New Hypertension Cure

Hypertension Exercise Program

The exercises in Three Easy Exercises to Drop Blood Pressure Below 120/80 take about 30 minutes a day, and you can do them while you're doing routine household chores. Christian Goodman is the researcher behind the Blue Heron Health High Blood Pressure Exercise Program. If this pressure is too high, it puts a strain on your arteries and your heart making you more likely suffer a heart attack, a stroke or kidney disease. All of your risk will be stopped instantly in less than 30 minutes a day to practice exercises. These exercises used in Natural Blood Pressure are focused on mind and body ones in the system called Focused Break. You will start experiencing the calming effects of the exercises within minutes. Best of all, you won't need to rely on medication or implement any major dietary changes. They're safe, easy and effective. More here...

Hypertension Exercise Program Overview

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Definition of hypertension

A survey of the literature of the past few decades shows that the definition of hypertension has changed drastically, and it seems to continue to change. It is presently recommended that antihypertensive therapy is started in patients who have confirmed hypertension, defined by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment ofHigh Blood Pressure (JNC 7) as a blood pressure (BP) level exceeding 140 90 mmHg. However, data from the Framingham Heart Study 1 make it exceedingly clear that BP is directly related to cardiovascular events, even at levels below that defined as hypertensive by the JNC 7 2 . High normal BP was associated with a several-fold increase of cardiovascular disease in the Framingham population (Figure 1). A number of recent studies have shown that lowering BP in the so-called normotensive population reduces morbidity and mortality. These recent data indicate that any arbitrary definition of hypertension, such as...

Antihypertensive therapy in physically active patients

Lifestyle modifications often have to be adapted to fit a specific antihypertensive therapy and vice versa. Regular aerobic exercise has a mild antihypertensive effect, probably because oflow-grade, chronic fluid volume and salt depletion. Thus, aerobic exercise should be encouraged in all patients with hypertension conversely, drugs that decrease aerobic exercise performance, such as beta-blockers and, to a lesser extent, diuretics, should be avoided in the physically active patient. Fluid and salt depletion associated with diuretic therapy may make the patient more prone to dehydration during prolonged aerobic exercise. Isometric exercise (weightlifting) is relatively contraindicated in patients with hypertension because of the excessive spikes in systolic pressure that have been documented during strenuous weightlifting. Profound hypotension can be observed in patients on ACE inhibitors or ARBs, together with dehydration, such as that which occurs when running or when undertaking...

A1 Lifestyle Trials in Hypertensive Patients

Evidence Statement Weight loss produced by lifestyle modifications reduces blood pressure in overweight hypertensive patients. Evidence Category A. Rationale A 1987 meta-analysis 381 covering five of the acceptable studies 351, 352, 356-358 in hypertensive patients concluded that weight loss accomplished by dietary interventions significantly lowered blood pressure. In hypertensive patients, Since publication of this meta-analysis in 1987, almost all relevant studies have reported that weight loss reduces blood pressure or the need for medication in hypertensive patients 346- 348, 350, The Trial of Antihypertensive Interventions and Management (TAIM), conducted in hypertensive individuals not taking medication for 6 months, reported that, compared with controls, a mean net weight reduction of 4.7 kg (10.4 lb) reduced systolic and diastolic blood pressure by 2.8 mm Hg and 2.5 mm Hg, respectively 355 the effects on blood pressure were equivalent to drug therapy among those participants...

Blood pressure lowering in prehypertensive patients

The JNC created a new BP class in 2003 called prehypertension 2 . The issue surrounding this entity has stirred tempers to an extent that seems more suitable to medieval theologians than to modern scientists. The extensively quoted meta-analysis of Lewington 33 suggested a continuous relationship between the risk of cardiovascular disease (stroke, coronary heart disease, and vascular disease) and usual BP values down to at least 115 75 mmHg. In the Framingham cohort 1 , an increase in cardiovascular events was reported in individuals with a higher baseline BP within the normotensive range (ie, below 140 90 mmHg). In this cohort of normotensive subjects, BP levels paralleled cardiovascular disease risk in the same way as they did in hypertension. It follows that normotensive individuals with a host of additional risk factors could be at higher overall cardiovascular risk than patients without risk factors with mild hypertension. It follows further that the absolute benefits of...

Dietary Factors That Lower Blood Pressure

Additional trials have documented that modest weight loss can prevent hypertension by approximately 20 among overweight, prehypertensive individuals and can facilitate medication step-down and drug withdrawal. Lifestyle intervention trials have uniformly achieved short-term weight loss, primary through a reduction in total caloric intake. In some instances, substantial weight loss has also been sustained over 3 or more years. In aggregate, available evidence strongly supports weight reduction, ideally attainment of a body mass index less than 25 kg m2, as an effective approach to prevent and treat hypertension. Weight reduction can also prevent diabetes and control lipids. Hence, the One of the most important dose-response trials is the DASH-Sodium trial, which tested the effects of three different salt intakes separately in two distinct diets the DASH (Dietary Approaches to Stop Hypertension) diet and a control diet more typical of what Americans eat. As displayed in Figure 3, the...

Antihypertensive Effects

High blood pressure is associated with decreased life expectancy and increased risk of stroke, coronary heart disease, and other end-organ diseases such as renal failure. Ginseng contains active compounds that normalize blood pressure. The effect of a certain drug on blood pressure can be analyzed by investigating the effect of the drug on the smooth muscle of blood vessels. It is well established that blood vessel smooth muscle tone is regulated by the available intracellular Ca2+ concentration, which in turn is profoundly influenced by interaction of the cellular membrane and sarcoplasmic reticu-lum in the smooth muscle. It was found that both protopanxatriol and protopanaxadiol saponins inhibit Ca2+ binding to the cellular membrane protopanaxatriol is approximately 180 more potent than protopanaxadiol ginsenosides (76). It was reported that ginseng induced no significant change in blood pressure in subjects with normal blood pressure, but had a normalizing effect on subjects with...

Hypertension in Pregnancy

Pregnancy-induced hypertension is a syndrome characterized by hypertension, proteinuria, and edema. This condition usually develops in the third trimester and occurs in approximately 7 or 8 of pregnant women. It occurs more often in women who are young, pregnant for the first time, or are of low socioeconomic status. The exact cause of this condition is unknown, but most researchers agree that it is associated with a decreased uterine blood flow leading to reduced fetal nourishment. Previous treatments for this condition included sodium restriction and diuretics however, neither of these has been successful in altering blood pressure, weight gain, or proteinuria in this condition.

Preexisting Chronic Hypertension

Mild and uncomplicated chronic hypertension during pregnancy has a better prognosis than pre-eclampsia. However, there is an increased risk of superimposed pre-eclampsia and possible complications if preexisting renal disease or systemic illness is present. The primary aim of therapy, if necessary, is to prevent cerebrovascular complications and to avoid progression to superimposed pre-eclampsia with its worse prognosis. Nonpharmacological management of this condition during pregnancy remains controversial. In a published review of management of mild to chronic hypertension during pregnancy, no trials were found that compared nonpharmacological interventions with either pharmacological agents or no intervention in pregnant women. This comprehensive search identified 50 randomized controlled trials, but they involved either normotensive women or women with a history of pre-eclampsia. For the management of established chronic hypertension during pregnancy, no relevant evidence could be...

Whitecoat hypertension and masked hypertension

BP is a very labile hemodynamic parameter it varies from heartbeat to heartbeat, from morning to evening, from winter to summer, from sleeping to awake, and from sitting to standing. The same holds true for any other cardiovascular hemodynamic parameter, such as heart rate, cardiac output, ejection fraction, or pulmonary wedge pressure. However, the information that is based on invasively obtained measurements is often considered more reliable than information based on simple BP recording. Numerous studies have documented that BP carefully measured by cuff, under standardized conditions in physicians' offices, is a powerful and reliable predictor of morbidity and mortality. More recent studies have documented that 24-hour ambulatory BP monitoring is an even closer surrogate end point for heart attack and stroke than is office-measured BP. As the correlation between 24-hour ambulatory BP measurement and office BP measurement is moderate at best, there will be, not unexpectedly, a...

Resistant hypertension

Resistant hypertension is said to be present if, despite triple therapy including a thiazide diuretic, BP remains distinctly above target range. Figure 31 lists some of the more common underlying causes of resistant hypertension. Of particular concern are NSAIDs, as well as the cyclooxygenase 2 (COX2) inhibitors. These drugs elevate BP by a variety of mechanisms, ranging from direct binding with mineralocorticoid receptors to interference with prostaglandin synthetase. Very often, the antihypertensive efficacy of ACE inhibitors and ARBs is completely abolished when NSAIDs, or COX2 inhibitors, are added to the regimen. In contrast, these drugs have little, if any, effect on the antihypertensive efficacy of calcium antagonists. Perhaps the most common error is to diagnose resistant hypertension when triple antihypertensive therapy is given without a diuretic. In volume-expanded patients, in those who abuse salt, and in black patients, the antihypertensive efficacy of ACE inhibitors and...

Types of Hypertension

Hypertension is classified as either primary (or essential) hypertension or secondary hypertension. Primary hypertension has no specific origin but is strongly associated with lifestyle. It is responsible for 90 to 95 percent of diagnosed hypertension and is treated with stress management, changes in diet, increased physical activity, and medication (if needed). Secondary hypertension is responsible for 5 to 10 percent of diagnosed hypertension. It is caused by a preexisting medical condition such as congestive heart failure, kidney failure, liver failure, or damage to the endocrine (hormone) system. Pregnancy-induced hypertension (PIH) may appear in otherwise healthy women after the twentieth week of pregnancy. It is more likely to occur in women who are overweight or obese. PIH may be mild or severe, and it is accompanied by water retention and protein in the urine. About 5 percent of PIH cases progress to preeclampsia. Preeclampsia is characterized by dizziness, headache, visual...

Causes of Hypertension

Many prescription and over-the-counter drugs can cause or exacerbate hypertension. For example, corticosteroids and immunosuppressive drugs increase blood pressure in most solid-organ transplant recipients. Medication taken for pain and inflammation such as nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors may raise blood pressure since their antiprostaglandin properties affect the kidneys. There does not appear to be a direct relationship between caffeine and chronic hypertension, even though caffeine intake can cause an acute (rapid but brief) increase in blood pressure. This may be due to the fact that tolerance to caffeine develops rapidly. Chronic overuse of alcohol is a potentially reversible cause of hypertension. Five percent of hypertension is due to alcohol consumption and 30 to 60 percent of alcoholics have hypertension. Alcohol-induced hypertension is more likely to occur in women than men.

Diet and Hypertension

Sodium intake has been a primary target for hypertension control, though it is ranked fourth as the lifestyle factor associated with hypertension. About 50 percent of individuals appear to be sodium sensitive. This means that excessive sodium intake tends to increase blood pressure in these groups of people, and they do not appear to excrete excessive amount of salt via the kidneys. Sodium-sensitive individuals include the elderly, obese individuals, and African Americans. The Dietary Guidelines for Americans recommend that adults consume no more than 2,400 milligrams of sodium daily. There are a number of ways to limit sodium in the diet, including Potassium supplements (2-4 grams daily) have been shown to moderately decrease blood pressure. Fruits and vegetables are excellent sources of potassium. The Dietary Guidelines for Americans recommend that adults consume at least 3,500 milligrams of potassium daily. A diet high in fruits and vegetables has been linked to a decreased risk of...

Pharmacological Treatment of Hypertension

Hypertension is commonly treated with medication, and a combination of two or more drugs is common. Patients are usually given a diuretic to help them excrete excess fluids. However, most diuretics also cause excretion of potassium in the urine, and individuals on diuretics should monitor their potassium intakes. Drugs used to control hyertension include beta-blockers (e.g., atenolol Tenorim ) which act to slow heart rate and cause some vasodilation (widening of the lumen, or interior, of blood vessels). Drugs that contain calcium channel blockers (e.g., amlopidine Norvasc ) or angiotensin-converting enzyme (ACE) inhibitors also cause vasodilation.

Lifestyle Treatment of Hypertension

Most of the risk factors for primary hypertension are preventable, and lifestyle modification may prevent as well as treat the condition. Secondary hypertension can be managed by treating the underlying cause. Individuals in the high normal and stage 1 hypertension categories should attempt to lower blood pressure through diet and lifestyle changes before going on a regimen of medications. Recommendations include Onusko, E. (2003). Diagnosing Secondary Hypertension. American Family Physician 67 67-74. Also available from < http www.aafp.org afp>

Antihypertensive Actions of Vitamin B6

Vitamin B6 depletion leads to the development of hypertension in experimental animals, which is normalized within 24 hours by repletion with the vitamin. 4. Increased end-organ responsiveness to glucocorticoids, mineralocorti-coids, and aldosterone (Section 9.3.3). Oversecretionof (andpresumably also enhanced sensitivity to) any of these hormones can result in hypertension. Vitamin B6 supplementation would be expected to reduce endorgan sensitivity to these hormones, and thus might have a hypotensive action. A number of studies suggest that supplements of vitamin B6 may have a hypotensive action. Supplements of 300 mg of vitamin B6 per kg of body weight per day attenuated the hypertensive response of rats treated with deoxycor-ticosterone acetate (Fregly and Cade, 1995). At a more realistic level of supplementation (five times the usual amount provided in the diet), vitamin B6 prevented the development of hypertension in the Zucker (fa fa) obese rat. Withdrawal of the vitamin...

Asthenia And Familial Hypertension And Diabetes

Fig. 7.9 Clusters of points with low ESR in 26 patients with familial hypertension but who themselves have normal blood pressure values on the left cluster of tender points with PPT of the same subjects on the right. The colored sectors correspond to a significantly higher concentration of points, respectively, for ESRT vs. PPT on the left side or for PPT vs. ESRT on the right side of the figure. Colored areas lateral surface blank areas medial surface. Fig. 7.9 Clusters of points with low ESR in 26 patients with familial hypertension but who themselves have normal blood pressure values on the left cluster of tender points with PPT of the same subjects on the right. The colored sectors correspond to a significantly higher concentration of points, respectively, for ESRT vs. PPT on the left side or for PPT vs. ESRT on the right side of the figure. Colored areas lateral surface blank areas medial surface. It is interesting, in my opinion, to see how these patterns of distribution of...

Isolated systolic hypertension

There are three main reasons why isolated systolic hypertension has become increasingly important over the past few years We are seeing more and more elderly patients, and isolated systolic hypertension is the most common form of high BP in the geriatric population. The treatment goals of systolic BP have become increasingly lower over the past few years, thereby creating numerous hypertensive patients who, according to previous criteria, would not have fulfilled this definition. Even in very elderly patients, a systolic BP goal of less than 140 mmHg can be a realistic goal with modern antihypertensive therapy, although sometimes The most common pitfall encountered in the treatment of isolated systolic hypertension is the failure to recognize that bradycardia can be its major perpetrator. Any decrease in heart rate is prone to an increase in stroke volume a higher stroke volume ejected into a stiff aorta will elevate systolic and lower diastolic pressure. Thus, bradycardia often...

Hypertension High Blood Pressure

When pressure exerted by blood on the walls of the arteries is greater than normal, blood pressure rises. Usually, blood pressure falls when at rest. It rises in response to strenuous physical activity, stress, or a perceived danger in which the sympathetic nervous system dominates, arteries constrict, and more blood is sent to the brain increasing blood pressure. This heightened state of the sympathetic system does not seem to retreat in individuals with hypertension and damage to the heart, kidney, arteries, and other organs becomes inevitable. Blood pressure is considered high at a reading of 140 90. There are no symptoms of the illness and it is recommended individuals over 40 be checked. Hypertension can be controlled by permanent diet and lifestyle changes this includes reducing stress, maintaining proper weight (not more than 5 lb overweight), and eating foods containing compounds that reduce blood pressure such as celery, garlic, and fresh fruits and vegetables. Having a home...

Early morning hypertension

Ever since the pioneering studies of Sir George Pickering, we have known that BP follows a distinct diurnal pattern, decreasing throughout the evening to a nadir at midnight, followed by an early morning rise shortly before awakening. This pattern is qualitatively similar in both normotensive and hypertensive patients. Hypertensive complications, such as stroke, acute MI, and sudden death follow a very similar pattern the time period between 6 00 a.m. and 10 00 a.m. seems to confer the highest risk for these events. In a meta-analysis of 31 studies, Elliott showed a 49 higher stroke risk in the period from 6 00 a.m. to noon than in the remaining hours ofthe day 81 . Similarly, Kario etal. 82 showed a higher prevalence of silent cerebral ischemia and stroke in patients who have a morning surge of BP, as opposed to patients who did not exhibit such a surge. Although the exact relationship between BP and the occurrence of these events remains to be elucidated, good BP control during the...

Antihypertensive efficacy

Concomitant medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), or a high salt intake can mitigate the antihypertensive efficacy of certain drug classes, such as ACE inhibitors or ARBs. Beta-blockers have little, if any, effect in isolated systolic hypertension in elderly patients. A high salt intake can counteract the effects of diuretics and blockers of the RAS. In contrast, few, if any, drugs or dietary interventions affect the efficacy of calcium antagonists. Calcium antagonists, of which amlodipine is the prototype, lower BP regardless of age, sex, race, diet, concomitant diseases, or medications. Numerous prospective randomized trials have documented that calcium anatagonists reduce the rate of stroke and heart attack. From an

Hypertension as a gateway to cardiovascular risk modification

Measurement of BP is a simple, straightforward procedure that allows us to identify the risk of cardiovascular disease. However, treatment of raised BP is clearly inefficient to reduce the overall associated cardiovascular disease risk. Antihypertensive therapy should, therefore, serve as a gateway to overall cardiovascular risk management and give rise to normal risk estimation. This can be done by using the Framingham risk score 1 or the systems put forward by the European Society of Cardiology 24 and others. We have learned recently that the use of more elaborate risk assessment by a series of biomarkers does not really add much to additional methods of assessing the cardiovascular disease risk. However, one ofthe most important criticisms of cardiovascular risk estimation is that it is based on limited time projections, most often on 10-year absolute risk estimation. This approach strongly favors treatment of the elderly population because age is a more powerful determinant of the...

Hypertension And Cholesterol Lowering

CoQ10 has been studied both as stand-alone and adjunctive treatment in hypertension. According to a review of 8 studies, supplemental CoQ10 results in a mean decrease in systolic blood pressure of 16 mmHg and in diastolic blood pressure of 10 mmHg (Rosenfeldt et al 2003). The effect on blood pressure has been reported within 10 weeks of treatment at doses usually starting at 100 mg daily. One small 10-week open study of 26 subjects with essential hypertension study found that an oral dose of 50 mg taken twice daily also reduced total serum cholesterol levels with a

AHypertension

Data from NHANES III show that the age-adjusted prevalence of high blood pressure increases progressively with higher levels of BMI in men and women (Figure 2). 2 High blood pressure is defined as mean systolic blood pressure > 140 mm Hg, or mean diastolic blood pressure > 90 mm Hg, or currently taking anti-hypertensive medication. The prevalence of high blood pressure in adults with BMI > 30 is 38.4 percent for men and 32.2 percent for women, respectively, compared with 18.2 percent for men and 16.5 percent for women with BMI < 25, a relative risk of 2.1 and 1.9 for men and women, respectively. The direct and independent association between blood pressure and BMI or weight has been shown in numerous cross-sectional studies 3-5, including the large international study of salt (INTERSALT) carried out in more than 10,000 men and women. 6 INTERSALT reported that a 10 kg (22 lb) higher body weight is associated with 3.0 mm Hg higher systolic and 2.3 mm Hg higher diastolic blood...

Hypertension

The current nutritional management of hypertension focuses on reducing dietary sodium intake and weight reduction, as well as the recently proven 'DASH' diet. There has been long-standing evidence that in both normal and hypertensive people, a Modest amounts of weight loss and increased activity are also beneficial for the person with hypertension. Thus, overweight and obese individuals should be encouraged to lose weight as part of their medical therapy. In diabetes, ACE inhibitors or ARBs (Angrotensin Receptor Blockers) are usually the first line of medication used when diet and exercise are not effective in controlling blood pressure. Frequently, additional antihypertensives must be added.

High Blood Pressure

Stress increases blood pressure, as does too much saturated or hydrogenated fat in the diet. Coffee, sugar, tobacco and alcohol don't help either, neither does salt. Overweight is another important factor, and lack of exercise. An entirely vegetarian diet is the most straightforward way to reduce blood pressure. In terms of supplements, take plenty of B Complex, C, E, Niacin, Calcium and magnesium.

What Is Hypertension

Hypertension, or high blood pressure, is defined as a reading of 140 90 on three consecutive measurements at least six hours apart. The definition varies for pregnant women, where hypertension is defined as 140 90 on two consecutive measurements six hours apart. Consistently high blood pressure causes the heart to work harder than it should and can damage the coronary arteries, the brain, the kidneys, and the eyes. Hypertension is a major cause of stroke. A kidney (left) and a cross-section of a heart (right) that were affected by hypertension. The heart shows signs of advanced atherosclerosis, one possible complication arising from hypertension. Photograph by Dr. E. Walker. Photo Researchers, Inc. Reproduced by permission. A kidney (left) and a cross-section of a heart (right) that were affected by hypertension. The heart shows signs of advanced atherosclerosis, one possible complication arising from hypertension. Photograph by Dr. E. Walker. Photo Researchers, Inc. Reproduced by...

Portal Hypertension

Portal hypertension is frequently a systemic complication of liver cirrhosis, however different pathologies such as obstruction at the post-sinusoidal (e.g. hepatic vein), sinusoidal (e.g. cirrhosis) or pre-sinusoidal (e.g. portal vein) level may also cause portal hypertension 27 . The most common cause of portal hypertension is liver cirrhosis. Associated complications include variceal bleeding, ascites and splenomegaly. A primary consequence of the increased pressure in the portal tract is dilatation of vessels. Later, as a result of the development of porto-systemic shunting, the blood flow to the liver diminishes and the size of the portal vessels is again reduced. Increased porto-systemic shunting results in less effective metabolism of absorbed nutrients and accumulation of toxic metabolites such as ammonia in the blood. This may lead to the clinical manifestations of hepatic encephalopathy. As decreased portal flow correlates with the presence of liver atrophy, porto-systemic...

Antihypertensive

In the 1970s Yamagami et al observed a deficiency in CoQ10 in patients with hypertension (1975, 1976) and suggested that correction of the deficiency could result in hypertensive effects. Small studies were initially conducted with hypertensive patients identified as CoQ10 deficient. Since then, significant antihypertensive activity has been observed in several clinical studies (Burke et al 2001, Digiesi et al 1994, Langsjoen et al 1994), however, not all have identified the subjects' baseline CoQ10 plasma levels and whether oral administration restored levels to within the normal range. It has been suggested that CoQ10 supplementation is associated with a decrease in total peripheral resistance, possibly because of action as an antagonist of vascular superoxide, either scavenging or suppressing its synthesis (McCarty 1999).

Drug therapy or lifestyle modification

The lifestyle modifications recommended by the JNC 7 were mostly nutritional, consisting of weight loss in the overweight, lowering of dietary sodium intake to less than 100 mmol day, modification of alcohol intake to, at most, two drinks per day, and maintenance of an adequate dietary intake of potassium, calcium, and magnesium 2 . The JNC 7 also recommended regular physical activity for all patients with hypertension who have no conditions that would make exercise contraindicated. There is little doubt that many lifestyle factors, such as dietary salt, alcohol intake, lack of exercise, and stress, can affect BP and contribute to hypertension. Conversely, it has been well documented that BP can be lowered by modifying lifestyle. The antihypertensive efficacy oflifestyle modification in four thorough meta-analyses ofa large number ofpatients has been reported 8-11 . Although the fall in BP may appear relatively small, it should not be forgotten that, in contrast to drug therapy,...

Adverse effects and tolerability

Most antihypertensive drugs have some adverse effects that can affect tolerability. For instance, the main adverse effect of dihydropyridine calcium antagonists is pedal edema 23 , which is dose dependent and more common in women than in men. In an overweight, middle-aged woman, calcium antagonist monotherapy will almost invariably trigger, or aggravate, pedal edema and make the patient unhappy with the selection of the initial antihypertensive drug. Of note, not all dihydropyridine calcium antagonists have an equal effect with regard to pedal edema. For a given fall in BP, lercanidipine, manidipine and lacidipine elicit less edema than do amlodipine and nifedipine. The great majority of patients with mild hypertension cannot be controlled with monotherapy, but need two or more drugs to lower BP into the target range. Monotherapy rarely lowers BP sufficiently, because it invariably triggers compensatory mechanisms that serve to maintain BP at its usual pretreat-ment level. Treatment...

When initial therapy is insufficient To uptitrate to substitute or to combine

One of the most common questions practicing physicians face after starting a patient on treatment with a given antihypertensive drug is how to proceed when BP remains elevated. That physicians are uneasy with this question is illustrated by the fact that patients are often treated for years with the same dose of the same drug or combination, despite the fact that BP is not at goal. Any excuses volunteered by the patient (ie, crowded parking garage, mother-in-law visiting) seem good enough to rationalize that day's high BP as an exception and delay further therapeutic intervention.

How aggressively should blood pressure be lowered

The VALUE study clearly established that patients whose BP was under control after 6 months had a much lower risk of heart attack and stroke than did patients whose BP remained elevated 32 . This appears to indicate that swift BP control should be achieved and argues against the old dictum of start low, go slow. It should be considered, however, that in the VALUE study most patients were taken off multiple drugs and were put on monotherapy (ie, valsartan 80 mg) for several months. Clearly, this is not the way a practicing physician would treat patients. In most placebo-controlled antihypertensive trials, the Kaplan-Meier curves of morbidity and mortality grow apart after 6 months to 1 year. It seems reasonable to treat elevated BP aggressively in a younger patient whose cardiovascular system can tolerate an abrupt decrease in BP. In such a patient, antihypertensive therapy may be initiated with two drugs, such as an ARB and a diuretic, or a calcium antagonist and an ACE inhibitor....

Blood pressure lowering in normotensive patients

The Framingham study has clearly documented that, even within the normo-tensive range, patients with higher BPs have a higher risk of cardiovascular morbidity than those who have an optimal BP 1 . This raises the question of whether one should consider antihypertensive therapy in normotensive patients. Indeed, several studies have shown that lowering BP in the so-called normotensive population reduces cardiovascular morbidity and mortality. This is particularly true for stroke but less so for coronary heart disease. Although it has been accepted that lipid lowering in high-risk patients is beneficial regardless of lipid levels, the same principle is still somewhat foreign with regard to antihypertensive therapy. In my opinion, some normotensive patients at high cardiovascular risk may benefit from antihypertensive therapy. In fact, the benefits of antihypertensive therapy in these normotensive patients will probably exceed those seen in mildly hypertensive patients without any...

Evidencebased versus eminencebased therapy

Eminence-based therapy can be defined as making the same mistakes with increasing confidence over an impressive number of years 36 . Numerous prospective, randomized large trials have taught us what is now defined as evidence-based medicine (EBM) in the treatment of hypertension. However, a critical analysis of these trials remains extremely important because they provide the results that should be translated into clinical practice. For instance, the SHEP program 18 is commonly used as EBM for the safety and efficacy of diuretics in patients with isolated systolic hypertension. Before applying this evidence to an individual patient, however, the physician should remember that out of 100 screened patients with isolated systolic hypertension only one was included in the SHEP study and 99 were excluded for one reason or another. Can the evidence derived from 1 of the population be extrapolated to the remaining 99 The application of published inclusion criteria from 13 randomized clinical...

Diuretics and diuretic combinations

Fixed combinations of a thiazide diuretic and a potassium-sparing drug are commonly used as initial therapy for the treatment of hypertension. In the USA, there are three such fixed combinations available (Figure 11). Of note, triamterene and amiloride have relatively little diuretic or antihypertensive effect, whereas spironolactone and eplerenone act synergistically on BP. ferred by the decrease in BP. In addition, the risk of sudden death has been shown to rise with increasing doses of thiazide diuretics and to be reduced with the addition of a potassium-sparing compound. In general, fixed diuretic combinations are well tolerated and have remarkably few adverse effects. In combinations containing high doses of ACE inhibitors or ARBs hyperkalemia is of concern in susceptible patients, such as patients with diabetes or chronic renal failure. In rare instances, triamterene has been associated with kidney stones. Spironolactone is known to cause gynecomastia, impotence, menstrual...

Antiadrenergic and diuretic combinations

Diuretic and antiadrenergic combinations were common a few years ago, but are sparingly used in this day and age. Most contain fairly high doses of diuretics and some have to be given twice a day (Figure 13). Antiadrenergic drugs, such as methyldopa, clonidine, guanabenz, and even reserpine, have a favorable effect on a variety of pathophysiologic findings of hypertensive cardiovascular disease. These drugs reduce LVH, vascular hypertrophy, vascular resistance, and proteinuria, maintain cardiac output, and preserve renal hemodynamics. Even in patients with metabolic syndrome, antiadrenergic drugs exert a favorable effect on abnormal endocrine metabolic findings. In low doses, these drugs are reasonably well tolerated. Unfortunately, at the dose at which their antihypertensive efficacy equals that of other drug classes, their adverse-effect profile often prohibits their use in patients with mild hypertension. The most common adverse effects are fatigue, depression, sexual dysfunction...

Calcium antagonist and diuretic combinations

Calcium antagonists, particularly the dihydropyridines, commonly cause pedal edema. Most physicians' knee jerk response when presented with pedal edema is to add a diuretic. However, the pedal edema seen with the use of calcium antagonists is not caused by salt and water retention, but by intra-capillary hypertension secondary to the diminished arteriolar vasoconstriction with upright posture. Thus, this form of vasodilatory edema responds poorly to diuretic therapy, but very well to blockade of the RAS, either by an ACE inhibitor or an ARB. The fact that no fixed combination of a calcium antagonist and a diuretic is available indicates that pharmaceutical companies seem to be reluctant, for good reason or not, to tackle this issue.

Calcium antagonist and betablocker combinations

Calcium antagonists can be counteracted by the addition of a beta-blocker. Therefore, the combination of these two drug classes seems useful, not only in hypertension but also in patients with stable coronary disease. Both beta-blockers and dihydropyridine calcium antagonists have benefits in patients with coronary disease the negative effects of the calcium antagonist can be diminished by concomitant beta-blockade. In one morbidity and mortality study, such a combination was shown to be beneficial in patients with coronary heart disease. In contrast to dihydropyridine calcium antagonists, verapamil and diltiazem should not be combined with beta-blockers this is because of additive effects on sinus node and atrioventricular conduction.

Betablockers with either ACE inhibitors or ARBs

No fixed combination is available of a beta-blocker with either an ACE inhibitor or an ARB, indicating that there is little interest in developing such a combination. Indeed, there are some reasons to suspect that such a combination may have a distinctly less-than-additive effect on BP this viewpoint is supported by the ALLHAT study 43 . Although beta-blockers have been available for the treatment of hypertension for a number of decades, the mechanism of their antihypertensive effect is still ill understood. To some extent, it seems to be related to a decrease in renin secretion from juxtaglomerular cells. A decrease in renin secretion means that there is less angiotensin I available for conversion to angiotensin II. As a consequence, an ACE inhibitor will have less substrate to work on, which, obviously, would translate into a diminished efficacy. The same reasoning holds true for the ARB, as beta-blockade will diminish the levels of circulating angiotensin II, and so the ARB will...

Direct renin inhibitor and diuretic combinations

There are several reasons why the combination of an ACE inhibitor and an ARB should have some additional effects with regard to both BP and hypertensive target organ disease. Indeed, several small studies have demonstrated an additive effect ofthis combination, not so much on BP, but for microproteinuria and also for hemodynamic features in patients with heart failure. In the Candesartan and Lisinopril Microalbuminuria (CALM) study, for instance, 20 mg of lisinopril was combined with 16 mg of candesartan 49 . This combination led to a further decrease in BP and a further reduction in microproteinuria in patients with diabetes and hypertension. However, we cannot possibly conclude from this and other similar studies that the combination had an additive effect because only relatively small doses of the two drug classes were added to each other. A factorial design study, combining increasing doses of losartan with increasing doses of enalapril in a substantial number of patients, showed...

Synergism of combination therapy

The most common adverse effect of the dihydropyridine calcium antagonist is pedal edema, which is clearly dose dependent. Pedal edema is seen in about 5 of patients on amlodipine 5 mg, in 25 of patients on amlodipine 10 mg, and in over 80 of patients on amlodipine 20 mg (which is above the FDA-approved dose). Pedal edema is predominantly caused by arteriolar dilatation that increases intracapillary pressure (capillary hypertension) and thereby causes fluid exudation into the interstitium (Figure 20). Any drug that causes venular dilatation may diminish capillary hypertension and decrease pedal edema. Both ACE inhibitors and ARBs are known to have this effect. Thus, unsurprisingly, pedal edema was shown to dissipate when benazepril was added to amlodipine in several well-documented studies (Figure 21). In the Lotrel Gauging Improved Control (LOGIC) trial 55 , patients were included on the basis of pedal edema. After 4 weeks, pedal edema diminished significantly in over 80 of patients...

When not to use fixed combination therapy

As attractive as fixed combinations are, and although many patients benefit from them, it should be remembered that not every patient with mild to moderately severe hypertension is a candidate for such therapy. Patients need to be thoroughly informed that they are taking a combination of drugs, such as an ARB and a diuretic, in the same pill. Commonly, the labeling of fixed combinations may be deceptive to patients and physicians. In numerous instances, patients have been given inappropriate medication because the physician was not familiar with the ingredients of a fixed Occasionally, some therapeutic flexibility is lost when a patient is taking a fixed combination drug, and this could be a disadvantage in certain clinical situations. For instance, the need for diuresis may vary a great deal depending on the dietary salt intake. This is particularly true in disease states that are susceptible to sudden unexpected changes such as heart failure or severe coronary artery disease....

Metabolic syndrome and newonset diabetes

The prevalence of obesity, the metabolic syndrome, and frank diabetes has doubled in the USA over the past decade. With more than 60 of adults and 30 of children classified as overweight or obese, the USA has become the fattest nation on earth. Approximately half of all overweight individuals have insulin resistance and 25 of the population of the USA has multiple risk factors for cardiovascular disease. Cardiovascular risk factors tend to cluster, and insulin resistance or diabetes, obesity, and hypertension are common in the same patient. Ever since the pioneering observation of Colin Dollery's team 59,60 more than 20 years ago, a variety of studies have documented that long-term diuretic therapy, particularly when combined with a beta-blocker, diminishes glucose tolerance and increases the risk of new-onset diabetes. Conversely, as has been revealed in more recent trials, treatment with antihypertensive drugs, such as blockers of the RAS or calcium antagonists, appears to decrease...

Hypertensive heart disease coronary artery disease and heart failure

ACE inhibitors, and possibly ARBs, are the best monotherapeutic way to reduce LVH, followed by calcium antagonists, diuretics, and, distinctly less effective, beta-blockers. ACE inhibitors are also a cornerstone in the management of the patient with heart failure and the post-MI patient. ACE inhibitors, and possibly ARBs, are probably the best choice for initial therapy in the patient with hypertensive heart disease. Beta-blockers have morbidity and mortality benefits in the post-MI patient but do not have any primary cardioprotective effects in hypertension. Low-dose beta-blockade is also very useful in patients with heart failure. As shown in the Val-HeFT study, the combination of an ACE inhibitor and an ARB may benefit certain patients with heart failure 45 . Morbidity and mortality benefits of diuretics have never been documented in heart failure. However, as in any other edematous state, diuretics will bring symptomatic relief. Calcium antagonists are useful in the patient with...

The prothrombotic paradox

Hypertension by definition is a hemodynamic disorder and, as such, exposes the arterial tree to increased pulsatile stress. Paradoxically, however, most major complications of longstanding hypertension (ie, heart attack and strokes) are thrombotic rather than hemorrhagic, referred to as the so-called thrombotic paradox of hypertension. Virchow suggested three components facilitating thrombus formation (Virchow's triad) For thromboembolic events to take place, all the components of Virchow's triad must be fulfilled 70 . In hypertensive individuals, abnormalities in blood flow have been well recognized. Hypertension has also been associated with endothelial damage or dysfunction 71 and a hypercoagulable state 70 . This prothrombotic state could be the result of chronic low-grade inflammation. Chronic shear stress can lead to remodeling of the vascular endothelium, turning it from an anticoagulant into a procoagulant surface. The mechanisms leading to endothelial dysfunction are...

The I want to do it the natural way patient

Not uncommonly, the physician is challenged by a patient who insists on doing it his or her own natural way. Even though most physicians recognize that this endeavor will be futile, an enthusiastic patient should be encouraged to exercise regularly, lose weight and follow a healthy sodium-restricted diet. The only harm that can come from this is that BP remains elevated and the cardiovascular system of the patient continues to be exposed to a high pressure load. It is therefore important to monitor these patients carefully. In this context, the 24-hour ambulatory BP monitor is very useful and allows you to confront the patient with the before and after BP pattern. Very often, there is little difference between the two, and the evidence suffices to motivate the patient to start antihypertensive therapy. Home BP monitoring is less objective because patients have a tendency to cherry pick good BP readings, record these and then bring them to their physician. A good part of white-coat...

The nothing worksallergic to everything patient

These patients are also called heart sink patients because the physician's heart sinks whenever they show up in the waiting room. What, perhaps, is most important with patients like this is to try to sort the wheat from the chaff. Thus, a very thorough, detailed history regarding previous medications, duration of use and reasons for discontinuation can often provide an astonishing insight. If a patient who is allergic to everything lists among these allergies a dry cough with certain drugs, or pedal edema with others, the physician has to take the reported adverse events more seriously and try to find a drug that the patient can tolerate. Commonly, the patient is willing to be rechallenged when the options are carefully explained. Using low-dose aspirin, and even iron supplements, can mitigate the cough seen with ACE inhibitors. Consider that some patients may be perfectly willing to continue with the ACE inhibitor, despite the persistence of a low-grade cough. Similarly, a patient...

Dual calcium channel blockade

Occasionally, the combination of a dihydropyridine and a nondihydropy-ridine calcium antagonist may be considered. There is some evidence of an additive effect of this combination and it seems, in general, to be well tolerated 102 . Pedal edema is not aggravated by the addition of a nondihydro-pyridine calcium antagonist to a dihydropyridine agent. The combination may be particularly useful in patients with renal failure and hyperkalemia in whom RAS blockade has become relatively contraindicated. However, it must be emphasized that there are only a very few studies in a small number of patients reporting antihypertensive efficacy. Thus, there is surrogate end point evidence only, and no data indicate that the combination reduces morbidity and mortality.

Dual RAS blockade Blood pressure

Most BP studies showed a small additional drop in systolic and diastolic pressure when an ARB was added to an ACE inhibitor, and vice versa, regardless of the dose level of the first drug. A thorough systematic review and metaanalysis assessed 14 BP studies in hypertensive patients in which patients were evaluated by 24-hour ambulatory BP monitoring 91 . The authors found that the combination of an ACE inhibitor and an ARB reduced BP by an average of 4 3 mmHg when compared with monotherapy. The incremental fall in BP with dual RAS blockade compared with that seen with monotherapy is certainly only a fraction of what is commonly observed with the addition of either a thiazide or calcium antagonist. In conclusion, the recent ONTARGET study data 94 have shattered the halo of dual RAS blockade not only for hypertension but also for nephroprotec-tion. The meta-analysis of Lakhdar et al. 98 has cast doubts on the safety of dual RAS blockade in patients with left ventricular dysfunction. In...

Betablocker and diuretic combinations

Both beta-blockers and diuretics have been documented to lower BP. The Fifth Report of the JNC, released in 1992, labeled diuretics and beta-blockers as the preferred agents for initial therapy of hypertension. This stand was somewhat softened in 1997 by the JNC VI 39 . Nevertheless, the JNC VI still recommended diuretics and beta-blockers as first-line therapy for uncomplicated hypertension because these were, supposedly, the only two drug classes for which a reduction in morbidity or mortality was shown in hypertension. While this is true for diuretics, it is incorrect for beta-blockers. There is no study in which beta-blockers have been shown to reduce morbidity and mortality in hypertension when compared with placebo. In the large UK Medical Research Council (MRC) study, in patients younger than 65 years of age, diuretics reduced the risk of stroke between two and four times better than beta-blockers, despite an equal fall in BP 40 . One can also estimate from this study that, in...

Pill burden and compliance

Experienced clinicians have long recognized that the patient's compliance with a given treatment regimen depends, to some extent, on its complexity. As a simple rule, the more pills a patient has to take the sicker he or she feels and the lesser the compliance. This is particularly true when the treatment regimen requires dosing several times a day. Fixed combinations, therefore, have a distinct advantage. Putting two or three drugs into the same pill may reduce side effects thus, the patient feels less sick and compliance may be enhanced. Indeed, a meta-analysis of four hypertension studies documented a 24 decreased risk of medication noncompliance with a fixed-drug combination regimen when compared with the same medications taken in two separate pills (Figure 24) 58 . Effect of fixed-dose combination vs free-drug combination on the risk of medication noncompliance in cohort with hypertension Hypertension cohort Figure 24 Effect of fixed-dose combination vs free-drug combination on...

Erectile and orgasmic dysfunction

Long-standing, untreated hypertension is well known to have a negative impact on sexual function and can lead to complete impotence. Unfortunately, antihypertensive drugs still have a bad reputation with regard to erectile function. Some of the older antihypertensive drugs, such as resurpine and guanethidine, have a well-known negative effect on erectile and orgasmic function. Diuretics, beta-blockers, and antiadrenergic drugs, as well as alpha-blockers, diminish erectile function. Failure to ejaculate, or even retrograde ejaculation into the bladder, may occur with some antiadrenergic drugs. In women, diuretics and certain antiadrenergic drugs may interfere with lubrication. Beta-blockers are known to cause orgasmic dysfunction in women and men alike. BP lowering (by any drug) may by itself, at least initially, have a slight negative impact on erectile function. However, the body fairly rapidly adjusts to the lower BP level and, with modern antihypertensive therapy (calcium...

To twofer or not to twofer

The two-for-one therapeutic concept or, namely, to treat two conditions with one drug, is attractive for a variety of reasons among these are a reduction in adverse effects, the number of pills, and cost. Physicians and patients, therefore, like the twofer and use it whenever possible. Unfortunately, the concept of the twofer has never been vigorously tested. Ironclad trials have shown that beta-blockers confer secondary cardioprotection in patients who have suffered an acute MI 26 . However, beta-blockers have no primary cardioprotective effect in hypertension, and there are no studies showing that the reduction of BP by beta-blockers confers any additional benefit in the post-MI patient with hypertension, as would be expected from the fact that two risk factors are modified by one and the same drug. In the post-MI patient, it seems more logical to use a beta-blocker for secondary cardioprotection and to treat hypertension separately by adding another drug class that has been shown...

The J curve

Much ink has been expended on whether the relationship between BP and cardiovascular morbidity and mortality follows a J-shaped pattern. Conceivably, as BP is lowered, morbidity and mortality diminish, but, clearly, there is a point at which further lowering leads to the under-perfusion of vital organs and, thereby, will increase morbidity and mortality. Thus, it stands to reason that a J curve has to exist. However, it is not so clear whether the nadir of the J curve is anywhere near the target range of the systolic or diastolic pressure. Most studies have shown that for both cerebrovascular and renal disease there seems to be no J-shaped curve with regard to systolic or diastolic pressure. However, numerous studies have shown that the issue is different for diastolic pressure and coronary artery disease. The myocardium is perfused almost exclusively during diastole and, therefore, diastolic pressure is critically important for coronary perfusion. Most studies that have examined the...

Lowsalt diet

Lifestyle modifications can profoundly affect antihypertensive therapy for instance, a low sodium diet will decrease potassium excretion in a patient who is on a diuretic, as less sodium is available at the level of the distal tubule for exchange against potassium. Thus, a low-sodium diet will prevent total body potassium depletion and, thereby, may enhance the morbidity and mortality benefits of diuretic therapy. In the Systolic Hypertension in the Elderly (SHEP) study 12 , patients who had hypokalemia showed no reduction in heart attacks and strokes when compared with patients whose potassium was normal, despite a similar fall in BP. In addition, by stimulating the renin-angiotensin-aldosterone system (RAS), a low-sodium diet also enhances the antihypertensive efficacy of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). Not only is BP lowered more efficiently with ACE inhibitors and ARBs in a patient on a low-sodium diet, but also the...

Outcome

The drug class best documented to reduce morbidity and mortality in hypertension, when compared with either placebo or active therapy, remains the thiazide diuretics, specifically chlorthalidone. In all diuretic-based trials, other antihypertensive drug classes, such as beta-blockers and antiadrenergics, have been added to titrate BP to target. However, although the addition of these drugs to diuretic therapy adds to the antihypertensive efficacy (and therefore, seemingly has a beneficial effect on the surrogate end point), they have not been shown to enhance the benefit of diuretics on morbidity and mortality (the real end point). Thus, it cannot be concluded that the addition of these drugs is beneficial. Even shakier is the conclusion that these drugs by themselves (when not added to diuretics) will be beneficial. In contrast to chlorthalidone therapy, treating hypertension with beta-blockers, for instance, has not been shown to offer any primary cardioprotective or...

Uptitration

Uptitration of the original drug to double the dosage is reasonable only if distinctly enhanced antihypertensive efficacy has been documented and the cost is not prohibitive. Most antihypertensive drugs have a rather shallow dose-response curve and increasing the dose has little additional effect on BP. For instance, doubling the starting dose oflosartan from 50 mg to 100 mg, has not been shown to increase antihypertensive efficacy. In a situation like this, it is more rational to combine a low dose of a diuretic with the ARB. Indeed, the combination has been shown to lower BP better than a higher dose of losartan monotherapy 29 . In contrast, additional antihypertensive efficacy can be gained using amlodipine when the starting dose is doubled from 5 mg to 10 mg furthermore, the cost of the 10 mg dose is less than that of two 5 mg doses. However, the incidence of pedal edema also increases with the higher dose of amlodipine. Pedal edema is a well-known, dose-dependent side effect...

Substitution

Substituting a different antihypertensive drug should be considered if there is no antihypertensive efficacy with a reasonable dose, as is occasionally seen with beta-blockers, ACE inhibitors or ARBs in black patients, or if there are intolerable side effects, such as angioedema. Fortunately, most modern antihypertensive drugs are well tolerated and serious adverse effects are few. Some patients are even willing to put up with a scratchy throat or low-grade cough associated with ACE inhibitors, or the pedal edema associated with calcium antagonists, once they know that these are harmless conditions related to the drugs.

Drug interactions

Drug-drug interactions have become increasingly important over the past few decades because, in most cases, two or more drugs are needed to get BP to goal, and also because hypertension is rarely an isolated disorder and concomitant risk factors or diseases may require multiple drugs that can, potentially, interact with a given antihypertensive agent. It is almost impossible for the practicing physician to remember all potential interactions, some of which can lead to severe and even fatal adverse events. Fortunately, computer programs, such as Epocrates, have become very useful in identifying the most important interactions. Of particular interest is the long list of drugs or agents that interfere with the cytochrome P450 system. An example of such an agent is grapefruit juice, which has been shown to increase plasma concentration of certain calcium antagonists and statins. All other factors being equal (which they rarely are), the practicing physician is advised to preferentially...

Atrial fibrillation

Atrial fibrillation is an under-recognized complication of long-standing hypertension and increases the likelihood of morbidity and mortality - at least doubling the risk for cardiovascular death or stroke. The main factors predicting development of atrial fibrillation are age, male sex, severity of hypertension, obesity, and presence of LVH on electrocardiogram. Some findings suggest that the choice of BP-lowering treatment could reduce the risk of developing atrial fibrillation. Notably, treatment that inhibits the RAS might be more likely to prevent new-onset atrial fibrillation than other antihypertensitive drug classes. The mechanism for this benefit is unclear but could be, at least in part, dependent on favorable structural regression of left ventricular mass and a reduction in left atrial size.

Hyperlipidemia

The effects of antihypertensive agents on lipids Antihypertensive agent Figure 28 The effects of antihypertensive agents on lipids. increase decrease , uncertain ACE, angiotensin-converting inhibitor HDL, high-density lipoprotein component NC, no change TC, total cholesterol TG, triglyceride. Adapted from Cohn etal. 45 . Figure 28 The effects of antihypertensive agents on lipids. increase decrease , uncertain ACE, angiotensin-converting inhibitor HDL, high-density lipoprotein component NC, no change TC, total cholesterol TG, triglyceride. Adapted from Cohn etal. 45 .

Dementia

Dementia is a major concern in the elderly hypertensive patient. Patients with hypertension have been shown to suffer cognitive dysfunction and dementia of all types more commonly than do normotensive subjects. The effects of antihypertensive therapy on dementia are not well documented. However, provocative findings from the Syst-Eur trial have shown that dihydropyridine calcium antagonists reduce dementia by as much as 55 (Figure 29) 69 . In some, but not all, studies, statins also showed a beneficial effect on dementia. Although this remains to be confirmed, it nevertheless makes calcium antagonists, possibly in combination with a statin, an attractive choice for the elderly patient. More recently ARBs and lipophilic ACE inhibitors have also been reported to reduce the risk of dementia. Figure 29 Syst-Eur Effect of calcium antagonist treatment on dementia. Syst-Eur, Systolic Hypertension in Europe. Reproduced from Forette etal. 69 . Figure 29 Syst-Eur Effect of calcium antagonist...

Nephroprotection

In the patient with diabetic hypertensive renal disease, blockade of the RAS has been shown to be nephroprotective that is, to diminish proteinuria and slow down the decline in renal function. In type 1 diabetes, most proteinuria studies have used ACE inhibitors, whereas, for type 2 diabetes, ARBs have mostly been used. However, the American Diabetes Association (ADA) have concluded that the evidence was sufficient to state that both drug classes, ACE inhibitors and ARBs, are indicated for nephroprotection in susceptible patients. Although neither ACE inhibitors nor ARBs are labeled for use to decrease proteinuria albuminuria or to exert any nephroprotective effect, some studies show that nondihydropyridine calcium antagonists, such as diltiazem and verapamil, reduce urinary protein excretion more than the dihydropyridines, specifically nifedipine. A systematic review by Bakris et al. showed a significantly greater reduction of proteinuria with the nondihydropyridine derivatives than...

Black patients

Hypertension is more common in black than in white patients, and its course is distinctly more severe. Black patients have a three-times higher mortality rate from cardiovascular disease than do white patients, and their risk of end-stage renal disease is several times greater. These simple facts indicate that cardiovascular diseases, such as hypertension, hyperlipidemia, and diabetes, should be treated most aggressively in the black population. However, the impediments to aggressive therapy in this population are numerous and range from relative inefficacy of certain antihypertensive drug classes and ill-perceived adverse effects, to socioeconomic factors. No racial difference in antihypertensive efficacy has been documented for calcium antagonists and diuretics. In a meta-analysis, calcium antagonists were the only drug class showing efficacy in all BP strata 85 . In contrast, ACE inhibitors and ARBs, at a given dose, have distinctly less effect on BP in black patients than in white...

Alcohol abuse

It stimulates the sympathetic nervous system, as well as the RAS, and may cause thirst and dehydration, which often are counteracted by excessive salt and water retention. Chronic alcohol abuse is not an uncommon cause of seemingly refractory hypertension. Calcium antagonists are the most efficient first-line therapy in the alcoholic hypertensive patient. If combination therapy is needed, a beta-blocker could be useful because it diminishes the activity of the sympathetic nervous system. ACE inhibitors are somewhat less efficacious because of alcohol-associated fluctuations in fluid volume state. Diuretics are often relatively contraindicated because they may trigger an attack of gout in susceptible patients. Not uncommonly, allopuritol or febroxustat may have given to control hyperuricemix before diuretic therapy can be initiated.

Outcome trials

The ASCOT study further attests to the benefit ofthe combination of an ACE inhibitor with a dihydropyridine calcium antagonist 54 . ASCOT was designed to compare the effect of the standard antihypertensive regimen (a beta-blocker and a diuretic) with that of a more contemporary regimen (calcium antagonist and an ACE inhibitor) on coronary artery disease. In the randomized, double-blind Avoiding Cardiovascular events through Combination therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial, 11,506 patients with hypertension who were at high risk for cardiovascular events were randomized to either benazepril plus amlodipine or benazepril plus HCTZ 57 . The study was terminated early because there was a significant 20 reduction in primary outcome events (cardiovascular death, nonfatal MI, nonfatal stroke, hospitalization for angina, resuscitation after sudden cardiac arrest, and coronary revascularization) in the benazepril amlodipine arm when compared with the...

Combination therapy

Cardiovascular risk factors, such as hypertension, diabetes, and hyperlipidemia, as well as cardiovascular disease states, such as coronary heart disease, heart failure, and certain arrhythmias, are amenable to a variety of therapeutic interventions that have been proven to be beneficial. However, the combination ofthese interventions has rarely been studied in a rigorous scientific way. No data are available that analyze the relevant contribution of each drug to the overall outcome in a given patient. Progress has been made in identifying and understanding some drug interactions, allowing the rational combination of certain drugs in a given patient. Drug combinations may be rational for several reasons (Figure 10) Drug A is effective but has an adverse effect or elicits a risk that can be antagonized or abolished by Drug B Drug B may or may not have an effect on a surrogate end point. A classic example of this scenario is the use of a potassium-sparing diuretic, such as triamterene,...

Stepdown therapy

Should the patient be successful in modifying their lifestyle weeks or months after BP is controlled with antihypertensive therapy, it is reasonable to consider using the step-down approach to decrease the dose, or number, of antihypertensive drugs taken, or even to stop therapy completely. Lowering BP over the long term by using antihypertensive drugs such as ACE inhibitors, ARBs and calcium antagonists, will reduce vascular hypertrophy and target organ disease and will restore endothelial function. After antihypertensive therapy is stopped in a successfully treated patient, it is often possible for that patient to stay off therapy for months, even years, provided that they maintain reasonable lifestyle modifications and monitor their BP regularly 16 . Again, lifestyle modification should not be considered as a substitute for drug therapy in hypertension, but rather should be complementary to drug therapy.

Introduction Normal Adolescent Growth and Diets

Adolescence is a unique time of rapid growth, with half of eventual adult weight and 45 of peak bone mass accumulated during adolescence. Adolescence is a time when peak physical muscular development and exercise performance is reached. However, adolescent diets are often notorious for their reliance on snacks and 'junk foods' that are high in calories, sugar, salt, and saturated fat, which could provide extra energy for high-activity demands of teenagers, but often risk becoming part of bad habits leading to obesity and increased risk of atherosclerotic heart disease in later life. Although most studies have been on older subjects, it is now clear that many Western diseases, especially heart disease, stroke, diabetes, hypertension, and many cancers, are diet related, and that diets high in saturated fat and low in fruits, vegetables, and fiber may increase risks of heart disease.

Effects of Alcohol on the Cardiovascular System

Alcohol affects both the heart and the peripheral vasculature. Acutely, alcohol causes peripheral vasodilatation, giving a false sensation of warmth that can be dangerous. Heat loss is rapid in cold weather or when swimming, but reduced awareness leaves people vulnerable to hypothermia. The main adverse effect of acute alcohol on the cardiovascular system is the induction of arrhythmias. These are often harmless and experienced as palpitations but can rarely be fatal. Chronic ethanol consumption can cause systemic hypertension and

The unique efficacy of dryneedling acupuncture in sports medicine

Some athletes resort to drugs to achieve better performance, and they risk paying a high price for this in the future. Anabolic steroids greatly increase the risk of cardiovascular damage, heart attack, and stroke, because they cause hypertension, a decrease in high-density blood lipoproteins, and an increase in low-density lipoproteins. The consumption of male sex hormones by male athletes can decrease testicular function, causing both lowered sperm formation and a reduction in the natural secretion of testosterone. The use of amphetamines and cocaine

Evidence Report Endorsements

NATIONAL HIGH BLOOD PRESSURE EDUCATION PROGRAM (NHBPEP) Lee A. Green, M.D., M.P.H., American Academy of Family Physicians, Jack P. Whisnant, M.D., American Academy of Neurology, Barry N. Hyman, M.D., F.A.C.P., American Academy of Ophthalmology, Lisa Mustone-Alexander, M.P.H., P.A., American Academy of Physician Assistants, Henry Guevara, B.S.N., R.N., C.O.H.N.-S., American Association of Occupational Health Nurses, Edward D. Frohlich, M.D., American College of Cardiology, Sheldon G. Sheps, M.D., American College of Chest Physicians, Ron Stout, M.D., American College of Occupational and Environmental Medicine, Jerome D. Cohen, M.D., American College of Physicians, Carlos Vallbona, M.D., American College of Preventive Medicine, James R. Sowers, M.D., American Diabetes Association, Inc., Mary C. Winston, Ed.D., R.D., American Dietetic Association, Daniel W Jones, M.D., American Heart Association, Roxane Spitzer, Ph.D., F.A.A.N., American Hospital Association, Nancy Houston Miller,...

Alcoholic Liver Disease

Alcoholic liver disease is among the top ten causes of mortality in the US with somewhat higher mortality rates in western European countries where wine is considered a dietary staple, and is a leading cause of death in Russia. Among the three stages of alcoholic liver disease, fatty liver is related to the acute effects of alcohol on hepatic lipid metabolism and is completely reversible. By contrast, alcoholic hepatitis usually occurs after a decade or more of chronic drinking, is associated with inflammation of the liver and necrosis of liver cells, and carries about a 40 mortality risk for each hospitalization. Alcoholic cirrhosis represents irreversible scarring of the liver with loss of liver cells, and may be associated with alcoholic hepatitis. The scarring process greatly alters the circulation of blood through the liver and is associated with increased blood pressure in the portal (visceral) circulation and shunting of blood flow away from the liver and through other organs...

Activities Indian Gum Arabic Tree

Alexiteric (f KAB) Algicide (1 ZUL) Amebicide (1 ZUL) Analgesic (1 X8982438) Anthelmintic (f KAB) Antiaggregant (1 X9251908) Anticarcinogenic (1 WO3 X12616620) Antiedemic (1 X8982438) Antihepatitic (1 PR14 510) Antihistaminic (1 ZUL) AntiHIV (1 X10189947) Antihypertensive (1 X10594935) Anti-inflammatory (f1 X8982438) Antimalarial (1 X10479756) Antimutagenic (1 WO3 X12616620 X11850969) Antiplasmodial (1 X10479756) Antiplatelet (1 X9251908) Antioxidant (1 X11837686) Antiseptic (1 WO3) Antispasmodic (1 X10594935) Antitussive (f BIB) Aphrodisiac (f KAB MPI ZUL) Astringent (f GMH PH2 SUW) Bactericide (1 ZUL X15476301) Calcium-Antagonist (1 X9251908) Chemopreventive (1 X11850969) Decongestant (f BIB EB22 173) Demulcent (f BIB DEP SUW) Expectorant (f KAB MPI

Indications Indian Gum Arabic Tree

(f KAB WO3) Burn (f SKJ WO3) Cancer (f BIB JLH) Cancer, ear (f JLH) Cancer, eye (f JLH) Cancer, liver (f JLH) Cancer, spleen (f JLH) Cancer, testes (f JLH) Cataract (f GHA) Catarrh (f GHA HH2) Childbirth (f DEP) Chill (f ZUL) Cholecystosis (f BIB EB22 173) Cholera (f SKJ WO3) Cold (f GHA) Colic (f KAB) Condyloma (f BIB) Congestion (f BIB) Conjunctivosis (f DEP NAD) Cough (f DEP KAB NAD) Cramp (f BOU) Cystosis (f DEP) Dermatosis (f BOU WO3) Diabetes (f1 BOU DEP GHA SUW WO3 ZUL) Diarrhea (f GHA GMH PH2 SUW) Dysentery (f BIB DEP SUW) Dyslactea (1 X15283686) Dyspepsia (f ZUL) Dysuria (f KAB) Edema (1 X8982438) Enterosis (f1 DEP X15476301) Fever (f BIB BOU UPW) Flu (1 FNF) Fracture (f KAB) Fungus (1 WO3) Gastrosis (f DEP) Gingivosis (f BOU DEP PH2) Gonorrhea (f1 DEP KAB ZUL) Hemorrhoid (f BIB KAB PH2) Hepatosis (f1 BIB WO3 PR14 510 X11054840) High Blood Pressure (f1 BOU ZUL) HIV (1 X10189947) Hypersalivation (f DEP) Impotence (f NAD UPW) Induration (f BIB JLH) Infection (1 WO3 ZUL...

Advantages of Weight Loss

The recommendation to treat overweight and obesity is based not only on evidence that relates obesity to increased mortality but also on RCT evidence that weight loss reduces risk factors for disease. Thus, weight loss may not only help control diseases worsened by obesity, it may also help decrease the likelihood of developing these diseases. The panel reviewed RCT evidence to determine the effect of weight loss on blood pressure and hypertension, serum plasma lipid concentrations, and fasting blood glucose and fasting insulin. Recommendations focusing on

Recommending Psychodynamic Treatment of Depression and Possible Adjunctive Use of Medication

One helpful model uses hypertension as an analogue for depression. Stress, poor diet, overweight, and physiological propensities can all contribute to hypertension. Changes in the first of those three characteristics can lead to decreases in blood pressure and may obviate the need for medication. However, in some patients these interventions would be inadequate. If blood pressure is too high, it is more imminently dangerous, and medication should be given even while other changes are employed. In using this analogy with the patient, the therapist can describe psychotherapy for depression as equivalent to stress reduction and dietary changes. As with hypertension, in some patients the depression may respond to these interventions, whereas in other individuals medication may be needed. In some cases, the depression may be highly disruptive to functioning or even dangerous, requiring medication more immediately.

General Dietary Influences

Folk beliefs and remedies have also been passed down through generations, and they can still be observed today. The majority of African-American beliefs surrounding food concern the medicinal uses of various foods. For example, yellow root tea is believed to cure illness and lower blood sugar. The bitter yellow root contains the antihist-amine berberine and may cause mild low blood pressure. One of the most popular folk beliefs is that excess blood will travel to the head when one eats large amounts of pork, thereby causing hypertension. However, it is not the fresh pork that should be blamed for this rise in blood pressure, but the salt-cured pork products that are commonly eaten. Today, folk beliefs and remedies are most often held in high regard and practiced by the elder and more traditional members of the population. hypertension high blood pressure

Personal beliefs and treatment selection

Extensive research has found that personal beliefs can predict a range of outcomes, including quality of life, help-seeking behaviour and treatment adherence 16-18 . These beliefs have also been shown to affect treatment choice, mainly by way of selecting between conventional treatment and complementary and alternative medicines (CAM) for conditions, such as chronic pain, hypertension, and both localised and advanced prostate cancer 19-22 . These studies reported that patients who used CAM were more likely to hold negative beliefs about their illness (i. e. , that their illness was chronic and that they had little personal control over its management) and about conventional treatments (i. e. , believed the treatments would result in significant undesirable side-effects). In contrast, patients who were less likely to favour CAM held positive beliefs about their illness and its treatment (i. e. , believed the condition was not severe and would easily be controlled with conventional...

Effects of Socioeconomic Status Poverty and Health

Hypertension ( ) high blood pressure elevation of the pressure in the bloodstream maintained by the heart potassium. In 1989, 9.3 million of the black population (30.1 ) had incomes below the poverty level. Individuals who are economically disadvantaged may have no choice but to eat what is available at the lowest cost. In comparison to other races, African Americans experience high rates of obesity, hypertension, type II diabetes, and heart disease, which are all associated with an unhealthful diet. Obesity and hypertension are major causes of heart disease, diabetes, kidney disease, and certain cancers. African Americans experience disproportionately high rates of obesity and hypertension, compared to whites. High blood pressure and obesity have known links to poor diet and a lack of physical activity. In the United States, the prevalence of high blood pressure in African Americans is among the highest in the world. The alarming rates of increase of obesity and high blood pressure,...

Assessment Of Risk And Benefits

Subject selection also raises another issue. While some studies have unfairly singled out specific groups to bear the risks of research other studies have unjustifiably excluded groups of potential subjects. Besides depriving these potential subjects as individuals of the advantages of participation such as access to free medications or drugs that have clinical promise otherwise not available to them, exclusion can pose larger societal problems. If a group of subjects, such as fertile women, is systematically excluded from research, then information regarding the benefits and risks of the drugs tested are not available to those patients. For example, if a drug is only tested in postmenopausal women, even if it is found to be effective, it might not be used in pre-menopausal women because of the lack of data on safety and efficacy. Similarly, drugs for diseases such as hypertension have been shown to have differing efficacy depending on the race of the patient. If the clinical trial...

Methodology of integrated care

Of this popular concept has had such modest success when tested empirically. The authors of a major systematic review used the following definition ''An intervention designed to manage or prevent a chronic condition using a systematic approach to care and potentially employing multiple treatment modalities 12 . The concept is broader than that of interprofessional collaboration and case management, although it usually would involve those processes. Disease management plans emphasize the use of evidence-based practice guidelines. Prevention by screening, education, and monitoring are other key components. The U.S. Government has funded several demonstration disease management projects, but such projects seem premature further research on the conceptual model and its active ingredients is required 13 . In the U.S. Agency for Healthcare Research and Quality review on hypertension in the series ''Closing the Quality Gap,'' Walsh and colleagues 14 highlighted the evidence for the impact of...

Ephedra Ephedra SiNiCA

No published studies to date exist supporting the use of either ephedra or herbal caffeine individually for weight loss. One study of combination product Metabolife-356 (containing ma huang and guarana) has shown significant effects of a combination of these two herbs on body weight, with a loss of 4.0 kg in the treatment group vs. 0.8 kg in the placebo group (p < 0.001) (34). This study was limited owing to a small sample size, short-term outcomes, and a high dropout rate, primarily secondary to cardiac side effects (e.g., palpitations, hypertension, chest pain). Additionally, Metabolife-356 contans a number of other ingredients (including chromium picolinate), whose effects on weight loss are unclear. Another study by the same principal investigator looked at the effects of a combination of ma huang and kola nut on obese individuals. In this 6-month study, significant improvement in body weight and lipid profiles was seen (35). Blood pressure changes, increased heart rate,...

Supplementation During Pregnancy And Lactation

Prevention of pre-eclampsia Epidemiological evidence illustrates an inverse relationship between calcium status and the prevalence of pre-eclampsia (Frederick et al 2005, Lopez-Jaramillo et al 2001 ) and recent studies confirm abnormalities in markers of calcium metabolism and status in a pre-eclamptic population compared to controls, including low urinary and serum calcium levels (Ingec et al 2006, Sukonpan & Phupong 2005). Trials that included a 1996 meta-analysis of studies involving calcium and hypertension in pregnancy have shown a substantial mean reduction in both SBP and DBP, which was also confirmed by more recent reviews (Atallah et al 2002, B cher et al 1996). Positive correlations demonstrated in original smaller trials between calcium supplementation and reduced prevalence of pre-eclampsia, involving over 400 women, were put into question when the Calcium for Prevention of Pre-eclampsia study (CPEP), the largest trial to date, found no effect on the incidence or...

Sex Specific Measurements

Evidence from epidemiological studies indicates that a high waist circumference is associated with an increased risk for type 2 diabetes, dys-lipidemia, hypertension, and CVD. Therefore, the panel judged that sex-specific cutoffs for waist circumference can be used to identify increased risk associated with abdominal fat in adults with a BMI in the range of 25 to 34.9. These cutpoints can be applied to all adult ethnic or racial groups. On the other hand, if a

Some statistical issues

In the study of the alcohol-health relationship, it is sometimes difficult to differentiate a potential confounder from a mediator of a causal outcome. Examples of these factors are blood pressure, lipoproteins, hemostasis, perceived health status, and other indicators of current health. Control strategies in a data analysis initially should not include risk factors that might serve as potential mediators lying in the pathway between alcohol intake and outcome. Failing to control for confounders may inflate the potential benefit of alcohol intake. On the other hand, improper control for mediators may spuriously deflate the potential benefit of alcohol intake. If, for example, alcohol use increases hemorrhagic stroke risk through alcohol-induced hypertension alone, then control for blood pressure would produce a non-significant association between alcohol consumption and stroke.

Effectiveness studies

The earlier literature on disease management suggested a generally positive effect on disease control. Weingarten and colleagues 12 concluded that education, feedback, and reminders to service providers were associated with significant improvement in patient disease control, which may be mediated by the significant improvement in service provider adherence to guidelines. Education of patients, reminders to them, and financial incentives were associated with significant improvements in their disease control. The effects on patient outcome were small, except in the case of financial incentives where a larger effect size (0.44) was observed. The biggest impact of disease management was on patients who had depression, diabetes, or hypertension. The investigators were unable to compare interventions directly, mainly because many studies used more than one. Effect sizes were used as measures of difference the investigators warned that the clinical significance of such effect sizes may be...

What causes newonset GERD

In addition to weight, dietary issues, alcohol consumption, and anatomic factors, other medical conditions or medications for other problems can also lead to GERD symptoms. As they age, people tend to take more medications, and many medications can affect stomach acid production, the speed at which the stomach empties, and the ability of the LES to maintain its strength. High blood pressure medications called calcium channel blockers, such as nifedipine, can relax the LES. Drugs used for depression such as tricyclic antidepres-sants and drugs for psychosis impair stomach emptying.

Body Composition Applications During Growth

Fat or adipose tissue distribution is recognized as a risk factor for cardiovascular disease in both adults and children. An android or male fat pattern, with relatively greater fat in the upper body region, is associated with negative metabolic predictors whereas a gynoid or female fat pattern, with relatively greater fat in the hip and thigh areas, is associated with less metabolic risk. More and more studies are showing that the syndrome develops during childhood and is highly prevalent among overweight children and adolescents. While the concept of the metabolic syndrome referred initially to the presence of combined risk factors including VAT, dyslipidemia, hypertension, and insulin resistance in adults, it is now known to exist in children, especially where obesity and or higher levels of VAT are present. Although sex-specific patterns of fat distribution had previously been thought to emerge during puberty, sex and race differences in fat distribution are now known to exist in...

Has she had any problems with past pregnancies or births

Did she have high blood pressure If she had high blood pressure in a past pregnancy, she is likely to get it again . High blood pressure (see page 124) can be a sign of pre-eclampsia. Find out if the baby was born early (it is normal for early babies to be small). If the baby came on time, ask the mother if she had anemia, high blood pressure, or pre-eclampsia . Also ask if she had enough to eat, or if she smoked cigarettes or used drugs . Any of these things could have made the baby small Find out if the baby was sick or died . If some of her babies died, she may have a problem in her blood called Rh incompatibility (see page 504). Or the deaths could have had other causes Check the mother for high blood pressure (see page 122), diabetes (see page 115), anemia (see page 116), malnutrition (see page 117), and illness . These can all cause death in babies . Get medical advice.

Commission E Evaluation Methods And Criteria

Unapproved herbs with negative evaluations are those where no plausible evidence of efficacy was available or where safety concerns outweigh the potential benefits. Even products with minor risks were eliminated if they are not balanced by an acceptable benefit. Negative monographs were also given to herbs with no traditional usage or for which there are no clinical or pharmacological studies. Herbs that pose a risk were withdrawn immediately and those unapproved drugs that do not pose a health risk can be sold in the German market only until 2004. Unapproved drugs with specified risks include angelica seed (photosensitivity caused by coumarins), ergot (wide spectrum of activity), hound's-tongue (hepatotoxic pyrrolizidine alkaloids), nutmeg (psychoactive and abortifacient effect in large doses), lemongrass (toxic alveolitis), and yohimbine (anxiety hypertension and tachycardia).

Common Cooccurring Disorders And Symptoms

Bipolar disorder is also related to high rates of medical illnesses. Cardiovascular conditions such as heart disease, high blood pressure, and elevated cholesterol occur much more frequently in people with bipolar disorder than in the general population (Kupfer 2005). In addition, there is an increased risk for weight gain, often due to side effects of medications prescribed to treat mood fluctuations. Therefore, it's helpful for people with bipolar disorder to communicate regularly with their doctors to find a balance in their medications that allows for greater benefits (stable mood and fewer mood episodes) and fewer negative side effects, including weight gain. If you experience any of these

The clinical of VHL disease

Pheochromocytomas are endocrine neoplasias with intra- or extra-adrenal gland lesions that appear histologically as an expansion of large chromaffin positive cells, derived from neural crest cells (Lee et al., 2005). Seven to 18 of VHL patients are afflicted with pheochromocytomas (Crossey et al., 1994a Garcia et al., 1997). The absence or present of this phenotype will type the VHL into type 1or 2 (A,B,C), respectively (Woodward ER et al., 1997 Hofstra RMW et al., 1996). Untreated pheochromocytomas can result in hypertension and subsequent acute heart disease, brain edema, and stroke.

How much body fat is too much

High body fat levels have been linked to over 30 health problems including diabetes, high blood pressure, cardiovascular disease, cancer and osteoarthritis. Being categorized as clinically obese means that body fat is at such a level that these health problems become more of a concern. Men are considered borderline at 25 body fat and clinically obese at 30 , while women are borderline at 30 and clinically obese at 35 body fat.

Nutraceutical Properties Of Amaranth Proteins

Atively higher content of methionine and cysteine. Glutelins, on the contrary, contain higher levels of leucine, threonine, and histidine. Compared to legume grain albumins, which contain several antinutritional factors, the amaranth albumin fraction is considered safe. The amaranth albumin fraction is comparable with egg-white proteins and can be used as an egg substitute in different products. The 11S globulin fraction is rich in peptides of angiotensin-converting enzyme inhibitor, whereas the glutelin fraction contains antihypertensive activity as well as the anticarcinogenic lunasin-like peptide (Silva-Sanchez et al, 2008), thus signifying its nutraceutical properties.

Adverse Effects And Reactions Allergies And Toxicity

Betel nut chewing can produce significant cholinergic, neurological, cardiovascular, and gastrointestinal manifestations. High doses of its usage can cause hypercalcemia, hypokalemia, and metabolic alkalosis. Betel nut-induced extrapyramidal syndrome has been reported (Wikipedia, 2009). People should avoid betel nut if they have a known allergy to it signs of allergy include rash, itching, or difficulty in breathing. Betel nut can cause tremors, muscle stiffness, involuntary movements of the mouth and face, and seizures. Vision abnormalities can also occur. Betel nut usage has been associated with confusion, memory lapse, and anxiety. Acute effects of betel chewing include exacerbation of asthma, hypertension, and tachycardia (Wikipedia, 2009). Other effects, such as muscle stiffness and tremor, maybe increased when betel nut is used with drugs such as prochlorperazine, and blood pressure may rise to dangerously high levels if betel nut is taken with phenelzine (Natural Standard and...

Historical Cultivation And Usage

Swietenia macrophylla is an evergreen tree native to tropical America, Mexico, and South America. The trees regenerate naturally through seeds in their native countries, and grow luxuriantly under favorable conditions. The plant is well known for its fast growth and adaptability. This exotic was introduced into southern India and some other parts in 1872, using seeds obtained from Honduras, as an ornamental tree and for timber. The big-leaf mahogany has had long and successful history regarding the use of its woods and seeds. The wood is used as timber for many purposes it was so extensively used in tropical America, and exported, that its trade ended by the 1950s. The seeds have long been known for their ethono-medicinal significance against a number of diseases, being used for the treatment of leishmaniasis and abortion by an Amazonian Bolivian ethnic group, and as a folk medicine in Indonesia for the treatment of hypertension, diabetes, and malaria.

Rationale for Guidelines Development

An estimated 97 million adults in the United States are overweight or obese, 1 a condition that substantially raises their risk of morbidity from hypertension, 2-6 type 2 diabetes, 7-10 stroke, 11-13 gallbladder disease, 14, 15 osteoarthritis, 16-18 sleep apnea and respiratory problems, 19-21 and endometrial, breast, prostate, and colon cancers. 22-24 As a major contributor to preventive death in the United States today, 25 overweight and obesity pose a major public health challenge. Not only is the prevalence of this serious medical condition soaring among adults (between 1960 and 1994, overweight increased from 30.5 to 32 percent among adults ages 20 to 74 and obesity increased from 12.8 percent to 22.5 percent), but it is also affecting ever greater numbers of American youth and exacting a particularly harsh toll from low income women and minorities. The Third National Health and Nutrition Examination Survey (NHANES III) estimated that 13.7 percent of children and 11.5 percent of...

Clinical Manifestations

In CS, the most common type of vasculitis affects the large vessels and resembles Takayasu's arteritis. A large-sized vessel vasculitis, depending on the nature and severity of disease, may present with an asymptomatic bruit, intermittent limb claudication, severe hypertension, or constitutional complaints. Less frequently, CS may be associated with a

Reducing Blood Pressure Naturally

Reducing Blood Pressure Naturally

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