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When and How to Recommend ‘Alternative Approaches’ in the Management of High Blood Pressure

Published:January 30, 2015DOI:https://doi.org/10.1016/j.amjmed.2014.12.029

      Abstract

      Several nonpharmacologic therapies, such as sodium restriction and weight loss, have been promoted by hypertension guidelines based on the trial evidence supporting their capacity to lower blood pressure. However, many patients may not respond or be able to adhere to these nonpharmacologic treatments. Despite numerous formal diet and lifestyle recommendations, the prevalence of hypertension continues to grow worldwide. As such, additional approaches are needed to help combat this public health epidemic. In this review, we outline the evidence supporting the efficacy of a number of alternative approaches for blood pressure lowering. On the basis of the recommendations by a recent American Heart Association scientific statement, we also provide guidance on when and how to implement these methods in clinical practice. The available evidence supports several approaches, including Transcendental Meditation, device-guided slow breathing, and aerobic, resistance, and isometric exercises. Nonetheless, many questions remain, and future recommendations for using alternative approaches will need to be updated as new trials are published.

      Keywords

      Clinical Significance
      • Several alternative approaches, including Transcendental Meditation, device-guided slow breathing, and aerobic, resistance, and isometric exercises, can effectively lower blood pressure by a modest degree (∼5 mm Hg).
      • Patients at low cardiovascular risk with mild stage 1 hypertension are ideal candidates for using these approaches for up to 1 year.
      • Other appropriate patients include individuals with refractory hypertension, prehypertension, or multiple drug side effects, and those aiming to reduce medication requirements.
      A 54-year-old woman presents with concerns about “borderline” blood pressure readings over the previous year. She is without known atherosclerotic cardiovascular disease and is asymptomatic during brisk walking. She is a nonsmoker and drinks a few caffeinated and alcoholic beverages per week. She takes no prescription or over-the-counter medications. Her parents developed hypertension by middle-age, but there is no family history of premature cardiovascular disease. Her body mass index is 27 kg/m2, and the average of 3 clinic blood pressure values is 152/88 mm Hg. Her physical examination results are otherwise normal. Laboratory testing reveals normal comprehensive, thyroid, and lipoprotein panels. Her calculated 10-year atherosclerotic cardiovascular disease risk is low (<5%), and she has no microalbuminuria or left ventricular hypertrophy on electrocardiography. On the basis of this clinical information and the doctor's recommendations, she begins a trial of lifestyle therapy composed of jogging 150 minutes per week, stopping all caffeine and alcohol intake, and starting a low sodium (<2.3 g/d) Dietary Approaches to Stop Hypertension eating plan. She returns to the clinic after 10 weeks, having lost 5 pounds; however, both her clinic (146/86 mm Hg) and reliable home blood pressure readings (140-150/85-90 mm Hg) remain elevated. She wants to avoid medications “unless absolutely necessary” and asks for guidance regarding further options.

      Discussion

      Several questions arise from considering this patient case. (1) What is the current evidence-based management of stage 1 hypertension (blood pressures from 140-159/90-99 mm Hg)? (2) For whom is it appropriate to advise nondrug treatments for high blood pressure? (3) Beyond dietary and lifestyle interventions, what is the evidence regarding the antihypertensive efficacy of other “alternative approaches”? (4) When and how should alternative approaches be recommended for treating high blood pressure?

      Management of Mild Hypertension

      There is a paucity of evidence to guide treatment among low-risk individuals with stage 1 hypertension.
      • Martin S.A.
      • Boucher M.
      • Wright J.M.
      • et al.
      Mild hypertension in people at low risk.
      Most hypertension trials were conducted among patients with multiple risk factors or target organ disease (eg, left ventricular hypertrophy) who had systolic blood pressure values ≥160 mm Hg or were already receiving drug therapy.
      • Martin S.A.
      • Boucher M.
      • Wright J.M.
      • et al.
      Mild hypertension in people at low risk.
      • Weber M.A.
      • Schiffrin E.L.
      • White W.B.
      • et al.
      Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension.
      • Mancia G.
      • Fagard R.
      • Narkiewicz K.
      • et al.
      2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension and of the European Society of Cardiology.
      The relevance of older “mild hypertension” trials is unclear because they focused on diastolic targets and were performed before the widespread use of contemporary medications (eg, angiotensin-converting enzyme inhibitors and statins). Although some recent meta-analyses support drug treatment,
      • Thomopoulos C.
      • Parati G.
      • Zanchetti A.
      Effects of blood pressure lowering on outcome incidence in hypertension: 2. Effects at different baseline and achieved blood pressure levels - overview and meta-analyses of randomized trials.
      others do not, citing a large (costly) number needed to treat to prevent cardiovascular events.
      • Martin S.A.
      • Boucher M.
      • Wright J.M.
      • et al.
      Mild hypertension in people at low risk.
      On the other hand, the health risks related to high blood pressure begin within the prehypertensive range (ie, above ideal values >115/75 mm Hg).
      • Weber M.A.
      • Schiffrin E.L.
      • White W.B.
      • et al.
      Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension.
      • Mancia G.
      • Fagard R.
      • Narkiewicz K.
      • et al.
      2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension and of the European Society of Cardiology.
      Treatment of mild blood pressure elevations is safe and prevents the future development of target organ disease (eg, left ventricular hypertrophy) and the onset of more severe hypertension stages.
      • Black H.R.
      • Elliott W.J.
      • Weber M.A.
      • et al.
      One-year study of felodipine or placebo for stage 1 isolated systolic hypertension.
      Outcome studies are also limited by the short-term nature (3-5 years) of clinical trials, although emerging evidence demonstrates that the lifetime health risks related to even small elevations in blood pressure are substantial.
      • Ference B.A.
      • Julius S.
      • Mahajan N.
      • et al.
      Clinical effect of naturally random allocation to lower systolic blood pressure beginning before the development of hypertension.
      In acknowledgment of these controversies, questions 1 and 2 have been addressed in both American and European guidelines by expert opinion consensus.
      • Weber M.A.
      • Schiffrin E.L.
      • White W.B.
      • et al.
      Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension.
      • Mancia G.
      • Fagard R.
      • Narkiewicz K.
      • et al.
      2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension and of the European Society of Cardiology.
      The following approach to patients with mild stage 1 hypertension is recommended.
      • First, ensure that they are truly “low risk,” meaning that they do not meet guideline criteria for medications on the basis of the presence of target organ damage (eg, left ventricular hypertrophy, chronic kidney disease), cardiovascular disease (eg, myocardial infarction, stroke, aortic aneurysm, heart failure), or diabetes.
        • Weber M.A.
        • Schiffrin E.L.
        • White W.B.
        • et al.
        Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension.
        • Mancia G.
        • Fagard R.
        • Narkiewicz K.
        • et al.
        2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension and of the European Society of Cardiology.
      • Individuals validated to be truly low risk are recommended to undergo 3- to 12-month trials of lifestyle therapies, including a low sodium diet (<2.3 g/d), a Dietary Approaches to Stop Hypertension eating plan, weight loss, aerobic exercise, and alcohol restriction.
        • Appel L.J.
        • Brands M.W.
        • Daniels S.R.
        • et al.
        Dietary approaches to prevent and treat hypertension: a scientific statement from the American Heart Association.
        The appropriate trial duration is individualized on the basis of the number of other cardiovascular risk factors.
      • Consideration for trying other alternative approaches beyond dietary changes alone (eg, device-guided slow breathing, isometric handgrip exercise) also may be appropriate among truly low-risk patients with mild hypertension.
        • Brook R.D.
        • Appel L.J.
        • Rubenfire M.
        • et al.
        Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the American Heart Association.
      • Drug therapy should be considered if blood pressures remain elevated thereafter (eg, 3-12 months later) under the assumptions that nonpharmacologic trials were unsuccessful and that the net health benefits reported in clinical trials can be extrapolated to these lower-risk patients.
        • Weber M.A.
        • Schiffrin E.L.
        • White W.B.
        • et al.
        Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension.
        • Mancia G.
        • Fagard R.
        • Narkiewicz K.
        • et al.
        2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension and of the European Society of Cardiology.
        • Thomopoulos C.
        • Parati G.
        • Zanchetti A.
        Effects of blood pressure lowering on outcome incidence in hypertension: 2. Effects at different baseline and achieved blood pressure levels - overview and meta-analyses of randomized trials.

      Alternative Approaches for Hypertension

      In addition to well-established dietary and lifestyle changes,
      • Appel L.J.
      • Brands M.W.
      • Daniels S.R.
      • et al.
      Dietary approaches to prevent and treat hypertension: a scientific statement from the American Heart Association.
      numerous alternative approaches for hypertension have been studied over the prior few decades.
      • Brook R.D.
      • Appel L.J.
      • Rubenfire M.
      • et al.
      Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the American Heart Association.
      These methods are important to consider because many patients may not respond or be able to adhere to diet or lifestyle interventions. In fact, despite the publication of many formal diet and lifestyle recommendations,
      • Appel L.J.
      • Brands M.W.
      • Daniels S.R.
      • et al.
      Dietary approaches to prevent and treat hypertension: a scientific statement from the American Heart Association.
      the prevalence of hypertension continues to grow worldwide.
      • Brook R.D.
      • Appel L.J.
      • Rubenfire M.
      • et al.
      Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the American Heart Association.
      To help inform health care providers about the appropriate use of other alternative approaches in clinical practice, the American Heart Association recently published a scientific statement reviewing the blood pressure-lowering efficacies, safety profiles, and real-life feasibility of several of these approaches.
      • Brook R.D.
      • Appel L.J.
      • Rubenfire M.
      • et al.
      Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the American Heart Association.
      Question 3 was also specifically addressed (Table 1). The main conclusions in this regard were as follows.
      • The blood pressure-lowering effectiveness among alternative approaches varies substantially, with many methods lacking high-quality study support.
      • Some alternative approaches can effectively lower blood pressure on average by 3-5/2-3 mm Hg within 8 to 12 weeks of treatment. Although modest, these mean responses are comparative to most diet and lifestyle therapies formally recommended by guidelines (eg, sodium reduction).
        • Weber M.A.
        • Schiffrin E.L.
        • White W.B.
        • et al.
        Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension.
        • Mancia G.
        • Fagard R.
        • Narkiewicz K.
        • et al.
        2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension and of the European Society of Cardiology.
        • Appel L.J.
        • Brands M.W.
        • Daniels S.R.
        • et al.
        Dietary approaches to prevent and treat hypertension: a scientific statement from the American Heart Association.
      • At present, the most consistent or high-quality studies currently support the effectiveness of 5 alternative approaches: Transcendental Meditation,
        • Anderson J.W.
        • Liu C.
        • Kryscio R.J.
        Blood pressure response to transcendental meditation: a meta-analysis.
        device-guided slow breathing,
        • Mahtani K.R.
        • Nunan D.
        • Heneghan C.J.
        Device-guided breathing exercises in the control of human blood pressure: systematic review and meta-analysis.
        and aerobic,
        • Cornelissen V.A.
        • Smart N.A.
        Exercise training for blood pressure: a systematic review and meta-analysis.
        resistance,
        • Cornelissen V.A.
        • Smart N.A.
        Exercise training for blood pressure: a systematic review and meta-analysis.
        and isometric exercises.
        • Carlson D.J.
        • Dieberg G.
        • Hess N.C.
        • et al.
        Isometric exercise training for blood pressure management: a systematic review and meta-analysis.
      Table 1American Heart Association Recommendations Regarding Alternative Approaches for Blood Pressure Lowering
      Level of EvidenceClass of RecommendationMean Blood Pressure Reduction (mm Hg)Recommended for Clinical Practice
      Recommendations were based on higher levels of evidences or classes of recommendations and expert opinions regarding the feasibility of adopting each alternative approach within real-world settings (eg, widely available techniques or commercially available products). For example, although several biofeedback methods based on heart rate variability monitoring have some evidence that they can lower blood pressure, there are no commercially available products for patients, unlike device-guided slow breathing and isometric handgrip approaches.
      Behavioral Therapies
       Transcendental MeditationBIIB4.7/3.2
      • Anderson J.W.
      • Liu C.
      • Kryscio R.J.
      Blood pressure response to transcendental meditation: a meta-analysis.
      Yes
       Other meditation techniquesCIII (no benefit)Unreliable estimate
      Although blood pressure was reduced in some studies/analyses, published trials were limited and inconsistent, or of low-quality.
      No
       Biofeedback approachesBIIBUnreliable estimate
      Although blood pressure was reduced in some studies/analyses, published trials were limited and inconsistent, or of low-quality.
      No
       YogaCIII (no benefit)Unreliable estimate
      Although blood pressure was reduced in some studies/analyses, published trials were limited and inconsistent, or of low-quality.
      No
       Other relaxation techniquesBIII (no benefit)Unreliable estimate
      Although blood pressure was reduced in some studies/analyses, published trials were limited and inconsistent, or of low-quality.
      No
      Noninvasive Procedures
       AcupunctureBIII (no benefit)Unreliable estimate
      Although blood pressure was reduced in some studies/analyses, published trials were limited and inconsistent, or of low-quality.
      No
       Device-guided breathingBIIA3.7/2.5
      • Mahtani K.R.
      • Nunan D.
      • Heneghan C.J.
      Device-guided breathing exercises in the control of human blood pressure: systematic review and meta-analysis.
      • Landman G.W.
      • van Hateren K.J.
      • van Dijk P.R.
      • et al.
      Efficacy of device-guided breathing for hypertension in blinded, randomized, active-controlled trials: a meta-analysis of individual patient data.
      Yes
      Exercise-Based Regimens
       Dynamic aerobic exerciseAI3.5/2.5
      • Cornelissen V.A.
      • Smart N.A.
      Exercise training for blood pressure: a systematic review and meta-analysis.
      Yes (first option)
       Dynamic resistance exerciseBIIA1.8/3.2
      • Cornelissen V.A.
      • Smart N.A.
      Exercise training for blood pressure: a systematic review and meta-analysis.
      Yes
       Isometric handgrip exerciseCIIB6.8/4.0
      • Cornelissen V.A.
      • Smart N.A.
      Exercise training for blood pressure: a systematic review and meta-analysis.
      • Carlson D.J.
      • Dieberg G.
      • Hess N.C.
      • et al.
      Isometric exercise training for blood pressure management: a systematic review and meta-analysis.
      Yes
      Recommendations were based on higher levels of evidences or classes of recommendations and expert opinions regarding the feasibility of adopting each alternative approach within real-world settings (eg, widely available techniques or commercially available products). For example, although several biofeedback methods based on heart rate variability monitoring have some evidence that they can lower blood pressure, there are no commercially available products for patients, unlike device-guided slow breathing and isometric handgrip approaches.
      Although blood pressure was reduced in some studies/analyses, published trials were limited and inconsistent, or of low-quality.
      In regard to question 4, the following conclusions were also made by the American Heart Association regarding the appropriate implementation of alternative approaches in clinical practice.
      • Brook R.D.
      • Appel L.J.
      • Rubenfire M.
      • et al.
      Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the American Heart Association.
      Beyond low-risk patients with mild hypertension, reasonable candidates for trials of alternative approaches include the following:
      • adults with pre-hypertension;
      • patients with well-controlled hypertension attempting to step-down/reduce medications; and
      • individuals with multiple drug side effects or refractory hypertension (ie, other standard or pharmacologic options have been exhausted).
      It was also concluded that most patients with high blood pressure can consider trying alternative approaches as an adjuvant part of the overall comprehensive strategy (ie, diet, medications) to help control blood pressure because they are generally safe and well tolerated.
      In addition to reviewing the trial evidence, the American Heart Association statement sought to serve as a resource for clinicians by providing references that outline how to actually practice each of the recommended alternative approaches.
      • Brook R.D.
      • Appel L.J.
      • Rubenfire M.
      • et al.
      Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the American Heart Association.
      Several additional conclusions regarding their implementation in clinical practice were highlighted, including the following:
      • The first-line alternative approach should generally be moderate-intensity aerobic exercise (150 min/wk), given its blood pressure–lowering efficacy
        • Cornelissen V.A.
        • Smart N.A.
        Exercise training for blood pressure: a systematic review and meta-analysis.
        and proven ability to reduce overall cardiovascular risk.
      • The use of other alternative approaches alone or in addition to aerobic exercise should involve a shared decision-making process (eg, individual patient preferences). However, recommendations should be directed toward using alternative approaches with the most substantiated evidence available at this time (Table 1).
      • It was also recognized that many approaches (eg, yoga, acupuncture, relaxation, or other meditation techniques) have mixed study results or the current level of evidence is inconclusive largely because of the low quality of prior trials. This is an evolving field, and recommendations regarding the use of any technique may need to be reassessed periodically as the evidence builds and future trials more conclusively demonstrate for any approach the blood pressure-lowering efficacy or lack thereof, or even call into question prior findings.
        • Landman G.W.
        • van Hateren K.J.
        • van Dijk P.R.
        • et al.
        Efficacy of device-guided breathing for hypertension in blinded, randomized, active-controlled trials: a meta-analysis of individual patient data.

      Case Follow-up

      The patient discussed has low-risk stage 1 hypertension. An appropriate trial of dietary and lifestyle therapy was unsuccessful. Guidelines
      • Weber M.A.
      • Schiffrin E.L.
      • White W.B.
      • et al.
      Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension.
      • Mancia G.
      • Fagard R.
      • Narkiewicz K.
      • et al.
      2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension and of the European Society of Cardiology.
      • Black H.R.
      • Elliott W.J.
      • Weber M.A.
      • et al.
      One-year study of felodipine or placebo for stage 1 isolated systolic hypertension.
      support that after only 10 weeks she remains an appropriate candidate for continued nonpharmacologic efforts (for up to 1 year) to help control her blood pressure, including trying an alternative approach before starting drug therapy. After discussion and a review of the overall study evidence, she decides to add a program of isometric hand grip exercise (12 min/d; 3-5 times/wk) because of its comparatively robust blood pressure-lowering potency among the existing published trials.
      • Brook R.D.
      • Appel L.J.
      • Rubenfire M.
      • et al.
      Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the American Heart Association.
      • Carlson D.J.
      • Dieberg G.
      • Hess N.C.
      • et al.
      Isometric exercise training for blood pressure management: a systematic review and meta-analysis.
      After 8 weeks, her blood pressure was successfully reduced to goals (<135/85 mm Hg).

      Conclusions

      In addition to dietary and lifestyle changes, several alternative approaches have evidence supporting their efficacy to lower blood pressure and are therefore reasonable to try in the management of hypertension among appropriate patients.
      • Brook R.D.
      • Appel L.J.
      • Rubenfire M.
      • et al.
      Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the American Heart Association.
      However, a number of questions remain. Few studies have directly compared the effectiveness of various techniques or evaluated the determinants of blood pressure-lowering responses (eg, patient characteristics) to help optimally tailor therapy choices. Whether or not certain approaches can be performed together to yield more robust or additive blood pressure reductions in combination also remains unknown. Most important, future studies are needed for each approach to demonstrate the persistence of antihypertensive effects and the degree of patient adherence over longer-term durations of treatment (≥12 months), particularly in real-world practices.

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      Linked Article

      • Hypertensives May Safely Consume Ethanol and Coffee in Moderation
        The American Journal of MedicineVol. 128Issue 11
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          In their discussion of alternative approaches in the management of hypertension, Brook et al1 present a clinical vignette example. A 54-year-old woman presented with a history of “borderline” hypertension over the previous year, and 3 clinic blood pressures, which averaged 152/88 mm Hg. She reported drinking “a few caffeinated and alcoholic beverages per week.” Her physician prescribed a trial of lifestyle therapy composed of moderate exercise, a low sodium diet, and stopping all caffeine and alcohol intake.
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