Hypertension affects about 26% of adults worldwide and ranks as the leading chronic risk factor for mortality. The prevalence of hypertension is projected to affect more than 1.5 billion people by 2025, according to recent estimates. About half of all strokes and ischemic heart disease events are attributable to high blood pressure (BP). “An important component of preventing the adverse consequences of hypertension is to adopt lifestyle changes that reduce BP,” says Robert D. Brook, MD. “Several lifestyle approaches have been promoted in guidelines.” These include losing weight, reducing sodium and alcohol intake, adopting a Dietary Approaches to Lower Hypertension (or DASH) eating pattern, and aerobic exercise for 30 minutes on most days per week.
Several scientific statements on different approaches to caring for hypertension have been released by various organizations in an effort to address the problem. To further these efforts, the American Heart Association (AHA) published a scientific statement in 2013 that provides recommendations for alternative approaches to lowering BP that go beyond medications and diet. The AHA published the statement in Hypertension.
Dr. Brook, who chaired the panel that developed the AHA scientific statement, says there are few large, well-designed studies lasting longer than a few weeks that look at alternative therapies, but he adds that many patients still ask about their value. “Patients often say that they don’t like to take medications and ask about other strategies they can use to lower their BP. The goal of the AHA scientific statement was to provide direction for clinicians when these situations come up.”
For the AHA scientific statement, an expert panel assessed three alternative remedy categories: 1) exercise regimens, 2) behavioral therapies, such as meditation, and 3) non-invasive procedures or devices, such as acupuncture and device-guided slow breathing (Table). The panel did not review dietary and herbal treatments. The alternative therapies assessed—which included aerobic exercise, resistance or strength training, and isometric hand grip exercises—were found to be of help when seeking to reduce BP. “These approaches can modestly help those with BP levels higher than 120/80 mm Hg,” says Dr. Brook. “They can also benefit those who cannot tolerate or do not respond well to standard medications.”
Alternative therapies rarely caused serious side effects and posed few health risks. However, some approaches were more beneficial than others and could be part of a comprehensive BP-lowering treatment plan. The AHA scientific statement also provides clinicians with an algorithm for using alternative treatments (Figure). Aerobic, resistance or weight training, and isometric exercises—most commonly handgrip devices—helped to reduce BP. Walking programs provided modest benefit, whereas 4 weeks of iso-metric hand grip exercises resulted in some of the most impressive improvements, namely a 10% drop in systolic and diastolic BP. Isometric exercise, on the other hand, should be avoided in those with BPs of 180/110 mm Hg or higher.
“Alternative approaches can be added to a treatment regimen after patients discuss their goals with their physicians.”
Behavioral therapies, such as biofeedback and transcendental meditation, may help lower BP by a small amount, but the AHA cautions that there is insufficient data to support using other types of meditation. Strong clinical evidence is also lacking to recommend yoga and other relaxation techniques and acupuncture for reducing BP. However, device-guided slow breathing was effective in lowering BP when performed for 15-minute sessions three to four times a week.
Not a Replacement
Dr. Brook says it is important to note that alternative therapies should not replace proven methods to lower BP, such as exercising regularly, managing weight, not smoking or drinking excess alcohol, eating a low-sodium balanced diet, and taking medications when prescribed. “Most alternative approaches reduce systolic BP by only 2 to 10 mm Hg, whereas standard doses of BP-lowering drugs reduce systolic BP by about 10 to 15 mm Hg,” he says. “Alternative approaches can be added to a treatment regimen after patients discuss their goals with their physicians.”
More Research Needed
Considering the global burden of hypertension, the AHA notes that more research is needed into the long-term cardiovascular health impact of alternative therapies and the effects of combining them together or adding them to other proven lifestyle measures. “The number of people with hypertension and pre-hypertension continues to climb,” says Dr. Brook. “Further clarifying the effects of alternative strategies to reduce BP may help us identify appropriate candidates for these treatments. For now, the choice of specific alternative approaches should be made on a patient-by-patient basis.”
Brook RD, Appel LJ, Rubenfire M, et al; on behalf of the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity and Metabolism. Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the American Heart Association. Hypertension. 2013;61:1360-1383. Available at: http://hyper.ahajournals.org/content/61/6/1360.full.pdf+html.
Chobanian AV, Bakris GL, Black HR, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-2572.
Dickinson HO, Mason JM, Nicolson DJ, et al. Lifestyle interventions to reduce raised blood pressure: a systematic review of randomized controlled trials. J Hypertens. 2006;24:215-233.
Woolf KJ, Bisognano JD. Nondrug interventions for treatment of hypertension. J Clin Hypertens (Greenwich). 2011;13:829-835.
Lin JS, O’Connor E, Whitlock EP, Beil TL. Behavioral counseling to promote physical activity and a healthful diet to prevent cardiovascular disease in adults: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;153:736-750.
Mancia G, Laurent S, Agabiti-Rosei E, et al; European Society of Hypertension. Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document. J Hypertens. 2009;27:2121-2158.