scientific rationale for preventive practices in hypertensive cardiovascular

1. Scientific rationale for preventive
practices in hypertensive
cardiovascular disease
Hiba Anis
MPT 3rd Sem
Jamia Millia Islamia

2. • It is known that, as blood pressure increases, there is a clinically
significant association with risk of CVDs, arteriosclerotic disease, and
other diseases, such as congestive heart failure and cerebrovascular
disease
• The exact mechanism of the genetic influence remains unknown;
however, inadequate volume regulation, enhanced vasoconstriction,
and changes in the arterial wall (eg, increased resistance and
decreased luminal diameter), are all known to lead to increased blood
pressure

3. Types
• Primary hypertension is defined as a chronic elevation in blood
pressure without a known cause. Both genetic and environmental
factors play in a role in the development of primary hypertension,
which makes up approximately 90% to 95% of cases.
• Secondary hypertension is an elevation in blood pressure due to a
known cause and constitutes the remaining 5% to 10% of cases.

5. • The following are potential causes of secondary hypertension in order of
prevalence :
• OSA (25%–50%)
• Renal disease (5%–34%)
• Chronic renal disease
• Renal artery stenosis
• Polycystic kidney disease
• Primary aldosteronism (8%–20%)
• Alcohol, drugs, or exogenous substances (2%–4%)
• Ethanol, cocaine, methamphetamine, nicotine, licorice, erythropoietin, OCPs,
decongestants, NSAIDs, herbals (eg, ephedra, ma huang), some psychiatric
medications, and steroids.

7. NONMODIFIABLE RISK FACTORS
• Family History
• Hypertension is definitively observed in individuals with a family history;
however, the exact genetic influence remains unknown.
• Age
• An increase in blood pressure occurs as vasculature becomes less elastic,
which occurs as an age-related situation. It is primarily SBP that increases with
age, such that most people older than the age of 70 years have hypertension.
• Race
• Hypertension is both more common and more severe in African Americans.
The cause is unclear; however, some research suggests that African
Americans may have relatively lower renin levels, as well as salt sensitivity

8. • Obesity Related to Insulin Resistance
• It has been long established that overweight or obese individuals are more likely to develop
hypertension. Some of this is due to genetic predisposition to lower insulin sensitivity; however,
recent focus has been on the effect of the actual fat distribution in obese patients with their
predetermined insulin resistance. In other words, all individuals are born with a certain level of
insulin sensitivity; however, in those who develop obesity, the insulin resistance is greatly
increased.
• Studies have demonstrated that a more important factor is the location of the adiposity;
specifically, a large waist-to-hip ratio is a greater indication of visceral fat. This is often referred to
as central obesity (abdominal fat). The risks are less with lower body obesity in which the fat
deposits are located in the legs and buttocks.
• The former is a problem because visceral fat leads to insulin resistance and multiple metabolic
derangements, which result in metabolic syndrome leading to significantly higher chance of CVD.
The exact relationship between the neuroendocrine effects of the adiposity on hypertension is
unknown; however, it is thought that the adipocytes produce the hormone leptin, which may
have an effect on metabolism and appetite, as well as on the hypothalamus, thus increasing
blood pressure via activation of the sympathetic nervous system.

9. Lifestyle Modifications for Prevention and
Treatment of Hypertension
• Although risk factors should be addressed regularly, so should the
possible therapeutic lifestyle changes in an effort to aim for
prevention of hypertension.
• When the decision is made that antihypertensive therapy should
begin, the importance of lifestyle modification maintenance should
be stressed. Importantly, blood pressure reduction is observed in
both hypertensive patients and normotensive persons who maintain
lifestyle modifications.

10. • Weight loss
• The aim is to reduce body weight to that which achieves a normal body mass index
(BMI); however, it has been shown that even modest reductions in weight result in a
linear relationship with blood pressure reduction.
• Approximately 1 mm Hg reduction in blood pressure may be achieved for every 2.3 lb of
weight loss. In fact, even in normotensive individuals, weight loss results in lower blood
pressure.
• Patients should be educated on the importance of monitoring not only weight but also
measurement of waist circumference and BMI (charts or a BMI calculator can be useful).
With the advent of technology on smartphones, there are a vast array of tools and
telephone applications that can aid patients with tracking their weight, and as well as
ways to reduce weight and waist circumference.
• Physicians may consider using a team-based approach with dieticians, nutritionists, and
exercise personnel, which may reinforce and/or complement patient education and
compliance.

11. Healthy diet
• In large trials, the Dietary Approaches to Stop Hypertension (DASH) diet
promoted by the National, Heart, Lung, and Blood Institute has been
shown to result in significant reductions in blood pressure independent of
weight loss.
• This diet is rich in fruits, vegetables, nuts, fish, poultry, and grains; has
reduced saturated fat and cholesterol intake; uses low-fat dairy; and has
minimal amounts of sugars and red meat
• Along with the aforementioned general dietary food groups, patients can
be taught how to review and interpret nutritional labels to be aware of
their daily intake and the properties of several macronutrients (fats,
proteins, carbohydrates), as well as calorie counting.

12. Reduction in sodium intake
• The recommended limit of dietary sodium intake per ACC/AHA guidelines is less
than 1500 mg/d or 1.5 g/d; however, it has been shown that even modest
reductions in sodium from high to medium to low result in lower blood pressures
(ref/cite).
• It is important to ensure that patients be made aware of the sources of dietary
sodium because many assume that merely not adding salt at the table or during
food preparation and cooking is considered adequate. They should be counseled
that many food items are high in sodium (ie, canned foods, cheeses, breads, and
many processed foods).
• Most food items are now required to carry labels of their nutritional content. If
counseled appropriately, patients can know their specific sodium intake merely
by monitoring labels for their dietary intake. Of note, combining the DASH diet
and sodium reduction has been proven to provide even more benefit in lowering
blood pressure than either intervention alone

13. Reduction in sodium intake
• The recommended limit of dietary sodium intake per ACC/AHA guidelines is less
than 1500 mg/d or 1.5 g/d; however, it has been shown that even modest
reductions in sodium from high to medium to low result in lower blood pressures.
• It is important to ensure that patients be made aware of the sources of dietary
sodium because many assume that merely not adding salt at the table or during
food preparation and cooking is considered adequate. They should be counseled
that many food items are high in sodium (ie, canned foods, cheeses, breads, and
many processed foods).
• Most food items are now required to carry labels of their nutritional content. If
counseled appropriately, patients can know their specific sodium intake merely
by monitoring labels for their dietary intake. Of note, combining the DASH diet
and sodium reduction has been proven to provide even more benefit in lowering
blood pressure than either intervention alone

14. Alcohol consumption
• An early study from the Oakland–San Francisco Kaiser Permanente
Medical Care Program showed a link between consistent alcohol
intake and increased blood pressure.
• In this study of 84,000 individuals, it was revealed that the regular
intake of 3 or more drinks per day resulted in an increased risk for
hypertension.21 SBP was found to be affected more than DBP;
however, the exact mechanism is unclear. The maximum
recommended amounts of alcohol are less than or equal to 2 drinks
daily for men and less than or equal to 1 drink daily for women,
corresponding to a 12 oz beer, 5 oz wine, or 1.5 oz of distilled spirits.

15. Physical activity
• The most commonly prescribed physical activity or exercise is aerobic. Most
guidelines provided advocate specific amounts of cardiovascular exercise, which
are 150 minutes per week or 30–40 minutes most days of the week.
• Patients should be counseled to monitor their heart rate and maintain it to
between 65% and 75% of their maximum, which is calculated based on the
formula of 220 beats per minute minus age.
• It is important to stress that the effect of aerobic exercise is limited, so
performing the entire amount of exercise on a weekend as opposed to
throughout the week has not been shown to confer the same benefit. Also shown
to be helpful is providing tailored aerobic exercise to fit the needs of each
patient, while paying attention to their physical limitations, their access to
equipment, and their interests.
• For example, patients with arthritis or joint problems can often exercise in the
pool without added stress and pain to their joints. For others, engaging in
organized sports provides aerobic benefits that are enjoyable.

16. Stress reduction
• Psychosocial stress is a ubiquitous lifestyle factor that contributes to
increased blood pressure.
• Studies have demonstrated that chronic stress and hypertension are
linked to subsequent cardiac disease, which is mediated via
continuous overactivation of the sympathetic nervous system. A
meta-analysis found that transcendental meditation supported blood
pressure reduction
• There is disagreement about whether biofeedback is helpful,
although some studies report that it can provide benefits.
• No recommendations have been made; however, stress reduction
tips may be suggested.

17. Tobacco cessation
• There is a strong association between smoking and CVD.
• Smoking immediately causes excessive stimulation of the sympathetic
nervous system, resulting in increased myocardial oxygen demand,
thus resulting in increased heart rate, blood pressure, and
contractility
• Patients should be educated and counseled at every visit regarding
tobacco use, as well as assessed for readiness to quit. Cessation tools
should be offered.

20. • Thank you !