Non‐pharmacological management of hypertension Verma, Narsingh; Rastogi, Smriti; Chia, Yook‐Chin ...
The journal of clinical hypertension (Greenwich, Conn.),
July 2021, Volume:
23, Issue:
7
Journal Article
Peer reviewed
Open access
Hypertension is an insidious disease which predisposes to cardiovascular complications and if not treated properly can lead to various serious complications. Economic limitations, having additional ...benefits with few or almost no side effects have made non‐pharmacological management of hypertension an attractive approach for dealing with hypertension, in developed and developing countries alike. A MEDLINE search was done for relevant references with emphasis on original studies, randomized controlled trials, and meta‐analyses for this review paper. Lifestyle modifications including changes in the dietary pattern, adopting special diets with low sodium, saturated fat and high calcium, magnesium and potassium and trying the new methods like time restricted meal intake which work in tandem with the circadian rhythm are opening new vistas in the field of non‐pharmacological management of hypertension. Lifestyle modifications that effectively lower blood pressure are increased physical activity, weight loss, limited alcohol consumption, relaxation techniques of Yoga, Acupuncture, Tai chi, mindfulness‐based stress‐reduction program, and Transcendental Meditation. Air pollution of the surrounding air is linked with poor health outcomes and is a major contributor to the global burden of disease. Fine particulate matter <2.5 μm in diameter (PM2.5) is strongly associated with cardiovascular morbidity and mortality. Short‐term PM exposure (hours to weeks) increases the likelihood of adverse cardiovascular events including myocardial infarction, stroke, and heart failure, and longer‐term exposure multiplies that risk. Non‐pharmacological methods should be initiated early phase of disease and should be continued with medication.
Non‐pharmacological methods are an integral part of management of hypertension. It includes lifestyle changes in farm of special diets and reduction of salt, alcohol, and saturated fat. Reduction of weight, increased physical activity and time restricted meal has also been found effective. Some traditional methods like yoga, acupuncture, and transcendental meditation are helpful.
Insulin resistance (IR), a metabolic risk factor, is linked to the pathogenetic mechanism of primary hypertension. Detecting IR in the patients with hypertension will help to predict and stratify the ...added cardiovascular risk, institute appropriate IR management, and manage hypertension optimally. There are many methods for assessing IR, each with distinct advantages and disadvantages. The euglycemic insulin clamp and intravenous glucose tolerance test, gold standards for measuring IR, are used in research but not in clinical practice. Homeostatic model assessment (HOMA‐IR), a method for assessing β‐cell function and IR, is frequently applied presently, particularly in Asia. Besides, the triglyceride–glucose index (TyG) first published by South American authors showed a good correlation with the insulin clamp technique and HOMA‐IR index. This simple, convenient, and low‐cost TyG index is of research interest in many countries in Asia and can be used to screen for IR in the Asian hypertensive community.
Hypertension is an important public health issue because of its association with a number of significant diseases and adverse outcomes. However, there are important ethnic differences in the ...pathogenesis and cardio‐/cerebrovascular consequences of hypertension. Given the large populations and rapidly aging demographic in Asian regions, optimal strategies to diagnose and manage hypertension are of high importance. Ambulatory blood pressure monitoring (ABPM) is an important out‐of‐office blood pressure (BP) measurement tool that should play a central role in hypertension detection and management. The use of ABPM is particularly important in Asia due to the specific features of hypertension in Asian patients, including a high prevalence of masked hypertension, disrupted BP variability with marked morning BP surge, and nocturnal hypertension. This HOPE Asia Network document summarizes region‐specific literature on the relationship between ABPM parameters and cardiovascular risk and target organ damage, providing a rationale for consensus‐based recommendations on the use of ABPM in Asia. The aim of these recommendations is to guide and improve clinical practice to facilitate optimal BP monitoring with the goal of optimizing patient management and expediting the efficient allocation of treatment and health care resources. This should contribute to the HOPE Asia Network mission of improving the management of hypertension and organ protection toward achieving “zero” cardiovascular events in Asia.
Cardiovascular disease (CVD) accounts for a third of all deaths in Malaysia. The background CV risk of Malaysia is much higher than that of developed countries in the west and in Asia. This high CV ...mortality is contributed by the high prevalence of CV risk factors especially hypertension which is very prevalent, coupled with low awareness and low control rates. This highlights the importance of home blood pressure measurements (HBPM). HBPM is an important adjunct in the management of hypertension, particularly to identify those unaware as well as white‐coat hypertension which is high in treated hypertensive patients in Malaysia. Ownership of HBPM devices in Malaysia is high, and this is an opportunity as well as timely to encourage more use of HBPM. The Malaysian national guidelines do not require HBPM for the diagnosis of hypertension but do recommend HBPM for specific situations. The most commonly prescribed anti‐hypertensives are calcium channel blockers, followed by renin‐angiotensin system blockers. Despite the wide availability of anti‐hypertensive agents, BP control rates remain low. It is important that strategies are in place to ensure that individuals are aware of the need to have their BP monitored regularly and this can be facilitated by the use of HBPM. Hence, there is a plan to develop a local HBPM consensus document. Strategies to reduce salt intake would also be beneficial. In summary, identification of those unaware and better control of BP with the help of HBPM would help reduce the burden of CV mortality and morbidity in Malaysia.
Asia has an enormous number of older people and is the primary contributor to the rise in neurodegenerative diseases such as Alzheimer's and Parkinson's disease. The therapy of many neurodegenerative ...diseases has not yet progressed to the point where it is possible to alter the course of the disease. Mid‐life hypertension is an important predictor of later‐life cognitive impairment and brain neurodegenerative conditions. These findings highlight the pivotal role of preventing and managing hypertension as a risk factor for neurodegenerative disease. Autonomic dysfunction, neuropsychiatric and sleep disturbances can arise in neurodegenerative diseases, resulting in blood pressure variability (BPV). The BPV itself can worsen the progression of the disease. In older people with neurodegenerative disease and hypertension, it is critical to consider 24‐h blood pressure monitoring and personalized blood pressure therapy.
Asia is a large continent and there is significant diversity between countries and regions. Over the last 30 years, absolute blood pressure (BP) levels in Asia have increased to a greater extent than ...those in other regions. In diverse Asia‐Pacific populations, for choosing an Asia‐specific approach to hypertension management is important to prevent target organ damage and cardiovascular diseases. In this consensus document of HOPE Asia Network, we introduce seven action approaches for management of hypertension in Asia.
TRENDS IN HYPERTENSION PREVALENCE Fortunately, there is a growing body of evidence to support locally-relevant solutions for hypertension management in clinical practice. 3–5 Excellent data and ...guidance comes from the in-depth work of the NCD (Non-Communicable Diseases) Risk Factor Collaboration, who recently published an extensive population study of worldwide trends in hypertension prevalence, and progress in treatment and control from 1990 to 2019. ...in 2019, 82% of the world's hypertensive population was made up of people from low- and middle-income countries. 13 Of these, morning hypertension (including exaggerated morning BP surge) and nocturnal hypertension are more common in Asians compared with other populations. 14,15 The BP level prior to morning antihypertensive dosing is the most difficult to control and is strongly associated with the risk of stroke, coronary artery disease and organ damage. 16 This emphasizes the region-specific importance of strategies to identify and control morning hypertension. 17,18 Other actions include widespread screening, use of a home BP-guided strategy, choosing the most appropriate antihypertensive agent(s), strict BP control and utilizing telemedicine. 13 NEXT STEPS The important next step is to determine how to integrate these core principles and messages into administrative planning and clinical practice in each Asian country/region.
Cardiovascular risk assessment tools in Asia Zhang, Yuqing; Miao, Huanhuan; Chia, Yook‐Chin ...
The journal of clinical hypertension (Greenwich, Conn.),
April 2022, Volume:
24, Issue:
4
Journal Article
Peer reviewed
Open access
Cardiovascular disease (CVD) is becoming the most important burden to health care systems in most part of the world, especially in Asia. Aiming at identifying high risk individuals and tailoring ...preventive treatment, many cardiovascular risk assessment tools have been established and most of them were developed in Western countries. However, these cardiovascular risk assessment tools cannot be used interchangeably without recalibration because of the different risk factor profiles (ie, greater absolute burden of hypertension and lower level of total‐cholesterol in Asians and higher prevalence of metabolic disorders in South Asians) and different CVD profiles (higher ratio of stroke/coronary heart disease in Asians) between Western and Asian populations. Original risk models such as Prediction for ASCVD Risk in China (China‐PAR) and Japan Arteriosclerosis Longitudinal Study (JALS) score have been developed and well validated for specific countries, while most of countries/regions in Asia are using established models. Due to higher incidence of stroke in Asians, risk factors like hypertension should weigh more in cardiovascular risk assessment comparing with Western populations, but their actual proportions should be based on CVD profiles in specific countries/regions. The authors encourage the development of new cardiovascular risk assessment tools for Asians, if possible. Still, modifying established models with native epidemiological data of risk factor as well as CVD is acceptable in regions where health care resources are insufficient.
Morning hypertension is an important clinical target in the management of hypertension for perfect 24‐h blood pressure (BP) control. Morning hypertension is generally categorized into two types: ...“morning surge” type and “sustained nocturnal and morning hypertension” type. The “morning surge” type is characterized by an exaggerated morning blood pressure surge (MBPS), and the “sustained nocturnal and morning hypertension” type with continuous hypertension from nighttime to morning (non‐dipper/riser type). They can be detected by home and ambulatory blood pressure measurements (HBPM and ABPM). These two forms of morning hypertension both increase the risk of cardiovascular and renal diseases, but may occur via different pathogenic mechanisms and are associated with different conditions. Morning hypertension should be treated to achieve a morning BP level of < 135/85 mmHg, regardless of the office BP. The second target morning BP levels is < 125/75 mmHg for high‐risk patients with morning hypertension and concomitant diseases. Morning hypertension is more frequently found in Asians, than in Westerners. Thus, the management of morning hypertension is especially important in Asia. The detection of morning hypertension and the individual home BP‐guided treatment approach targeting morning BP in combination with ABPM, and the optimal treatment of morning hypertension would reduce cardiovascular events in Asia.
Hypertension is highly prevalent worldwide and is the major risk factor for heart failure (HF). More than half of the patients with HF in Asia suffer from hypertension. According to the 2022 American ...Heart Association/American College of Cardiology/Heart Failure Society of America HF guideline, there are four stages of HF, including at risk for HF (stage A), pre‐HF (stage B), symptomatic HF (stage C), and advanced HF (stage D). Given the high prevalence of hypertension as well as HF and the stronger association between hypertension and cardiovascular diseases in Asians compared to the west, measures to prevent and alleviate the progression to clinical HF, especially controlling the blood pressure (BP), are of priority for Asian populations. After reviewing evidence‐based studies, we propose a BP target of less than 130/80 mmHg for patients at stages A, B, and C. However, relatively higher BP may represent an opportunity to maximize guideline‐directed medical therapy (GDMT), which could potentially result in a better prognosis for patients at stage D. Traditional antihypertensive drugs are the cornerstones for the management of hypertension at stages A and B. Notably, calcium channel blockers (CCBs) are inferior to other drug classes for the preventing of HF, whereas diuretics are superior to others. For patients at stage C, GDMT is essential which also helps the control of BP. In particular, sodium‐glucose cotransporter‐2 (SGLT2) inhibitors are newer therapies recommended for the treatment of HF and presumably even in hypertension to prevent HF. Regarding patients at stage D, GDMT is also recommended if tolerable and measures should be taken to improve hemodynamics.
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