Hypertension Nonpharmacologic Therapy

Lifestyle modification may have an impact on morbidity and mortality. A diet rich in fruits, vegetables, and low-fat dairy foods and low in saturated and total fats (DASH diet) has been shown to lower blood pressure. Additional measures can prevent or mitigate hypertension or its cardiovascular consequences as shown in Table 11-2.

All patients with high-normal or elevated blood pressures, those who have a family history of cardiovascular complications of hypertension, and those who have multiple coronary risk factors should be counseled about nonpharmacologic approaches to lowering blood pressure. Approaches of proved but modest value include weight reduction, reduced alcohol consumption and, in some patients, reduced salt intake. Gradually increasing activity levels should be encouraged in previously sedentary patients, but strenuous exercise training programs in already active individuals may have less benefit. Calcium and potassium supplements have been advocated, but their ability to lower blood pressure is limited.

Smoking cessation will reduce overall cardiovascular risk.

Bibliography

_{Bray GA et al: A further subgroup analysis of the effects of the DASH diet and three dietary sodium levels on blood pressure: results of the DASH-Sodium Trial. Am J Cardiol 2004;94:222. [PMID: 15246908] Hooper L et al: Advice to reduce dietary salt for prevention of cardiovascular disease. Cochrane Database Syst Rev 2004;(1): CD003656. [PMID: 14974027] Krousel-Wood MA et al: Primary prevention of essential hypertension. Med Clin North Am 2004;88:223. [PMID: 14871061] Stewart KJ: Exercise training and the cardiovascular consequences of type 2 diabetes and hypertension: plausible mechanisms for improving cardiovascular health. JAMA 2002;288:1622. [PMID: 12350193] Whelton SP et al: Effect of aerobic exercise on blood pressure: a meta-analysis of randomized controlled trials. Ann Intern Med 2002;136:493. [PMID: 11926784] Wilburn AJ et al: The natural treatment of hypertension. J Clin Hypertens (Greenwich) 2004;6:242. [PMID: 15133406]}

Who Should Be Treated with Medications?

Many excellent trials have shown that drug therapy of patients with stage 2 hypertension reduces the incidence of stroke by 30-50%, congestive heart failure by 40-50%, and progression to accelerated hypertension syndromes. The decreases in fatal and nonfatal coronary heart disease and cardiovascular and total mortality have been less dramatic, ranging from 10% to 15%. This lesser decrease in coronary heart disease has generated controversy. Some experts have attributed the decreased benefit to characteristics of the drugs (primarily diuretics and β-blockers), such as their adverse effect on lipid profiles and electrolyte balance. Others believe it is due to the more chronic and multifactorial nature of coronary artery disease, the generally low-risk populations included in trials, and the large number of crossovers from placebo to active therapy. Several studies in older persons with predominantly systolic hypertension have confirmed that antihypertensive therapy prevents fatal and nonfatal myocardial infarction and overall cardiovascular mortality. These trials have also placed the focus on control of systolic blood pressure - in contrast to the historical emphasis on diastolic blood pressures.