptoms of cardiovascular disease or suffered a heart attack or stroke.”

11. Framingham Heart Study: Risks of Hypertension Cardiac disease Cardiac disease Heart attack and heart failure Heart attack and heart failure Cerebrovascular disease Cerebrovascular disease Stroke Stroke Peripheral vascular disease Peripheral vascular disease Circulation in the extremities Circulation in the extremities Microvascular disease Microvascular disease Kidney and eye disease Kidney and eye disease

12. Benefits of Blood Pressure Control Blood pressure control can reduce the risk of heart attack by 20% to 25% Blood pressure control can reduce the risk of heart attack by 20% to 25% Blood pressure control can reduce the risk of heart failure by more than 50% Blood pressure control can reduce the risk of heart failure by more than 50% Blood pressure control can reduce the risk of stroke by 35% to 40% Blood pressure control can reduce the risk of stroke by 35% to 40% A 10mmHg drop in SBP lowers the risk of death from stroke by 50-60% and the risk of death from heart attack by 40-50% A 10mmHg drop in SBP lowers the risk of death from stroke by 50-60% and the risk of death from heart attack by 40-50%

13. Blood Pressure Control

14. Lowering Blood Pressure Lifestyle modification Lifestyle modification Smoking cessation Smoking cessation Increased physical activity Increased physical activity Limitation of alcohol intake Limitation of alcohol intake Maintenance of a healthy body weight Maintenance of a healthy body weight Diet comprised of healthy foods Diet comprised of healthy foods Pharmacotherapy (medications) Pharmacotherapy (medications)

15. Lifestyle Modification ModificationRecommendation Approximate drop in SBP Weight reduction Maintain normal body weight 5-10 mmHg/ 10kg weight loss DASH eating plan Rich in fruits, vegetables, low fat dairy; reduced saturated & total fat 8-14 mmHg Less dietary sodium No more than 2.4 g sodium/day 2-8 mmHg Physical activity Aerobic activity for 30 minutes at least 5 days/week 4-9 mmHg Alcohol in moderation No more than 2/day for men No more than 1/day for women 2-4 mmHg

16. Diet

17. Diet & Blood Pressure Salt Excess can increase blood pressure Excess can increase blood pressurePotassium Insufficient can increase blood pressure Insufficient can increase blood pressureWeight Excess can increase blood pressure Excess can increase blood pressureAlcohol

18. Diet & Blood Pressure Several research studies have shown beneficial effects of diets rich in magnesium, potassium, calcium, fiber, and protein Several research studies have shown beneficial effects of diets rich in magnesium, potassium, calcium, fiber, and protein Studies looking at supplementation of individual nutrients have not shown much improvement in blood pressure Studies looking at supplementation of individual nutrients have not shown much improvement in blood pressure

19. DASH Clinical Trial Looked at the effect of dietary patterns rather than individual nutrients for blood pressure lowering Looked at the effect of dietary patterns rather than individual nutrients for blood pressure lowering Studied three different diet patterns: Studied three different diet patterns: Control (typical) diet Control (typical) diet Fruits and vegetables diet Fruits and vegetables diet Combination (DASH) diet Combination (DASH) diet

20. Control Diet Potassium, magnesium, and calcium levels were close to 25 th percentile of U.S. consumption Potassium, magnesium, and calcium levels were close to 25 th percentile of U.S. consumption Macronutrients (carbohydrate, fat, protein) and fiber were similar to average U.S. consumption Macronutrients (carbohydrate, fat, protein) and fiber were similar to average U.S. consumption Typical “American” diet Typical “American” diet

21. Fruits & Vegetables Diet Potassium and magnesium close to the 75 th percentile of U.S. consumption Potassium and magnesium close to the 75 th percentile of U.S. consumption High amount of fiber High amount of fiber More fruits and vegetables and fewer snacks and sweets than control diet, but was otherwise similar More fruits and vegetables and fewer snacks and sweets than control diet, but was otherwise similar

22. Combination (DASH) Diet Potassium, magnesium, and calcium close to the 75 th percentile of U.S. consumption Potassium, magnesium, and calcium close to the 75 th percentile of U.S. consumption High amounts of fiber and protein High amounts of fiber and protein Rich in fruits, vegetables, and low fat dairy foods Rich in fruits, vegetables, and low fat dairy foods Reduced amount of saturated fat, total fat, and cholesterol Reduced amount of saturated fat, total fat, and cholesterol

23. DASH Clinical Trial Study subjects were provided with meals that were prepared in research kitchens Study subjects were provided with meals that were prepared in research kitchens All diets contained approximately 3 grams sodium per day All diets contained approximately 3 grams sodium per day Each subject was given the appropriate calories to maintain weight and diet was adjusted for weight loss or weight gain Each subject was given the appropriate calories to maintain weight and diet was adjusted for weight loss or weight gain

24. Results (Change in SBP/Change in DBP) Category DASH – Control DASH – Fruits/Veg Fruits/Veg – Control All subjects -5.5/-3.0-2.7/-1.9-2.8/-1.1 Men-4.9/-3.3-1.6/-1.3-3.3/-2.0 Women-6.2/-2.7-3.9/-2.5-2.3/-0.2 HTN-11.4/-5.5-4.1/-2.6-7.2/-2.8 No HTN -3.5/-2.1-2.7/-1.8-0.8/-0.3

25. DASH Results Weeks Systolic Blood Pressure

26. DASH Meal Plan Fruits: 4-5 servings/day Fruits: 4-5 servings/day 1 medium fruit; 6 ounces fruit juice 1 medium fruit; 6 ounces fruit juice Vegetables: 4-5 servings/day Vegetables: 4-5 servings/day 1 cup raw leafy; ½ cup cooked 1 cup raw leafy; ½ cup cooked Low fat dairy products: 2-3 servings/day Low fat dairy products: 2-3 servings/day 8 ounces milk/yogurt; 1.5 ounces cheese 8 ounces milk/yogurt; 1.5 ounces cheese Grains: 7-8 servings/day Grains: 7-8 servings/day 1 slice bread; ½ cup cereal, rice, pasta 1 slice bread; ½ cup cereal, rice, pasta Meat, Fish, Poultry: 2 or less servings/day Meat, Fish, Poultry: 2 or less servings/day 3 ounces 3 ounces Nuts, Seeds, Dried Beans: 4-5 servings/week Nuts, Seeds, Dried Beans: 4-5 servings/week 1/3 cup nuts; 2 tablespoons seeds, ½ cup cooked beans 1/3 cup nuts; 2 tablespoons seeds, ½ cup cooked beans

27. Exercise

28. Aerobic Activity To promote and maintain health, all healthy adults age 18-65 years need moderate-intensity physical activity for a minimum of 30 minutes on five days each week OR vigorous-intensity for a minimum of 20 minutes on three days each week. Also, combinations of moderate- and vigorous-intensity activity can be performed to meet this recommendation. American College of Sports Medicine American Heart Association 2007 Recommendations

29. Muscle-Strengthening Activity To promote and maintain good health and physical independence, adults will benefit from performing activities that maintain or increase muscular strength and endurance for a minimum of two days each week. It is recommended that 8-10 exercises be performed on two or more nonconsecutive days each week using the major muscle groups. American College of Sports Medicine American Heart Association 2007 Recommendations

30. Pharmacotherapy

31. Antihypertensive Medications All antihypertensive medications are effective at lowering blood pressure All antihypertensive medications are effective at lowering blood pressure Some provide additional benefits Some provide additional benefits Newer medications are not necessarily better than older medications Newer medications are not necessarily better than older medications Medications control hypertension, they don’t cure it Medications control hypertension, they don’t cure it Medications only work if they are taken every day Medications only work if they are taken every day

32. Antihypertensive Medications ACE Inhibitors (ACEI) ACE Inhibitors (ACEI) Angiotensin receptor blockers (ARB) Angiotensin receptor blockers (ARB) Diuretics Diuretics Beta blockers (BB) Beta blockers (BB) Calcium channel blockers (CCB) Calcium channel blockers (CCB) Alpha blockers Alpha blockers Nitrates Nitrates

33. Treatment Recommendations Area of Concern BP Target Lifestyle Modification Specific Drug Indications General CAD Prevention <140/<90Yes Any effective BP drug or combination High CAD Risk* <130/<80Yes ACEI, ARB, CCB, thiazide, or combination Stable Angina <130/<80Yes Β-blocker AND ACEI or ARB *Diabetes, chronic kidney disease, known CAD or CAD equivalent, or 10y Framingham risk score >10%

34. Side Effects Unintended effects of a medication Unintended effects of a medication Many medications cause minor side effects Many medications cause minor side effects All antihypertensive medications can cause you to feel dizzy if you stand up quickly, especially when you first start taking the medication All antihypertensive medications can cause you to feel dizzy if you stand up quickly, especially when you first start taking the medication

35. Monitoring Blood pressure should be rechecked within 2 to 4 weeks after starting a new blood pressure medication Blood pressure should be rechecked within 2 to 4 weeks after starting a new blood pressure medication Blood pressure can be monitored at home or in the clinic Blood pressure can be monitored at home or in the clinic Some antihypertensive medications also require laboratory or heart rate monitoring (ACEI, ARB, diuretic, BB, some CCBs) Some antihypertensive medications also require laboratory or heart rate monitoring (ACEI, ARB, diuretic, BB, some CCBs)

36. Adherence to Therapy Medications won’t work if you don’t take them as prescribed Medications won’t work if you don’t take them as prescribed Medications must be taken daily to keep blood pressure under control Medications must be taken daily to keep blood pressure under control Talk to your provider about any problems that you have with taking your medication Talk to your provider about any problems that you have with taking your medication

37. Summary High blood pressure increases risk of cardiovascular, kidney, and eye disease High blood pressure increases risk of cardiovascular, kidney, and eye disease Lifestyle modification is an effective means of lowering blood pressure Lifestyle modification is an effective means of lowering blood pressure Medications are needed to achieve optimal blood pressure levels in many people Medications are needed to achieve optimal blood pressure levels in many people