OMG!! Do We Really Need All TheseAntihypertensives?? Traditional vs. Natural Therapies. Kristen Luttenberger MSN, RN, CCRN-CMC, PCCN, APN-c

Transcription

1 OMG!! Do We Really Need All TheseAntihypertensives?? Traditional vs. Natural Therapies Kristen Luttenberger MSN, RN, CCRN-CMC, PCCN, APN-c

2 Hypertension Defined as persistently elevated pressure in the arteries at or above 140/90mmHg Asymptomatic Primary (90-95%) or Secondary Has been shown to be a major risk factor for: Hypertensive Heart Disease Coronary Artery Disease Stroke Aortic Aneurysm Peripheral Artery Disease Chronic Kidney Disease

3 Pathophysiology

4 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults-JNC8 Grade A-Strong Recommendation Grade B-Moderate Recommendation Grade C-Weak Recommendation Grade D-Recommendation Against Grade E-Expert Opinion Grade N-No recommendation for or against

5 Recommendation 1 In the general population >60 yrs., initiate pharmacologic treatment to lower BP at >150 systolic or >90 diastolic. Treat to goal <150/90 mmhg. Grade A Strong

6 Recommendation 2 In the general population <60 yrs., initiate pharmacologic treatment to lower BP at DBP>90 mmhg and treat to a goal DBP<90 Ages Strong Grade A Ages Expert Opinion E

7 Recommendation 3 In the general population <60yrs., initiate pharmacologic treatment to lower BP at SBP>140mmHg and treat to a goal SBP<140mmHg Grade E-Expert Opinion

8 Recommendation 4 In the population >18 yrs., with chronic kidney disease (CKD) initiate pharmacologic treatment to lower BP at SBP>140 or DBP>90mmHg and treat to goal <140/90 mmhg. Expert Opinion-Grade E

9 Recommendation 5 In the population >18 yrs. with diabetes, initiate pharmacologic treatment to lower BP at SBP>140 mmhg or DBP >90and treat to a goal SBP<140mmHg and DBP<90mmHg Expert Opinion-Grade E

10 Recommendation 6 In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensinconverting enzyme inhibitor (ACE1), or angiotensin receptor blocker (ARB). Moderate Recommendation-Grade B

11 Recommendation 7 In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB General black population-grade B Moderate Black patients with diabetes-grade C Weak

12 Recommendation 8 In the population >18 yrs. with CKD, initial (or add on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status Moderate Recommendation-Grade B

13 Recommendation 9 If BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from one of the classes in recommendation 6. Ongoing assessment until goal BP is reached. May add up to 3 from list then move to other drug class. No ACEI and ARB together. Expert Opinion-Grade E

14 ACE Inhibitors pril Angiotensin Receptor blockers sartan Captopril 50mg Enalapril 5mg Lisinopril 10mg Eprosartan 400mg Candesartan 4mg Losartan 50mg Valsartan 40-80mg Irbesartan 75mg

15 colorado.edu

16 Calcium Channel Blockers Target Dose in RCTs Amlodipine 2.5mg 10mg Diltizem ER mg 360mg Nitrendipine 10mg 20mg

17 Peripheral and coronary vasodilation Depression of cardiac contractility Depression of SA node Depression of AV node Nifedipine Diltiazem Verapamil

18 Thiazide-type diuretics Target Dose in RCTs Bendroflumethiazide 5mg 10mg Chorthalidone 12.5mg mg Hydroclorothizide mg mg Indapamide 1.25mg mg

19 Each diuretic targets specific segments in the nephron

20 Healthy Living Quotes in JN8 For all persons with hypertension, the potential benefits of a healthy diet, weight control, and regular exercise cannot be overemphasized These lifestyle treatments have the potential to improve BP control and even reduce medication needs Although the authors of this hypertension guideline did not conduct an evidence review of lifestyle treatments in patients taking and not taking antihypertensive medication, we support the recommendation of the 2013 Lifestyle Work Group

21 2013 AHA Lifestyle Management Guideline DASH dietary pattern - Grade A Lower sodium intake - Grade A Aerobic physical activity - Grade B

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23 Sodium No more than 2,400mg/day Further restriction to 1,500mg/day is further associated with greater reduction in BP or Reduce daily intake by 1,000mg/day even if target is not achieved yet

24 There is insufficient evidence from RCTs to determine whether reducing sodium intake plus changing dietary intake of any other single mineral (K, Ca, Mg) lowers BP more than reducing sodium intake alone.

25 Aerobic Physical Activity 3-4 sessions/week lasting 40 minutes per session Must involve moderatevigorous intensity physical activity

26 YOGA 10 Studies met inclusion criteria First research done in US was at UPENN in 2008 RCTs, quasi-experimental, & pilot studies Reduces BP, glucose levels, cholesterol levels, body weight

27 Relaxation Therapies

28 Hibiscus sabdariffa L. (Sour Tea)

29 Qi gong

30 Melatonin

31 Folic Acid

32 Garlic

33 Eicosapentaenoic Acid Docosahexaenoic Acid

34 CoEnzyme Q10

35 Dietary Supplements & Hypertension Precautions Evidence for Dietary Supplements is frequently limited and meager quality Plant based preparations may contain numerous compounds with a myriad of unknown effects Factors may alter the quantity and quality of the active ingredient Dietary Supplements do not require FDA approval thereby are not held to the same standard in regards to safety and efficacy

36 How do I know what I m taking?? uary/certifications%20logos/usp.jpg

37 In Summary Despite the medical knowledge, hypertension in this country is not well controlled Adverse events and the complexity of antihypertensive therapy tends to decrease adherence There is good evidence that complementary and alternative medicines/therapies help with the control of blood pressure primarily or as adjunctive therapy; but the studies need to get better There is evidence that just a mild reduction of 5-6mmHg in blood pressure cuts the risk of stroke by 40%, heart disease by 15%, and overall mortality 7% (Law et al., 2009)

38 References DeSimone, M. E., & Crowe, A. (2009). Nonpharmacological approaches in the management of hypertension. Journal of the American Academy of Nurse Practitioners, 21(4), Dickinson, H. O., Beyer, F. R., Ford, G. A., Nicolson, D., Campbell, F., Cook, J. V., & Mason, J. (2008). Relaxation therapies for the management of primary hypertension in adults. The Cochrane Library. Eckel, R. H., Jakicic, J. M., Ard, J. D., de Jesus, J. M., Miller, N. H., Hubbard, V. S.,... & Yanovski, S. Z. (2014) AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 63(25_PA), Grossman, E., Laudon, M., & Zisapel, N. (2011). Effect of melatonin on nocturnal blood pressure: meta-analysis of randomized controlled trials. Vascular health and risk management, 7, 577. Hulin, I., Duris, I., Paulis, L., Sapakova, E., & Mravec, B. (2009). Dangerous versus useful hypertension (A holistic view of hypertension). European journal of internal medicine, 20(2), James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J.,... & Ortiz, E. (2014) evidencebased guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). Jama, 311(5), Lee, M. S., Pittler, M. H., Guo, R., & Ernst, E. (2007). Qigong for hypertension: a systematic review of randomized clinical trials. Journal of hypertension, 25(8), Miller, P. E., Van Elswyk, M., & Alexander, D. D. (2014). Long-chain omega-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid and blood pressure: a meta-analysis of randomized controlled trials. American journal of hypertension, 27(7), McRae, M. P. (2009). High-dose folic acid supplementation effects on endothelial function and blood pressure in hypertensive patients: a meta-analysis of randomized controlled clinical trials. Journal of chiropractic medicine, 8(1), Okonta, N. R. (2012). Does yoga therapy reduce blood pressure in patients with hypertension?: an integrative review. Holistic nursing practice, 26(3), Rasmussen, C. B., Glisson, J. K., & Minor, D. S. (2012). Dietary supplements and hypertension: potential benefits and precautions. The Journal of Clinical Hypertension, 14(7), Rosenfeldt, F. L., Haas, S. J., Krum, H., Hadj, A., Ng, K., Leong, J., & Watts, G. F. (2007). Coenzyme Q10 in the treatment of hypertension: a meta-analysis of the clinical trials. Journal of human hypertension, 21(4),

39 References Serban, C., Sahebkar, A., Ursoniu, S., Andrica, F., & Banach, M. (2015). Effect of sour tea (Hibiscus sabdariffa L.) on arterial hypertension: A systematic review and meta-analysis of randomized controlled trials. Journal of hypertension, 33(6), Xiong, X. J., Wang, P. Q., Li, S. J., Li, X. K., Zhang, Y. Q., & Wang, J. (2015). Garlic for hypertension: A systematic review and metaanalysis of randomized controlled trials. Phytomedicine, 22(3),