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  • A variety of epidemiological and clinical studies suggest th

    2019-07-10

    A variety of epidemiological and clinical studies suggest that light alcohol consumption may exert a favorable effects on BP levels but chronic heavy alcohol consumtion causes sustained BP elevation [16], [17]. The hypertensive effect of heavy drinking occurs with all forms of alcohol (i.e. beer wine and spirits) and limitation of alcohol consumption to no more than 20–30g of ethanol per day in men and to no more than 10–20g of ethanol per day in women should be recommended. Hypertensive patients should be advised to consume a diet that emphasizes fruits, vegetables, low-fat dairy products, dietary and soluble fibre, whole grains, and protein from plant sources that is reduced in saturated fat and cholesterol [18]. Diet changes should be accompanied by other lifestyle measures as the long-term effects on BP of a switch to a vegetarian or reduced saturated-fat diet are somewhat inconclusive at present. Furthermore, it has been shown that in hypertensive patients, compared with the Dietary Approaches to Stop Hypertension (DASH) diet alone, the combination of the DASH diet with regular physical exercise and weight loss resulted in a greater reduction in BP [19]. All overweight/obese hypertensive individuals should be advised to lose weight, this is because an impressive number of trials of weight reduction as a method of BP lowering have provided favorable results about the impact of weight loss on BP levels. It deserves to be mentioned, however, that the extent of BP fall has varied markedly between studies [20]. In a meta-analysis by Neter et al. [21] including twenty-five randomized, controlled trials with a total of 4874 participants, the mean systolic BP and diastolic BP reductions associated with an average weight loss of 5.1kg were 4.4mmHg and 3.6mmHg, respectively. Further data have led to the popular notion that for each kilogram of weigth lost, a 1mmHg reduction of systolic and diastolic BP can be achieved. Consequently, maintenance of a healthy body weight (body mass index of about 25kg/m2) is generally recommended for normotensive individuals to prevent hypertension and for hypertensive patients to improve the efficacy of antihypertensive medications and the cardiovascular risk profile. Higher Sodium Nitroprusside level is associated with lower probability and incidence of hypertension. Several randomized trials have assessed the hypotensive effect of physical exercise suggesting a small but useful reduction in BP. A meta-analysis of 54 randomized controlled trials with 2419 participants showed that aerobic exercise was associated with a significant reduction in systolic BP and diastolic BP (3.8 and 2.6mmHg, respectively) [22]. The health benefits resulting from physical exercise depend on the type and regularity and include improvements in glucose and lipid metabolism. In this regard, the guidelines recommend regular moderate dynamic exercise (i.e. walking, jogging, cycling or swimming at least 30min on 5–7days per week). Smoking leads to an acute increase in BP and heart rate, persisting for more than 15min after smoking one cigarette, as a consequence of a powerful stimulation of the sympathetic nervous system [23]. Studies using ambulatory BP monitoring (ABPM) have shown that smoking is a key correlate of masked hypertension. In fact, day-time BP values have been reported to be significantly higher in smokers than in non smokers, whereas office and night-time values did not differ between the two groups [24]. Beside the direct influence on BP values, smoking is the most important modifiable cardiovascular risk factor and smoking cessation is probably the single most effective lifestyle measure for the prevention of cardiovascular morbidity and mortality in the general population.
    Pharmacological therapy Indisputable evidence is available that antihypertensive treatment reduces the elevated incidence of cardiovascular morbid and fatal events related to high BP [25]. Evidence is also available that the main benefits of antihypertensive treatment are due to lowering of BP per se and are largely independent of the drugs employed [26], [27]. The 2013 ESH/ESC guidelines reiterating previous indications [4], [5] confirm that five classes of drugs such as: 1) diuretics, 2) beta-blockers, 3) calcium antagonists, 4) angiotensin converting enzyme (ACE) inhibitors and 5) angiotensin receptor blockers are all suitable for the initiation and maintenance of antihypertensive treatment, either as monotherapy or in some combinations. It is important to note that the guidelines state clearly that there are no solid scientific elements that allow to classify the various classes of medications in a hierarchical order of efficacy. This is because the effects on cause-specific outcomes of the various agents are similar or differ marginally, the type of outcome in a given patient is unpredictable, and all classes of antihypertensive drugs have their clinical advantages but also contra-indications.