Transcript Blood Pressure (mm Hg)

In The Name of God
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Prevention and
Nondrug Management
of HTN
Mohammad Garak Yaraghi,MD
Cardiologist
Associate Professor of
Isfahan University of Medical Sciences
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Blood Pressure Classification
SBP mmHg*
DBP mmHg
Lifestyle
Modification
Drug
Therapy**
<120
and <80
Encourage
No
Prehypertension
120-139
or 80-89
Yes
No
Stage 1
Hypertension
140-159
or 90-99
Yes
Single
Agent
Stage 2
Hypertension
≥ 160
or ≥ 100
Yes
Combo
BP Classification
Normal
*Treatment determined by highest BP category; **Consider treatment for compelling indications
regardless of BP
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JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314
Why Prehypertension?
• Patients normotensive at age 55 have a
90% lifetime risk to develop HTN
• Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of
High Blood Pressure
• Prehypertensive: 120–139 / 80–89
mmHg
– Require health-promoting lifestyle
modifications to prevent CVD
• Public health goal: Prevent hypertension
and cardiovascular disease before it
happens
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Causal Factors for Hypertension
• Excess body weight
– 122 million Americans are overweight or
obese
• Excess dietary sodium
– Mean intake: Men 4100 mg; Women 2750
mg
– 75% from processed foods
• Reduced physical activity
• Inadequate fruit, vegetable and potassium
intake
• Excess alcohol consumption
Hypertension
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2003;289:2560-2572
www.hypertensiononline.org
.
Recommended Lifestyle Modifications and Their
Individual Effects on Blood Pressure
Approximate
SBP Reduction
Modifications*
Recommendation
Reduce weight
Maintain normal body weight (BMI
of 18.524.9 kg/m2)
320 mm Hg
Adopt DASH diet
Rich in fruit, vegetables, and lowfat dairy; reduced saturated and
total fat content
814 mm Hg
Reduce dietary sodium
<100 mmol (2.4 g)/day
28 mm Hg
Increase physical
activity
Aerobic activity >30 min/day most
days of the week
49 mm Hg
Moderate alcohol
consumption
Men: ≤ 2 drinks/day
Women: ≤ 1 drink/day
24 mm Hg
*Combining 2 or more of these modifications may or may not have an additive
effect on blood pressure reduction.
SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to
Stop Hypertension
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
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Impact of a 5 mmHg Reduction
Overall Reduction
Stroke
14%
Coronary Heart Disease
9%
All Cause Mortality
7%
Hypertension
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.
Effects of Lifestyle Modifications on
Blood Pressure
•
•
•
•
•
•
•
Reduce systolic and diastolic blood pressures
Correct obesity or overweight
Decrease insulin resistance
Prevent or delay the onset of hypertension
Enhance antihypertensive drug efficacy
Decrease cardiovascular risk
Augment antihypertensive effect when two or
more lifestyle modifications are used
concurrently*
*Data from a randomized trial conducted by Hyman et al. (2007) provide some
evidence favoring the simultaneous adoption of multiple lifestyle modifications.
Chobanian AV, et al. JAMA. 2003;289:2560-2572;
Hyman DJ, et al. Arch Intern Med. 2007;167:1152-1158.
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Osteoarthritis
Disability
OBESITY
Cancer
T2 Diabetes
Mental Health
Heart Disease
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Dietary
Approaches to
Stop
Hypertension
• Lowers systolic
BP
– in normotensive
patients by an
average of 3.5 mm
Hg
– In hypertensive
patients by 11.4
mm Hg
• Copies available
from NHLBI
http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/
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The DASH eating plan
"DASH" stands for "Dietary Approaches to Stop
Hypertension"
• Study results indicated that elevated blood
pressures were reduced by an eating plan
that emphasizes fruits, vegetables, and low
fat dairy foods and is low in saturated fat,
total fat, and cholesterol
• The DASH eating plan includes whole grains,
poultry, fish, and nuts and has reduced
amounts of fats, red meats, sweets, and
sugared beverages
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The DASH Eating Plan
High in:
Fruits and vegetables (four or five servings each per
day)
Fiber (seven or eight servings per day)
Low-fat dairy products (two or three servings per day)
Lean meat (two servings per day)
Calcium
Magnesium
Potassium
Low in:
Saturated fat
Cholesterol
Salt*
DASH = dietary approaches to stop hypertension.
*—Low sodium intake was a later addition to the plan.
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Sample Menu
• Breakfast
– 1 whole-wheat bagel
– 2 tablespoons peanut butter
– 1 medium orange
– 1 cup fat-free milk
– Decaffeinated coffee
• Lunch
– Spinach salad made with 4 cups of fresh spinach leaves, 1
sliced pear, 1/2 cup mandarin orange sections, 1/3 cup
unsalted peanuts and 2 tablespoons reduced-fat red wine
vinaigrette
– 12 reduced-sodium wheat crackers
– 1 cup fat-free milk
• Dinner
– Herb crusted baked cod
– 1 cup bulgur
– 1/2 cup fresh green beans, steamed
– 1 sourdough roll with 1 teaspoon trans-free margarine
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– 1 cup fresh berries with chopped mint
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– Herbal iced tea
Adopting the DASH eating plan
Change gradually
• If you now eat one or two vegetables a day, add a
serving at lunch and another at dinner.
• If you don't eat fruit now or have only juice at
breakfast, add a serving to your meals or have it as
a snack.
• Use only half the butter, margarine, or salad
dressing you do now.
• Try lowfat or fat free condiments, such as fat free
salad dressings.
• Gradually increase dairy products to three servings
per day. For example, drink milk with lunch or
dinner, instead of soda, alcohol, or sugar-sweetened
tea. Choose lowfat (1 percent) or fat free (skim)
dairy products to reduce total fat intake.
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What’s In A Teaspoon?
• A teaspoon of salt contains about 2,300 mg of
sodium
Wow!
That’s a lot
of sodium!
One teaspoon of salt has about a day’s supply of
sodium for most people
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What Is the Difference Between
Table Salt and Sea Salt?
•Sea salt is “chunkier” than table salt; so a teaspoon of it
will contain more air (between the chunks) and less salt.
•One level teaspoon (6 grams) of table salt = 2,300 mg
sodium.
•One teaspoon of sea salt (5 grams) =1960 mg of sodium
•Sea salt may a have a nutritionally insignificant amount of
additional minerals, which may add a subtle flavor
difference.
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Current Sodium Consumption is
Too High
• Institute of Medicine’s Upper Limit for
Sodium = 2300 mg
• This is the maximum level that is
likely to pose no risk of adverse
effects for healthy individuals.
–May be too high for individuals who
already have hypertension or who
are under the care of a health care
professional.
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DASH Study Results
(Dietary Approach to Stop Hypertension)
DASH-Sodium
• Three different sodium levels
• Usual (Control) diet and DASH diet (rich
in produce, low fat dairy, whole grains and
nuts)
• The 3 sodium levels were:
– a “higher” intake of 3,300 mg per day
– an “intermediate” intake of 2,400 mg
per day
– a “lower” intake of 1,500 mg per day.
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DASH Study Results
(Dietary Approach to Stop Hypertension)
DASH-Sodium
• At every sodium level, Blood Pressure was
lower for the DASH diet compared with the
“regular” control diet.
• Lower sodium
lower BP
– for both the usual and DASH diets.
Results: blood pressure lowered with lower sodium diet.
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Excess Sodium Intake May Play
A Role In Other Diseases Such
As…
•Osteoporosis
•Stomach cancer
•Kidney stones
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Where Does Salt Intake Come From?
6%
5%
Processed food
12%
Naturally Occurring
At the Table
77%
During Cooking
Salt intake comes mostly from processed foods and
meals that are eaten away from home.
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Read the Label
•If a food
contains 140
mg or less of
sodium, then
it is low in
sodium.
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Scientifically established benefits
of physical activity (PA)
•
•
•
•
•
•
•
•
•
•
↓ risk of dying prematurely
↓ risk of dying from heart disease
↓ risk of developing diabetes
↓ risk of developing high blood pressure
Helps ↓ blood pressure in people who already have high blood
pressure
↓ risk of developing colon cancer
↓ feelings of depression and anxiety
Helps control weight
Helps build and maintain healthy bones, muscles, and joints
Promotes psychological well-being
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Absolute Intensity
• Activities are classified into light-, moderate-, or
vigorous-intensity based on amount of energy
expended/minute (METs)
– Moderate = 3.0 to 5.9 METs
– Vigorous = 6.0+ METs
• One needs to look up the intensity of an activity
(see tables in guidelines)
– Brisk walk = moderate; Jog/run = vigorous
– Activities can be either light, moderate, or vigorous
based on (usually) speed of doing them
• Leisurely walk = light intensity
• Brisk walk = moderate intensity
• Race-walking = vigorous intensity
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Relative Intensity
• Effort required relative to person’s fitness level
• Guidelines use 0-10 scale to communicate relative intensity, where:
–
–
–
–
Sitting is 0
Highest level of effort possible is 10
Moderate-intensity activity = a 5 or 6
Vigorous-intensity activity = a 7 or 8.
• To help communication, the PA guidelines endorsed the “talk test”
and advises people to pay attention to heart rate and breathing
– Moderate-intensity = can talk without pausing, but cannot sing
– Vigorous-intensity = cannot say more than a few words without
pausing for breath
• Relative intensity of a brisk walk depends on fitness and can be:
–
–
–
–
light-intensity for elite athletes
moderate-intensity for recreational walkers
high intensity for inactive middle-aged adults
Impossible for near-frail older adults
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The Benefits of Exercise
Primary Prevention
• Brisk walking, 30mins/day, 5 times/week
– 30% ↓vascular events in 3.5 years follow-up1
• 3 hours of brisk walking/week = 1.5 hours of
vigorous exercise per week2
• Resistance exercise and weight training were
also beneficial3
1. Manson JE, Greenland P, LaCroix AZ, et al: Walking compared with vigorous
exercise for the prevention of cardiovascular events in women N Eng J. Med
347;716, 2002
2. Manson JE, Hu FB, Rich Edward JW , et al: a prospective study of walking as
compared with vigouous exercise in the prevention of coronary artery disease
in women. N Eng J. Med 341:650, 1999
3. Tanasescu M, Leitzmann MF, Rimm EB, et al: Exercise type and intensity in
relation to coronary heart disease in men. JAMA 288:1994, 2002
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The Benefits of Exercise
Secondary Prevention
Physical activity with 1000kcal/wk
– 20-30% ↓ all cause mortality1
For patients without revascularization
– Exercise training improves SBP, angina
symptoms and exercise tolerance2
For patients with revascularization
– Improvement in QoL, exercise tolerance
– ↓29% cardiac events
– ↓re-admissions (18.6 vs 46%)3
1.
2.
3.
Lee I-M, Skerett PJ: Physical activity and all-cause mortality—What is the dose
response relation? Med. Sci Sports exerc33(6Suppl):S459,2001
Hambrecht R. Wolf A, Gielen S, et al: Effects of exercise on coronary endoothelial
function in patients wwith coronary artery disease. Am J Cadriol 90:124, 2002
Belardinelli R, Paolini I, Cianci G, et al: Exercise training intervention after coronary
angioplasty: The ETICA trial. J Am Coll Cardiol 37:1891, 2001
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Safety of Exercise
Exercise without medical advice:
– Sudden Cardiac Arrest: 1 per 60,000 pt. hours1
Supervised Programs:
– Cardiac events: 8.9 per 1,000,000 pt. hours
– Myocardial Infarction: 3.4 per 1,000,000 pt.
hours
– Mortality: 1.3 per 1,000,000 pt. hours2
1.
2.
Fletcher GF, Balady GJ, Amsterdam EA, et al: Exercise standards for testing and training: A statement
for healthcarecare professionals from the American eart Association. Circulation 104:1694, 2001
Ades PA: Cardiac rehabilitation and secondary prevention of coronary heart disease. N Eng J Med
345:892, 2001
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Principles of Exercise
Avoid:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Unstable angina
SBP ≥ 180mmHg or DBP ≥ 100mmHg
Symptomatic orthostatic BP drop > 20mmHg
Critical aortic stenosis
Acute systemic illness or fever
Uncontrolled arrhythmia
Uncompensated CHF
3rd degree AV Block (complete heart block)
Acute pericarditis & myocarditis
Recent embolism
Thrombophlebitis
Resting ST displacement ≥ 2mm
Uncontrolled DM
Electrolyte disturbance
hypovolemia
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Pre- exercise treadmill Stress
test was indicated:
1. Age > 40
2. Age > 30 with
– DM > 10 yrs
– HT
– Smoking
– Hyperlipidemia
– Retinopathy
– Nephropathy (microalbuminuria)
3. Coronary Artery Disease
4. CVA
5. Peripheral vascular disease
6. Autonomic neuropathy
7. Renal Failure
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Current Recommendations for Physical Activity
Among United States Adults
American College of Sports Medicine
and the American Heart Association
• Moderate-intensity* aerobic physical activity for a minimum of
30 minutes on 5 days each week,
or
• Vigorous-intensity† aerobic physical activity for a minimum of
20 minutes on 3 days each week,
or
• Combinations thereof for adults between the ages of 18 and 65
years,
and
• Muscle-strengthening activities for a minimum of 2
nonconsecutive days each week.
*Exemplified
by a brisk walk; noticeably accelerates heart rate.
by jogging; causes rapid breathing and a substantial
increase in heart rate.
†Exemplified
Haskell WL, et al, for the American College of Sports Medicine and
the American Heart Association. Circulation. 2007;116:1081-1093.
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PA Guidelines – Children and
Adolescents (ages 6–17)
• 1 hour (60 minutes) or more of daily physical
activity that is mixture of moderate and
vigorous
– It is important to encourage young people to
participate in physical activities that are age
appropriate, enjoyable, and offer variety.
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PA Guidelines – Adults
(ages 18–64)
• Minimum levels a week
– 2 hours and 30 minutes moderate-intensity aerobic
activity; or
– 1 hour and 15 minutes vigorous-intensity aerobic
activity; or
– OR an equivalent combination of the two
• Muscle-strengthening activities 2 or more days/wk
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PA Guidelines – Older Adults
(ages 65 years and older)
• Follow adult guidelines
• If at risk for falls, perform balance
exercises
• If cannot follow the guidelines for
‘adults,’be as physically active as abilities
and conditions allow
• No need for medical clearance
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KEEP IT UP!
• It takes about one to three
months for regular exercise to
have a stabilizing effect on
blood pressure. The benefits
last only as long as you
continue to exercise.
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Key Messages
• Any activity is better than none
• Accumulate activity in small or large
bouts
• Walking is a universally accepted
mode of activity
• Gain benefits at any body weight
• Pregnant and postpartum women
have a lot to gain by being active
• Choose enjoyable activities
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Summary
• Modification of unhealthy lifestyle practices can
lower blood pressure among hypertensive
patients, regardless of age, ethnicity, or
gender. These practices include:
– Restriction of dietary sodium intake
– Reduction of weight if overweight or obese
– Initiation or maintenance of a regular
aerobic exercise program.
• Lifestyle modifications can augment blood
pressure reduction caused by antihypertensive
drugs.
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Thank You for Your Attention
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Meat
Treat meat as one part of the whole meal,
instead of the focus.
• Buy less meat. If it's not there, you won't eat it
• Limit meat to 6 ounces a day (two servings)--all
that's needed. Three to four ounces is about the
size of a deck of cards.
• If you now eat large portions of meat, cut them
back gradually--by a half or a third at each meal.
• Include two or more vegetarian-style (meatless)
meals each week.
• Increase servings of vegetables, rice, pasta, and
dry beans in meals. Try casseroles and pasta,
and stir-fry dishes, having less meat and more
vegetables, grains, and dry beans.
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Fruits and lowfat foods
• Fruits and lowfat foods offer great taste and
variety. Use fruits canned in their own juice.
Fresh fruits require little or no preparation.
Dried fruits are easy to carry with you.
• Try these snack ideas: unsalted pretzels or
nuts mixed with raisins; graham crackers;
lowfat and fat free yogurt and frozen yogurt;
plain popcorn with no salt or butter added;
and raw vegetables.
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Blood Pressure Reductions Resulting
from Various Lifestyle Modifications
Trials of Hypertension Prevention  Phase I
Net Mean Change in
Blood Pressure (mm Hg)
1
Systolic Blood Pressure
Diastolic Blood Pressure
0
-1
-2
-3
-4
-5
Measures*
Weight
Loss
Reduced
Sodium
Added
Calcium
Added
Potassium
–5.67 kg
–58.45 mmol/24 h
1.22 mmol/24 h
44.4 mmol/24 h
*All values are averages and are statistically significant at P < 0.01.
Trials of Hypertension Prevention Collaborative Research Group. JAMA.
1992;267:1213-1220. Copyright © 1992, American Medical Association. All
rights reserved.
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Blood Pressure Reductions Resulting from
Lifestyle Modifications Can Persist Over Time*
Trials of Hypertension Prevention  Phase II
Study Group
(Baseline SBP
in mm Hg)
Change in
SBP at
6 Months
Change in
SBP at
18 Months
Change in
SBP at
36 Months
Change in
SBP at
48 Months
Weight Loss Only
(127.6 ± 6.1)
–6.0 (8.1)†
–3.6 (7.9)‡
0.8 (8.7)§
–0.8 (9.0)¶
Sodium Reduction
(127.7 ± 6.6)
–5.1 (9.6)†
–3.8 (8.2)‡
–0.7 (9.0)§
–0.7 (9.2)¶
Combined
(127.4 ±6.5)
–6.2 (8.6)†
–3.9 (8.3)‡
–0.5 (9.0)
–0.6 (9.3)
Usual Care
(127.3 ± 6.4)
–2.2 (8.1)
–1.8 (7.0)
+0.6 (8.5)
+0.3 (8.9)
*The values for the baseline systolic blood pressure (SBP) and the changes in SBP
at the different time points are expressed as the mean ± the standard deviation.
Statistical significance found in comparisons with the usual care group: †P < 0.001;
‡P < 0.003; §P < 0.03; ¶ P < 0.05.
The Trials of Hypertension Prevention Collaborative
Research Group. Arch Intern Med. 1997;157:657-667.
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Combining Lifestyle Modifications
Can Have Additive Effects
to Reduce Blood Pressure
Change in
Systolic BP†
Change in
Diastolic BP†
Control
(n=22)
–0.9 mm Hg
–1.4 mm Hg
Exercise Only
(n=44)
–4.4 mm Hg
–4.3 mm Hg
Weight Loss
and Exercise
(n=46)
–7.4 mm Hg
–5.6 mm Hg
Study Group*
*The differences in mean blood pressure (BP) values between the study groups at 6
months were statistically significant (multivariate F4,258 = 6.76, P < 0.001).
†All values are expressed as averages of the blood pressure reductions achieved by all
participants within a single study group.
Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958.
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Effect of Weight Loss on Blood Pressure in
Overweight or Obese Subjects by Gender
Trials of Hypertension Prevention  Phase I
Mean Change (mm Hg)
0
Systolic
Blood Pressure
0
-1
Diastolic
Blood Pressure
-1
-1.1
-2
-3
-4
-2.0
-3.1
-2
-3
-2.8
Men
Women
-4
Stevens VJ, et al. Arch Intern Med. 1993;153:849-858.
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Decreasing Dietary Salt Intake Reduces Systolic
Blood Pressure
Dietary Approaches to Stop Hypertension Trial
Systolic Blood
Pressure (mm Hg)
136
134
*
132
*
130
*
128
*
*
126
124
High-Salt
Diet†
1
2
3
4
Weeks on Low-Salt Diet‡
*Error bars represent standard deviation; †140 mmol/day; ‡62 mmol/day.
Reprinted from Obarzanek E, et al. Hypertension. 2003;42:
459-467, with permission from Lippincott Williams & Wilkins.
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Effects of Diet on Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Fruits-andVegetables Diet
Control Diet
Diastolic Blood Pressure
(mm Hg)
Systolic Blood Pressure
(mm Hg)
132
130
128
126
124
122
0
1
2
3
4
5
6
7
8
Combination
Diet*
88
86
84
82
80
78
0
Week of Intervention
1
2
3
4
5
6
7
Week of Intervention
*Rich in fruits and vegetables, and rich in low-fat dairy products and
low in saturated and total fat. 0 = baseline.
Appel LJ, et al. N Engl J Med. 1997;336:1117-1124. Copyright © 1997,
Massachusetts Medical Society. All rights reserved.
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Greater Restriction of Sodium Intake Lowers DietReduced Blood Pressure
Dietary Approaches to Stop Hypertension Sodium Trial
Systolic Blood
Pressure (mm Hg)
135
Control Diet
130
–5.9
(–8.0 to –3.7)†
–2.1
(–3.4 to –0.8)*
–4.6
(–5.9 to –3.2)†
–5.0
(–7.6 to –2.5)†
–2.2
(–4.4 to –0.1)†
DASH Diet
125
120
–1.3
(–2.6 to –0.0)†
–1.7
(–3.0 to –0.4)‡
150 mmol/day
100 mmol/day
50 mmol/day
Daily Dietary Sodium Content
*P < 0.05; †P < 0.011; ‡P < 0.01; ( ) denote 95% confidence interval.
DASH = Dietary Approaches to Stop Hypertension
Sacks FM, et al. N Engl J Med. 2001;344:3-10. Copyright © 2001,
Massachusetts Medical Society. All rights reserved.
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Dietary Sodium Reduction Results in
Greater Blood Pressure Reduction
in Older Than in Younger Adults*
Dietary Approaches to Stop Hypertension Sodium Trial
Patient Age Groups
Mean SBP Reduction
with DASH Diet†
(mm Hg)
Mean SBP Reduction
with American Diet†
(mm Hg)
23–41 years
1.0
4.8§
42–47 years
1.8‡
5.9§
48–54 years
4.3§
7.5§
55–76 years
6.0§
8.1§
*Patients were fed a 2,100 kcal diet containing either 150, 100 or 50 mmol sodium daily for 30 days
while consuming either the DASH diet or a typical American diet.
†These data reflect a reduction from the highest (150 mmol) to the lowest (50 mmol)
level of sodium.
‡p < 0.10; §p < 0.01.
DASH = Dietary Approaches to Stop Hypertension; SBP = systolic blood pressure
Bray GA, et al. Am J Cardiol. 2004;94:222-227.
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Regular Aerobic Exercise Lowers
Blood Pressure in Adults with
Mild to Moderate Hypertension*
Control Group
mm Hg
160
Systolic
Blood Pressure
150
†
‡
140
130
110
Diastolic
Blood Pressure
100
†
‡
90
80
120
110
mm Hg
170
Exercise Group
141.2 144.4
136.2 137.9
Baseline
Week 6
137.6 131.3
70
Week 10
*Values are expressed as the mean ± standard deviation.
†P < 0.05 vs. baseline; ‡P < 0.001 vs. baseline.
Tsai JC, et al. Clin Exp Hypertens. 2004;26:255-265.
94.9
95.2
Baseline
96.2
92.0
Week 6
98.9
88.9
Week 10
Slide Source
Hypertension Online
www.hypertensiononline.org
Even Modest Amounts of Aerobic Exercise
Can Lower Systolic Blood Pressure
Changes in Systolic Blood
Pressure (mm Hg)
Baseline Value (mm Hg ± SD)
0
149±15
149±11
149±10
149±9
149±9
*†
*†
-5
*
-10
*†
-15
SD = standard deviation
-20
-25
*P < 0.01 vs. sedentary control group.
†P < 0.01 vs. 30–60 min/wk exercise group.
None
30–40
min/wk
61–90
min/wk
91–120
min/wk
>120
min/wk
Exercise Duration
Reprinted from Ishikawa-Takata K, et al. Am J Hypertens.
2003;16:629-633, with permission from Elsevier.
Slide Source
Hypertension Online
www.hypertensiononline.org
Physical Activity Reduces the Prevalence of
Hypertension Regardless of Ethnicity
Prevalence of
Hypertension* (%)
National Health and Nutrition Examination Survey – Phase III
35
African-Americans
30
25
Anglo-Americans
20
Mexican-Americans
15
0
0.1-4.9
5+
Leisure-Time Physical Activity (Bouts/Week)
*Hypertension is defined as a systolic blood pressure >140 mm Hg, a diastolic blood
pressure >90 mm Hg, or being treated with antihypertensive medication.
Reprinted from Bassett DR Jr, et al. Prev Med. 2002;34:179-186,
with permission from Elsevier.
Slide Source
Hypertension Online
www.hypertensiononline.org
Effect of Antihypertensive Monotherapy Is
Augmented by Lifestyle Modifications*
Systolic
Blood Pressure
150
140
Drug
therapy
alone†
130
Drug and
lifestyle
modifications
120
110
6
8 10 12 14 16 18 20 22 0 2
4
Blood Pressure (mm Hg)
Blood Pressure (mm Hg)
Diet-Exercise-Weight Loss Intervention Trial
Diastolic
Blood Pressure
100
90
Drug
therapy
alone†
80
Drug and lifestyle
modifications
70
60
Time (hours)
6
8 10 12 14 16 18 20 22 0 2
4
Time (hours)
*Low-calorie,
†A
low-sodium diet and exercise.
single antihypertensive drug.
Reprinted from Miller ER III, et al. Hypertension. 2002;40:
612-618, with permission from Lippincott Williams & Wilkins.
Slide Source
Hypertension Online
www.hypertensiononline.org
Slide Source
Hypertension Online
www.hypertensiononline.org