What is the place of lifestyle changes in the treatment of hypertension?



What is the place of
lifestyle changes in the
treatment of hypertension?

1. J. Börgel,, Germany
2. D. A. Castán Flores, Mexico
3. J. R. Guillén Moreno, Guatemala
4. P. C. B. Veiga Jardim, Brazil
5. K. Kostka-Jeziorny, Poland
6. S. Kumar,India
7. N. Kupstyte, Lithuania
8. L. Mishchenko, Ukraine
9. A. Vachulova, Slovak Republic

1. J. Börgel, Germany

Jan BÖRGEL, MD
Head of the Department of Internal Medicine
Cardiology, Pneumology, Intensive Care Medicine
and Hypertension-Unit Hochdrucklabor
St. Barbara-Clinic, Teaching Hospital, University
of Münster, Hamm, GERMANY
(email: jboergel@barbaraklinik.de)

The relationship between arterial hypertension and cardiovascular morbidity and mortality represents a major challenge for clinicians and health-care systems. Elevated blood pressure is a risk factor for coronary artery disease, heart failure, cerebrovascular disease, peripheral artery disease, chronic kidney disease, and atrial fibrillation. Many patients with arterial hypertension are asymptomatic, and too often high blood pressure values are recognized by chance. Based on the current European Society of Cardiology (ESC) hypertension guidelines,1 the initial step in the management of hypertension comprises lifestyle changes. Lately attention has shifted towards these measures of prevention, with the publication of the ESC guidelines on cardiovascular disease prevention in clinical practice.2 Lifestyle changes may delay or prevent hypertension in nonhypertensive subjects, delay or prevent medical therapy in grade 1 hypertensive patients, and contribute to blood pressure reduction in hypertensive individuals already on medical therapy. Nevertheless, lifestyle changes should not delay the initiation of drug therapy in individuals at a high total cardiovascular risk. Recommendations for lifestyle changes include:
Weight reduction – reduction to 25 kg/m<sup<2 is recommended, and an average weight loss of 5.1 kg was associated with a decrease in blood pressure of 4.4/3.6 mm Hg
Salt restriction – reducing intake to 5-6 g/day lowers systolic blood pressure by 4-5 mm Hg in hypertensive individuals
Moderation of alcohol consumption – there is a linear relationship between alcohol consumption and hypertension
Regular physical activity – aerobic endurance training reduces resting systolic and diastolic blood pressure by 6.9/ 4.9 mm Hg in hypertensive subjects
Smoking cessation – smoking one cigarette increases blood pressure for over 15 minutes, and
Dietary changes – increased consumption of vegetables, fruit, and low-fat products is recommended

Although the positive effects of adherence to lifestyle changes have been well documented, earlier pharmacological intervention may be useful because lifestyle benefits may be overvalued. To put the controversy into context, UK hypertension guidelines shows that the average blood pressure decrease over 6 months in hypertensive patients who undergo a combined lifestyle intervention is limited (5.5/4.5 mm Hg).3 Furthermore, patient adherence to lifestyle changes is suboptimal; most patients do not adhere to healthy lifestyle recommendations.4 Thus, in the majority of patients with newly diagnosed hypertension, lack of adherence to lifestyle changes leads to delayed hypertension control. Delayed control of high systolic blood pressure >150 mm Hg is associated with increased cardiovascular risk.5 Although lifestyle changes remain an important adjunct in the treatment of hypertension, earlier pharmacological intervention may be a therapeutically rational choice, even in patients with mild hypertension.6 Patients with additional cardiovascular risk factors, in particular, benefit from rigorous pharmacological blood pressure control, and thus therapy initiation in these individuals should not be delayed.7 Despite this evidence, international guidelines for hypertension1 continue to promote a period of lifestyle changes before treatment initiation. The newer cardiovascular prevention guidelines state that lifestyle changes with close blood pressure monitoring should be recommended in young individuals with isolated moderate elevation of brachial systolic blood pressure as well as in individuals with high-normal blood pressure who are at low or moderate risk.

Clearly, the initiation, maintenance, and regular checking of lifestyle changes is mandatory for every hypertensive patient, but one has to recognize the logistic challenges as well. The decision to initiate antihypertensive treatment depends on blood pressure level and total cardiovascular risk, but lifestyle changes remain the cornerstone of prevention in the downstream management of every hypertensive patient.■

References
1. 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 (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-2219.
2. Piepoli MF, Hoes AW, Agewall S, et al; Authors/Task Force Members. 2016 European guidelines on cardiovascular disease prevention in clinical practice: the sixth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of 10 societies and by invited experts) developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37:2315-2381.
3. National Institute of Health and Care Excellence: Guidance. Hypertension: the clinical management of primary hypertension in adults: update of Clinical Guidelines 18 and 34. London, UK: Royal College of Physicians, National Clinical Guidelines Centre; August 2011. www.ncbi.nlm.nih.gov/pubmedhealth/PMH0047679/pdf/ PubMedHealth_PMH0047679.pdf. Accessed January 13, 2017.
4. Hamer M. Adherence to healthy lifestyle in hypertensive patients: ample room for improvement? J Hum Hypertens. 2010;24:559-560.
5. Xu W, Goldberg SI, Shubina M, Turchin A. Optimal systolic blood pressure target, time to intensification, and time to follow-up in treatment of hypertension: population based retrospective cohort study. BMJ. 2015;350:h158.
6. Gradman AH, Parisé H, Lefebvre P, Falvey H, Lafeuille MH, Duh MS. Initial combination therapy reduces the risk of cardiovascular events in hypertensive patients: a matched cohort study. Hypertension. 2013;61:309-318.
7. Wright JT Jr, Williamson JD, Whelton PK, et al; SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103-2116.

2. D. A. Castán Flores, Mexico

David Arturo CASTÁN FLORES, MD
Professor of the Advanced Heart Failure
Subspeciality Course, Heart Failure, Transplant
and Extracorporeal Circulatory Support Unit
Cardiology Hospital, National Medical Center
Siglo XXI, Mexican Institute for Social Security
300 Cuauhtemoc Avenue, Doctores District
Cuauhtemoc, Mexico City 06720, MEXICO
(email: drdavidcastan@gmail.com)

Hypertension is one of the most important chronic conditions related to increased risk of cardiovascular morbidity and mortality. According to the World Health Organization, each year around the world the number of deaths associated with hypertension is almost 8 million. Evidence has demonstrated the existence of a relationship between lifestyle patterns, excess weight, and outcomes in hypertension. Therefore, reaching pharmacological and nonpharmacological goals is the cornerstone of treatment to reduce cardiovascular morbidity and mortality.

Hypertensive patients are often interested to find out how they should alter their lifestyles. The most frequently asked questions during a clinical consultation by hypertensive patients, whether newly diagnosed or not, are “What kind of lifestyle changes should I make?”, “What kind of exercises should I do?”, “Can I stop taking medication if I change my lifestyle?”, and “How long will I have to take medications to treat hypertension?”

There is strong evidence that early control of high blood pressure, especially in patients at high cardiovascular risk (even those without diabetes), is useful for decreasing morbidity and mortality.1 However, in patients with low or medium cardiovascular risk or in stage 1 hypertensive patients, the situation remains unclear. The latest UK hypertension guidelines show that lifestyle changes produce a modest reduction in blood pressure after a 6-month intervention, with an average reduction of approximately 5 mm Hg in systolic and diastolic pressures.

Lifestyle interventions in hypertension involve weight loss in patients who are overweight or obese, although the long-term effects of weight reduction remain unclear. A reduction in dietary sodium to less than 2300 mg/day (about one teaspoonful of salt) is recommended. A recent meta-analysis concluded that a modest reduction in salt intake over a period of four or more weeks produces a significant fall in blood pressure in a hypertensive population (and even normotensive people), with no gender or ethnic differences. Furthermore, increasing aerobic exercise—such as walking or jogging, cycling, and swimming, reaching 40%-60% of maximal age based heart rate for up to 180 minutes weekly—and smoking cessation can also reduce blood pressure.

Based on this evidence, we would be able to strongly recommend lifestyle interventions “the earlier, the better” to improve outcomes in hypertensive patients. Nevertheless, most of the time, patients come to us with high or very high cardiovascular risk already and so, according to current guidelines, lifestyle modifications would not be enough to reach goals and thus reduce cardiovascular risk.

The role of early pharmacological treatment relies on cardiovascular outcomes avoidance by preventing endothelial remodelling and myocardial concentric hypertrophy,2 therefore reducing the possibility of stroke or coronary artery disease. In relation to this, fixed-dose combinations of antihypertensive drugs have been shown to have more benefits than monotherapy, such as well-defined tolerability, enhanced treatment adherence, and better effectiveness. As such, they represent a useful tool in treatment for hypertension.3

Once antihypertensive treatment has been initiated, it is unlikely that patients can revert to blood pressure control by lifestyle change alone. Withdrawal of antihypertensive drugs would probably only be safe in a small proportion of young male patients on a monotherapy regimen who were following an effective behavioral change program.4 For the heterogeneous group of moderate-to-very high cardiovascular risk older male patients this would not be the case. For these patients, a fixed-dose combination (perindopril/amlodipine, for example) would be needed to control blood pressure,5 helping most of these patients reach blood pressure goals in three months on average.6 In short, once started it is strongly suggested that antihypertensive medical treatment should continue, regardless of the implementation or not of lifestyle changes, unless there is proven evidence of serious side effects or lack of efficacy.■

References
1. Wright JT Jr, Williamson JD, Whelton PK, et al; SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103-2116.
2. Milan A, Caserta MA, Avenatti E, Abram S, Veglio F. Anti-hypertensive drugs and left ventricular hypertrophy: a clinical update. Intern Emerg Med. 2010;5(6): 469-479.
3. Shirley M, McCormack PL. Perindopril/amlodipine (Prestalia®): a review in hypertension. Am J Cardiovasc Drugs. 2015;15(5):363-370.
4. Nelson MR, Reid CM, Krum H, Ryan P, Wing LM, McNeil JJ; Management Committee, Second Australian National Blood Pressure Study. Short-term predictors of maintenance of normotension after withdrawal of antihypertensive drugs in the second Australian National Blood Pressure study (ANBP2). Am J Hypertens. 2003;16:39-45.
5. Abdelhady A, Khader S, Sinnuqrut S, Albow A. The efficacy of perindopril/amlodipine in reaching blood pressure targets: results of the CONTROL study. Clin Drug Investig. 2016;36(5):357-366.
6. Karpov YA, Gorbunov VM, Deev AD. Effectiveness of fixed-dose perindopril/amlodipine on clinic, ambulatory and self-monitored blood pressure and blood pressure variability: an open-label, non comparative study in the general practice. High Blood Press Cardiovasc Prev. 2015;22(4):417-425.

 

3. J. R. Guillén Moreno, Guatemala

Julio Ricardo GUILLÉN MORENO, MD
Cardiology & Electrophysiology
Clínica del Centro Médico II, of 309
Guatemala City, GUATEMALA
(email: drjulio.guillenm@gmail.com)

Hypertension is the most common chronic condition dealt with by primary care physicians and other health practitioners. It is a major contributor to the onset and progression of chronic heart and kidney failure and, importantly, a major risk factor for stroke and coronary heart disease. Understanding its incidence, prevalence, and role in cardiovascular disease is crucial, as is an in-depth knowledge of risk factors, pathophysiology, and levels of hypertension.1,2 Knowledge of the epidemiology of the disease is the first step towards appropriate treatment.

Although the pharmacological management of hypertension has been studied since the 1950s and has been refined over the years, it is only in the last decade or so that the importance of lifestyle has been established in the treatment of hypertension.3 In the 1980s, the association between hypertension, diabetes, dyslipidemia, smoking and cardiovascular risk was defined, so a lot of effort since then has been directed at drug treatment, smoking reduction, and specific control of these diseases.3 Ongoing research over the years has shown that the goal of treatment should not only be to decrease the value of blood pressure and maintain lipid and glucose levels within normal ranges. Above and beyond these objectives, management of risk should also include changes in lifestyle. These kinds of changes reflect a comprehensive approach towards risk that is multicausal in origin.4

Currently, management of hypertensive patients begins with the categorization of risk by assessment of blood pressure level and risk factors. Once the category of risk has been determined, recommendations focus on the use of antihypertensive drugs and changes in lifestyle. Lifestyle modifications are indicated for all patients, regardless of whether or not they are on drug therapy. In addition to lowering blood pressure, recommended lifestyle changes confer health benefits and improve outcomes in several common, chronic diseases, not only those that are cardiovascular-related.2

Lifestyle recommendations in hypertensive patients are based on2-5:
1. Smoking cessation – smoking causes an immediate increase in blood pressure and in heart rate that persists for over 15 minutes for one cigarette. It is a strong independent risk factor. The recommendation is simple: stop immediately!
2. Nutrition and salt intake – a healthy diet (containing fruit, vegetables, wholegrain foods, unprocessed meats, poultry, fish, and moderate amounts of polyunsaturated and monounsaturated fats) is important, but so too is controlling salt intake. Added salt (at the table) should be avoided
3. Water consumption – the recommendation is 1.5 liters/day to be drunk slowly throughout the day between meals
4. Alcohol – limit intake to a maximum of one or two standard drinks per day (for women and men, respectively) as well as planning at least two alcohol-free days per week
5. Physical activity – moderate intensity cardiovascular exercise (walking, cycling, swimming, etc) 20-50 minutes a day, 150-180 minutes a week, 5 to 7 days per week
6. Body weight – body mass index should be less than 25 kg/m2. Weight reduction confers other benefits, reducing insulin resistance, hyperlipidemia, risk of left ventricular hypertrophy, and obstructive sleep apnea
7. Obstructive sleep apnea – an independent risk factor that is also associated with sudden cardiac death

Several studies have shown that to reduce morbidity/mortality and improve quality of blood pressure control in hypertension, all risk factors must be considered. Lifestyle encompasses a number of these and is one of the most important modifiable elements in hypertension and cardiovascular disease.1 The health community has understood that hypertension is really multicausal in nature, which is why the current recommendation worldwide in the treatment of this pathology is no longer just pharmacological, but also now includes lifestyle changes.3

References
1. 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.
2. Huang N, Duggan K. Lifestyle management of hypertension. Aust Prescr. 2008; 31:150-153. www.nps.org.au/australian-prescriber/articles/lifestyle-management- of-hypertension. Accessed January 13, 2017.
3. Mancia G, Fagard R, Narkiewicz K, et al; Task Force Members. 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 (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013;31: 1281-1357.
4. Cordero A, Bertomeu-Martínez V, Mazón P, et al. Factors associated with uncontrolled hypertension in patients with and without cardiovascular disease [in Spanish]. Rev Esp Cardiol. 2011;64:587-593.
5. Weber MA, Schiffrin EL, White WB, 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. J Hypertens. 2014;32(1):3-15.

4. P. C. B. Veiga Jardim, Brazil

Paulo César B. VEIGA JARDIM, MD, PhD
Full Professor of Cardiology
Hypertension League/Cardiology
School of Medicine Federal University of
Goiás/Brasil, BRAZIL
(email: fvjardim@terra.com.br)

The beneficial effects of nonpharmacological treatment (ie, healthy lifestyle) on blood pressure are well established.1-5 Studies of up to 24 months’ duration that combined moderate-to-intense physical activity with dietary interventions reduced mean systolic blood pressure by 4.5 mm Hg and mean diastolic blood pressure by 1.1 mm Hg after 12 months. Other shorter-term studies, ranging from 12 to 24 months, showed a reduction of 2.3 mm Hg and 1.0 mm Hg in systolic and diastolic blood pressure, respectively.1 Nevertheless, no scientific evidence shows that blood pressure treatment using only nonpharmacological strategies changes the natural history of the disease. In contrast, clear evidence is available showing that pharmacological treatment combined with nonpharmacological treatment decreases cardiovascular morbidity and mortality in hypertensive patients.2-5

This information shows us clearly the importance of adopting a healthy lifestyle as adjuvant care for all hypertensive patients, since it decreases the number of drugs needed and avoids or at least delays the onset of other cardiovascular risk factors (dyslipidemia, diabetes, obesity, etc). From this point on, the question is related to two other aspects of hypertension treatment.

The first regards how long one should wait before starting pharmacological treatment. In this matter, there is a consensus that patients with stages 2 and 3 hypertension and those with high cardiovascular risk or with established cardiovascular disease, even in stage 1 hypertension, must receive pharmacological treatment from diagnosis.2,3 The question about when to start pharmacological treatment in subjects with stage 1 hypertension and low cardiovascular risk remains as yet unanswered. For this scenario, there are no studies showing the right time, only expert opinions recommending several weeks to months of lifestyle changes (normally 3 to 6 months) before starting pharmacological treatment.2,3

The second aspect is related to the choice of antihypertensive monotherapy or drug combinations at the beginning of treatment. As before, there are no clinical studies that have been designed to specifically answer this question, and the answer will probably not be based on strong scientific evidence. However, it is well known that 70% of patients will need drug combinations to achieve blood pressure goals established by international guidelines. It is also clear that by getting blood pressure under control as early as possible, benefits are better for high-risk subjects, with marked changes in disease evolution.2-4

For patients with low or moderate cardiovascular risk, there are limited data available showing the advantages of starting combination therapy early, even though antihypertensive drug combinations are used to achieve blood pressure control in the majority of studies in hypertension. It is well known that achieving blood pressure goals is important, achieving these goals fast is beneficial, and, furthermore, difficulties in achieving these goals lead to lower treatment adherence rates.2-6 An interesting real-world study published in 2013 showed that patients who started treatment on drug combinations had a 34% reduction in the risk of cardiovascular events or death compared with those who started treatment on monotherapy. In addition to this, there was a 9% decrease in the use of health services in the group that started treatment on a combination.6

From the set of available information, two important points should be kept in mind: (i) there will always be a place for healthy lifestyle as an adjuvant in the care of hypertensive patients; and (ii) pharmacological treatment must be initiated early, with drug combinations being considered a first-line approach for most patients since they promote better and faster blood pressure control, improve adherence, and decrease the risk of cardiovascular events.■

References
1. Lin JS, O’Connor EA, Evans CV, Senger CA, Rowland MG, Groom HC; Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. Behavioral counseling to promote a healthy lifestyle for cardiovascular disease prevention in persons with cardiovascular risk factors: an updated systematic evidence review for the U.S. Preventive Services Task Force. Published August 2014. https://www.ncbi.nlm.nih.gov/pubmedhealth/ PMH0066955/pdf/PubMedHealth_PMH0066950.pdf. Accessed January 13, 2017.
2. Mancia G, Fagard R, Narkiewicz K, et al; Task Force Members. 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 (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013;31: 1281-1357.
3. Brazilian Society of Cardiology; Brazilian Society of Hypertension; Brazilian Society of Nephrology. Seventh Brazilian guideline of arterial hypertension. Arq Bras Cardiol. 2016:107(3 suppl 3):1-83. http://www.scielo.br/pdf/abc/v107n3s3/ 0066-782X-abc-107-03-s3-0000.pdf. Accessed January 13, 2017.
4. Sundström J, Arima H, Jackson R, et al; Blood Pressure Lowering Treatment Trialists’ Collaboration. Effects of blood pressure reduction in mild hypertension: a systematic review and meta-analysis. Ann Intern Med. 2015;162(3):184-191.
5. 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. J Hypertens. 2014;32(12):2296-2304.
6. Gradman AH, Parisé H, Lefebvre P, Falvey H, Lafeuille MH, Duh MS. Initial combination therapy reduces the risk of cardiovascular events in hypertensive patients: a matched cohort study. Hypertension. 2013;61:309-318.

5. K. Kostka-Jeziorny, Poland

Katarzyna KOSTKA-JEZIORNY, MD, PhD
Department of Hypertension, Angiology
and Internal Medicine
Poznan University of Medical Sciences
Poznan, POLAND
(email: kostkajeziorny@gmail.com)

The 2013 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) hypertension guidelines clearly and strongly underline the importance of appropriate lifestyle changes in hypertensive treatment (Class I, level A/B). This said, lifestyle changes should never delay the initiation of antihypertensive drug treatment in patients with a high level of risk.

Measures that help control blood pressure include: salt restriction, regular physical exercise, weight reduction, smoking cessation, moderation of alcohol consumption, high consumption of vegetables and fruits, and low-fat and other types of diet. A single change in one of the lifestyle measures listed above can help prevent or control high blood pressure, while changes to several measures result in even better prevention or blood pressure reduction.

Beside their blood pressure–lowering effect, lifestyle changes contribute to the control of other cardiovascular risk factors and clinical conditions. For example, combined dietary and physical activity interventions in prediabetic patients have a protective effect against the incidence of diabetes. Sodium restriction may reduce the number of doses and dosage of antihypertensive drugs, although effective salt reduction is by no means easy to achieve. Epidemiological papers suggest that regular, aerobic physical activity may be beneficial for the prevention of hypertension and as antihypertensive treatment. Physical activity might also lower cardiovascular risk and mortality. It should be noted that, for the moment, isometric exercises are not recommended. Everybody knows that smoking is major risk factor for atherosclerotic cardiovascular diseases, so we should recommend that our patients quit smoking and offer them assistance, including treatment with nicotine replacement therapy, bupropion, or varenicline.

Every hypertensive patient should be advised to eat vegetables, low-fat dairy products, dietary and soluble fiber, whole grain cereals, protein from plant sources (reduced in saturated fat and cholesterol), and fish (at least twice a week). Fresh foods are also recommended for patients with normal weight, because carbohydrates may promote weight gain.

I want to mention one more important risk factor of arterial hypertension that is often omitted from guidelines: hyperuricemia. Even though the latest European hypertension guidelines recommend the routine measurement of serum uric acid levels, the algorithm for evaluating total cardiovascular risk does not include this parameter. Observational studies have shown that the relative risk of hypertension increases with increasing serum uric acid, independently of regular risk factors. This finding was confirmed by a meta-analysis of 18 prospective cohort studies in patients who were not hypertensive at baseline. The pooled adjusted relative risk for incident hypertension was greater in patients with hyperuricemia than in those without. It was later found that hyperuricemia is an independent predictor of new-onset hypertension. So, in my opinion, we should recommend a low-purine diet in hypertensive patients with hyperuricemia. According to the American College of Rheumatology, a diet that has an excessive amount of the following foods can lead to hyperuricemia: seafood, red meat, sugary beverages, and alcohol.

The implementation of lifestyles that most favorably reduce blood pressure has implications for the prevention and treatment of hypertension and for population-based strategies to shift the overall distribution of risk downwards. Even if lifestyle modifications do not produce a sufficient reduction in blood pressure to avoid drug therapy, fewer medications and lower dosages of these may be needed for blood pressure control.■

6. S. Kumar, India

Soumitra KUMAR, MD
Professor and Head of Department of
Cardiology, Vivekananda Institute of Medical
Sciences, Kolkata, INDIA
(email: dr.soumitrakumar@gmail.com)

Hypertension is a key risk factor for stroke and coronary heart disease and is also a major contributor to the initiation and progression of chronic heart failure and chronic renal failure. Effective, specific lifestyle modifications should be the first step in the management of hypertension because these can delay initiation of drug treatment and may help reduce the number and dose of drugs when they are required to control blood pressure. In addition to achieving the immediate goal of blood pressure lowering, lifestyle changes also serve to reduce total cardiovascular risk. Current international guidelines1,2 recommend that in patients with hypertension no more severe than stage 1 (systolic blood pressure 140 to 159 mm Hg and/or diastolic blood pressure 90-99 mm Hg) without evidence of target organ damage or other cardiovascular risk factors, 6 to 12 months of lifestyle changes can be attempted. However, it is considered prudent to start treatment sooner if blood pressure does not respond to lifestyle methods or if other risk factors appear. For more severe hypertension, lifestyle changes should be regarded as complementary to drug therapy.

The following lifestyle changes are recommended:
◆ Weight reduction. Blood pressure reduction is proportional to weight loss, and every 10 kg of weight lost can result in a reduction of systolic blood pressure of 5-20 mm Hg.3 The aim of weight loss should to be achieve normal body weight (body mass index, 18.5-24.9 kg/m2)
◆ Healthy eating. A healthy way of eating based on the DASH (Dietary Approach to Stop Hypertension) diet can lower systolic blood pressure by 8-15 mm Hg. The DASH diet contains fruit, vegetables, whole grain cereals, low-fat dairy products, and dietary fiber, and low levels of dietary sodium, cholesterol, and saturated fat.4 High-dose (at least 3 g/day) omega-3- polyunsaturated fatty acid supplement (fish oil) may lower blood pressure in hypertension.5 Potassium-rich whole foods— such as bananas, kiwi fruit, avocado, potatoes, nuts, etc— are more effective in reducing systolic blood pressure in hypertensive individuals (4-8 mm Hg) than in normotensive individuals (2 mm Hg)
◆ Salt restriction. An average reduction of systolic blood pressure of 2 to 8 mm Hg5 occurs following a reduction in salt intake. The recommendation is to restrict dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). Practical steps towards this end are to choose fresh, rather than processed, food and to reduce salt added to food for cooking and seasoning
◆ Physical activity. Engaging in regular, aerobic physical activity, such as brisk walking, for at least 30 minutes per day on most days of the week can reduce systolic blood pressure by 4-9 mm Hg
◆ Smoking. People who smoke have higher ambulatory blood pressure levels than nonsmokers.2 Since smoking is a major independent cardiovascular risk factor, hypertensive patients must be strongly urged to discontinue this habit
◆ Alcohol consumption. More than 2 drinks (ie, 30 mL ethanol, 672 mL of beer, 280 mL of wine, or 84 mL of 80% proof whiskey) per day in most men, and more than one drink per day in women and lighter men, can raise blood pressure and should thus be discouraged

The lifestyle changes mentioned above not only lower blood pressure significantly, but also confer other important cardiovascular health benefits. All hypertensive patients should be advised to adopt and maintain healthy lifestyle behaviors.■

References
1. Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and International Society of Hypertension. J Hypertens. 2014;32(1):3-15.
2. 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 (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-2219.
3. Bonow RO, Smaha LA, Smith SC Jr, Mensah GA, Lenfant C.World Heart Day 2002: the international burden of cardiovascular disease: responding to the emerging global epidemic. Circulation. 2002;106:1602-1605.
4. Khan NA, Hemmelgarn B, Padwal R, et al; Canadian Hypertension Education Program. The 2007 Canadian Hypertension Education Program recommendations for the management of hypertension: part 2 – therapy. Can J Cardiol. 2007; 23:539-550.
5. Dyer AR, Elliott P. The INTERSALT study: relations of body mass index to blood pressure. INTERSALT Co-operative Research Group. J Hum Hypertens. 1989;3: 299-308.

7. N. Kupstytė, Lithuania

Nora KUPSTYTĖ, MD, PhD
Consultant Cardiologist, Department of
Cardiology, Hospital of Lithuanian University
of Health Sciences, Kaunas Clinics, LT-50009
Eivenių g. 2, Kaunas, LITHUANIA
(email: nora.kupstyte@yahoo.com)

Cardiovascular diseases, including heart attack and stroke, account for 17.5 million deaths per year.1 One of the most important modifiable risk factors is arterial hypertension. According to recommendations of the European Society of Cardiology (ESC), all patients with hypertension should be advised to change lifestyle, namely health-related behavior and physical activity. Patients with low risk and mild hypertension should only start pharmaceutical treatment if measures to modify lifestyle are ineffective.2,3 Despite these recommendations, few patients reach target blood pressure. Controlling hypertension and its complications can improve quality of life and lifespan and, consequently, reduce the economic burden on society. However, due to the absence of symptoms, patients do not perceive the importance of antihypertensive treatment. Blood pressure control is easier said than done. Even specialized hypertension treatment centers have difficulty helping patients achieve target blood pressure, with patients’ failure to follow medication regimens more important than the inability to modify lifestyle.

The importance of lifestyle modification cannot be denied. Nevertheless, a short conversation about physical activity, diet, and weight is often not enough to motivate patients to change lifestyle. The time required, from initial idea to implementation of change, may actually be months or even years.4 Maintenance of motivation is necessary. Regular counseling on dietary change and physical activity would be ideal, but change takes time. Even then, only a minority of patients are normotensive after lifestyle changes. Perhaps due to frustration with themselves and/or treatment many patients abandon lifestyle changes. These “lost” patients eventually present with complications of untreated hypertension. Once lifestyle modifications have been initiated, benefits also take time to manifest. The longer they take, the more negative the effect on patients’ prognosis. Even optimal conditions of patient education and motivation do not increase the proportion of patients who adhere to healthy lifestyle recommendations.

As such, early pharmacological treatment of hypertension is crucial, even in mild or moderate arterial hypertension. Early pharmacological intervention in mild-to-moderate hypertension can reduce the risk of stroke and myocardial infarction and prevent or minimize other costly consequences of untreated hypertension. Despite the availability of modern medicines, target arterial blood pressure is not achieved in the majority of patients. Finding ways to avoid the risk of target organ damage, shorter survival, and poorer quality of life is important, and one of these is simplification of medication regimens.

The flexibility of modern pharmaceutical treatments of hypertension, such as the combining drugs or prescribing one tablet per day, assist good medication compliance. Other cardiovascular risk factors, like dyslipidemia, should be simultaneously corrected for high-risk patients. Combining drugs and simplifying medication regimens have positive effects in hypertension treatment. Compliance with drug treatment is better when fewer tablets are prescribed.5 At a national level in Lithuania, there is a demand for the development of programs for the primary and secondary prevention of cardiovascular diseases. At a personal level, every cardiologist and family doctor should focus on individualized treatment (assessment of motivation) and consider patients’ perceived problems with hypertension and attitudes towards its medical treatment. Factors to consider include patient education on the use of medicines, a good doctor-patient relationship, continuous monitoring and assessment of treatment, a nonjudgmental attitude, and a willingness to assist. Patient education programs and the development of tools to measure patients’ adherence to healthy lifestyle recommendations would help. Ultimately, both lifestyle modification and early, effective pharmaceutical treatment are needed to promptly reach target blood pressure.

Lifestyle modifications are an important factor, but in the treatment of arterial hypertension optimal pharmaceutical treatment is often crucial even in mild hypertension. Since-long term lifestyle modification strategies, special programs, and the ability to monitor clinical results are unavailable, I do not support the promotion of a period of lifestyle changes before treatment initiation in hypertension ■

References
1. World Health Organization. Cardiovascular diseases (CVDs) fact sheet. http:// www.who.int/mediacentre/factsheets/fs317/en/. Reviewed September 2016. Accessed January 13, 2017.
2. Piepoli MF, Hoes AW, Agewall S, et al; Authors/Task Force Members. 2016 European guidelines on cardiovascular disease prevention in clinical practice: the sixth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of 10 societies and by invited experts) developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37:2315-2381.
3. Task Force for the management of arterial hypertension of the European Society of Hypertension; Task Force for the management of arterial hypertension of the European Society of Cardiology. 2013 ESH/ESC guidelines for the management of arterial hypertension. Blood Press. 2013;22(4):193-278.
4. Prochaska JO, DiClemente CC. The transtheoretical approach. In: Norcross JC, Goldfried MR, eds. Handbook of Psychotherapy Integration. 2nd ed. New York, NY: Oxford University Press; 2005:147-171. 5. Ho PM, Bryson CL, Rumsfeld JS. Medication adherence: its importance in cardiovascular outcomes. Circulation. 2009;119:3028-3035.

8. L. Mishchenko, Ukraine

Larysa MISHCHENKO, MD, PhD
Senior Scientist of Department of Essential
Hypertension in National Scientific Centre
“M. D. Strazhesko Institute of Cardiology”
Kiev, UKRAINE
(email: larmish@ukr.net)

Lifestyle modification is a cornerstone of the management of arterial hypertension. All hypertensive patients, regardless of blood pressure level, should be recommended to restrict salt consumption, moderate alcohol intake, stick to a diet rich in vegetables and fruit, reduce consumption of saturated fats and cholesterol, lose weight, and do regular physical exercise. These recommendations are based on the results of large clinical trials that demonstrate significant blood pressure reduction, from 3 to 8 mm Hg, for each type of lifestyle changes measure.1,2 Lifestyle modification— smoking cessation, first, and healthy diet and physical exercise—reduces the risk of cardiovascular disease as well as improving blood pressure control.

The relevance of lifestyle changes for the treatment of hypertension progressively rises with the increasing prevalence of arterial hypertension risk factors in the general population with age. Primarily, this concerns excess weight and obesity. In Ukraine, according to the results of an urban population study, 70.1% of 30 to 69 year olds are overweight or obese and 24.2% smoke. Smoking prevalence was greater in young people, reaching 47.3% in the group of 30-39 year olds.3 Excessive salt consumption is also a problem in our country, related to individual mealtime habits and industry standards of salt content in food products as well. The average amount of salt in bread is 1 g per 100 g bread, which increases the consumption of “hidden” salt.

According to the 2013 European Society of Hypertension/European Society of Cardiology guidelines for management of arterial hypertension, lifestyle changes are advised in the treatment of mildly hypertensive patients. A multifaceted approach to lifestyle modification for this category of patient could result in blood pressure normalization without any pharmacological agents. It would also allow the quantity or dose of antihypertensive medication for goal blood pressure achievement to be decreased in patients with moderate or severe hypertension.1

The difficulties of managing resistant hypertension have been discussed a lot, and optimal approaches using multidrug combinations and device therapy for the amelioration of blood pressure control are under active investigation. Measures of lifestyle modification offer one simple, inexpensive, safe, and effective way of overcoming antihypertensive therapy resistance. Obesity, high levels of dietary salt consumption, and heavy alcohol intake are not only frequent companions of resistant hypertension, but they are also risk factors in its formation. Targeted modulation of these factors leads to significant improvement in blood pressure control.4,5

he data from the randomized clinical trial of Pimenta et al are relevant in this context.6 On the one hand, the results confirm the causal relationship between high sodium intake and blood pressure elevation and, on the other hand, they show the significant antihypertensive effect of a low-sodium diet in patients with resistant hypertension. Office blood pressure was decreased by 22.7/9.1 mm Hg in this group of patients in comparison to patients on a high-sodium diet. The substantial antihypertensive impact of a low-sodium diet has been confirmed with ambulatory blood pressure measurement: daytime and nighttime blood pressures were correspondingly lowered by 20.7/9.6 mm Hg and 20.3/9.1 mm Hg. Such a meaningful blood pressure reduction with a low-sodium diet indicates that resistant hypertension is characterized by high salt sensitivity.

The main challenge of antihypertensive therapy, both pharmacological and nondrug (lifestyle changes), is still adherence to treatment, which is determined by individual factors of the patient and the doctor as well as social conditions. Getting patients to commit to a healthy lifestyle and tackling the issue of cardiovascular risk factors are critical medical and social problems, whose solutions could improve blood pressure control in the hypertensive population and significantly reduce the risk of cardiovascular disease.■

References
1. Mancia G, Fagard R, Narkiewicz K, et al; Task Force Members. 2013 ESH/ESC Guidelines for management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and European Society of Cardiology (ESC). J Hypertens. 2013;31:1281-1357.
2. Gay HC, Rao SG, Vaccarino V, Ali MK. Effects of different dietary interventions on blood pressure: systematic review and meta-analysis of randomized controlled trials. Hypertension. 2016;67:733-739.
3. Mitchenko EI, Mamedov MN, Kolesnik TV, Deev AD. Actual problems of cardiovascular risk in urban population of Ukraine. Kardiologiia 2014;54:55-59.
4. Nishizaka MK, Pratt-Ubunama M, Zaman MA, Cofield S, Calhoun DA. Validity of plasma aldosterone-to-renin activity ratio in African American and white subjects with resistant hypertension. Am J Hypertens. 2005;18:805-812.
5. Aguilera MT, de la Sierra A, Coca A, Estruch R, Fernández-Solá J, Urbano- Márquez A. Effect of alcohol abstinence on blood pressure: assessment by 24-hour ambulatory blood pressure monitoring. Hypertension. 1999;33:653-657.
6. Pimenta E, Gaddam K, Oparil S, et al. Effects of dietary sodium reduction on blood pressure in subjects with resistant hypertension: results from a randomized trial. Hypertension. 2009;54:475-481.

9. A. Vachulova, Slovak Republic

Anna VACHULOVA, MD, PhD
National Cardiovascular Institute
Pod Krasnou horkou 1
833 48 Bratislava, SLOVAK REPUBLIC
(email: anna.vachulova@nusch.sk)

Antihypertensive treatment is of paramount importance for protecting patients from the consequences of untreated hypertension: stroke, heart failure, coronary artery disease, and kidney failure. There is strong evidence from randomized clinical trials that the administration of blood pressure– lowering drugs reduces the risk of major clinical cardiovascular outcomes.1 The question is when should drug therapy be initiated. On the one hand, appropriate lifestyle changes are the cornerstone for the prevention and treatment of hypertension. However, lifestyle changes should never delay the initiation of drug therapy. Many important concerns remain about the best way in which to combine pharmacological treatment with lifestyle interventions.

Do patients adhere to recommendations of lifestyle changes? In my daily practice, I recommend lifestyle changes to all hypertensive patients both initially, at the time of diagnosis of arterial hypertension, and then regularly thereafter. However, adherence to these recommendations among hypertensive patients from my practice is poor, not only in older patients, but especially in younger ones. The reasons might be that, first, arterial hypertension is a painless disease at the beginning and, second, not all patients wish to know the consequences of their disease. Data from literature also show that only a small proportion of patients adhere to healthy lifestyle recommendations.2 In Slovakia, there are very few strong healthcare teams or patient organizations that provide support for patients wanting to adhere to these recommendations. One of the few existing initiatives is a campaign, which has taken place every year from 2006 to 2016 in September, as part of “Cardiac Topics Month”. This campaign informs the general public about blood pressure management and lifestyle changes.

Blood pressure decrease and lifestyle changes

Lifestyle changes do have a real place in hypertension management in daily practice, but by themselves they may not be enough to protect our hypertensive patients. There are very good data on how lifestyle changes contribute to reducing blood pressure. In my daily practice, only a small number of patients adhere to nonpharmacological intervention, both in the short and long term. Also, evidence shows that the average blood pressure decrease over 6 months in hypertensive patients who undergo lifestyle intervention is only 5.5/4.5 mm Hg.3 The impact of this decrease in blood pressure is not sufficient to protect hypertensive patients for a long time. To obtain adequate blood pressure control, it is better to combine lifestyle changes with pharmacological treatment, even in patients with mild hypertension.

Time to achievement of target blood pressure

The most advantageous time frame for achieving target blood pressure has never been defined in the literature nor in clinical practice. We know, notwithstanding, that an earlier decrease of blood pressure is better. Evidence also shows that delayed control of systolic blood pressure >150 mm Hg leads to increased cardiovascular risk.4 These findings should prevent clinical inertia when treatment goals are not reached by lifestyle changes.5 Because of advantages of rapid control of blood pressure, earlier pharmacological intervention is important. Hypertension is a complex disease that impacts the cardiovascular system, and earlier blood pressure control is associated with early cardiovascular protection.

In conclusion, now is the time to reconsider the management strategy of hypertensive patients. For reducing their blood pressure, we recommend that both interventions—lifestyle changes and pharmacological treatment—start simultaneously.

Reference
1. 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 (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-2219.
2. Hamer M. Adherence to healthy lifestyle in hypertensive patients: ample room for improvement? J Hum Hypertens. 2010;24:559-560.
3. National Institute of Health and Care Excellence. Hypertension in adults: diagnosis and management. www.nice.org.uk/guidance/cg127. Published August 2011. Updated November 2016. Accessed January 13, 2017. Clinical guideline CG127.
4. Xu W, Goldberg SI, Shubina M, Turchin A. Optimal systolic blood pressure target, time to intensification, and time to follow-up in treatment of hypertension: population based retrospective cohort study. BMJ. 2015;350:h158.
5. Huebschmann AG, Mizrahi T, Soenksen A, Beaty BL, Denberg TD. Reducing clinical inertia in hypertension treatment: a pragmatic randomized control. J Clin Hypertens (Greenwich). 2012;14(5):322-329.