Ikkefarmakologisk behandling Hva slags plass br det ha ved hypertensjon

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Ikke-farmakologisk behandling- Hva slags plass
bør det ha ved hypertensjon?

• Henrik M. Reims
• Ullevål Universitetssykehus
• Oslo

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EAT AS MUCH AS YOU CAN, WHENEVER YOU CAN!
DONT MOVE UNLESS YOU HAVE TO!
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Disposisjon

• Hypertensjon og risiko
• Blodtrykkssenkning uten medikamenter
• Vekt
• Fysisk aktivitet
• Frukt, grønnsaker og umettet fett
• Salt
• Alkohol
• Røyking og andre risikofaktorer
• Hva sier retningslinjene?

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1. Essensiell hypertensjon og risiko for hjerte-
og karsykdom
5
Definitions and Classification of Blood Pressure
Levels (mmHg)
2003 European Society of HypertensionEuropean
Society of Cardiology Guidelines for the
Management of Arterial Hypertension
Multiple measurements on separate occasions
Guidelines Committee. J Hypertens
2003,211011-1053
6
Hypertension Prevalences in 6 European and 2
North American Countries (Both Genders)
Wolf-Maier K et al. JAMA 20032892363-2369.
7
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8
Ischaemic Heart Disease (IHD) and Stroke
Mortality by Systolic Blood Pressue and Age
One Million Adults without Previous Vascular
Disease from 61 Studies
Prospective Studies Collaboration. Lancet
20023601903-1913
9
Summarised Results of 13 Randomised Trials of
Antihypertensive Drug Therapy (n 37 000)
Treatment versus Control (Placebo or Usual Care)
DBP at entry 99 mm Hg Difference during follow-up
5-6 mm Hg Mean time to vascular event 2-3 years.
Collins R et al. Lancet 1990335827-838
10
Factors influencing prognosis
Guidelines Committee. J Hypertens
2003,211011-1053
11
Stratification of Risk to Quantify Prognosis
Guidelines Committee. J Hypertens
2003,211011-1053
2003 ESHESC Guidelines
12
Metabolic Syndrome
Type 2 Diabetes
Abdominal Obesity Insulin Resistance Dyslipidemia
Hypertension Hyperglycemia
Atherosclerotic Disease
13
Changes in Prevalence of Overweight and Obesity
in Norway Helseundersøkelsen i Nord-Trønderlag
(HUNT) Ages 20 years
Men (n 21 565)
Women (n 24 337)
Overweight (BMI 25.0 29.9 kg/m2)
Obese (BMI 30 kg/m2)
60
50
53.2
40
41.7
40.0

30
28.6
20
21.0
15.5
10
11.0
6.7
0
HUNT1
HUNT2
HUNT1
HUNT2
19951997
19951997
19841986
19841986
Drøyvold WB et al. Int J Obes 2006advance online
publication
14
Prevalence of Hypertension by Body Mass
IndexNational Health and Nutrition Examination
Survey III (1988-1994)
Brown CD et al. Obes Res 20008605
15

• 2. Blodtrykkssenkning uten medikamenter

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Change in Blood Pressure by Weight ChangeTrials
of Hypertension Prevention (THOP) II
Normotensives, 110-165 of ideal body weight at
baseline
Combined Study Groups (n 1191)
Quintiles of Weight Change
Data adjusted for age, ethnicity, and gender
Intervention 3-year program of group meetings
and individual counseling (dietary change,
physical activity, social support).
Stevens VJ et al. Ann Intern Med 20011341-11
17
Change in Blood Pressure by Weight Change
PatternTrials of Hypertension Prevention (THOP)
II
Systolic BP Change
4
Weight loss lt2.5 kg (n 198)
2
Control Group (n 554)
0
-2
Weight loss 4.5 kg relapse to lt2.5 kg (n 129)
(mm Hg)
-4
-6
Weight loss 4.5 kg, maintained (n 73)
-8
-10
Months
24
30
36
0
6
12
18
Intervention Dietary change, physical activity,
social support goal 4.5 kg
Data adjusted for age, ethnicity, and gender
Remaining (n 195) not classified (other pattern
or missing data)
Stevens VJ et al. Ann Intern Med 2001
18
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Risk of Hypertension by Physical Activity Level
and Body Mass Index (Adjusted Hazard Ratios)
Men Aged 25 - 64 years, Mean Follow-Up 11 Years
(n 8302)
Adjusted for age, area, study year, education,
alcohol intake, diabetes at baseline.
Low Light levels of occupational, commuting (30
minutes), and leisure time physical
activity Moderate 1 type of moderate-to-high
physical activity High 2 - 3 types of
moderate-to-high physical activity.
Hu G et al. Hypertension 20044325-30
20
Effect of Aerobic Exercise on Blood Pressure
Meta-Analysis of Randomized, Controlled Trials
Systolic
Diastolic
Hypertensives (15 Trials)
Normotensives (27 Trials)
0
-1
-2
Changes in Blood Pressure (mm Hg)
-3
-4
-5
-6
-7
-8
Whelton SP et al. Ann Intern Med 2002196493
21
Training-Induced Hemodynamic Changes
Meta-analysis of Randomized Controlled Trials on
Effects of Chronic Dynamic Aerobic Endurance
Training
Mean Net Percentage Changes and 95 CI
Cornelissen VA, Fagard RH. Hypertension
200546667
22
Cardiovascular Mortality by Physical Activity in
9185 Hypertensive Patients with Left Ventricular
Hypertrophy The LIFE Study
Proportion of Patients with an Event
Age 55-80 years
Fossum E et al. 2006
HR adjusted for alcohol use, smoking, gender,
age, and race
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Effect of Fruit and Vegetable Intake on Blood
Pressure6 Months Randomized Controlled Trial in
Healthy Men and Women
Changes in Intake, Body Weight, and Blood Pressure
Control (n 346)
Intervention (n 344)
Intervention Oral and written information and
encouragement to eat five-a-day.
John JH et al. Lancet 20023591969-1974
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Fish Oil and Blood Pressure in HypertensionRandom
ized, Double-Blind Intervention Trial from the
Tromsø Study
10 Week Dietary Supplementation in Untreated Mild
Hypertension
Corn Oil (n 78)
Fish Oil (n 78)
Baseline BP 145/95 mm Hg (fish oil) and 143/95 mm
Hg (corn oil)
Capsules, 6 g daily Fish oil 85
eicosapentaenoic and docosahexaenoic
acids Average increase from 1.0 to 6.1 g/d
(recommended 1.2 g )
Bønaa KH et al. N Engl J Med 1990322795-801
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Effect of Salt Restriction and Diet on Blood
Pressure Men with Untreated, Mild to Moderate
Hypertension
100 mmol Sodium 6 g NaCl)
Beckmann SL et aI. Am J Hypertens 19958704
29
Salt and Blood Pressure The DASH-Sodium Trial
DASH (n 208) vs. Control Diet (n 204) at
Sodium Intake 150, 100, 50 mmol/d)
All food during run-in and the 30-day
intervention periods provided (1 daily meal taken
on site). Intervention periods separated by up to
5 days.
Sacks FM et al. N Engl J Med 20013443-10
DASH, Dietary Approach to Stop Hypertension
30
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31
Alcohol and Blood PressureAnnual Health Survey
for England (1994-1996)
Systolic Blood Pressure by Alcohol Consumption in
4398 Non-Smoking Men Adjusted for Age and BMI
Primatesta P et al. Hypertension 200137187-193
32
Endpoint Rates by Alcohol Consumption in
Hypertensive Patients with Left Ventricular
Hypertrophy The LIFE Study
Drug Groups Combined (n 9188)
P lt 0.05, P lt 0.01 for hazard ratios vs.
non-drinkers Adjusted for smoking, exercise,
gender, age, and race
Reims HM et al. J Hum Hypertens 200418381
33
BP Response to Dietary and Lifestyle
InterventionsMeta-analysis of Controlled Trials
in Finland, Italy, the Netherlands, UK and USA
Blood Pressure Change weighted by trial sample
size (95 C.I.)
aAverage change in dietary intake (per day) or
lifestyle factor in trials. bSupplementation of
fish fatty-acids (eicosapentaenoic acid and
docosahexaenoic acid).
mm Hg
Geleijnse JM et al. J Hum Hypertens 200519S1-S4
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3. Røyking og andre ledsagende risikofaktorer
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Cigarette Smoking and Blood PresureData from
Annual Health Survey for England (1994-1996)
Men (n 15 861) Ages 16-97 Years
Systolic
Observed Blood Pressure (mm Hg)
Diastolic
160
140
120
100
BP (mm Hg)
80
60
40
20
0
Never
Ex
1-9
10-19
20
(n 4398)
(n 7303)
(n 1084)
(n 1505)
(n 1571)
Smoking Categories
Mean of last 2 of 3 automated measurements after
5 min seated. No food, alcohol, or smoking for
gt30 min before measurement.
Primatesta P et al. Hypertension 200137187-193
37
Cardiovascular Mortality by Smoking and Blood
PressureThe Malmö Preventive Project
22 444 men born 1921-1949, Mean Follow-Up 17 years
Khalili P et al. J Hypertens 2002201759
38
Endpoint Rates by Smoking Status in Hypertensive
Patients with Left Ventricular Hypertrophy The
LIFE Study
Drug Groups Combined (n 9188) Endpoint Rates
per 1000 Years of Follow-Up
Cardiovascular Death
Stroke
Myocardial Infarction

25
20


15

10
5
0
Previous
1-5/d
11-20/d
6-10/d
gt20/d
(n 4656)
(n 428)
(n 3033)
(n 454)
(n 435)
(n 182)
P lt 0.05, P lt 0.01, P lt 0.001 for
Adjusted Hazard Ratios vs. Never-Smokers Adjusted
for alcohol consumption, exercise, gender, and age
Reims HM et al. Blood Press 200413376
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Effects of Diet and Exercise on Glucose
Metabolism One Year Intervention The Oslo Diet
and Exercise Study (ODES)
Controls (n 43)
Diet (n 52)
Exercise (n 49)
Diet Exercise (n 65)

Entry Criteria (All Fulfilled) BMI gt 24
kg/2 Diastolic BP 86-99 mm Hg Cholesterol
5.20-7.74 mmol/L HDL lt 1.2 mmol/L Triglyceride gt
1.4 mmol/L
Diet Reduction of total calories, increased
fish, reduced saturated fat and
salt. Exercise Dynamic training, 60-80 of max.
HR, 3 times per week.
Anderssen SA et al. J Intern Med 1996240203-209
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Diabetes Prevention by Lifestyle ModificationThe
Finnish Diabetes Prevention Study
Cumulative Probability of Remaining Free of
Diabetes
Intervention (n 265) 27 Cases
1.0
0.9
0.8
Hazard Ratio 0.4 (95 C.I. 0.3-0.7) P lt0.001
0.7
Control Group (n 257) 59 Cases
0.6
0.5
0.4
4
0
2
5
6
3
1

• Intervention Individualized counseling aimed at
• Reducing weight, total intake of fat, and intake
  of saturated fat
• Increasing intake of fiber and physical activity

Tumoilehto J et al. N Engl J Med 20013441343
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Effect of Weight Loss on Plasma
LipidsMeta-analysis of 70 Clinical Trials
1.5 kg Weight Loss by 2 weeks Dietary
Intervention
LDL, low density lipoprotein cholesterol HDL,
high-density lipoprotein cholesterol
Dattilo AM et al. Am J Clin Nutr 199256320
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5. Hva sier retningslinjene?
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European Society of Hypertension Position
StatementLifestyle Changes
Lifestyle measures should be instituted whenever
appropriate in all patients, including subjects
with high normal blood pressure and patients who
require drug treatment. The purpose is to lower
blood pressure and to control other risk factors
and clinical conditions present.
Guidelines Committee. J Hypertens
2003,211011-1053
44
2003 European Society of HypertensionEuropean
Society of Cardiology Guidelines for the
Management of Arterial Hypertension
Guidelines Committee. J Hypertens
2003,211011-1053
45
2003 European Society of HypertensionEuropean
Society of Cardiology Guidelines for the
Management of Arterial Hypertension
Alcohol 1 unit (0.33 L beer, 1 glass of wine , 1
double drink of liquour) 13g
Guidelines Committee. J Hypertens
2003,211011-1053
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Oppsummering (1)
Livsstilsendringer som senker blodtrykket eller
reduserer risikoen for hjerte- og karsykdom

• Røykavvenning
• Vektreduksjon
• Reduksjon av alkoholinntak ved overforbruk
• Fysisk aktivitet
• Reduksjon av saltinntak
• Øket inntak av frukt og grønnsaker
• Redukjon av inntak av mettet fett og av totalt
  fettinntak

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Oppsummering (2)

• Fordeler
• Påvirker flere viktige risikofaktorer i gunstig
  retning.
• Kan gi ønsket blodtrykkssenkende effekt hos noen
  pasienter med mild hypertensjon.
• Nyttig for alle pasienter med hypertensjon, enten
  de samtidig bruker medikamenter eller ikke.
• Ulemper
• Begrenset dokumentasjon av langtidseffekter
• Begrenset dokumentasjon av forebyggende effekt på
  sykdelighet og dødelighet.
• Usikkerhet for den enkelte pasient
• når er det trygt å prøve livsstilsendring
  alene?

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Konklusjoner

• Viktig verktøy for å bedre den totale
  risikoprofilen.
• Nyttig behandling for pasienter med lav risiko,
  spesielt i startfasen, men også ved oppfølgning.
• Bør supplere, men ikke erstatte medikamentell
  behandling (med dokumentert forebyggende effekt)
  hos pasienter med moderat eller høy risiko.

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MOVE WHENEVER YOU CAN! DONT EAT TOO MUCH!