Nonpharmacologic approaches to the treatment of systemic hypertension

There are 3 areas of nonpharmacologic approaches that are recommended at present for control of arterial pressure elevation: (1) weight reduction to ideal body weight, since it reduces risk from hypertension and overall cardiovascular morbidity and mortality, (2) moderation in alcohol consumption to less than 2 ounces a day and (3) dietary sodium restriction to less than 2 g a day, without the promise that it will normalize arterial pressure. These interventions may also facilitate the effectiveness of already prescribed antihypertensive drugs. Other nonpharmacologic approaches have yet to be shown to be effective in controlling arterial pressure and their recommendation at present is, at best, preliminary.     

Nonpharmacologic approaches for the treatment of hyperlipidemia

Coronary heart disease (CHD) is the leading cause of death in the United States. Dyslipidemias, like decreased high-density lipoprotein (HDL) and increased low-density lipoprotein (LDL), have been linked through epidemiologic and experimental studies with the development of atherosclerosis and an increased risk of CHD. The introduction of various classes of lipid-lowering drugs, especially the hydroxymethylglutaryl-coenzyme-A-reductase inhibitors (statins), has allowed for effective treatment of hyperlipidemia. This article reviews the following nonpharmacologic approaches to hyperlipidemia: LDL apheresis, surgery, the emergence of HDL as a therapeutic target, gene therapy, and finally, the possibility of developing a vaccine against atherosclerosis.     

Supplementing a home exercise programme with a class-based exercise programme is more effective than home exercise alone in the treatment of knee osteoarthritis

OBJECTIVE: The study aimed to compare the relative effectiveness of providing a home-based exercise programme versus home-based exercise supplemented with an 8-week class-based exercise programme in reducing pain and improving function in patients with knee osteoarthritis. METHODS: Patients (n = 214) with radiologically confirmed knee osteoarthritis were selected. Patients were randomly allocated to either home or home supplemented with class-based exercise programmes. Both groups were given a home exercise programme whilst the supplemented group also attended for 8 weeks of twice weekly knee classes. Assessments of locomotor function, walking pain and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were made. Assessments were made pre- and post-treatment and also at 6- and 12-month follow-ups. Statistical analysis involved the use of a longitudinal linear model ANCOVA with baseline values entered as a covariate. RESULTS: Patients from the class-based group demonstrated significantly greater improvement in locomotor function (-3.7 seconds; 95% C.I. -4.9 to -2.5) and decrease in walking pain (-15 mm; 95% C.I. -20 to -11) than the home-based group, at 12-months follow-up. CONCLUSIONS: The supplementation of a home based exercise programme with a class-based exercise programme led to clinically significant superior improvement. These improvements were still evident at 12-month review. This is the first trial to evaluate this common physiotherapeutic practice, and based on this evidence, supplementation of home exercises with a class-based exercise programme can be recommended to patients, clinicians and service providers.     

Nonpharmacologic treatment of heart failure in the elderly

Nonpharmacologic therapy is an integral part of the management of elderly patients with heart failure. Reinforcement of dietary sodium restriction and other nutritional concerns are critical features of therapy. Quality standards for the management of patients with heart failure are being developed, and the implementation of these standards is a goal of clinicians. A multidisciplinary approach to elderly patients with heart failure is beneficial.     

Nonpharmacologic treatment of supraventricular tachycardia

During the last 2 decades, more than 1,000 patients have undergone surgical division of an accessory pathway; many refinements in epicardial mapping and surgical techniques have been made. In institutions where the procedure is routinely performed, the rate of successful accessory pathway interruption now approaches 98%. Concomitant risk of complete heart block among patients with posteroseptal pathways has declined to <5%. Among patients with other organic heart disease, myocardial preservation techniques result in mortality rates within 1 to 2%; among those with significant cardiac abnormalities, the mortality rate is 4 to 6%.

Two techniques are generally used to ablate an accessory pathway: the endocardial and the epicardial. The aim of both approaches is to identify the site of the accessary pathway and disarticulate the atrioventricular groove or expose and ablate the atrioventricular junction to interrupt accessory pathway conduction. Although each technique has its advantages, the choice of technique is far less important than the skill of the surgeon and clinical electrophysiologist performing the procedure.

Newer surgical techniques include application of external epicardial shocks in the area of the accessory pathway and use of a cryosurgical probe in the sinus to ablate accessory pathways. Whereas our current thought is that surgery should be limited to those adults who fail to respond to pharmacologie therapy, advances in atrial endocardial and epicardial mapping, as well as surgical techniques, may expand the role of surgery in the treatment of ectopic atrial tachycardia.     

Nonpharmacologic treatment of life-threatening cardiac arrhythmias

Numerous nonpharmacologic modalities have been introduced for the management of patients with life-threatening arrhythmias. These include cardiac pacing, insertion of an automatic internal cardiac defibrillator (AICD), cardiac electrosurgery, and catheter ablative techniques. Each modality is effective; AICD shows particular promise because it has demonstrated remarkable efficacy in decreasing the incidence of sudden cardiac death in patients with malignant ventricular arrhythmias. Each modality also has its limitations or contraindications. Nonpharmacologic antiarrhythmic therapy represents an important advance against the serious public health problem of sudden cardiac death.     

Nonpharmacologic treatment of resistant hypertensives by device-guided slow breathing exercises

BACKGROUND: Recent studies have demonstrated the antihypertensive effect of slow breathing exercises, guided interactively by a device, in patients with uncontrolled blood pressure (BP) without changing medication. This study examined the response to the same treatment protocol in resistant hypertensives. METHODS: Seventeen resistant hypertensives exercised device-guided slow breathing for 8 weeks, 15 min daily, and self-monitored BP. Data stored in the devices were collected on a PC-based system. Clinical outcomes were office and home BP changes from baseline to end values. RESULTS: Significant reductions in both office BP (-12.9/-6.9 mm Hg, P <.001 and home BP (-6.4/-2.6 mm Hg, P <.01/P <.05) without side effects with 82% responders and good compliance. CONCLUSIONS: Resistant hypertensives can benefit from and are compliant with self-treatment by device-guided slow breathing.     

Nonpharmacologic treatment of atrial fibrillation in elderly persons

In recent years, new nonpharmacologic possibilities have emerged for the treatment of atrial fibrillation. The roles of surgery, radiofrequency catheter ablation, pacing, and atrial defibrillation in the treatment of atrial fibrillation are discussed. This text focuses on the interaction between different treatment modalities and the pathophysiologic mechanisms of atrial fibrillation and on the available data about the effectiveness in elderly persons.     

Effectiveness of hypertension treatment assessed by blood pressure level achieved in primary care setting in Poland

The effectiveness of hypertension treatment remains low in many developed countries. The aim of our study was to evaluate the treatment effectiveness in hypertensives treated by general practitioners (GPs) in Poland. Twenty thousand three hundred and five hypertensive patients (mean age 60.1 +/- 12.0 years, 9918 women, 10 387 men), pharmacologically treated by 677 GPs in Poland, were investigated. Blood pressure (BP) in every patient was measured twice, within approximately a 5-min interval, in a seated position, using a mercury sphygmomanometer, after a rest of at least 10 min. Mean blood pressure from both measurements was used for further analysis. Measurements were carried out by a GP in the office. Every physician investigated 30 consecutive hypertensive patients. Of the investigated hypertensive patients treated, 8.3% had systolic blood pressure (SBP) < 140 mmHg and diastolic blood pressure (DBP) < 90 mmHg (7.8% in women, 8.8% in men respectively; p > 0.05). Mean SBP in the investigated group was 161.9 +/- 20.4 mmHg, 162.7 +/- 20.8 mmHg in women and 161.1 +/- 20.1 mmHg in men, respectively; p < 0.05. Mean DBP was 95.4 +/- 11.0 mmHg. The difference between mean DBP in women (95.3 +/- 11.0 mmHg) and men (95.5 +/- 11.1 mmHg) was not significant, p > 0.05. Mean pulse pressure (PP) for the whole group was 66.5 +/- 16.3 mmHg. In this cohort, 26.7% of patients were treated with one, 37.6% with two, 26.7% with three, 8.2% with four and 0.8% with five antihypertensive drugs. Mean number of antihypertensive drugs prescribed for one hypertensive patient was 2.2 +/- 1.0. Effectiveness of hypertension treatment by GPs in Poland remained unsatisfactory despite frequent implementation of combined antihypertensive drug therapy.     

运动疗法在肺动脉高压患者治疗中的作用

肺动脉高压(pulmonary hypertension,PH)是一种以肺血管阻力进行性增加为特征的潜在的致命性疾病,严重威胁人类身心健康。目前,PH 的治疗方法主要包括一般治疗、支持治疗、靶向药物治疗、肺移植等治疗手段。运动疗法是帮助 PH 患者提高活动能力和生活质量的一种新型疗法,但由于运动疗法对于 PH 的作用长久以来存在争议,该疗法一直未被充分研究和利用。本文对国内外相关文献进行了疏理,发现国外正在逐步开展运动疗法在 PH 患者中的试验研究,并不断提高其重视程度,而国内仅有少量综述类文献,对此项的深入研究很少,因此,国内仍有很大的探索和研究空间。     

Nonpharmacologic therapy in hypertension: From single components to overall dietary management

Improved lifestyle and dietary practices are now recognized as essential factors in the optimal management of high blood pressure. This chapter discusses the nonpharmacologic approaches that are generally recommended for hypertension treatment as well as prevention, including summaries of the evidence on which these recommendations are based. For many of these approaches, specifically dietary modifications, the evidence is strong but not yet definitive. Potential sources of the conflicting data and the lack of scientific consensus are addressed, as well as recent findings of the effects of the total diet and dietary patterns that may ultimately resolve much of the controversy regarding nonpharmacologic means of treating and preventing hypertension. Copyright © 1999 by W.B. Saunders Company

Progress in Cardiovascular Diseases, Vol. 41, No. 6 (May/June), 1999: pp 451-460     

Attenuation of fructose-induced hypertension in rats by exercise training

This study was initiated to see if the insulin resistance, hyperinsulinemia, and hypertension that follow feeding normotensive Sprague-Dawley rats a fructose-rich diet could be prevented by letting rats run spontaneously in exercise wheel cages. Blood pressure in sedentary rats increased from (mean +/- SEM) 125 +/- 2 to 148 +/- 3 mm Hg in response to 2 weeks of a high fructose diet, and this increment was significantly (p less than 0.001) attenuated in exercising rats (from 121 +/- 1 to 131 +/- 2 mm Hg). In addition, mean (+/- SEM) plasma insulin concentration was lower in fructose-fed rats allowed to run spontaneously (44 +/- 2 vs 62 +/- 5 microU/ml; p less than 0.01). Finally, resistance to insulin-stimulated glucose uptake was assessed by determining the steady state plasma glucose response to a continuous glucose and exogenous insulin infusion during a period in which endogenous insulin secretion was suppressed. The results of these studies indicated that the mean (+/- SEM) steady state plasma glucose concentration was significantly lower in the exercise-trained rats (127 +/- 5 vs 168 +/- 6 mg/dl; p less than 0.001), despite the fact that the steady state plasma insulin levels were also lower in rats allowed to run spontaneously (75 +/- 4 vs 90 +/- 5 microU/ml; p less than 0.05). Thus, the ability of exercise-trained rats to stimulate glucose disposal was enhanced as compared with that of sedentary rats fed the same fructose-rich diet. These data demonstrate that the insulin resistance, hyperinsulinemia, and hypertension produced in normotensive rats by feeding them a high fructose diet can be attenuated if rats are allowed to run spontaneously.(ABSTRACT TRUNCATED AT 250 WORDS)     

Physician practice patterns in the treatment of isolated systolic hypertension in a primary care setting

The authors evaluated the treatment of isolated systolic hypertension based on medical record review of charts between 1998 and 1999 in a multispecialty physician practice group. Two age-stratified random samples of ambulatory medical records were examined (393 patients aged ≥65 years and 251 patients aged 50–64 years). The samples corresponded to the practices of 35 primary care physicians who were surveyed about their hypertension care. Isolated systolic hypertension was defined as systolic blood pressure ≥140 mm Hg and diastolic blood pressure <90 mm Hg. Results showed that isolated systolic hypertension represented 76% and 45% of uncontrolled blood pressure in the older and middle-aged samples, respectively. Isolated systolic hypertension was often undiagnosed and untreated. Physicians reported treatment thresholds and goals that were significantly less aggressive for their patients ≥65 years of age. Physician awareness and treatment of isolated systolic hypertension have not yet caught up with consensus guidelines, and older patients may be affected most by this gap.     

Ovarian hyperthecosis in the setting of portal hypertension

Hepatocellular dysfunction and perturbed portal hemodynamics alter steroid metabolism. Men with liver disease have gynecomastia, although women similarly affected rarely show virilization. We report a 10-yr-old girl with portal hypertension and shunting associated with precocious puberty and ovarian hyperandrogenism. This was one of premature twin girls; neither had clitoromegaly or genital ambiguity. In one child, neonatal respiratory problems led to umbilical vein catheterization with subsequent development of portal hypertension. Pubic hair was first noted at age 6 yr, breasts at 7 yr, and severe acne and clitoromegaly at 10 yr. Baseline sex hormones were elevated: androstenedione (A), 413 ng/dL; testosterone (T), 226 ng/dL; and estradiol (E2), 160 pg/mL. Liver transaminases were within the normal range, however, the coagulation profile was mildly abnormal. Cosyntropin adrenal stimulation revealed no steroidogenic defect. Dexamethasone suppression reduced A and T slightly. LH-releasing hormone stimulation produced a pubertal rise in LH and FSH. Pelvic sonography showed a large right ovary with numerous follicles. Surgical exploration revealed symmetrically enlarged ovaries with dense capsules. Histology of ovarian wedge resections showed hyperthecosis; immunohistochemistry showed stromal cells expressing steroidogenic enzymes and proteins. One month postoperatively, A and T were unchanged from baseline, whereas E2 decreased to 56 pg/mL. A single dose of depot leuprolide acetate significantly reduced T. Subsequent treatment with oral contraceptives reduced T to 50 ng/dL, and cyclical menses occurred. We conclude that precocious puberty and ovarian hyperthecosis were induced in this young girl by elevated circulating levels of sex hormones, a consequence of portasystemic shunting and impaired hepatic steroid metabolism.     

Nonpharmacologic intervention to reduce blood pressure in older patients with mild hypertension.

BACKGROUND--Although nonpharmacologic interventions are widely recommended in the therapy of high blood pressure in older adults, surprisingly little data exist to confirm the efficacy of these interventions in older persons. METHODS--We conducted a randomized, controlled clinical trial in persons aged 60 to 85 years with a diastolic blood pressure of 85 to 100 mm Hg. The experimental arm was a nonpharmacologic intervention combining weight reduction, sodium restriction, and increased physical activity. The nonpharmacologic intervention consisted of eight weekly group and two individual sessions during the intensive phase, followed by four monthly group sessions during the maintenance phase. The control group received no treatment during the study. Blood pressure was assessed by certified technicians (blinded to group assignment) using random zero sphygmomanometers. RESULTS--Of 56 participants randomized, 47 completed the entire 6-month trial (21 in the intervention group and 26 in the control group). Attendance at the intervention sessions was excellent. The intervention group lost more weight (-2.1 kg) over 6 months than the control group (+0.3 kg). Trends for decreasing 24-hour urine sodium excretion in both the intervention and control groups, with greater trend in the intervention group, were not statistically significant. The intervention group experienced more reduction in systolic and diastolic blood pressure than did the control group (mean differences between groups at 6 months, 4.2/4.9 mm Hg, respectively). CONCLUSIONS--Our data indicate that a nonpharmacologic intervention will lower systolic and diastolic blood pressure levels in older people with borderline or mild elevations of diastolic blood pressure.     

Osteoporosis risk in a home care setting

Aim: To investigate the osteoporosis risk profile of older home care clients and the prevalence of fracture and treatment within this group. Methods: A total of 1500 home care clients were randomly selected and mailed a survey. Overall, 874 (58%) of those surveyed completed and returned the survey. Results: A third (37%, n = 318) reported at least one fracture and 871(99.7%) reported at least one risk factor for osteoporosis. Despite this only 28% reported a diagnosis of osteoporosis, which was more likely if they had sustained a fracture. Bone mineral density tests were reported by 37.4% of respondents and 51.9% of those who had fractured. Only 34.5% who had fractured had been referred for an osteoporosis assessment following their fracture. Conclusions: The home care clients surveyed have many of the risk factors associated with osteoporosis and fracture. A large number reported that they had already sustained fractures that can be attributed to osteoporosis. Despite this, a minority have been assessed or treated for osteoporosis.