XAVIER UNIVERSITY ATENEO DE CAGAYAN

The Comparison between Pharmacologic and Non-pharmacologic Management of Hypertensive Patients.

Research Paper

Presented to: Christine Salvador Instructor

Presented by: Octubre, Karenn Joy C. Pagute, Demelyn J. English 27- NG

February 27, 2012

Sentence Outline

Title: The Comparison between Pharmacologic and Non-pharmacologic Management of Hypertensive Patients.

Thesis statement: Non-pharmacologic intervention is more effective compared to pharmacologic intervention in the management of hypertension.

I.

The most common worldwide disease afflicting humans is hypertension.

II.

The comparison between pharmacologic and non-pharmacologic intervention used in the management of hypertension based on its advantages and disadvantages. A. What are the different pharmacologic interventions used to manage hypertension? B. What are the different non-pharmacologic interventions used to manage hypertension? C. What are the advantages and disadvantages of each intervention?

III.

Non-pharmacologic intervention is more effective compared to pharmacologic intervention because of it offers more advantages and less disadvantages.

Chapter I Introduction Hypertension is defined as systolic blood pressure greater than 140mmHg and a diastolic greater than 90mmHg over a sustained period of time. It is also known as high blood pressure. There are two types of hypertension, the primary which is the reason for the elevation in blood pressure is unknown, and secondary which high blood pressure results from an identified cause such as sedentary lifestyle, high fat diet, and genetics. Hypertension is sometimes called the silent killer because people who had high blood pressure are sometimes unaware of their elevated blood pressure and have no accompanying signs and symptoms, such as dizziness, palpatations, nape pain, and alterations in speech and vision (Smeltzer & Bare, 2010). Major risk factors of having hypertension include smoking, dyslipidemia, diabetes mellitus, impaired renal function, obesity, physical inactivity, age over 55 years for men and 65 years for women, and a family history of cardiovascular disease. Some of these risk factors can be controlled or prevented by an individual such as smoking, obesity, and physical inactivity. Having hypertension would lead to serious complications such as heart failure, stroke, chronic kidney disease, peripheral arterial disease, retinopathy, and even death. So, prompt identification of the disease condition and treatment is very important (Smeltzer & Bare, 2010). Hypertension is the number one attributable risk factor for death throughout the world. According to the Control for disease control (CDC, 2006), about one out of three U.S. adults have high blood pressure. High blood pressure is a major risk factor for heart disease, stroke, congestive heart failure, and kidney diseases. In 2006, hypertension was

listed as a primary contributing cause of death for 326, 000 Americans and hypertension also cost United States $76.6 billion in health care services, medications, and missed days of work. In the Philippines, hypertension is the fifth leading cause of morbidity (DOH, 2005), accounting for 448 per 100,000 population and sixty-one deaths per 100,000 Filipinos. According to the Philippine Society of Hypertension (2006), one out of five adult Filipinos is hypertensive and not even aware of the condition, while 90 percent of the countrys population has one or more of the risk factors that contributes to high blood pressure. These reveal that most Filipinos are at high risk of having hypertension which could be very fatal if left untreated. Furthermore, because of the alarming number of cases having hypertension and number of people who died from it, the researchers were motivated to study about hypertension and what are its different treatments and managements. Hypertensive

people can lower their blood pressures into safety zone with the use of medications (pharmacologic therapy) or with lifestyle modification (non-pharmacologic interventions). In this study, the will researchers compare the two interventions that can effectively manage hypertension. The researchers will provide evidences on which intervention is more effective in the management of hypertension basing on the advantages and disadvantages of each intervention. Based on having more advantages and less disadvantages, the researchers will be able to determine the most effective intervention. The main aim of this study is to gain knowledge on what are the different treatment plans of hypertension and to compare which is more effective from the two variables. The findings of this study will be beneficial not only the hypertensive patients for whom the

treatment plans are indicated, but as well as the health care providers through giving their patients appropriate intervention. And also, findings of this study can also serve as basis for future researchers to conduct another study related to hypertension and its management.

Chapter II Hypertension is defined as systolic blood pressure greater than 140mmHg and a diastolic pressure greater than 90mmHg over a sustained period. It is also known as high blood pressure. There are two types of hypertension, the primary and the secondary hypertension. In primary hypertension, the reason for the elevation in blood pressure cannot be identified. It means that the cause of hypertension is unknown; his/her blood pressure just increases. In secondary hypertension, high blood pressure results from an identified cause which is sedentary lifestyle, high fat diet, stress, and genetics. Hypertension is sometimes called the silent killer because people who have it are often symptom free. It means that people who had high blood pressure are unaware of their elevated blood pressure and they dont have accompanying signs and symptoms, such as dizziness, palpitations, nape pain, and alterations in speech and vision (Smeltzer & Bare, 2010). Hypertension is the number one attributable risk factor for death throughout the world. According to the Control for disease control (CDC, 2006), about one out of three U.S. adults have high blood pressure. High blood pressure is a major risk factor for heart disease, stroke, congestive heart failure, and kidney diseases. In 2006, hypertension was listed as a primary contributing cause of death for 326, 000 Americans and hypertension also cost United States $76.6 billion in health care services, medications, and missed days of work. In the Philippines, hypertension is the fifth leading cause of morbidity (DOH, 2005), accounting for 448 per 100,000 population and sixty-one deaths per 100,000 Filipinos. According to the Philippine Society of Hypertension (2006), one out of five adult Filipinos is hypertensive and not even aware

of the condition, while 90 percent of the countrys population has one or more of the risk factors that contributes to high blood pressure. This reveals that most Filipinos are at high risk of having hypertension, which could be very fatal if left untreated. Smeltzer and Bare (2010) said that blood pressure is the product of cardiac output multiplied by peripheral resistance. Cardiac output is the product of the heart rate multiplied by the stroke volume. In normal circulation, pressure is transferred from the heart muscle to the blood each time the heart muscle contracts and then pressure is exerted by the blood as it flows through the blood vessels. Hypertension can result from an increase in cardiac output, an increase in peripheral resistance, or both. Hypertension is a multifactorial condition. Smeltzer and Bare (2010) stated that because hypertension is a sign, it is most likely to have many causes, just as fever has many causes. For hypertension to occur there must be a change in one or more factors affecting peripheral resistance or cardiac output. These factors include excess sodium intake, fewer nephrons, stress, genetic alteration, obesity, and endothelial factors. In addition, increased sympathetic nervous system activity, increased renal absorption of sodium, chloride, and water, increased activity of the rennin-angiostensin-aldosterone system, decreased vasodilation, and resistance to insulin action are some of the causes of hypertension. In addition, major risk factors for hypertension includes smoking, dyslipidemia, diabetes mellitus, impaired renal function, obesity, physical inactivity, age older than 55 years for men and 65 years for women, and family history of cardiovascular disease. Physical examination may reveal no abnormalities other than elevated blood pressure. However, retinal changes and papilledema (swelling of the optic disk) may be

seen. Coronary artery disease with angina and myocardial infarction are common consequence of hypertension. Increased in blood urea nitrogen and serum creatinine levels may indicate pathologic changes in the kidneys. Cerebrovascular involvement may lead to stroke or transient ischemic attack, manifested by alterations in vision and speech, dizziness, weakness, a sudden fall, or transient or permanent paralysis on one side (Smeltzer & Bare, 2010). Hypertension (high blood pressure) is a sustained elevation of systemic blood pressure to a level that places the patient at increased risk for target organ damage. It has been called the silent disease because there may be no initial symptoms. When left untreated, hypertension can lead to heart disease, kidney disease and stroke. There is no cure; therefore lifestyle modifications and pharmacological therapy are necessary for blood pressure (pressure against the flow of blood to or from the arteries or veins outside the chest) control. Treatment of hypertension must continue throughout life, making non-compliance a significant problem (Daniels, 2007). Constant, excessive high blood pressure, called hypertension, can damage the fragile inner lining of the blood vessels and cause a disruption of blood flow to the tissues. It also puts a tremendous strain on the heart muscle, increasing myocardial oxygen consumption and putting the heart muscle itself at risk. Hypertension can be caused by neurostimulation of the blood vessels that causes them to constrict and to raise pressure or by increased volume in the system. In most cases, its cause is not known, and drug therapy to correct it is aimed at changing one or more of the normal reflexes that control vascular resistance or the force of cardiac muscle contraction (Karch, 2008).

Hypertension has no symptoms; it is difficult to diagnose and treat and is often called as a silent killer. All of the drugs used to treat hypertension have adverse effects, many of which are seen as unacceptable by otherwise healthy people. Nurses face a different challenge trying to convince patients to comply with their drug regimens when they experience adverse effects and do not see any positive effects on their bodies (Karch, 2008). If hypertension is controlled, the patients risk of cardiovascular and disease is reduced. The risk of developing cardiovascular complications is directly related to the patients degree of hypertension. Lowering the degree can lower the risk. The Seventh Joint National Committee on Prevention, Detection, Evaluation and Treatment of Hypertension, from the National Institute of Health, has established a stepped care approach to treating hypertension that has proved effective in national studies (Karch, 2008).

On the Pharmacological Management The goal of hypertension treatment is to prevent complications and death by achieving and maintaining the arterial blood pressure at 140/90mmHg or lower. The medications used for treating hypertension decreased peripheral resistance, blood volume, or the strength and rate of myocardial contraction (Smeltzer & Bare, 2010). The classes of antihypertensive drugs include diuretics, sympatholytics and other components of drugs. Diuretics can enhance the effects of other hypotensive drugs and it reduces blood pressure if taken alone. Under of which includes three categories thiazide, loop diuretics and potassium sparing diuretics. In thiazide diuretics, there are

two ways or mechanism to reduce blood pressure: reduction of blood volume and reduction of arterial resistance. Loop diuretics promote vasodilation and reduce blood volume. Potassium- sparing diuretics conserve the potassium in the body and balance the potassium level. For the sympatholytics, there are five categories: beta blockers, alpha blockers, alpha/beta blockers, centrally acting alpha2 agonist and adrenergic neuron blocker. These subcategories have a common effect which is to suppress and prevent sympathetic effects on the body by causing vasodilation to constricted arteries (Lehne, 2007). The drugs currently available for treatment of hypertension work in one of two ways, reduction of the systemic vascular resistance (SVR) or decrease the volume of circulating blood. Vasodilating drugs increase the diameter of the arterioles, by various mechanisms. Pharmacological therapy usually begins with a diuretic. It is divided into several classes: loop, potassium sparing, thiazide and aldosterone receptor blockers. Diuretics promote the excretion of water (decrease the blood volume) and electrolytes by increasing the renal GFR (Karch, 2008). Drugs used to treat hypertension work to alter the normal reflexes that control the blood pressure. Treatment for essential hypertension does not cure the disease but is aimed to maintaining the blood pressure within normal limits to prevent the damage that hypertension has caused. Not all patients respond the same way to antihypertensive drugs, because different factors may contribute to each persons hypertension (Karch, 2008).

On the Non- pharmacological Management According to Gottlieb (2000), most people with hypertension can lower their blood pressures into safety zone without resorting to drugs. There are alternative remedies presented that can bring blood pressure down to a healthier level. According to Dr. Whitaker, the number one recommendation for hypertensive patients is water remedy. Fifteen glasses of water a day is required for hypertensive patients because it mimics the effects of medication. Water helps the entire system and arteries to relax. Other alternatives are potassium-rich foods which lowers the level of sodium in the body. Exercise at least four times a week within thirty minutes to decrease stress as well as relaxes the artery walls and also increase the intake of fish oil, garlic, and magnesium gluconate which is said to lower the blood pressure. Smeltzer and Bare (2010) stated that studies show that diets high in fruits, vegetables, and low-fat dairy products can lower elevated blood pressure. The Dietary Approaches to Stop Hypertension (DASH) diet can lower blood pressure in people who follow it. Lifestyle modifications to prevent and mange hypertension includes weight reduction, adopt DASH diet, dietary sodium restriction, physical activity, and moderation of alcohol consumption. Maintain a normal body weight with a body mass index of 18.524.9 kg/m2. Consume a diet rich in fruits, vegetables, and low-fat diet with a reduced content of saturated fat and total fat. Dietary sodium intake should be no more than 100mmol/day or 2.4 g sodium. According to Silverberg (1990), weight reduction, alcohol restriction, mild salt restriction, eating a vegetarian diet and increasing aerobic exercise will generally lower the blood pressure in patients with essential hypertension. Eating a diet rich in

potassium and reducing caffeine intake may also be helpful in reducing the pressure, but increasing the fiber or calcium intake will generally be ineffective. Reducing fat intake from the usual 40% of total calories to 25-30% may reduce hypertension directly or by weight reduction. Smoking, when combined with excessive caffeine or alcohol intake may have an additive effect on blood pressure. Monotherapy with such behavioral techniques as self-monitoring of blood pressure, biofeedback, meditation, yoga, progressive muscular relaxation or cognitive therapy may reduce the blood pressure to a variable degree, and combinations of these treatments may be even more successful. A solid body of evidence shows that men and women of all age groups who are physically active have a decreased risk of developing high blood pressure. Findings from multiple studies indicate that exercise can lower blood pressure as much as some drugs can. People with mild and moderately elevated blood pressure who exercises 30 to 60 minutes three to four days per week (walking, jogging, cycling, or a combination) may be able to significantly decrease their blood pressure. In addition, blood pressure increases when a person is under emotional stress and tension, but whether or not psychological interventions aimed at stress reduction can decrease blood pressure in patients with hypertension is not clear. Nevertheless, recent studies suggest that ancient relaxation methods that include controlled breathing and gentle physical activity, such as yoga, Qigong, and Tai Chi, are beneficial. People with mild hypertension who practiced these healing techniques daily for two to three months experienced significant decreases in their blood pressure, had lower levels of stress hormones, and were less anxious. Also, the results of a recent small study suggest that a daily practice of slow

breathing (15 minutes a day for 8 weeks) brought about a substantial reduction in blood pressure. However, these findings need to be confirmed in larger and better-designed studies before these ancient healing techniques are recommended as effective nonpharmacological approaches to treating hypertension. Still, possible benefits, coupled with minimal risks, make these gentle practices a worthwhile activity to incorporate into a healthy lifestyle (http://www.webmd.com/hypertension-high-blood-pressure/guide/ hypertension-complementary-alternative-treatments). Bhatt (2007) stated that lifestyle modification, previously termed nonpharmacologic therapy, has an important role in hypertensive as well as

nonhypertensive individuals. In hypertensive individuals, lifestyle modification is recommended as initial therapy in stage 1 hypertension (for up to 12 months in those without other risk factors and for up to 6 months in those with other risk factors) before initiation of drug therapy and as an adjunct to medication in persons already on drug therapy. In those with medication-controlled blood pressure, lifestyle modifications can help reduce drug dosage or, in some cases, even stop drug therapy. In normotensives, lifestyle modifications can reduce the incidence of hypertension and also lower endorgan damage. Non-pharmacologic measures should be part of routine management of hypertension. It is emphasized that simple advice from physicians can have a positive influence on patients' motivation to make lifestyle changes. Enriquez (2004) said that there are alternative treatments on how to keep ones heart healthy. This includes diet, exercise, stress management, and attitude. In the diet, counting the calories and choosing healthy food can make ones heart stay healthy and functioning. Medical science has shown that high levels of cholesterol, saturated fats

and homocysteine are detrimental to cardiovascular system and can result to heart attack or stroke. On the other hand, regular physical and mental health benefits, including a sound and healthy heart. Exercise does not need to be intense or long i9n duration. As simple as brisk walking, it strengthens the cardiovascular system, helping o protect a person from hypertension. Furthermore, stress management can have beneficial effects on your heart. As long as one stays calm and relaxes, it lowers the heart rate and blood pressure. And lastly, people with positive attitudes are healthier than those with negative attitudes according to a study conducted by Dr. GrossarthMaticek in Heildelburg, Germany. Having a positive attitude controls intense emotions, thus, controlling the heart rate and blood pressure. Meditation has been applied to an array of both healthy and harmful activities that is hard to get consistent agreement about its impact on health. It offers a wide range of practices to take away stressful events. It also helps in relaxing the body that is overworked. Sitting comfortably, focusing on thoughts, minimizing distractions, and focus on own breathing are forms of meditation. To some extent, with practice people can consciously relax the muscle and learn to control other bodily functions which are not usually under their control. Clinical studies have shown and confirmed that meditation can provide short-term results in reducing stress, relieving pain, and reducing blood pressure (Mathuna & Larimore, 2001).

Advantages and Disadvantages of pharmacologic treatment The classes of antihypertensive drugs include diuretics, sympatholytics and other components of drugs. Diuretics can enhance the effects of other hypotensive drugs and

it reduces blood pressure if taken alone. Under of which includes three categories thiazide, loop diuretics and potassium sparing diuretics. In thiazide diuretics, there are two ways or mechanism to reduce blood pressure: reduction of blood volume and reduction of arterial resistance. Loop diuretics promote vasodilation and reduce blood volume. Potassium- sparing diuretics conserve the potassium in the body and balance the potassium level. For the sympatholytics, there are five categories: beta blockers, alpha blockers, alpha/beta blockers, centrally acting alpha2 agonist and adrenergic neuron blocker. These subcategories have a common effect which is to suppress and prevent sympathetic effects on the body by causing vasodilation to constricted arteries (Lehne, 2007). However, long-term adherence or compliance with antihypertensive drug therapy is poor. It has been estimated that within the first year of treatment 16-50% of hypertensive discontinue their anti-hypertensive medications. Even among those who remain on therapy long term, missed medication doses are common. Epidemiological studies have shown that drug-treated hypertensive have higher blood pressures than age, gender and body mass index-matched normotensives. In addition, drug treated hypertensive men and women who achieve blood pressure normalization are less likely to die over a 9-5-year period than those whose blood pressure remains elevated while taking anti-hypertensive drugs. Thus, one reason for less than optimal reduction of blood pressure-related cardiovascular-renal risk in drug treated hypertensive is inadequate blood pressure lowering. Side effects that are perceived as secondary to anti-hypertensive medication have correlated with non-adherence to anti-hypertensive drug regimens in several previous studies. Thus, the magnitude of expected medication

side effects should be an important consideration when prescribing anti-hypertensive drug therapy. It can be difficult to know, at least with any degree of confidence, if side effects occurring during anti-hypertensive drug therapy are actually caused by the prescribed medications because there is overlap between clinical symptoms attributable to hypertension and drug-induced side effects. Some of the side effects of hypertension medications can be life-threatening, so it is important to consider the possible side effects when choosing a course of treatment for hypertension. Not all medications are right for everyone (Flack, 1996).

Advantages and Disadvantages of non-pharmacological treatment Bhatt (2007) stated lifestyle modifications can help reduce drug dosage or, in some cases, even stop drug therapy. In normotensives, lifestyle modifications can reduce the incidence of hypertension and also lower end-organ damage. Nonpharmacologic measures should be part of routine management of hypertension. It is emphasized that simple advice from physicians can have a positive influence on patients' motivation to make lifestyle changes. In addition, these non-pharmaceutical approaches have a proven efficacy in the reduction and prevention of high blood pressure. But they require substantial perseverance and will-power to comply with. You should know how much effort is required to follow dietary restrictions or to stop smoking recommendations. Low compliance with these recommendations is usually

accompanied by low compliance with drug therapy. For people who want to be healthy and prevent or at least control this dangerous disease, there is good news. Non-

pharmaceutical recommendations really work according to Alifimoy (2005) because it will definitely reduce your risk of having hypertension by following them. However, Ramsay (1994) said that hypertensive patients may be shifted from just above some arbitrary intervention level to just below it by non-pharmacological treatment, and the perceived benefits of non-pharmacological management may be offset by an increased risk of vascular complications related to suboptimal blood pressure control. Moreover even simple measures such as moderate sodium restriction may affect some aspects of quality of life adversely. Non-pharmacological measures should generally be regarded as useful adjuncts to antihypertensive drug therapy rather than alternatives to it.

Chapter III The study was about the two interventions used in the management of hypertension. The two interventions were compared as for the nature of the treatment plan and its advantages and disadvantages. Based on the gathered data, the researchers concluded that non-pharmacologic intervention is more effective compared to pharmacologic intervention in the management of hypertension. Bhatt (2007) stated that lifestyle modifications can help reduce drug dosage or, in some cases, even stop drug therapy. These lifestyle modifications include the DASH diet, weight reduction, smoking cessation, and active lifestyle shows significant decrease in having the risk factor of having hypertension (Smeltzer and Bare, 2010). In connection, Bhatt (2007) said that these non-pharmaceutical approaches have a proven efficacy in the reduction and prevention of high blood pressure. But they require substantial perseverance and will-power to comply with. In non-pharmacological approach, it will not offer any side effects affecting the body unlike in the pharmacological approach. Eventhough that pharmacologic therapy offers direct reduction of blood pressure, the medication itself, still causes other side effects. According to Flack, (1996), side effects that are perceived as secondary to anti-hypertensive medication have correlated with non-adherence to anti-hypertensive drug regimens in several previous studies. Thus, the magnitude of expected medication side effects should be an important consideration when prescribing anti-hypertensive drug therapy. Some of the side effects of hypertension medications can be life-threatening, so it is important to consider the possible side effects when choosing a course of treatment for hypertension. Furthermore, nonpharmacological intervention in the management of hypertension does not have any

side effects, thus, it is safe. In addition, relaxation techniques such as meditation is effective in lowering the blood pressure because it will relax the muscle and learn to control other bodily function which provide results in reducing blood pressure without any unnecessary discomforts (Mathuna & Larimore, 2001).

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Ramsay, L. et al.(1994). Non-pharmacologic management as adjunct to antihypertensive dugs. Retrieved February 26, 2012, from http://bmb.oxfordjournals .org/content/50/2/494.abstract. Silverberg, DS. (1990). The management of hypertension. Retrieved February 12, 2012, from http://www.ncbi.nlm.nih.gov/pubmed/2258779 Smeltzer, S. C., & Bare, B. G. (2010). Brunner & Suddarths textbook of medicalsurgical nursing. (12th Ed). Philadelphia: Lippincott Williams & Wilkins.