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Nonpharmacological management of hypertension

Hypertension is a prevalent cardiovascular disease factor in the developed world. The first in a two-part series, this article will look at the use of nonpharmacological interventions such as diet, smoking cessation and exercise. Part two will focus on pharmacological interventions

Helen Lewis
RN BSc(Hons)
BMid(Hons)

Practice Nurse
Brynderwen Siurgery
St Mellons
Cardiff

It has been suggested that children today spend 600 kcal per day less on physical exercise than their counterparts did 50 years ago.1 Therefore, it is not surprising that the NHS, both at primary and secondary care level, is facing an epidemic of hypertension, obesity, metabolic syndrome and diabetes mellitus.

This is a problem that, unless dealt with proactively, will result in an increase in cardiovascular disease and premature death from stroke and ischaemic heart disease. It is estimated that these diseases cause 60,000 and 94,000 deaths per year in the UK, respectively.2 It has been suggested that lifestyle changes – especially exercise regimens – and their relationship with hypertension will require greater focus.1

Hypertension is the most common disorder affecting the heart and blood vessels, and is a major cause of heart failure, kidney disease and stroke. Hypertension can remain a symptomless condition for many years until significant damage has been done. It is the fundamental risk factor for stroke and is one of the identified three major factors in conjunction with cholesterol and smoking for coronary heart disease.

Understanding hypertension
It is estimated that 40% of adults in England and Wales live with hypertension, with the proportion increasing with age. Despite 90 million prescriptions being funded by the NHS for drugs that lower blood pressure, accounting for 15% of the total annual cost of all primary care drugs, hypertension remains one of the most inadequately treated chronic conditions.3,5

If hypertension is managed well by both the practice nurse and compliant patient, it is possible to reduce the risk of ischaemic heart disease by 35% and stroke by as much as 44%, depending on age.3 To manage and treat hypertension with confidence it is essential that practice nurses have a sound understanding of what normal blood pressure is and the causes of the condition.

Blood pressure
For practice nurses to have the necessary knowledge, skills and confidence to manage hypertensive patients, it is essential that a basic understanding of blood pressure is established.

Blood flows from regions of higher pressure to regions of lower pressure; the greater the pressure difference, the greater the blood flow and, by contrast, the higher the resistance, the smaller the blood flow. For blood to reach body cells and exchange materials with them, it must be constantly propelled through the network of blood vessels. The heart circulates the blood through an estimated 100,000 km (60,000 miles) of blood vessels, the equivalent of flying five times around the world. It beats about 100,000 times every day, which equates to 35 million beats in one year – quite impressive for an organ which is no bigger than your fist.

On average, the heart pumps 30 times its own weight each minute. Approximately 5 litres of blood goes to the lungs, with the same volume going to the rest of the body; at this constant rate it is thought that 14,000 litres is pumped in one day. As we know, there are four chambers in the heart, consisting of two atria and two ventricles. The contraction of the ventricles generates the hydrostatic pressure exerted by blood on the walls of a blood vessel, otherwise referred to as the blood pressure. Blood pressure is at its highest in the aorta and large systemic arteries. A young adult, who is a nonsmoker, athletic, and of slim build, would have a resting systolic BP of 120 mmHg during systole (ventricular contraction) and a diastolic BP of 80 mmHg during diastole (ventricular relaxation).4

Hypertension defined
Hypertension is defined as systolic blood pressure of 140 mmHg or greater and diastolic blood pressure of 90 mmHg or greater in individuals not taking anti-hypertensive medication.4 A blood pressure of 120/80 is a normal and desirable in a healthy adult.

The condition rarely makes the patient feel ill. In a small number of patients it can cause headaches, but this is only when their blood pressure is very high. Other symptoms can include blurred vision, breathlessness and nosebleeds; however, the only definitive way to detect hypertension is to assess blood pressure over a period of time and not simply diagnose on one reading.

For a successful outcome, it is vital that the clinician also takes into account external factors. This includes answering the following questions:

  • Was the patient late arriving and may not have had enough time to calm down?
  • Is there any stress at work or at home which may increase the blood pressure acutely?
  • Is the patient overweight, or are they in pain?
  • What is their day-to-day diet and exercise regimen or do they have one at all?
  • Does the patient smoke and have hyperlipidaemia or any other predisposing condition which may be causing a high reading?

Choosing firstline therapy
One of the major considerations for practitioners when faced with a patient diagnosed with hypertension is what to choose as firstline therapy. The decision must be patient-specific, made in partnership with the individual, and not paternalistic. An element of "benefit of the doubt" must be given by clinicians if a patient is willing to make changes to their lifestyle in terms of diet, exercise, alcohol intake and smoking cessation. If successful, the clinician's role is then one of support and monitoring through regular reviews with frank and open discussion.

Implementation and review
If you suspect that a patient is suffering from hypertension, the recommendation is to assess the patient's blood pressure on at least two subsequent appointments where the blood pressure is measured under the best possible conditions available.4

At the first appointment, the nurse should discuss lifestyle changes, such as reducing alcohol intake and smoking, and eating a balanced diet. In general, patients are not keen to take medication and will often leave the consultation and start to make some changes, however small, before their next appointment.

Nonpharmacological treatment options
It would be very easy for clinicians to prescribe medication rather than explore the nonpharmacological route as a firstline treatment. We have all had patients in our consultation rooms who believe that to leave the surgery without holding a prescription equals an unsuccessful trip and a waste of their time. The likelihood would be another appointment scheduled with a doctor – possibly with the same outcome. What is crucial to the success of this course of treatment is the nurse's assessment of the patient's readiness to change his or her lifestyle.

Prochaska and DiClemente identified five stages of change (see Box 1).7 Their research revealed that once people are in the contemplation phase of the model they are far more likely to respond to education and feedback, and ultimately realise a positive outcome.

[[Box 1 hypert]]

The long-term support of patients is paramount if a successful outcome is to be achieved. It may be problematic for the patient and the clinician to tackle all of the changes necessary at once; therefore, patients should be encouraged to prioritise the lifestyle changes they have to make. This is by far the best way of achieving success. Once the priorities have been decided upon it is important that the goals set are realistic, manageable and ultimately achievable, with regular reviews between clinician and patient.

Dietary advice
Remember, dietary advice cannot be given as part of a "one-size-fits-all" approach, and will depend on the individual's cardiovascular risk. The main aim for the overweight patient is to lose weight steadily and over a period of time by introducing a healthy diet, and increasing their levels of exercise slowly so that a balance of negative energy is achieved. Blood pressure can be reduced by approximately 2.5/1.5 mmHg for each kilogram lost.8

The obese patient needs more specialist assessment in terms of diet and the factors that are contributing to their obesity. Referral to a community dietitian is recommended. The role of the practice nurse in this instance would be more of support and empowerment than actual intervention; however, that is not to say that at some point the ongoing management of this patient could not be transferred back to the practice-based team. Establishing a professional nurse–patient relationship will only make any transfer of care an easier passage for both.

For those patients with hyperlipidaemia, the support offered by the nurse in terms of diet and lifestyle changes may have a profound effect on both their cholesterol and blood pressure.
Dietary measures involve reducing saturated fat intake to below 10% of total calorie intake, as saturated fat increases LDL-cholesterol concentrations. Increasing intake of certain types of polyunsaturated fats (omega-3 and omega-6) has been reported in the Lyon Heart Health Study to be an effective nonpharmacological intervention.9 With the availability of plant sterols and stanols in functional food products, and depending on the level of consumption, a 14% reduction in LDL-cholesterol may be achievable.10 Table 1 gives a summary of fat and transfatty acid reduction to help rebalance the HDL/LDL cholesterol of such patients.

[[Tab 1 hypert]]

Smoking cessation
Approximately 10 million adults smoke in the UK, which equates to approximately one sixth of the population; however, two-thirds of smokers will start before the age of 18.
Approximately 50% of adults report never having smoked at all. Sadly, in England 12% of boys and 19% of girls will be regular smokers at the age of 15, notwithstanding the fact it is illegal to sell cigarettes to anyone under the age of 18.11

On a brighter note, there have been significant changes with regard to helping individuals give up smoking. The country-wide smoking ban in public buildings and on public transport has done much for those who wish to give up smoking. It remains a fact of life that there are some individuals who will continue to smoke, regardless of the restrictions placed upon this activity and the graphic warnings on cigarette packets. Education, information and support are a vital part of the successful management of this major cardiovascular risk factor for patients. It is true to say that the process must begin with the individual and cannot be forced by the professional. Research has shown that even the most minimal of interventions will result in 2% of patients quitting.11 However, supporting an individual to quit smoking should be a multiprofessional endeavour with self-help groups and telephone support networks, as well as practice nurses and GPs.

Alcohol intake
Department of Health guidelines recommend that men should not exceed more than 21 units of alcohol in one week, comprising no more than 3–4 units per day with one or two alcohol-free days. In women the limit is slightly lower at 14 units per week, averaging 2-3 units per day with one or two alcohol-free days.12 This area is probably best managed by outside agencies and appropriate referrals made by the practice nurse via the GP. However, by using screening questions, such as CAGE, the practice nurse can identify those patients who would benefit from appropriate onward referral and support.13

Exercise
Regular exercise brings benefits in terms of weight loss and cholesterol, which reduce the blood pressure of an individual, reduce insulin resistance, decrease blood clotting and increase fibrinolytic activity, while also helping in smoking cessation. However, the practice nurse must ensure that the information is patient specific, realistic and achievable.

A thorough history must be taken by the practice nurse and documented.14 This will ensure that the information given during the initial assessment process leads to implementation of a patient-specific treatment regimen, while protecting the practitioner and the patient from harm.

Different forms of exercise have differing effects on the individual's body. An exercise regimen should be implemented over a period of time for it to have the greatest benefit to the patient. High-intensity exercise such as weightlifting, sprinting or squash should be avoided, while cycling, swimming, tennis and jogging are low-intensity, rhythmic, repetitive aerobic exercises, which hold the key to reducing a patient's blood pressure over time.

Research suggests that regular aerobic exercise decreases blood pressure in approximately 75% of hypertensive individuals, with reductions in the systolic and diastolic BP averaging 11 and 8 mmHg respectively. It has also been noted that women may see better results than men with exercise, while middle-aged patients may obtain greater benefits than younger or older patients.15 Contraindications to exercise are:

  • Unstable angina.
  • Resting systolic BP >180 mmHg.
  • Resting diastolic BP >110 mmHg.
  • Symptomatic orthostatic BP drop of >20 mmHg.
  • Certain heart conditions.
  • Resting tachycardia >120 BPM.
  • Acute illness.
  • Uncontrolled diabetes.
  • Recent embolism or surgical procedure.

Any patient who has a history of CHD should be considered for an exercise tolerance test before taking up increased activity programmes. Effective activity programmes to lower BP should include:

  • Exercise duration of 15–60 minutes.
  • Exercise intensity of 12 on Borg's rating of perceived exertion scale slowly increasing to 16.
  • Frequency of at least five sessions per week.
  • Include exercise such as aerobics, and rhythmic, continuous activity such as walking, cycling, and swimming.
  • Exclude weight lifting.

Patient monitoring and support
For a successful outcome to be achieved, monitoring and support are vital areas for both clinician and patient alike. Patients should be offered BP monitoring on a monthly basis until levels are controlled and then every three to six months once control has been achieved where problems and concerns can be addressed. Blood pressure targets currently recommended by the British Hypertension Society are shown in Table 2, with the exception of patients living with co-existing diabetes mellitus or renal disease with the recommendation being

[[Tab 2 hypert]]

Conclusion
Based on the evidence and research and given the increase in our sedentary lifestyles, the recommendation and implementation of lifestyle changes in terms of establishing exercise regimens, smoking cessation, alcohol intake and dietary changes can benefit not only the life of primary care patients but also improve their lifespan.

Regular reviews and monitoring will need to be maintained so that patients feel empowered and supported to reduce their blood pressure and improve their metabolic profile. Ultimately, with sound management and patient compliance the risk of developing ischaemic heart disease or suffering a stroke will
be minimalised.

References
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