Hypertension: Medical Management and Nutritional Approaches

Circuits
Pulmonary circuit
The blood pathway between the right side of the heart, to the lungs, and back to the left side of the heart.

Systemic circuit
The pathway between the left and right sides of the heart.

Distribution of Blood in the Body Organs

Figure 15-13: Distribution of blood in the body at rest

Regulation of Blood Pressure

Figure 15-22: The baroreceptor reflex: the response to increased blood pressure

Baroreceptor and Chemoreceptor Reflexes

Hypertension
Persistently high arterial blood pressure Systolic blood pressure above 140 mm Hg and/or diastolic blood pressure above 90 mm Hg Normotensive = 120/80 mm Hg Prehypertensive = 120139/80-89 mm Hg Stage 1 hypertension = 140159/9099 mm Hg Stage 2 hypertension = >160/>100 mm Hg

Prevalence and Incidence

29% of adult US population Related to body mass index High prevalence in African Americans 5% of pediatric population; prevalence increases with age Strong positive relationship between blood pressure and risk of CVD events

Pathophysiology
Blood pressure is a function of cardiac output multiplied by peripheral resistance Affected by diameter of blood vessel Atherosclerosis decreases diameter, increases blood pressure Drug therapy increases diameter, lowers blood pressure

Circulatory Systems in the Body

1. Coronarysupplies blood to heart muscle (can form collateral circulation) 2. Cerebralsupplies blood to head 3. Splanchnicsupplies blood to abdomen (exercise removes blood and food attracts blood to this area) 4. Pulmonarysupplies blood to lungs (O2 and CO2 exchange)

Measures of Heart Function

1. Beats or pulse 2. BP systolic and diastolic 3. ECG

Determinants of Blood Pressure

1. Blood volume 2. Vascular resistance to pressure 3. Heart stroke volume

Cardiac Output
Amount of

blood pumped by heart (vol/min) Stroke volume times heart rate

Vascular Resistance
Viscosity of blood

Width of vessels(constriction or dilation)controlled by muscle tone in vessel walls

Regulation of Blood Pressure

Sympathetic nervous system (SNS)responds immediately; baroreceptors monitor BP Vasomotor center in brain SNS innervated tissues contract or dilate vascular bed 2. Renin-angiotensin systemretains Na and H2O to increase blood volume; constricts blood vessels; increases aldosterone 3. Kidneysrespond to renin-angiotensin system; aldosterone and antidiuretic hormone (ADH) are sent out as needed
1.

Homeostatic Control of Blood Pressure

Short term Sympathetic nervous system Vasoconstriction Vasodilation Long term Fluid volume Renin-angiotensin system

Hypertension
1. 90% HTN is essential HTN (cause unknown;

perhaps prenatal impacts?) 2. 10% HTN is secondary to other diseases 3. HTN is a risk factor for MI, CVA, renal failure

Renin-Angiotensin Cascade

Redrawn from Guyton AC: Textbook of medical physiology, ed 8, Philadelphia, 1991, WB Saunders.

Causes of Hypertension

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

Identifiable causes of hypertension

Chronic kidney disease\ Coarctation of the Aorta Cushings Syndrome Drug induced Obstructive uropathy Pheochromocytoma Primary aldosteronism and other mineralocorticoid excess states Renovascular HTN stenosis and fibromuscular dysplasia Sleep Apnea Thyroid (either HYPER or HYPO) or parathyroid disease

Risk Factors for Developing Hypertension

(Adapted from National High Blood Pressure Education Program Working Group report on primary prevention of hypertension. Arch Intern Med 153:186, 1993. Copyright 1993, American Medical Association. Reprinted with permission.)

Risk Stratification in Patients with Hypertension

(From The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. sixth report (JNC VI). Arch Intern Med 157:2413, 1997.)

Uncontrolled Hypertension
Leads to increased Workload on heart Damage to arteries Atherosclerosis Coronary heart disease esp. CHF Strokes Transient ischemic attacks (TIAs) Kidney damage Microvascular hemorrhages in brain and eye

The DASH Diet Trials

Randomized feeding trial comparing effects of 3 diet patterns: control, high fruits/vegetables, and high fruits/vegetables/whole grains/lowfat dairy (DASH diet) DASH diet high in potassium, magnesium, calcium, fiber and low in fat, saturated fat, and cholesterol DASH diet significantly lowered BP in all groups, but especially in African-Americans

Effects of Diet on BP (DASH Trial)

New Features and Key Messages

For persons over age 50, SBP is a more important than DBP as CVD risk factor. Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN. Those with SBP 120139 mmHg or DBP 8089 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications to prevent CVD.

New Features and Key Messages

(Continued)
Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes. Certain high-risk conditions are compelling indications for other drug classes. Most patients will require two or more antihypertensive drugs to achieve goal BP. If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually should be a thiazide-type diuretic.

Blood Pressure Classification

BP Classification Normal Prehypertension Stage 1 Hypertension Stage 2 Hypertension SBP mmHg <120 120139 140159 >160 and or or or DBP mmHg <80 8089 9099 >100

CVD Risk
HTN prevalence ~ 50 million people in the United States. The BP relationship to risk of CVD is continuous, consistent, and independent of other risk factors. Each increment of 20/10 mmHg doubles the risk of CVD across the entire BP range starting from 115/75 mmHg.

Prehypertension signals the need for increased education to reduce BP in order to prevent hypertension.

Benefits of Lowering BP

Average Percent Reduction Stroke incidence Myocardial infarction 3540% 2025%

Heart failure

50%

BP Control Rates
Trends in awareness, treatment, and control of high blood pressure in adults ages 1874
National Health and Nutrition Examination Survey, Percent II 197680 Awareness Treatment Control 51 31 10 II (Phase 1) 198891 73 55 29 II (Phase 2) 199194 68 54 27

19992000 70 59 34

Sources: Unpublished data for 19992000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.

BP Measurement Techniques
Method In-office Brief Description Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm.

Ambulatory BP monitoring

Self-measurement

Indicated for evaluation of white-coat HTN. Absence of 1020% BP decrease during sleep may indicate increased CVD risk. Provides information on response to therapy. May help improve adherence to therapy and evaluate white-coat HTN.

CVD Risk Factors

Hypertension* Microalbuminuria or estimated GFR <60 Cigarette smoking ml/min 2 Obesity* (BMI >30 kg/m ) Age (older than 55 for Physical inactivity men, 65 for women) Dyslipidemia* Family history of premature CVD (men Diabetes mellitus* under age 55 or women under age 65)
*Components of the metabolic syndrome.

Target Organ Damage

Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure Brain Stroke or transient ischemic attack

Chronic kidney disease

Peripheral arterial disease

Retinopathy

Goals of Therapy
Reduce CVD and renal morbidity and mortality.

Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease.
Achieve SBP goal especially in persons >50 years of age.

Lifestyle Modification
Modification *Weight reduction *Adopt DASH eating plan *Dietary sodium reduction Physical activity *Moderation of alcohol consumption
*medical nutrition therapy interventions

Approximate SBP reduction (range) 520 mmHg/10 kg weight loss 814 mmHg 28 mmHg 49 mmHg 24 mmHg

Classification of Antihypertensive Drugs

Diuretics

Thiazides
Loop diuretics Potassium-sparing diuretics Beta blockers (BB) Angiotensin II receptor blockers (ARBs) Alpha-beta blockers Alpha1 receptor blockers ACE inhibitors (angiotensin converting enzyme) Calcium antagonists Direct vasodilators

Algorithm for Treatment of Hypertension

Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling Indications

With Compelling Indications

Stage 1 Hypertension
(SBP 140159 or DBP 9099 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.

Stage 2 Hypertension
(SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB)

Drug(s) for the compelling indications

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.

Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.

Compelling Indications
These are reasons for using a particular class of medications For example, patients with diabetes, kidney damage, and high blood pressure should begin treatment with ACE inhibitors. Heart attack (in conjunction with hypertension) is a compelling indication for the prescription of betablockers and, in certain instances, ACE inhibitors Heart failure should first be treated with ACE inhibitors and diuretics.

Classification and Management of BP for adults

BP classification Normal SBP* mmHg <120 DBP* mmHg and <80 Lifestyle modification Encourage Yes Yes No antihypertensive drug indicated. Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). Drug(s) for compelling indications. Drug(s) for the compelling indications. Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Initial drug therapy

Without compelling indication

With compelling indications

Prehypertension 120139 or 8089 Stage 1 Hypertension 140159 or 9099

Stage 2 Hypertension

>160

or >100

Yes

*Treatment determined by highest BP category. Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.

Minority Populations
In general, treatment similar for all demographic groups. Socioeconomic factors and lifestyle important barriers to BP control. Prevalence, severity of HTN increased in African Americans. African Americans demonstrate somewhat reduced BP responses to monotherapy with BBs, ACEIs, or ARBs compared to diuretics or CCBs. These differences usually eliminated by adding adequate doses of a diuretic.

Children and Adolescents

HTN defined as BP95th percentile or greater, adjusted for age, height, and gender. Use lifestyle interventions first, then drug therapy for higher levels of BP or if insufficient response to lifestyle modifications. Drug choices similar in children and adults, but effective doses are often smaller.

Uncomplicated HTN not a reason to restrict physical activity.

Lifestyle Modifications
Sodium: not more than 2.4 grams sodium/day Activity: activity like brisk walking 30 minutes/day most days of the week Alcohol: not more than 1 drink a day for women; 2 drinks a day for men DASH diet: low in sodium, high in potassium, calcium, cholesterol, saturated fat Weight: weight loss of as little as 10 lb can prevent or treat high blood pressure

Weight Management
Risk of developing high blood pressure is 2-6 times higher in overweight than normal weight persons 20-30% of the hypertension in the US is attributable to excess weight In Framingham, weight increase of 10% predicted rise in blood pressure of 7 mm/hg Weight gain during adult life is responsible for much of the rise in blood pressure seen with aging

Weight Management
Excess body weight may increase blood pressure through increased insulin resistance and hyperinsulinemia, activation of the sympathetic nervous and renin-angiotensin systems, and changes in the kidney Weight loss lowers vascular resistance, total blood volume, cardiac output, and sympathetic nervous system activity; improves insulin resistance Weight loss in an overweight person is the single most effective lifestyle intervention to reduce blood pressure

Weight Management
In the Trial of Antihypertensive Intervention and Management, goal for energy intake to facilitate weight loss was 25 kcals/kg minus 500 to 1000 kcal daily to produce a .5 to 1 kg weight loss/week to achieve total weight loss of 4.5 kg.

Wylie-Rosett et al, 1993

Sodium and Hypertension

Relationship between sodium and hypertension is stronger in Older people Those with a family history of hypertension Those with higher blood pressures at baseline 30-50% of hypertensives and 15-25% of normotensives are salt sensitive Salt sensitivity more common in black race, obesity, advanced age, diabetes, renal dysfunction, use of cyclosporine

Sodium and Hypertension

Addition of a sodium restriction to a DASH diet lowers SBP 3 mmHg and DBP 2 mmHg This reduction is associated with a 17% reduction in prevalence of hypertension, 6% reduction in CHD, 15% reduction in stroke and TIA

Salt Restriction
Recommendation is for moderate salt restriction (6 grams salt, 100 mEq or 2400 mg Na daily) Salt is the issue, because chloride ion with sodium raises blood pressure May normalize blood pressure in Stage 1 hypertension

Levels of Na Restriction
g Na 4 2-3 mEq Na 174 87-130 Description No added salt Mild to moderate restriction Strict sodium restriction Severe sodium restriction

1 0.5

43 22

Alcohol and Hypertension

5-7% of hypertension is due to alcohol consumption 3 drinks per day is the threshold for raising blood pressure; associated with a 3 mmHg increase

Physical Activity and Hypertension

Less active persons are 30-50% more likely to develop hypertension than active persons Medium to high levels of activity protective against stroke (Framingham) Walking reduces blood pressure in adults by an average of 2% In a meta-analysis of 54 randomized trials, walking reduced blood pressure an average of 4 mmHg, irrespective of weight change

Potassium
In population studies, potassium intake and blood pressure are inversely related Sodium/potassium ratio is important Sodium/potassium ratio of 1:1 a 3.4 mmHg decrease in systolic BP is predicted High potassium intake inversely related to stroke

Other Factors
Calcium, Magnesium, and Lipids: role still unclear DASH diet high in lowfat dairy products

Response to Dietary Rx
Salt sensitive respond well to sodium restriction Most respond to increased potassium in diet. 1.1 to 3.3 g Na is safe 1.9 to 5.6 g K is recommended to achieve ratio Na:K of 1, which is goal If taking a potassium-wasting diuretic drug, increased potassium in diet is essential. Most respond to increased calcium (at least the RDA)use the DASH diet protocol

DASH Diet
Works within 14 days Lowers BP quite well Includes more potassium, calcium, other nutrients

DASH Fact Sheet

www.nhlbi.nih.gov/heal th/public/heart/hbp/dash/ new_dash.pdf

DASH Diet contd

Pattern

7-8 whole grains 4-5 vegetables 4-5 fruits 2-3 low-fat or fat-free dairy products 6 oz or less meat/poultry/fish 4-5 servings nuts, beans, or legumes/week 2-3 servings fat (total kcal = 27% fat)

DASH Diet Patterns for Different Calorie Levels

Kcals 1600 Grain 6 Veg 4 Fruit 4 Dairy 2 Meat/ Nuts/ Fats/ Pro Legume oils 1 .5 1

2000
2600 3100

8
10 13

5
5 6

5
5 6

3
3 4

2
2 2

1
1 1

2
2 3

Sodium
Processed and restaurant foods provide 80% of sodium intake Read labels; sodium content of different brands varies 10% added in cooking at home and at table; 10% naturally occurring Americans consume ~4,000 mg/day; 2005 Dietary Guidelines for Americans recommend <2,300 mg/day; those with hypertension, African Americans and middle-aged and elderly should consume <1,500 mg/day

Food Label Terms

Sodium free, no sodium = <5 mg/serving Very low sodium = <35 mg/serving and per 100 g food Low sodium = <140 mg/serving and per 100 g food Reduced sodium = 50% less than comparison food

Salt Substitutes
Composition: KCl, CaCl, Al-Cl KCl can provide extra potassium for those taking diuretics KCl can be harmful if patient has renal insufficiency Lite salt contains sodium Some spices and herbs are low in sodium Others are high in sodium

Classification of Antihypertensive Drugs

Diuretics

Thiazides
Loop diuretics Potassium-sparing diuretics Beta blockers (BB) Angiotensin II receptor blockers (ARBs) Alpha-beta blockers Alpha1 receptor blockers ACE inhibitors (angiotensin converting enzyme) Calcium antagonists Direct vasodilators

Renin-Angiotensin Aldosterone System

Non-ACE pathways
(eg, chymase)
Vasoconstriction Cell growth Na/H2O retention Sympathetic activation

Angiotensinogen Renin

Angiotensin I
Angiotensin II

AT1

ACE
Aldosterone
Cough, angioedema Benefits?

AT2
Vasodilation Antiproliferation (kinins)

Bradykinin

Inactive fragments

Lifestyle Modifications for Prevention of Hypertension

Lose weight if overweight Limit alcohol Increase physical activity Decrease sodium intake Keep potassium intake at adequate levels Take in adequate amounts of calcium and magnesium Decrease intake of saturated fat and cholesterol Stop smoking

Summary
Lifestyle modifications for prevention of hypertension quite effective! Management of hypertensionvery important to reduce risk of heart attack or stroke