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Nonpharmacological Management of Resistant Hypertension

  • Hypertension (DS Geller and DL Cohen, Section Editors)
  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

In the United States (US), 46% of adults have hypertension (systolic blood pressure ≥ 130 mmHg, diastolic blood pressure ≥ 80 mmHg). Approximately, 16% of patients with hypertension have apparent treatment-resistant hypertension (aTRH) and the incidence of true resistant hypertension (RHT) is thought to be much lower (~ 2%). These patients with RHT are at a higher risk for adverse events and worse clinical outcomes.

Recent Findings

Although lifestyle interventions have proven to be effective as the first line of defense in treating hypertension, their role in the management of patients with RHT is not well established. Despite fewer in number, available studies examining lifestyle interventions in patients with RHT do indeed show promising results.

Summary

In this review, we aim to discuss the role of common lifestyle interventions such as physical activity, exercise, weight loss, and dietary modifications on blood pressure control in patients with RHT.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Murray CJL, Aravkin AY, Zheng P, et al. Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet. 2020;396:1223–49.

    Article  Google Scholar 

  2. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: The JNC 7 report. JAMA. 2003;289:2560–71.

    Article  CAS  PubMed  Google Scholar 

  3. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Pr. J Am Coll Cardiol. 2018;71:e127–248.

    Article  PubMed  Google Scholar 

  4. Virani SS, Alonso A, Aparicio HJ, et al. Heart disease and stroke statistics-2021 update: a report from the American Heart Association. Circulation. 2021;143:e254–743.

    Article  PubMed  Google Scholar 

  5. Gakidou E, Afshin A, Abajobir AA, et al. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet. 2017;390:1345–422.

    Article  Google Scholar 

  6. Carey RM, Calhoun DA, Bakris GL, et al. Resistant hypertension: detection, evaluation, and management a scientific statement from the American Heart Association. Hypertension. 2018. https://doi.org/10.1161/HYP.0000000000000084.

    Article  PubMed  Google Scholar 

  7. Egan BM, Kai B, Wagner CS, Henderson JH, Chandler AH, Sinopoli A. Blood pressure control provides less cardiovascular protection in adults with than without apparent treatment-resistant hypertension. J Clin Hypertens Greenwich Conn. 2016;18:817–24.

    Article  CAS  Google Scholar 

  8. Daugherty SL, Powers JD, Magid DJ, Tavel HM, Masoudi FA, Margolis KL, O’Connor PJ, Selby JV, Ho PM. Incidence and prognosis of resistant hypertension in hypertensive patients. Circulation. 2012;125:1635–42.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Armario P, Calhoun DA, Oliveras A, et al. Prevalence and clinical characteristics of refractory hypertension. J Am Heart Assoc. 2017;6:1–7.

    Article  Google Scholar 

  10. Thomas G, Xie D, Chen HY, et al. Prevalence and prognostic significance of apparent treatment resistant hypertension in chronic kidney disease: report from the chronic renal insufficiency cohort study. Hypertension. 2016;67:387–96.

    Article  CAS  PubMed  Google Scholar 

  11. Sim JJ, Bhandari SK, Shi J, Reynolds K, Calhoun DA, Kalantar-Zadeh K, Jacobsen SJ. Comparative risk of renal, cardiovascular, and mortality outcomes in controlled, uncontrolled resistant, and nonresistant hypertension. Kidney Int. 2015;88:622–32.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Ozemek C, Tiwari S, Sabbahi A, Carbone S, Lavie CJ. Impact of therapeutic lifestyle changes in resistant hypertension. Prog Cardiovasc Dis. 2020;63:4–9.

    Article  PubMed  Google Scholar 

  13. Lopes S, Mesquita-Bastos J, Alves AJ, Ribeiro F. Exercise as a tool for hypertension and resistant hypertension management: current insights. Integr Blood Press Control. 2018;11:65–71.

    Article  PubMed  PubMed Central  Google Scholar 

  14. • Valenzuela PL, Carrera-Bastos P, Gálvez BG, Ruiz-Hurtado G, Ordovas JM, Ruilope LM, Lucia A. Lifestyle interventions for the prevention and treatment of hypertension. Nat Rev Cardiol. 2021;18:251–75. This is a comprehensive review on the effects and mechanisms of different lifestyle interventions for the management of hypertension.

    Article  CAS  PubMed  Google Scholar 

  15. Carvalho de CJ, Marins JCB, Lade de CG, Castilho P de R, Reis HHT, Amorim PR dos S, Lima LM. Aerobic and resistance exercise in patients with resistant hypertension. Rev Bras Med Esporte. 2019;25:107–111

  16. •• Dimeo F, Pagonas N, Seibert F, Arndt R, Zidek W, Westhoff TH. Aerobic exercise reduces blood pressure in resistant hypertension. Hypertension. 2012;60:653–8. This is the first trial on the effects of aerobic exercise in patients with RHT. This trial shows that exercise is an effective intervention for BP management in this patient population.

    Article  CAS  PubMed  Google Scholar 

  17. Santos LP, Moraes RS, Vieira PJC, Ash GI, Waclawovsky G, Pescatello LS, Umpierre D. Effects of aerobic exercise intensity on ambulatory blood pressure and vascular responses in resistant hypertension. J Hypertens. 2016;34:1317–24.

    Article  CAS  PubMed  Google Scholar 

  18. Pires NF, Coelho-Júnior HJ, Gambassi BB, De Faria APC, Ritter AMV, De Andrade BC, Ferreira-Melo SE, Rodrigues B, Júnior HM. Combined aerobic and resistance exercises evokes longer reductions on ambulatory blood pressure in resistant hypertension: a randomized crossover trial. Cardiovasc Ther. 2020. https://doi.org/10.1155/2020/8157858.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Sabbahi A, Arena R, Elokda A, Phillips SA. Exercise and hypertension: uncovering the mechanisms of vascular control. Prog Cardiovasc Dis. 2016;59:226–34.

    Article  PubMed  Google Scholar 

  20. Sawyer BJ, Tucker WJ, Bhammar DM, Ryder JR, Sweazea KL, Gaesser GA. Effects of high-intensity interval training and moderate-intensity continuous training on endothelial function and cardiometabolic risk markers in obese adults. J Appl Physiol. 2016;121:279–88.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Costa EC, Hay JL, Kehler DS, Boreskie KF, Arora RC, Umpierre D, Szwajcer A, Duhamel TA. Effects of high-intensity interval training versus moderate-intensity continuous training on blood pressure in adults with pre- to established hypertension: a systematic review and meta-analysis of randomized trials. Sports Med. 2018;48:2127–42.

    Article  PubMed  Google Scholar 

  22. MacDougall JD, Tuxen D, Sale DG, Moroz JR, Sutton JR. (1985) Arterial blood pressure response to heavy resistance exercise. J Appl Physiol Bethesda Md. 1985;58:785–90.

    CAS  Google Scholar 

  23. Cornelissen VA, Fagard RH, Coeckelberghs E, Vanhees L. Impact of resistance training on blood pressure and other cardiovascular risk factors: a meta-analysis of randomized, controlled trials. Hypertension. 2011;58:950–8.

    Article  CAS  PubMed  Google Scholar 

  24. Marzolini S, Oh PI, Brooks D. Effect of combined aerobic and resistance training versus aerobic training alone in individuals with coronary artery disease: a meta-analysis. Eur J Prev Cardiol. 2012;19:81–94.

    Article  PubMed  Google Scholar 

  25. Vranish JR, Bailey EF. Inspiratory muscle training improves sleep and mitigates cardiovascular dysfunction in obstructive sleep apnea. Sleep. 2016;39:1179–85.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Ferreira JB, Plentz RDM, Stein C, Casali KR, Arena R, Lago PD. Inspiratory muscle training reduces blood pressure and sympathetic activity in hypertensive patients: a randomized controlled trial. Int J Cardiol. 2013;166:61–7.

    Article  PubMed  Google Scholar 

  27. Craighead DH, Heinbockel TC, Rossman MJ, Jankowski LR, Jackman RA, Bailey EF, Chonchol M, Seals DR. Inspiratory muscle strength training lowers resting systolic blood pressure and improves vascular endothelial function in middle‐aged and older adults. FASEB J. 2019;33:541.4–541.4

  28. Silva CD, Abreu RM, Rehder‐Santos P, De Noronha M, Catai AM. Can respiratory muscle training change the blood pressure levels in hypertension? A systematic review with meta‐analysis. Scand J Med Sci Sports sms. 2021;13943

  29. Demede M, Pandey A, Zizi F, Bachmann R, Donat M, McFarlane SI, Jean-Louis G, Ogedegbe G. Resistant hypertension and obstructive sleep apnea in the primary-care setting. Int J Hypertens 2011;340929

  30. Shimbo D, Levitan EB, Booth JN 3rd, Calhoun DA, Judd SE, Lackland DT, Safford MM, Oparil S, Muntner P. The contributions of unhealthy lifestyle factors to apparent resistant hypertension: findings from the Reasons for Geographic And Racial Differences in Stroke (REGARDS) study. J Hypertens. 2013;31:370–6.

    Article  CAS  PubMed  Google Scholar 

  31. Egan BM, Zhao Y, Axon RN, Brzezinski WA, Ferdinand KC. Uncontrolled and apparent treatment resistant hypertension in the United States, 1988 to 2008. Circulation. 2011;124:1046–58.

    Article  PubMed  PubMed Central  Google Scholar 

  32. De La Sierra A, Banegas JR, Oliveras A, Gorostidi M, Segura J, De La Cruz JJ, Armario P, Ruilope LM. Clinical differences between resistant hypertensives and patients treated and controlled with three or less drugs. J Hypertens. 2012;30:1211–6.

    Article  PubMed  CAS  Google Scholar 

  33. Sim JJ, Bhandari SK, Shi J, In Liu LA, Calhoun DA, Mcglynn EA, Kamyar Kalantar-Zadeh Jacobsen SJ. Characteristics of resistant hypertension in a large, ethnically diverse hypertension population of an integrated health system Mayo Clin Proc 2013;88:1099-1107

  34. Hou H, Zhao Y, Yu W, Dong H, Xue X, Ding J, Xing W, Wang W. Association of obstructive sleep apnea with hypertension: a systematic review and meta-analysis. J Glob Health. 2018;8:10405.

    Article  Google Scholar 

  35. Holecki M, Duława J, Chudek J. Resistant hypertension in visceral obesity. Eur J Intern Med. 2012;23:643–8.

    Article  PubMed  Google Scholar 

  36. JE Hall do Carmo JM da Silva AA Wang Z Hall ME. Obesity-induced hypertension: interaction of neurohumoral and renal mechanisms Circ Res. 2015;116:991–1006

  37. Appel LJ, Giles TD, Black HR, Izzo JLJ, Materson BJ, Oparil S, Weber MA. ASH position paper: dietary approaches to lower blood pressure. J Clin Hypertens Greenwich Conn. 2009;11:358–68.

    Article  CAS  Google Scholar 

  38. Semlitsch T, Krenn C, Jeitler K, Berghold A, Horvath K, Siebenhofer A. Long-term effects of weight-reducing diets in people with hypertension. Cochrane Database Syst Rev. 2021;2:CD008274.

  39. Gay HC, Rao SG, Vaccarino V, Ali MK. (2016) Effects of different dietary interventions on blood pressure: systematic review and meta-analysis of randomized controlled trials. Hypertens Dallas Tex. 1979;67:733–9.

    Article  CAS  Google Scholar 

  40. Mozaffarian D, Fahimi S, Singh GM, Micha R, Khatibzadeh S, Engell RE, Lim S, Danaei G, Ezzati M, Powles J. Global sodium consumption and death from cardiovascular causes. N Engl J Med. 2014;371:624–34.

    Article  PubMed  Google Scholar 

  41. Whelton PK, Appel LJ, Sacco RL, et al. Sodium, blood pressure, and cardiovascular disease: further evidence supporting the American Heart Association sodium reduction recommendations. Circulation. 2012;126:2880–9.

    Article  CAS  PubMed  Google Scholar 

  42. Mente A, O’Donnell M, Rangarajan S, et al. Associations of urinary sodium excretion with cardiovascular events in individuals with and without hypertension: a pooled analysis of data from four studies. Lancet Lond Engl. 2016;388:465–75.

    Article  CAS  Google Scholar 

  43. McMahon EJ, Bauer JD, Hawley CM, Isbel NM, Stowasser M, Johnson DW, Campbell KL. A randomized trial of dietary sodium restriction in CKD. J Am Soc Nephrol JASN. 2013;24:2096–103.

    Article  CAS  PubMed  Google Scholar 

  44. Textor SC, Gloviczki ML, Flessner MF, Calhoun DA, Glockner J, Grande JP, McKusick MA, Cha SS, Lerman LO. Association of filtered sodium load with medullary volumes and medullary hypoxia in hypertensive African Americans as compared with whites. Am J Kidney Dis Off J Natl Kidney Found. 2012;59:229–37.

    Article  CAS  Google Scholar 

  45. Pimenta E, Gaddam KK, Oparil S, Aban I, Husain S, Dell’Italia LJ, Calhoun DA. Effects of dietary sodium reduction on blood pressure in subjects with resistant hypertension: results from a randomized trial. Hypertens Dallas Tex. 2009;54:475–81.

    Article  CAS  Google Scholar 

  46. Saneei P, Salehi-Abargouei A, Esmaillzadeh A, Azadbakht L. Influence of Dietary Approaches to Stop Hypertension (DASH) diet on blood pressure: a systematic review and meta-analysis on randomized controlled trials. Nutr Metab Cardiovasc Dis NMCD. 2014;24:1253–61.

    Article  CAS  PubMed  Google Scholar 

  47. Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med. 2001;344:3–10.

    Article  CAS  PubMed  Google Scholar 

  48. Diaz KM, Booth JN, Calhoun DA, Irvin MR, Howard G, Safford MM, Muntner P, Shimbo D. Healthy lifestyle factors and risk of cardiovascular events and mortality in treatment-resistant hypertension: the Reasons for Geographic and Racial Differences in Stroke study. Hypertension. 2014;64:465–71.

    Article  CAS  PubMed  Google Scholar 

  49. O’Brien E, Parati G, Stergiou G, et al. European Society of Hypertension position paper on ambulatory blood pressure monitoring. J Hypertens. 2013;31:1731–68.

    Article  PubMed  CAS  Google Scholar 

  50. Terés S, Barceló-Coblijn G, Benet M, Alvarez R, Bressani R, Halver JE, Escribá PV. Oleic acid content is responsible for the reduction in blood pressure induced by olive oil. Proc Natl Acad Sci U S A. 2008;105:13811–6.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Roerecke M, Tobe SW, Kaczorowski J, Bacon SL, Vafaei A, Hasan OSM, Krishnan RJ, Raifu AO, Rehm J. Sex-specific associations between alcohol consumption and incidence of hypertension: a systematic review and meta-analysis of cohort studies. J Am Heart Assoc. 2018. https://doi.org/10.1161/JAHA.117.008202.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Roerecke M, Kaczorowski J, Tobe SW, Gmel G, Hasan OSM, Rehm J. The effect of a reduction in alcohol consumption on blood pressure: a systematic review and meta-analysis. Lancet Public Health. 2017;2:e108–20.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Blumenthal JA, Sherwood A, Smith PJ, et al. Lifestyle modification for resistant hypertension: the TRIUMPH randomized clinical trial. Am Heart J. 2015;170:986-994.e5.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019. https://doi.org/10.1161/CIR.0000000000000678.

    Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Department of Physical Therapy, College of Applied Health Sciences, University of Illinois At Chicago, 1919 W. Taylor Street (MC 898), Chicago, IL, USA

    Ahmad Sabbahi, Richard Severin, Deepika Laddu, Ross Arena & Cemal Ozemek

  2. School of Physical Therapy, South College, Knoxville, TN, USA

    Ahmad Sabbahi

  3. Department of Physical Therapy, Robbins College of Health and Human Sciences, Baylor University, Waco, TX, USA

    Richard Severin

  4. College of Health and Medicine, Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia

    James E. Sharman

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  1. Ahmad Sabbahi
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  2. Richard Severin
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  3. Deepika Laddu
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  4. James E. Sharman
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  6. Cemal Ozemek
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Correspondence to Ahmad Sabbahi.

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Sabbahi, A., Severin, R., Laddu, D. et al. Nonpharmacological Management of Resistant Hypertension. Curr Cardiol Rep 23, 166 (2021). https://doi.org/10.1007/s11886-021-01601-4

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