Beth A. Staffileno

Beyond Medications and Diet: Alternative Approaches to Lowering Blood Pressure: A Scientific Statement From the American Heart Association

Many antihypertensive medications and lifestyle changes are proven to reduce blood pressure. Over the past few decades, numerous additional modalities have been evaluated in regard to their potential blood pressure–lowering abilities. However, these nondietary, nondrug treatments, collectively called alternative approaches, have generally undergone fewer and less rigorous trials. This American Heart Association scientific statement aims to summarize the blood pressure–lowering efficacy of several alternative approaches and to provide a class of recommendation for their implementation in clinical practice based on the available level of evidence from the published literature. Among behavioral therapies, Transcendental Meditation (Class IIB, Level of Evidence B), other meditation techniques (Class III, Level of Evidence C), yoga (Class III, Level of Evidence C), other relaxation therapies (Class III, Level of Evidence B), and biofeedback approaches (Class IIB, Level of Evidence B) generally had modest, mixed, or no consistent evidence demonstrating their efficacy. Between the noninvasive procedures and devices evaluated, device-guided breathing (Class IIA, Level of Evidence B) had greater support than acupuncture (Class III, Level of Evidence B). Exercise-based regimens, including aerobic (Class I, Level of Evidence A), dynamic resistance (Class IIA, Level of Evidence B), and isometric handgrip (Class IIB, Level of Evidence C) modalities, had relatively stronger supporting evidence. It is the consensus of the writing group that it is reasonable for all individuals with blood pressure levels >120/80 mm Hg to consider trials of alternative approaches as adjuvant methods to help lower blood pressure when clinically appropriate. A suggested management algorithm is provided, along with recommendations for prioritizing the use of the individual approaches in clinical practice based on their level of evidence for blood pressure lowering, risk-to-benefit ratio, potential ancillary health benefits, and practicality in a real-world setting. Finally, recommendations for future research priorities are outlined.

Recruiting and retaining young, sedentary, hypertension-prone African American women in a physical activity intervention study.

African American women have a high prevalence of hypertension and low level of physical activity compared with their counterparts. A sedentary lifestyle contributes to the development of hypertension, as well as other cardiovascular diseases, especially among African American women. Healthy People 2010 initiatives underscore the priority of reducing minority health disparities. To reduce health disparities, there has been recent emphasis on recruiting and retaining minority populations in clinical research studies. However, little information is available to guide researchers in the evaluation of impediments in successful recruitment and retention of young African American women. A first step is for researchers to report information concerning the efficacy of recruiting/retaining methods in order to facilitate minority participation in clinical trials and, ultimately, reduce health disparities. This report summarizes existing recruitment and retention methods from the literature, and describes how effective these strategies were in recruiting and retaining young, mildly hypertensive African American women to a physical activity intervention study. Multiple strategies, resources, and time were necessary to recruit and retain these women for the study. Among women enrolled, newspaper advertisements and flyers were the most effective recruiting strategies implemented (46% and 21%, respectively). Study retention was high (96%), which may have resulted from flexible scheduling, frequent contact, and a caring environment. Recruiting and retaining efforts need to be tailored to meet the needs of the target population.

The Relationship Between Physical Activity and Cognition in Older Latinos

OBJECTIVES The purpose of this study was to explore the relationship between minutes spent participating in light and moderate/vigorous-intensity physical activity (PA) and cognition in older Latinos, controlling for demographics, chronic health problems, and acculturation. METHOD A cross-sectional study design was used. Participants were self-identified Latinos, without disability, who had a score less than 14 on a 21-point Mini-Mental State Examination. Participants were recruited from predominantly Latino communities in Chicago at health fairs, senior centers, and community centers. PA was measured with an accelerometer, worn for 7 days. Episodic memory and executive function (inference control, inattention, and word fluency) were measured with validated cognitive tests. RESULTS Participants were 174 Latino men (n = 46) and women (n = 128) aged 50-84 years (M = 66 years). After adjusting for control variables (demographics, chronic health problems) and other cognitive measures, regression analyses revealed that minutes per day of light-intensity PA (r = -.51), moderate/vigorous PA (r = -.56), and counts per minute (r=-.62) were negatively associated with lower word fluency. DISCUSSION Findings suggest that the cognitive benefits of both light-intensity PA and moderate/vigorous PA may be domain-specific.

A lifestyle physical activity intervention for caregivers of persons with Alzheimer's disease.

Background: The purpose of this pilot study was to examine the effects of lifestyle physical activity in caregivers (CGs) of persons with Alzheimers disease. Methods: Fifteen CGs engaged in lifestyle physical activity during a 6-month, home-based health promotion program. Mean changes in self-reported physical activity were compared using repeated-measures analysis of variance. Results: Fifty percent of CGs increased total self-reported minutes and 42% increased total moderate minutes of physical activity from preintervention to postintervention; however, no CG engaged in vigorous physical activity and there were no significant improvements in self-reported physical activity for the total group. Hot summer weather, heavy noncaregiving responsibilities, heavy caregiving responsibilities, and feelings of anxiety, depressive symptoms, and fatigue were the most frequently identified physical activity barriers. Conclusion: Incorporating an individualized, home-based program of lifestyle physical activity appears feasible; however, attention needs to be given in the future to physical activity barriers identified by this select group of CGs.

Blood pressure responses to lifestyle physical activity among young, hypertension-prone African-American women.

Background: Physical inactivity and obesity increase the risk for hypertension, and both are more prevalent in African-American than Caucasian women. Regular physical activity serves as an important intervention for reducing cardiovascular risk, yet the ideal physical activity profile to meet the needs of young, sedentary African-American women remains unclear. We performed a randomized, parallel, single-blind study to examine the effect of lifestyle physical activity (LPA) on blood pressure indices in sedentary African-American women aged 18 to 45 years with prehypertension or untreated stage 1 hypertension. Methods: The primary intervention was an 8-week individualized, home-based program in which women randomized to Exercise (n = 14) were instructed to engage in lifestyle-compatible physical activity (eg, walking, stair climbing) for 10 minutes, 3 times a day, 5 days a week, at a prescribed heart rate corresponding to an intensity of 50% to 60% heart rate reserve. Women in the No Exercise group (n = 10) continued with their usual daily activities. Mean changes in cuff, ambulatory, and pressure load indices were compared using paired t tests, and physical activity adherence was expressed as percentages. Results: Women in the Exercise group had a significant reduction in systolic blood pressure (−6.4 mm Hg, P = .036), a decrease in diastolic blood pressure status to the prehypertensive level (90.8 vs 87.4 mm Hg), and greater reductions in nighttime pressure load compared with the No Exercise group. Adherence to LPA was exceedingly high by all measures (65%-98%) and correlated with change in systolic blood pressure (r = −0.620, P = .024). Conclusion: The accumulation of LPA reduced cuff, ambulatory, and pressure load. The accumulation of LPA appears well tolerated and feasible in this sample of young African-American women, demonstrated by the overall high adherence rates. Given the excess burden of pressure-related clinical sequelae among African Americans and the strong correlation between pressure load and target organ damage, LPA may represent a practical and effective strategy in this population.

The Accumulative Effects of Physical Activity in Hypertensive Post-Menopausal Women

Background Lifestyle modifications, such as physical activity, are recommended as first-line or adjunctive therapy for hypertension. However, controversy exists regarding the type, amount, and intensity of physical activity for optimal blood pressure lowering. Design and Methods This study evaluated the blood pressure changes in 18 post-menopausal, sedentary, untreated hypertensive women randomized to an individualized 8-week programme of intermittent moderate-intensity physical activity versus no change in physical activity. The physical activity group was asked to select activities (such as walking) to engage in physical activity for 10 min, three times a day, 5 days per week at an intensity of 50–60% heart rate reserve. Results Independent T-tests were used to compare the difference in resting blood pressure between groups. After 8 weeks, resting blood pressure was 8/5mmHg lower in the physical activity group (systolic blood pressure, P=0.006 and diastolic blood pressure, P=0.059). The between group differences remained significant after adjustment for age, baseline blood pressure and previous use of antihypertensive drug therapy. Conclusion These data show that hypertensive, post-menopausal women who engage in intermittent, moderate-intensity physical activity experience a reduction in blood pressure.

Physical Activity of Urban Community-Dwelling Older Latino Adults

BACKGROUND To date, little is known about the physical activity (PA) levels and commonly reported modes of PA of older Latinos, and this information is critical to developing interventions for this population. The purpose of the current study was to examine PA assessed by self-report and accelerometer and to assess the influence of acculturation, gender, and age on the PA of urban community-dwelling older Latino adults. METHODS Participants were self-identified Latinos, primarily women (73%), and individuals aged 50 to 59 (31%), 60 to 69 (30%), and 70+ (39%). PA was measured with an accelerometer and the Community Healthy Activity Model Program for Seniors (CHAMPS) PA questionnaire. RESULTS Men reported engaging in, and objectively participated in, significantly more minutes of moderate/vigorous PA than women, but women reported greater light intensity household PA. Latinos aged 50 to 59 engaged in significantly more accelerometer-assessed PA than Latinos aged 60 to 69 and 70+, respectively. The majority of participants did not meet the PA Guidelines for Americans. No differences in PA were demonstrated by acculturation level. Older Latino men and women reported walking and dancing as modes of leisure PA. CONCLUSIONS These findings suggest PA interventions should be targeted toward older Latinos, taking into account gender and age.

Treating hypertension with cardioprotective therapies: the role of ACE inhibitors, ARBs, and beta-blockers.

Hypertension is both a disease and risk factor for cardiovascular disease (CVD) and each 20/10 mm Hg rise in blood pressure (BP) doubles the risk for CVD. Although BP reduction through lifestyle modification and/or antihypertensive therapy has been shown to dramatically reduce the risk for CVD, recent evidence has shown that many patients with hypertension do not have adequate BP control. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) provides comprehensive guidelines on the diagnosis, classification, and management of hypertension and related CV conditions. The JNC 7 guidelines recommend that most patients receive first-line therapy with thiazide diuretics, but the majority of patients will require 2 or more antihypertensive agents to achieve adequate BP control. The selection of additional antihypertensive therapies should be based on the presence of concomitant CV and metabolic conditions as well as patient-specific factors such as race. An important role exists for angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and β-blockers, particularly in patients with comorbid CV or metabolic conditions. Clinical evidence suggests that these agents may offer benefits beyond simple BP lowering. Furthermore, synergies among antihypertensive classes may improve BP control and combination therapy may also permit the use of smaller doses of each medication and reduce the risk of dose-related adverse effects.

Variability in fibrinogen measurements: an obstacle to cardiovascular risk stratification

The clinical utility of fibrinogen measurement has been limited by large intraindividual variability. Several approaches that have been shown to improve the repeatability of fibrinogen include acquisition of samples at the same time of day, standardized sample procurement techniques, and multiple replicate sampling. This study employed established pre-analytical and analytical techniques known to reduce fibrinogen variability, including the acquisition of three replicate samples, each analyzed in duplicate, to evaluate the impact of intraindividual variability in fibrinogen measurement at baseline and 3 months on cardiovascular risk in 60 healthy subjects. Classification accuracy was evaluated by the ability to categorize subjects into tertiles of fibrinogen. Only 55% (33/60) of the subjects were correctly assigned to the appropriate fibrinogen tertile. Fibrinogen measurements varied by more than 10% in 45% of subjects and by 5% in 80% of subjects. Intraindividual variability in fibrinogen measurement with a functional assay limits cardiovascular risk assessment even when three replicates are averaged.

Renin-Angiotensin-Aldosterone-Kinin System Influences on Diabetic Vascular Disease and Cardiomyopathy

Diabetes mellitus is associated with an inordinately high risk of virtually all manifestations of cardiovascular-renal disease including atherosclerotic coronary and peripheral vascular disease, congestive heart failure, stroke, nephropathy, and cardiomyopathy unassociated with coronary heart disease. Abnormalities in the renin-angiotensin-aldosterone-kinin (RAAK) cascade have been implicated in the pathogenesis and clinical expression of these cardiovascular-renal sequelae. Thus, pharmacological modulation of the RAAK system is an attractive therapeutic target in diabetes mellitus. Indeed, emerging data from human clinical studies appear to confirm this thesis.