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Depending on the severity of high blood pressure, the physician may recommend lifestyle modifications, either with or without medications. In general, patients with a blood pressure reading of 140/90 or greater are candidates for medical intervention, in addition to lifestyle changes. Patients with isolated systolic hypertension (e.g., a blood pressure reading of 160/89) over the age of 65 are also candidates for medical therapy. Prehypertensive patients are generally advised to make a number of lifestyle changes before medical therapy is begun. Definite steps that should be taken to lower and control blood pressure include:
- Quitting smoking. This is perhaps the most important thing a smoker can do to promote his or her own health. Among many other side effects, smoking elevates blood pressure.
- Losing weight. Loss of weight, especially in the abdominal area, can immediately reduce blood pressure and help reduce the size of the heart. Weight loss accompanied by salt restriction may allow mild hypertensives to reduce or eliminate their need for medication.
- Following the DASH diet. Well-controlled studies have shown that people on the American Heart Association’s Dietary Approaches to Stop Hypertension diet, or “DASH” diet, for only eight weeks experienced a significant reduction in blood pressure. The DASH diet emphasizes fruits, vegetables, whole grains and low-fat dairy while limiting saturated fat and red meat.
- Getting adequate amounts of vitamins and minerals. Studies show that vitamin C protects normal levels of nitric oxide – the substance that keeps arteries flexible. Vitamin E and the B-vitamins may also be helpful. Also, adequate intake of minerals such as potassium, magnesium and calcium is thought by some experts to be even more helpful than reducing salt intake for reducing blood pressure. Individuals should consult with their physician before supplementing their diet.
- Engaging in regular aerobic exercise. Exercising three to four times per week is helpful for regulating high blood pressure, keeping in mind that the regularity of the exercise is more important than the intensity of the workout. For example, studies have shown that tai chi (an ancient Chinese workout involving slow, relaxing movements) may lower blood pressure almost as well as moderately intense aerobics. Individuals should consult with their physician before starting an exercise program.
- Limiting alcohol use to one drink per day for women and two drinks per day for men. One drink is defined as one 6-ounce glass of wine per day, one 12-ounce beer or one 1-ounce shot of distilled spirits.
- Limiting salt intake to 2,000 milligrams (2 grams) per day.
- Using stress management techniques. Emotional factors may play important roles in the development of hypertension. Studies have shown that cognitive-behavioral therapy, transcendental meditation, active religious faith and participation in church-related activities are all associated with reducing blood pressure to healthy levels.
- Having a pet may also lower blood pressure.
Women are encouraged to discuss with their physicians the increased risk of high blood pressure that results from taking birth control pills, particularly if they are over the age of 35. According to the American Heart Association, high blood pressure is two to three times more common in women taking birth control pills than those not taking them, especially in women who are overweight or obese. Also, studies have shown that women who develop high blood pressure during pregnancy have a higher risk of stroke, heart disease and kidney disease later in life.
As hypertensive patients make these changes, they are often encouraged to monitor their blood pressure at home, under the guidance of their physician. In addition to these lifestyle changes, patients are often prescribed blood pressure-reducing medications. These medications include:
- Diuretics. Medications that promote the formation of urine in the kidneys, causing the body to flush out excess fluids and minerals, especially sodium. These are often the first medications given to reduce high blood pressure. Though commonly used, they may have unwanted side effects, such as low potassium levels (hypokalemia). This side effect can be minimized with the use of potassium-sparing diuretics.
- Alpha blockers and beta blockers. Medications that inhibit alpha and beta receptors in various parts of the nervous system. This helps arteries to relax, decreases the force of the heartbeat and reduces blood pressure. Beta blockers are especially useful in patients with heart disease, but they should be used with caution among diabetic patients because they interfere with the body's normal responses to fluctuating glucose levels. Alpha blockers work by interfering with norepinephrine, which causes increased cardiac activity. They are not usually used as first-line therapy, however, because patients may develop a tolerance to the medication and their use has recently been implicated in an increase in cardiovascular events.
- ACE inhibitors. These medications are vasodilators that help to reduce blood pressure by inhibiting substances in the blood that cause blood vessels to constrict. Recent studies suggest that this class of drugs may be superior to others in preventing stroke, heart disease and kidney disease in patients (especially diabetic individuals) with risk factors for vascular disease. They are also very useful in patients with established heart disease.
- Angiotensin II receptor blockers (ARBs). This new class of drugs is showing good results and great promise in reducing complications related to high blood pressure. They have similar effects to ACE inhibitors, although they are more specific in their mode of action and have fewer side effects. Although beta blockers, ACE inhibitors and diuretics are currently used most often in the treatment of high blood pressure, ARBs may be prescribed more often in the future.
- Calcium channel blockers. These are vasodilators that inhibit the flow of calcium into heart and blood vessel tissues, which reduces tension in the heart, relaxes blood vessels and lowers blood pressure. However, most studies have not shown that these agents reduce the risk of death from high blood pressure, and some of these medications may increase the risk of death from high blood pressure.
Though some of the newer medications have been shown to lower both blood pressure and the risks of heart disease, they had not been tested against each other until recently. This was addressed with the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Begun in 1994, involving more than 42,000 individuals and the largest such trial to date, this important study showed that “traditional” diuretics were more effective in treating high blood pressure and should be used as first-line therapy. Participants with high blood pressure were randomly given diuretics, calcium channel blockers, ACE inhibitors or alpha blockers.
Results five years later revealed that, compared to the other classes of drugs in the study, diuretics were not only significantly more effective in lowering high blood pressure, but also in lowering the risk of cardiovascular events (e.g., stroke, angina, heart failure). In fact, the alpha blocker category was terminated in March 2000 due to a higher rate of cardiovascular events and hospitalization compared to diuretics. Based on these findings, the ALLHAT researchers concluded that drug therapy to lower blood pressure should be initiated with diuretics.
The ALLHAT researchers did recognize some limitations to the study. Commenting on the significantly lower blood pressure attained with the diuretic-controlled group (compared to calcium channel blockers and ACE inhibitors), the benefit may have been secondary to overall better blood pressure control in that group and perhaps not just from the diuretic itself. Indeed, other studies have shown a marked and significant benefit from ACE inhibitors, specifically ramipril, in reducing the progression of atherosclerosis, preventing strokes and heart attacks, and prolonging life in patients with vascular disease, high blood pressure, diabetes and heart failure.
Additional research has focused on risks associated with drugs used to treat hypertension. Recent studies have suggested that some blood pressure drugs may boost the risk of diabetes, especially among those who are already at risk for the disease. Beta blockers and diuretics are the classes of drugs most closely associated diabetes. In contrast, ARBs and ACE inhibitors were least related to the disease. Additional research is necessary to confirm the results of these studies.
Scientists are also examining the use of a drug combination for effective treatment of high blood pressure. Most patients take separate antihypertensive drugs to control their high blood pressure. Researchers are evaluating the combination of lower doses of established antihypertensives in a single capsule. Scientists believe considerable research is necessary to determine the benefits of this treatment approach.
The majority of patients with high blood pressure will need to take medications for the rest of their lives in order to control the condition. In some cases, two or three antihypertensives may be given. Recent studies have shown that such a combination of drugs not only lowers blood pressure but also may reduce the risk of stroke and ischemic heart disease. Other research has suggested that some patients with only slightly elevated blood pressures may eventually be able to stop taking medications and control their condition through lifestyle changes alone. The two most important lifestyle changes tracked by the study were weight loss and maintaining a low-salt diet. Strategies such as exercise, diet plans and, especially, changes in drugs should be discussed with a physician before they are attempted.
Researchers have also been exploring the genetic roots of high blood pressure. Identifying genes that cause high blood pressure in a particular patient could help physicians to prescribe the most effective antihypertensive drug.
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