Nutritional and behavioral measures in the non-pharmacological treatment of elderly hypertensive subjects

The antihypertensive treatments have resulted in favorable effects in terms of cardiovascular morbidity and mortality in the elderly, but the therapeutic approaches raise problems linked to the pathophysiological aspects of hypertensives and to the reduced homoeostatic capacity of the senile organism. The antihypertensive treatment in elderly must be aimed at achieving a maximal improvement in the cardiovascular risk profile with possibly minimal side effects. The first step is the non-pharmacological therapy which is a hygienic-behavioral program aimed at changing the patient's life style (physical exercise, reduced salt intake, body weight control, etc.). Non-pharmacological therapy in the elderly patients requires a preliminary evaluating protocol and a close monitoring of the individual responses. The diet, restriction of sodium intake (4-6 g/day), and aerobic physical exercise are important for decrease the development and persistence of hypertension. The non-pharmacological therapy has a low antihypertensive action, however, once established, it should not be abandoned, as its association with pharmacological treatment allows the use of fewer and lower doses of drugs, with a consequent reduction of the risks due to side effects.     

Beneficial effects of physical exercise on hypertension and cardiovascular adverse remodeling of diet-induced obese rats

Background and aimsObesity is present among all age groups and in all socioeconomic groups. This study on obese rats aims to quantify the beneficial effects of physical exercise on blood pressure (BP), the heart, the elasticity and resistance of arteries.Methods and resultsObese male Wistar rats, (obesity due to a high fat diet with 30% fat), and non-obese rats, were assigned to four groups (n = 5): sedentary obese; exercise-practice obese; sedentary control; and exercise-practice control (motor treadmill for 13 weeks). Their organs were studied through light microscopy and stereology. The diet-induced obesity caused mild hypertension with adverse cardiovascular changes. Physical exercise diminished the alterations associated with BP elevation and obesity. The pressure-lowering effect observed in obese rats submitted to physical exercise improved the myocardial vascularization and the aortic and the carotid wall structure by reducing the thickness and normalizing both the elastic lamellae and the smooth muscle cells. The adaptive response of the gluteus superficialis muscle to physical exercise also improved the peripheral resistance arteries of obese rats.ConclusionCurrent research supports the notion of physical exercise as a potential non-pharmacological antihypertensive treatment for diet-induced obesity hypertension.     

The effects of caloric restriction and controlled physical exercise on hypertension in the elderly

The overweight and sedentary life style are associated with elevated blood pressure values in the elderly patients. The first step in the therapy of arterial hypertension should be hygienic-behavioral measures in order to modify the life style of the patients. The present study evaluates the independent effects of caloric restriction and physical exercise on the blood pressure and on the anti-hypertensive treatment in elderely subjects with mild-moderate hypertension. The number of enrolled patients was 74 in the age range of 61-72 years, showing up in our Geriatric Day Hospital. The results obtained confirm that the non-pharmacological measures represent a valid alternative to the pharmacological treatment of hypertension in the elderly patients, or may be applied in combination with the latter, in order to reduce the doses of pharmaca.     

Non-pharmacological treatment of chronic widespread musculoskeletal pain

Individuals with chronic widespread pain, including those with fibromyalgia, pose a particular challenge to treatment, given the modest effectiveness of pharmacological agents for this condition. The growing consensus indicates that the best approach to treatment involves the combination of pharmacological and non-pharmacological interventions. Several non-pharmacological interventions, particularly exercise and cognitive-behavioural therapy (CBT), have garnered good evidence of effectiveness as stand-alone, adjunctive treatments for patients with chronic pain. In this article, evidenced-based, non-pharmacological management techniques for chronic widespread pain are described by using two broad categories, exercise and CBT. The evidence for decreasing pain, improving functioning and changing secondary symptoms is highlighted. Lastly, the methods by which exercise and CBT can be combined for a multi-component approach, which is consistent with the current evidence-based guidelines of several American and European medical societies, are addressed.     

Exercise training in hypertension: Role of microRNAs

Hypertension is a complex disease that constitutes an important public health problem and demands many studies in order to understand the molecular mechanisms involving his pathophysiology. Therefore, an increasing number of studies have been conducted and new therapies are continually being discovered. In this context, exercise training has emerged as an important non-pharmacological therapy to treat hypertensive patients, minimizing the side effects of pharmacological therapies and frequently contributing to allow pharmacotherapy to be suspended. Several mechanisms have been associated with the pathogenesis of hypertension, such as hyperactivity of the sympathetic nervous system and renin-angiotensin aldosterone system,impaired endothelial nitric oxide production, increased oxygen-reactive species, vascular thickening and stiffening, cardiac hypertrophy, impaired angiogenesis, and sometimes genetic predisposition. With the advent of microRNAs(miRNAs), new insights have been added to the perspectives for the treatment of this disease, and exercise training has been shown to be able to modulate the miRNAs associated with it. Elucidation of the relationship between exercise training and miRNAs in the pathogenesis of hypertension is fundamental in order to understand how exercise modulates the cardiovascular system at genetic level. This can be promising even for the development of new drugs. This article is a review of how exercise training acts on hypertension by means of specific miRNAs in the heart, vascular system, and skeletal muscle.     

Non-pharmacological interventions on cognitive functions in older people with mild cognitive impairment (MCI)

Mild cognitive impairment (MCI) can be a stage of pre-dementia. There is no consensus about pharmacological treatment for this population, so it is important to structure non-pharmacological interventions for increasing their cognitive reserve. We intended to analyze the effects of non-pharmacological interventions in the cognitive functions in older people with MC, in form of a systemic review. Data sources were the Web of Science, Biological Abstracts, Medline, Pub Med, EBSCHost, Scirus and Google Scholar. All studies were longitudinal trials, with MCI sample, aged > 60 years, community-dwelling, and having cognitive functions as dependent variable. Seven studies, from 91 previously selected ones, were identified according to the inclusion criteria. Six studies used cognitive intervention, improving memory and one study used physical activity as intervention, improving executive functions. The results show evidence that physical activity and cognitive exercise may improve memory and executive functions in older people with MCI. But yet, more controlled studies are needed to establish a protocol of recommendations regarding the systemization of exercise, necessary to produce benefits in the cognitive functioning in older people with MCI.     

Aerobic exercise reduces blood pressure in resistant hypertension

Regular physical exercise is broadly recommended by current European and American hypertension guidelines. It remains elusive, however, whether exercise leads to a reduction of blood pressure in resistant hypertension as well. The present randomized controlled trial examines the cardiovascular effects of aerobic exercise on resistant hypertension. Resistant hypertension was defined as a blood pressure ≥140/90 mm Hg in spite of 3 antihypertensive agents or a blood pressure controlled by ≥4 antihypertensive agents. Fifty subjects with resistant hypertension were randomly assigned to participate or not to participate in an 8- to 12-week treadmill exercise program (target lactate, 2.0±0.5 mmol/L). Blood pressure was assessed by 24-hour monitoring. Arterial compliance and cardiac index were measured by pulse wave analysis. The training program was well tolerated by all of the patients. Exercise significantly decreased systolic and diastolic daytime ambulatory blood pressure by 6±12 and 3±7 mm Hg, respectively (P=0.03 each). Regular exercise reduced blood pressure on exertion and increased physical performance as assessed by maximal oxygen uptake and lactate curves. Arterial compliance and cardiac index remained unchanged. Physical exercise is able to decrease blood pressure even in subjects with low responsiveness to medical treatment. It should be included in the therapeutic approach to resistant hypertension.     

Resistant hypertension: diagnosis, evaluation, and treatment. A scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research

Resistant hypertension is a common clinical problem faced by both primary care clinicians and specialists. While the exact prevalence of resistant hypertension is unknown, clinical trials suggest that it is not rare, involving perhaps 20% to 30% of study participants. As older age and obesity are 2 of the strongest risk factors for uncontrolled hypertension, the incidence of resistant hypertension will likely increase as the population becomes more elderly and heavier. The prognosis of resistant hypertension is unknown, but cardiovascular risk is undoubtedly increased as patients often have a history of long-standing, severe hypertension complicated by multiple other cardiovascular risk factors such as obesity, sleep apnea, diabetes, and chronic kidney disease. The diagnosis of resistant hypertension requires use of good blood pressure technique to confirm persistently elevated blood pressure levels. Pseudoresistance, including lack of blood pressure control secondary to poor medication adherence or white coat hypertension, must be excluded. Resistant hypertension is almost always multifactorial in etiology. Successful treatment requires identification and reversal of lifestyle factors contributing to treatment resistance; diagnosis and appropriate treatment of secondary causes of hypertension; and use of effective multidrug regimens. As a subgroup, patients with resistant hypertension have not been widely studied. Observational assessments have allowed for identification of demographic and lifestyle characteristics associated with resistant hypertension, and the role of secondary causes of hypertension in promoting treatment resistance is well documented; however, identification of broader mechanisms of treatment resistance is lacking. In particular, attempts to elucidate potential genetic causes of resistant hypertension have been limited. Recommendations for the pharmacological treatment of resistant hypertension remain largely empiric due to the lack of systematic assessments of 3 or 4 drug combinations. Studies of resistant hypertension are limited by the high cardiovascular risk of patients within this subgroup, which generally precludes safe withdrawal of medications; the presence of multiple disease processes (eg, sleep apnea, diabetes, chronic kidney disease, atherosclerotic disease) and their associated medical therapies, which confound interpretation of study results; and the difficulty in enrolling large numbers of study participants. Expanding our understanding of the causes of resistant hypertension and thereby potentially allowing for more effective prevention and/or treatment will be essential to improve the long-term clinical management of this disorder.     

Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research

Resistant hypertension is a common clinical problem faced by both primary care clinicians and specialists. While the exact prevalence of resistant hypertension is unknown, clinical trials suggest that it is not rare, involving perhaps 20% to 30% of study participants. As older age and obesity are 2 of the strongest risk factors for uncontrolled hypertension, the incidence of resistant hypertension will likely increase as the population becomes more elderly and heavier. The prognosis of resistant hypertension is unknown, but cardiovascular risk is undoubtedly increased as patients often have a history of long-standing, severe hypertension complicated by multiple other cardiovascular risk factors such as obesity, sleep apnea, diabetes, and chronic kidney disease. The diagnosis of resistant hypertension requires use of good blood pressure technique to confirm persistently elevated blood pressure levels. Pseudoresistance, including lack of blood pressure control secondary to poor medication adherence or white coat hypertension, must be excluded. Resistant hypertension is almost always multifactorial in etiology. Successful treatment requires identification and reversal of lifestyle factors contributing to treatment resistance; diagnosis and appropriate treatment of secondary causes of hypertension; and use of effective multidrug regimens. As a subgroup, patients with resistant hypertension have not been widely studied. Observational assessments have allowed for identification of demographic and lifestyle characteristics associated with resistant hypertension, and the role of secondary causes of hypertension in promoting treatment resistance is well documented; however, identification of broader mechanisms of treatment resistance is lacking. In particular, attempts to elucidate potential genetic causes of resistant hypertension have been limited. Recommendations for the pharmacological treatment of resistant hypertension remain largely empiric due to the lack of systematic assessments of 3 or 4 drug combinations. Studies of resistant hypertension are limited by the high cardiovascular risk of patients within this subgroup, which generally precludes safe withdrawal of medications; the presence of multiple disease processes (eg, sleep apnea, diabetes, chronic kidney disease, atherosclerotic disease) and their associated medical therapies, which confound interpretation of study results; and the difficulty in enrolling large numbers of study participants. Expanding our understanding of the causes of resistant hypertension and thereby potentially allowing for more effective prevention and/or treatment will be essential to improve the long-term clinical management of this disorder.     

Non-pharmacological control of blood pressure and physical fitness in subjects with arterial hypertension

In a group of 60 men and 17 women aged 54 +/- 9 yrs. suffering from mild and moderate arterial hypertension (i.e. 90 greater than DBP less than 120 mmHg), a five-week non-pharmacological intervention programme in spa led to a reduction in body weight by 5 kg, an increase in maximum tolerated workload by 4 W, a decrease in blood pressure at rest by 12/6 mmHg on average, and a decrease in heart rate during exercise and in the recovery phase. The training effect persisted in a certain degree for a long time (i.e. 14 months on average after spa treatment). The reduction in weight, heart rate and systolic blood pressure at rest persisted as well. The therapy resulted in a decrease in minute ventilation and there was no increase in aerobic capacity. No change in the number of pathological ECG changes at rest and during exercise was observed during spa treatment. The regimen and training measures enable to reduce pharmacological therapy in 60% of originally treated hypertensives. This kind of spa treatment constitutes a model of a rational lifestyle for persons with arterial hypertension.     

Role of endothelial function determined by asymmetric dimethylarginine in the prediction of resistant hypertension: A subanalysis of ReHOT trial

The authors conducted a subanalysis of the ReHOT (Resistant Hypertension Optimal Treatment) study to evaluate the association between endothelial dysfunction and resistant hypertension in a population of patients treated in a staged fashion for hypertension. One hundred and three hypertensive patients were followed for 6 months and participated in seven visits (V0‐V6) 28 days apart. There was a first phase (V0‐V3) of antihypertensive adjustment with three drugs and determination of resistant hypertension and a second randomized phase (V3‐V6) of treatment with a fourth drug (clonidine or spironolactone) in the hypertensive patients characterized as resistant. Of the 103 patients included, 86 (83.5%) underwent the randomization visit (V3), 71 were characterized as non‐resistant hypertensives (82.5%), and 15 as resistant hypertensives (17.5%). Serum asymmetric dimethylarginine (ADMA) was shown to be an independent predictor of resistant hypertension after adjustment for multiple variables (OR: 11.42, 95% CI: 1.02‐127.71, P = .048), and in addition, there was a reduction in blood pressure levels and ADMA values during follow‐up with a positive correlation in both groups and a greater reduction in the group of resistant hypertensives. We demonstrated that ADMA was an independent predictor of resistant hypertension, and we observed that the improvement in blood pressure levels obtained with the treatment was proportional to the reduction in ADMA values, suggesting a complementary role of ADMA not only as a stratification tool for the occurrence of resistant hypertension, but also as a possible therapeutic target in this population.     

Blutglukoseselbstkontrolle zum Selbstmanagement bei Typ-2-Diabetes

The role of self-measurement of blood glucose (SMBG) in people with type 2 diabetes has been discussed intensively for years. The therapeutic use of SMBG particularly among type 2 diabetics treated without insulin therapy is called into question. In contrast, the intensification of pharmacological therapy, especially early initiation of insulin therapy, is encouraged. Recent evidence suggests that non-pharmacological therapy in type 2 diabetes should assume a larger role. The 1-year interim analysis of the Look AHEAD Study revealed that lifestyle changes not only reduce the HbA1c from 7.3% to 6.6%, but also improve other cardiovascular risk factors such as hypertension and dyslipoproteinemia. Since type 2 diabetes is mostly without symptoms, SMBG, combined with lifestyle changes, plays an important role in increasing the affected person’s sense of personal responsibility. Recently published treatment instructions for SMBG suggest that, following manifestation/diagnosis of type 2 diabetes or elevated HbA1c levels, patients with type 2 diabetes should measure blood glucose pre- and postprandially (1.5-2 h after main meals). As a next step the event-driven SMBG is proposed as a measure to show patients the positive, as well as the negative, effects of food or physical activity on metabolic control.     

Recent Developments in Diagnosis and Assessment of Morphea

Pain is a complex phenomenon affected by biological, psychological, and social factors. Treatment of pain is most effective when using a multidisciplinary approach consisting of a careful selection of pharmacological and non-pharmacological interventions based upon disease factors, pain characteristics, psychological coping abilities, and lifestyle factors. In this review we focus on research-based evidence for non-pharmacological intervention including psychological intervention, physical exercise, patient education, and complementary approaches for pain management for patients with rheumatic diseases and common musculoskeletal pain conditions, such as low back pain. The vast majority of research studies on chronic pain conditions are focused on adults but pediatric studies are also reviewed wherever possible, to give the reader a more inclusive view of non-pharmacological approaches for pain management across the lifespan.     

Resistant hypertension and renal sympathetic denervation—what does the future hold?

Abstract

Hypertension is a major public health problem and despite adequate pharmacological treatment, blood pressure remains uncontrolled in a subset of patients with hypertension. Renal sympathetic denervation is a percutaneous catheter-based treatment for select patients with resistant hypertension. In this article, we discuss the development of this intervention, its role in patients with resistant hypertension and the need for guarded optimism in the future of device-directed renal sympathetic denervation.     

Device-based Therapy for Hypertension

Hypertension continues to be a major contributor to global morbidity and mortality, fuelled by an abundance of patients with uncontrolled blood pressure despite the multitude of pharmacological options available. This may occur as a consequence of true resistant hypertension, through an inability to tolerate current pharmacological therapies, or non-adherence to antihypertensive medication. In recent years, there has been a rapid expansion of device-based therapies proposed as novel non-pharmacological approaches to treating resistant hypertension. In this review, we discuss seven novel devices—renal nerve denervation, baroreflex activation therapy, carotid body ablation, central iliac arteriovenous anastomosis, deep brain stimulation, median nerve stimulation, and vagal nerve stimulation. We highlight how the devices differ, the varying degrees of evidence available to date and upcoming trials. This review also considers the possible factors that may enable appropriate device selection for different hypertension phenotypes.     

Exercise ventilation inefficiency in heart failure: pathophysiological and clinical significance.

Heart failure (HF) is a complex syndrome characterized by myocardial dysfunction and a poor prognosis. Among multiple markers of severity, an exercise ventilation inefficiency has important clinical and prognostic value. The pathophysiology determining exercise ventilatory inefficiency is complex and not definitively clarified. Three different mechanisms have been identified: (i) increased dead space, (ii) early occurrence of lactic acidosis, and (iii) abnormal chemoreflex and/or metaboreflex activity. Besides its prognostic value, abnormal ventilation can be influenced by pharmacological and non-pharmacological therapies such as beta-blockers, selective cyclic 3'-5' guanosine monosphosphate phosphodiesterase inhibitors, physical training, and nocturnal continuous positive airway pressure. There is an increasing interest for the exercise periodic breathing, which is frequently associated with HF syndrome and has prognostic importance. The precise mechanisms sustaining exercise periodic breathing are not fully defined but ventilatory and metabo-haemodynamic hypotheses have been proposed.     

不同运动方式对高血压患者心肺功能的影响研究进展

心肺功能是反应机体健康和心血管或全因死亡率的强有力指标,运动则是高血压防治策略中重要的非药物治疗手段,主要包括持续有氧运动、高强度间歇运动和抗阻运动。高血压患者通过不同运动方式不仅有利于降压,还可有效改善心肺功能。该文就不同运动方式,尤其是有氧运动对高血压患者心肺功能的影响进行综述,以期为高血压患者制定科学运动干预策略提供帮助。     

A meta-analysis to determine the effect of pharmacological and non-pharmacological treatments on fibromyalgia symptoms comprising OMERACT-10 response criteria

Fibromyalgia is characterized by widespread pain, sleep problems, fatigue, functional impairment, psychological distress, and cognitive dysfunction. The objective of this meta-analysis is to synthesize the available data on the effectiveness of pharmacological and non-pharmacological interventions across all domains included in the Outcome Measures in Rheumatology Clinical Trials (OMERACT-10) fibromyalgia response definitions, and to examine response based on these definitions. We searched Cochrane, PubMed, Scopus, and the reference lists of articles for randomized controlled trials of any drug formulation or non-pharmacological intervention used for fibromyalgia treatment. We extracted efficacy data regarding pain, sleep, physical function, fatigue, anxiety, depression, and cognition. The available data were insufficient to draw definite conclusions regarding response. Indirect evidence indicates that it may be expected with the use of serotonin noradrenaline reuptake inhibitors (SNRIs), noradrenaline reuptake inhibitors (NRIs), and multidisciplinary treatment.     

Reported treatment of hypertension by family physicians in Sweden and Minnesota: a physician survey of practice habits

Abstract. Objectives. To compare family physicians' reported practice habits on hypertension in Sweden and Minnesota, and to assess to what extent different national guidelines account for differences. Design. Random samples of family physicians were selected for telephone interviews on their practice of hypertension. Setting. Primary care in southern Sweden and in Minnesota. Subjects. Family medicine specialists. Participation rates were 236/264 (89%) in Sweden and 183/209 (88%) in Minnesota. Main outcome measures. Cut-off levels, and non-pharmacological and pharmacological treatment of hypertension, related to three case scenarios: a 48-year-old man, a 65-year-old man and a 65-year-old woman. Results. Swedish physicians reported significantly higher levels of diastolic blood pressure than Minnesota physicians for the institution of treatment of hypertension for all case scenarios. In both countries, physicians adhered to the cut-off levels of their national guidelines in the case of the 48-year-old man. Minnesota physicians did not use age as a modifying factor for treatment cut-off levels, as did Swedish physicians. Swedish physicians emphasized alcohol, fat and stress reduction, and Minnesota physicians weight and salt reduction as non-pharmacological treatment. While Swedish physicians generally preferred beta-blockers, Minnesota physicians chose ACE inhibitors or calcium channel blockers as the first choice drug. Conclusion. Swedish and US guidelines on hypertension were identical except for higher cut-off level for drug treatment in Sweden. Minnesota physicians reported cut-off levels close to national guidelines. For 65-year-old patients, Swedish physicians reported applying a higher cut-off level than indicated by guidelines. Swedish physicians also reported preferring less expensive drugs. As a consequence of the differing national guidelines and the identified physicians' practice habits in the two medical communities, it is likely that the segments of the populations treated and the drug costs differ substantially.