Benefit of exercise in patients with hypertension has been insufficiently investigated, experts say

ScienceDaily (Oct. 26, 2010) — There are many good reasons to ensure sufficient exercise in everyday life. However, advising patients with increased blood pressure (hypertension) to exercise regularly is often regarded as a specific medical measure aiming to reduce the increased risk of late complications. But whether more exercise actually helps to avoid illnesses related to hypertension or at least delay their onset has been insufficiently investigated. In order to provide better advice to patients with hypertension, informative clinical studies are therefore needed.

This is the result of a report published by the German Institute for Quality and Efficiency and Health Care (IQWiG) on Sept. 22, 2010.

Comprehensive commission package on hypertension

This report is part of a comprehensive commission package awarded by the Federal Joint Committee (G-BA) in which the benefit of various non-drug treatment strategies for essential hypertension was to be assessed. This is the most common type of hypertension, for which no clear cause can be found.

People with increased blood pressure receive much well-meant advice, for example, to adopt stress-management strategies, smoke less and drink less alcohol. These measures are also recommended in clinical practice guidelines. IQWiG has already completed reports on the questions as to how a reduction in weight and salt intake affect blood pressure.

What should "more exercise" achieve?

Patients with hypertension have an increased risk of certain diseases of the heart and circulatory system. Strokes, heart attacks and also kidney failure are more common in people with hypertension than in those without this disorder.

The researchers at IQWiG were therefore particularly interested firstly, to know whether people with hypertension, by exercising more, can actually reduce the risk of heart attacks or stroke, for example, and secondly, to determine how more exercise affects their health-related quality of life.

Studies included only a few participants

The researchers searched for studies in which volunteers with hypertension had been randomly assigned to two groups. Patients in the intervention group had been advised to exercise more over a longer period of time (e.g. cycling, running, hiking, swimming), while those in the control group had not been given this advice. In addition, only studies lasting 24 weeks or more were considered.

Overall, IQWiG and its external experts included 8 randomized controlled trials lasting 6 to 12 months in the assessment. The studies were relatively small; most included a maximum of 20 people per study group. In addition, most studies were prone to bias, which greatly limited their informative value.

Side effects not investigated

As the assessment showed, the studies considered in the report allow no conclusions on patient-relevant aspects of the benefit of increased physical activity in hypertension. The studies did not provide sufficient results, neither on mortality, disease of the heart and circulatory system (cardiovascular morbidity), and kidney failure (end-stage renal disease), nor on health-related quality of life. Sufficient data were also lacking on side effects (adverse events): as many elderly patients suffer from hypertension they could potentially have a higher risk of falling or injuring themselves.

Systolic blood pressure lowered

In contrast, in all studies the effects of exercise on blood pressure were analysed. The data show that increased physical activity could lower the systolic (higher) value by 5 to 8 mmHg. In contrast, no differences between treatment groups were shown for the diastolic (lower) value. However, the researchers cannot safely predict whether the reduction in the systolic value is long term and what the effects on health are. A reduction in blood pressure is an indication that the risk of late complications may be diminished. However, it is well-known with regard to drugs that even if medications are similarly effective in reducing blood pressure, they may still fail to prevent late complications such as heart damage equally well, and also produce different side effects.

In addition, it could not be concluded from the studies whether participants could reduce the intake of blood-pressure lowering medications through exercising more often.

Advice on lifestyle changes also investigated in studies

"To avoid misunderstandings: our conclusion is not that more exercise is useless or even harmful," says Professor Dr. med. Jürgen Windeler, IQWiG's Director. "However, it is a sobering fact that medications to lower blood pressure have been tested in dozens of large studies but we still know little about the advantages and disadvantages of physical activity, even though national and international professional associations have recommended this measure for a long time." This imbalance should be corrected. "Advising patients with hypertension to exercise more will often mean a substantial change in their life style; patients should know whether they benefit from this."

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The above story is reprinted (with editorial adaptations by ScienceDaily staff) from materials provided by Institute for Quality and Efficiency in Health Care, via EurekAlert!, a service of AAAS.

Note: If no author is given, the source is cited instead.

Disclaimer: This article is not intended to provide medical advice, diagnosis or treatment. Views expressed here do not necessarily reflect those of ScienceDaily or its staff.

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Lower blood pressure may preserve kidney function in some patients

ScienceDaily (Sep. 2, 2010) — Intensively treating hypertension in some African Americans with kidney disease by pushing blood pressure well below the current recommended goal may significantly decrease the number who lose kidney function and require dialysis, suggests a Johns Hopkins-led study publishing in the New England Journal of Medicine.

"This is not a panacea. We have a lot more to figure out. But our evidence suggests that we have a way to at least delay or possibly even prevent end-stage kidney disease in some patients," says Lawrence J. Appel, M.D., M.P.H., a professor of medicine at the Johns Hopkins University School of Medicine and the study's leader.

End-stage kidney disease is the point at which patients need to be on dialysis or receive a kidney transplant in order to survive.

Still, not everyone in the study was helped by the aggressive blood pressure treatment. Those patients who had little or no protein in their urine -- that is, patients who were not as sick -- saw their kidney disease progress at roughly the same rate regardless of how low they tried to get their blood pressure. It was the sicker patients, that is, those with protein in their urine, who benefited most from the more intensive blood pressure therapy, with roughly a 25 percent reduction in end-stage kidney disease as compared with those who met the standard blood pressure goal. Roughly one-third of the participants had higher amounts of protein in their urine.

"This has always been a hot topic: Is a lower blood pressure goal better at preserving kidney function than the standard goal? The answer is a qualified yes, notably in people who have some protein in their urine," Appel says.

In the National Institutes of Health-sponsored African-American Study of Kidney Disease and Hypertension (AASK), 1,094 hypertensive African Americans with chronic kidney disease were randomized to one of two groups: standard blood pressure goal versus intensive (or lower) blood pressure goal. Both groups needed to get their blood pressure in check -- the first group's goal was a blood pressure of roughly 140/90 (the standard target of doctors when treating hypertensive patients), while the second group's goal was approximately 130/80. Researchers lowered blood pressure through a combination of commonly used drugs. The patients were followed between 8.8 and 12.2 years.

Chronic kidney disease is a major public health problem and one that is only growing, Appel says. In the United States, roughly one-third of cases of end-stage kidney disease -- in which the kidneys no longer function and patients require dialysis or a transplant -- are attributed to hypertension. The burden of kidney disease is especially high in African Americans. Though they constitute only 12 percent of the population, African Americans make up 32 percent of those with end-stage kidney disease. Appel says African Americans are four to 20 times more likely to reach end-stage kidney disease, though researchers remain unsure of the reasons why.

Physicians consider patients with blood pressure over 140/90 to be hypertensive, and they will often put those patients on blood pressure-lowering medication with the goal of getting them back below that hazardous threshold. In recent years, some doctors have suggested that their patients with kidney disease try to get their blood pressure lower than that to stave off the progression of kidney disease, though without much scientific evidence, Appel says.

Appel says his study suggests that physicians should check for protein in the urine before determining the blood pressure goal for African Americans with kidney disease. If the patient has protein in the urine, a lower blood pressure goal has the potential to slow the progression of kidney disease. But if the patient has little or no protein in the urine, Appel says, the study suggests that reaching the lower blood pressure goal is not worth the extra effort, and the standard goal is just as good. Getting hypertensive patients down to 130/80 takes more doctor visits and requires more medication -- on average, one more blood pressure prescription. However, once the lower blood pressure level is achieved, keeping the blood pressure there is not particularly difficult.

Even though the study found a benefit of aggressive blood pressure treatment in one group of hypertensive African Americans with kidney disease, a significant number of those patients still ended up with end-stage kidney disease or worse. While roughly 90 percent of those who were in the standard blood pressure group saw their disease progress, about 75 percent of those in the aggressive therapy arm of the trial still progressed to a poor outcome.

"That's still pretty high," Appel says. "The key is preventing early kidney damage in the first place."

More research is necessary, he says, to identify more factors that prevent early kidney damage, as well as factors that delay kidney disease progression among those who already have chronic kidney disease.

The study was conducted at 20 medical centers in the United States. Along with Appel, other Johns Hopkins faculty and staff involved in the research include Edgar Miller, M.D., Ph.D., Brad Astor, Ph.D., M.P.H., M.S.; Charalett Diggs, R.N.; Jeanne Charleston, R.N.; and Charles Harris.

The National Institutes of Health was the primary sponsor of the study. In addition, King Pharmaceuticals provided financial support and donated antihypertensive medications. Pfizer Inc., AstraZeneca Pharmaceuticals, Glaxo Smith Kline, Forest Laboratories, Pharmacia and Upjohn also donated medication.

Story Source:

The above story is reprinted (with editorial adaptations by ScienceDaily staff) from materials provided by Johns Hopkins Medical Institutions, via EurekAlert!, a service of AAAS.

Journal Reference:

Appel et al. Intensive Blood-Pressure Control in Hypertensive Chronic Kidney Disease. New England Journal of Medicine, 2010; 363 (10): 918 DOI: 10.1056/NEJMoa0910975

Note: If no author is given, the source is cited instead.

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Tight blood pressure control for patients with diabetes and coronary artery disease not associated with improved cardiovascular outcomes, study finds

ScienceDaily (Sep. 26, 2010) — Patients with hypertension, diabetes and coronary artery disease who maintained their systolic blood pressure at less than 130 mm Hg did not have improved cardiovascular outcomes compared to patients with usual blood pressure control, according to a study in the July 7 issue of JAMA.

"Hypertension guidelines advocate treating systolic blood pressure (BP) to less than 130 mm Hg for patients with diabetes mellitus; however, data are lacking for the growing population who also have coronary artery disease (CAD)," according to background information in the article.

Rhonda M. Cooper-DeHoff, Pharm.D., M.S., of the University of Florida, Gainesville, and colleagues examined whether patients with hypertension, diabetes and CAD who achieved systolic BP of less than 130 mm Hg would have a reduced risk of cardiovascular events compared with those who managed to keep their systolic BP within the range of at least 130 mm Hg to less than 140 mm Hg. The analysis included 6,400 of the 22,576 participants in the International Verapamil SR-Trandolapril Study (INVEST). For this analysis, participants were at least 50 years old and had diabetes and CAD. Participants were recruited between September 1997 and December 2000 from 862 sites in 14 countries and were followed up through March 2003, with an extended follow-up through August 2008 through the National Death index for U.S. participants.

Patients received treatment with either a calcium antagonist or beta-blocker followed by angiotensin-converting enzyme inhibitor, a diuretic, or both to achieve systolic BP of less than 130 and diastolic BP of less than 85 mm Hg. Patients were categorized as having tight control if they could maintain their systolic BP at less than 130 mm Hg; usual control if systolic BP ranged from 130 mm Hg to less than 140 mm Hg; and uncontrolled if systolic BP was 140 mm Hg or higher. The primary outcome included the occurrence of all-cause death, nonfatal myocardial infarction (heart attack), or nonfatal stroke.

The primary outcome occurred in 12.7 percent (286 patients) of those in the tight-control group, 12.6 percent (249 patients) of the usual-control group, and 19.8 percent (431 patients) of the uncontrolled groups. When evaluating all-cause mortality for the entire follow-up period, after adjustment, risk of all-cause mortality was significantly greater in the tight-control group (22.8 percent) than in the usual-control group (21.8 percent).

"In this observational study, we have shown for the first time, to our knowledge, that decreasing systolic BP to lower than 130 mm Hg in patients with diabetes and CAD was not associated with further reduction in morbidity beyond that associated with systolic BP lower than 140 mm Hg, and, in fact, was associated with an increase in risk of all-cause mortality. Moreover, the increased mortality risk persisted over the long term," the authors write.

"At this time, there is no compelling evidence to indicate that lowering systolic BP below 130 mm Hg is beneficial for patients with diabetes; thus, emphasis should be placed on maintaining systolic BP between 130 and 139 mm Hg while focusing on weight loss, healthful eating, and other manifestations of cardiovascular morbidity to further reduce long-term cardiovascular risk."

Story Source:

The above story is reprinted (with editorial adaptations by ScienceDaily staff) from materials provided by JAMA and Archives Journals.

Journal Reference:

Rhonda M. Cooper-DeHoff; Yan Gong; Eileen M. Handberg; Anthony A. Bavry; Scott J. Denardo; George L. Bakris; Carl J. Pepine. Tight Blood Pressure Control and Cardiovascular Outcomes Among Hypertensive Patients With Diabetes and Coronary Artery Disease. JAMA, 2010; 304 (1): 61-68 [link]

Note: If no author is given, the source is cited instead.

Disclaimer: This article is not intended to provide medical advice, diagnosis or treatment. Views expressed here do not necessarily reflect those of ScienceDaily or its staff.

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Hypertension Patients Should Pay Attention to Daily Diets

Modern medical research has found out that, during the spring, people are vulnerable to many diseases, such as the fluctuation of blood pressure, headache, dizziness, insomnia and other symptoms. As a result, in addition to taking moderate exercise and medicine, people with hypertension should also pay great attention to daily diet.

First of all, eat more fresh vegetables and fruits.
According to the report, eating more fresh fruits and vegetables can significantly decrease the risk of stroke. Citrus, fruit juice, carrot, celery, cucumber, cabbage and other green leafy vegetables all have a protective effect on cardiovascular, so they can always eat these foods.

Secondly, control the intake of salt.
Too much salt will aggravate the disease. Generally speaking, the patients with hypertension should control the daily intake of salt between 4 to 6 grams. But they should pay attention to increase the intake of potassium at the same time. This is because potassium can protect the cardiac cells. Foods such as amaranth, spinach, tomato, bitter gourd, yam all contain a large number of potassium.

Thirdly, control the intake of cholesterol and fatty acids.
Eat less greasy foods, especially animal fats, and limit the intake of all animal organs (such as heart, liver, kidney), fatty meat, butter, egg yolk and other foods which are rich in cholesterol and fatty acids. They can appropriately take in some plant oil such as peanut oil and corn oil. At the same time, in order to avoid increasing the burden on the kidney, do not take in too much protein.

Fourthly, keep away from smoking and alcohol.
The nicotine in cigarette may stimulate the heart, accelerate the heart rate, thus leading to high blood pressure. What's more, nicotine can also promote the deposition of cholesterol on the vascular wall, which may increase the chance of coronary heart disease and stroke. Drinking a small amount of alcohol can increase the level of high-density lipoprotein in blood, so it can prevent atherosclerosis. While excessive drinking high-degree alcohol not only may accelerate the risk of atherosclerosis, but also has a resistant effect on the antihypertensive medicine.

Fifthly, choose a reasonable and healthy diet.
There are many kinds of foods which have the effect of bringing down the blood pressure, such as chrysanthemum, seaweed, celery, black fungus, and so on. These foods contain plenty of protein, cellulose, glucose, fructose, etc, so they can be taken as the medical food for hypertension and diabetics.

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Common hypertension drugs can raise blood pressure in certain patients

ScienceDaily (Aug. 19, 2010) — AlbCommonly prescribed drugs used to lower blood pressure can actually have the opposite effect -- raising blood pressure in a statistically significant percentage of patients. A new study by researchers at Albert Einstein College of Medicine of Yeshiva University suggests that doctors could avoid this problem -- and select drugs most suitable for their patients -- by measuring blood levels of the enzyme renin through a blood test that is becoming more widely available.

The study appears in the online edition of the American Journal of Hypertension.

"Our findings suggest that physicians should use renin levels to predict the most appropriate first drug for treating patients with hypertension," says lead author Michael Alderman, M.D., professor of epidemiology & population health and of medicine at Einstein. "This would increase the likelihood of achieving blood pressure control and reduce the need for patients to take additional antihypertensive medications."

The study involved 945 patients who were enrolled in a workplace antihypertensive treatment program in New York City from 1981 to 1998. All had a systolic blood pressure (SBP) of at least 140 mmHg. SBP, the top number in the blood pressure reading, represents the amount of force that blood exerts on the walls of blood vessels when the heart contracts. No patients were receiving treatment for high blood pressure before enrolling in the study.

The patients were given a single antihypertensive medication, either a diuretic or a calcium channel blocker (so-called "V" drugs, which lower blood volume) or a beta blocker or an ACE inhibitor ("R" drugs, which lower levels of renin, an enzyme secreted by the kidneys that plays a key role in maintaining blood pressure).

Plasma renin activity (PRA) and SBP were measured at enrollment, and SBP was measured again after one to three months of treatment. The renin level predicted those patients who were most likely to have a favorable response with either an R or a V drug. In addition, for both R and V drugs, the renin test was able to identify those patients most likely to experience a "pressor response" -- a clinically significant increase in SBP of 10 mmHg or more.

Overall, 7.7 percent of the patients exhibited a pressor response. The highest percentage of pressor responses -- 16 percent -- occurred in patients with low renin levels who were given a beta blocker or an ACE inhibitor (R drugs).

"Every clinician knows that there's a variation in response to antihypertensive treatment, and that some patients will have an elevation in blood pressure," says Dr. Alderman, a former president of the American Society of Hypertension. "The latter phenomenon is generally attributed to patients' failure to take their medications or to a random event. But these data show that it's not a random event -- it's due to a mismatch between the patients' renin status and the drug. We think it makes sense to use renin to predict the most appropriate treatment."

Dr. Alderman says that two groups of patients might especially benefit from having their renin levels measured: patients being prescribed antihypertensive drugs for the first time and patients who are taking multiple antihypertensive drugs when one or two might work just as well. "With renin testing, you will more often get blood pressure under control with less therapy," he adds.

PRA testing has long been used to help determine the underlying cause of a patient's hypertension (i.e. whether it's due to constricted blood vessels or too much blood volume, or both), which can help guide therapy. "The problem was that the test was expensive and difficult to perform accurately," says Dr. Alderman. "However, the methodology for measuring PRA is getting better and the test is becoming more widely available."

In an accompanying editorial, Morris J. Brown, M.D., professor of clinical pharmacology at the University of Cambridge School of Medicine in England, wrote, "The role of renin measurement may be to detect the extremes, and to reach rational treatment in those not controlled by standard combination [drug therapy]. Many hormones are measured on rather less reason and evidence than plasma renin, the 'oldest' of them all; its place in routine management of hypertension has at last arrived."

Story Source:

The above story is reprinted (with editorial adaptations by ScienceDaily staff) from materials provided by Albert Einstein College of Medicine, via EurekAlert!, a service of AAAS.

Journal Reference:

Alderman et al. Pressor Responses to Antihypertensive Drug Types. American Journal of Hypertension, 2010; DOI: 10.1038/ajh.2010.114

Note: If no author is given, the source is cited instead.

Disclaimer: This article is not intended to provide medical advice, diagnosis or treatment. Views expressed here do not necessarily reflect those of ScienceDaily or its staff.

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