Download Nonpharmacological Treatment: Lifestyle Modification

By jamshid najafian
Internist cardiologist
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Lifestyle modification is indicated for all
patients with hypertension, regardless of
drug therapy.
It may reduce, or even abolish, the need for
antihypertensive drugs.
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Lifestyle modifications may be the only treatment necessary
for preventing or even treating milder forms of hypertension
in the elderly
Smoking cessation
Reduction in excess body weight
Reduction mental stress
Modification of sodium and alcohol intake
Increased physical activity
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LSM may also reduce antihypertensive drug doses needed for
BP control.
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Nutrition
Exercise
35%
26%
patients 75 years of age are least likely to
receive such counseling
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Smoking cessation may not directly • reduce BP, but
markedly reduces overall cardiovascular risk.
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The risk of myocardial infarction is 2–6 times higher and the
risk of stroke is 3 times higher in people who smoke than in
non-smokers
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Smokers 65 years of age benefit greatly from abstinence
Older smokers who quit reduce their risk of
Death from CAD
Chronic obstructive pulmonary disease
Lung cancer
Osteoporosis.
Age does not appear to diminish the desire to quit or the
benefits of quitting.
However, smokers 65 years of age are less likely to be
prescribed smoking cessation medications.
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Pharmacotherapy (nicotine replacement therapy, bupropion,
varenicline) is effective.
The risk of adverse effects is small and is generally
outweighed by the significant risk of continuing to smoke.
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Consider pharmacotherapy for those who
smoke more than 10 cigarettes per day and
have no contraindications.
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Weight reduction lowers BP in overweight individuals:
loss of 3% to 9% of body weight reduces systolic and DBP about 3 mm Hg each
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In the TONE study, a diet that reduced weight by a
3.5 kg lowered BP by 4.0/1.1 mm Hg among 60- to
80-year-old patients with hypertension.
Every 1% reduction in body weight lowers systolic
BP by an average of 1 mmHg
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Dietary sodium restriction is perhaps the best-studied
lifestyle intervention for BP reduction.
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Mean BP reduction of 3.7/0.9 mm Hg for a 100
mmol/day decrease in sodium excretion
BP declines were generally larger in older adults.
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In patients 60 to 80 years of age
BP 145/85 mm Hg
taking 1 antihypertensive drug
mean BP reduction of 4.3/2.0 mm Hg occurred after
3 months of sodium restriction to 80 mmol/d
medication withdrawal
30 to m45 minutes brisk walking most days.
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However, BP and adverse outcome reductions did not
achieve statistical significance in 70 to 80 year olds.
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Other studies have confirmed benefits of lifestyle
modification in older subjects for BP Control.
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Increased potassium intake, either by fruits and vegetables or pills,
reduces BP. (In a meta-analysis of 33 RCTs)
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Potassium supplements significantly lowered BP by 3.1/2.0 mm Hg, and
this effect was enhanced in persons with higher sodium intake.
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Two trials confirmed significant BP reductions (4.3/1.7 mm Hg and 10.0/
6.0 mm Hg, respectively) among elderly patients with hypertension.
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Potassium supplementation (90 mmol [3500 mg] daily)
reduces BP in individuals with and without hypertension,
Effects are greater in individuals with higher dietary sodium
levels.
In elderly patients with substantially impaired renal function, serum
potassium should be monitored when supplementation is given.
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The DASH eating plan outlines a diet
Rich in fruits and vegetables
High in
Low-fat dairy products
Potassium,
Magnesium
Calcium
low in
Total saturated fats
Following this plan has been shown to produce mean reductions of 6 mm Hg in
systolic blood pressure and 3 mm Hg in diastolic blood pressure,
combining the plan with a reduction in sodium intake produces additional blood
pressure reduction.
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The DASH diet showed a mean BP decrease of 11.4/5.5 mm Hg in
patients with hypertension (mean age 47 years) with a diet enriched
with fruits and vegetables and low in saturated and total fat.
Similar BP reductions were seen in those 45 years of age
The DASH combination diet lowered SBP more in African Americans
(6.8 mm Hg) than in whites (3.0 mm Hg) (P0.05) and in persons with
hypertension (11.4 mm Hg) than in persons without hypertension
(3.4 mm Hg) (P0.05).
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Calcium and magnesium supplementation results in minimal
to no change in BP.
There is no evidence that vitamin, fiber, or herbal
supplements influence BP in the elderly.
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Consumption of 2 alcohol drinks per day is strongly
associated with BP elevations in epidemiologic studies.
Evidence for meaningful BP reduction from lowering alcohol
intake is limited in older adults
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There is strong evidence that regular physical activity has an
independent cardio protective effect.
Regular aerobic exercise can lower systolic BP by an average
of 4 mmHg and diastolic BP by an average of 2.5 mmHg.25
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Advise all patients to become physically active, as part of a
comprehensive plan to control hypertension, regardless of
drug treatment.
Aim for 30 minutes of moderate-intensity physical activity on
most, if not all, days of the week
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1- Sever hypertension (systolic BP ≥ 180 mmHg or diastolic BP ≥ 110
mmHg)
2- Unstable angina
3- Uncontrolled heart failure
4- Severe aortic stenosis
5- Resting tachycardia or arrhythmias
6-symptoms (e.g. chest discomfort, shortness of breath) on low activity
7- Diabetes with poor glycaemic control
Other acute illness.
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The daily dose can be accumulated in shorter bouts (e.g.
three 10-minute walks).
Moderate-intensity physical activity (e.g. brisk walking, lawn
mowing, low-paced swimming, cycling, gentle aerobics) will
cause a slight increase in breathing and heart rate, and may
cause light sweating.
Advise against isometric exercise routines that may raise BP
(e.g. weight lifting), except within professionally supervised
programs
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Exercise modality, frequency, intensity, and presence or
absence of hypertension did not significantly affect the
magnitude of BP decline.
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In 33 individuals 60 to 69 years of age
9 months of training
3 times weekly
53% or 73% peak aerobic capacity
BP reductions averaging 7/3 mm Hg and 6/9 mm
Hg,Respectively.
In 70 to 79 year old patients with hypertension
6 months training
At 75% to 85% peak aerobic capacity.
BP reductions of 8/9 mm Hg occurred after
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In sedentary men (mean age 59 years) with
prehypertension
9 months
aerobic training
3 days per week
Elicited a BP reduction of 9/7 mm Hg;
men who combined exercise and a weight loss diet had
a 11/9 mm Hg decline.
Thus, aerobic exercise alone or combined with a weight reduction
diet reduces BP in older adults with hypertension.
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The finding that exercise at moderate intensities elicits BP
reductions similar to those of more intensive regimens is
especially meaningful for the elderly.
MEDITATION
Meditation includes a variety of techniques, such as
repetition of a word or phrase (the mantra) and careful
attention to the process of breathing, to achieve a state of
inner calm, detachment, and focus.
Meditation was shown
To reduce blood pressure in one well-designed study that addressed
baseline blood pressure measurements Adequately
Although other studies have been inconsistent.
Long-term follow-up of 202 patients in two small studies
indicated that transcendental meditation may even reduce
mortality in patients with hypertension.
Meditation may have other benefits and does not appear to be
harmful except to patients with psychosis
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Classify all persons 70 or 75 years of age as high risk (ie,
10% risk of CAD in next 10 years), thus deserving therapy.
Older patients with hypertension may be classified at high or very
high risk (eg, those with diabetes mellitus).
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Patient preferences and values are also important in deciding
on the advisability and mode of therapy
IN older individuals Quality of Life sometimes becomes more
important than duration