Wednesday, May 27, 2015

Hypertension – Overview and Treatment Options

Hypertension, commonly known as high blood pressure, can be defined as an elevated force of pressure against the artery walls as the heart pumps blood to the rest of the body. It can eventually lead to various health problems if it becomes chronic in nature. 

Stroke is one of the most concerning health consequences that can occur due to chronic high blood pressure. Other ill health effects include heart attacks, kidney disease, peripheral vascular disease, heart failure, retinopathy (damage to the retina of the eye leading to possible blindness), dementia, and premature death.1

Needless to say, hypertension should be taken seriously by anyone suffering from it. Sadly, sometimes this isn’t the case because high blood pressure is known as the “silent killer”, manifesting no feelings of “sickness” by those suffering from it.

Hypertension is highly prevalent in our population, with nearly 1 out of every 3 (29.1%) U.S. adults suffering from it, and another 36.3%-37.4% of U.S. adults suffering from a condition known as prehypertension.2-4

In this article, I hope to provide some insights and analysis on the overview and treatment (both dietary and medical) of hypertension.

What Is Hypertension?

As mentioned before, hypertension is the chronic elevation of force on the artery walls by the heart as it pumps blood to the rest of the body. This leads to wear and tear on the heart, the blood vessels, and other organs resulting in negative health consequences. Watch the videos below for a better understanding of this process.

High blood pressure effects on the blood vessels

High blood pressure effects on the heart

Hypertension is officially defined and broken up into different stages by the following numerical categories:5

Systolic blood pressure is the measurement of force exerted on the arteries when the ventricles of the heart contract, pushing blood out to the lungs and rest of the body. Diastolic blood pressure is the measurement of force on the arteries when the ventricles relax, allowing for refilling of the bottom chambers of the heart with blood from the atria.

Elevations in systolic and/or diastolic blood pressure can both predict a greater risk of premature death, but, generally speaking, most people who have high blood pressure will experience rises in systolic pressures more than diastolic pressures.6

What Causes Hypertension?

With few exceptions, hypertension is caused by an unhealthy diet, not genes. It is uncommon or virtually nonexistent in areas of the world where populations live off a natural diet of whole, plant-based foods.7-9

Mainstream conventional medicine has even acknowledged the link between diet and hypertension, as stated in this article in the Journal of the American Society of Nephrology – “Hypertension, like most cardiovascular conditions, is a nutritional-hygienic disease. The seeds of hypertension are rooted in physical inactivity, obesity, high caloric intake, and excessive dietary sodium intake as well as alcohol consumption. Genetic susceptibility to hypertension remains ill-defined … Population-based hypertension prevention strategies would require widely implemented public health measures, such as significant alterations to the food supply and effective strategies to significantly augment energy expenditures above current levels.”1

This statement should speak volumes to the fact that food, not family history or genetics, is the main culprit in our present-day hypertension crisis in America, Europe, and other countries adopting a Western diet.

As with anything, though, the devil is in the details. While our modern-day medical community does make a valid effort in putting official dietary advice in place (DASH diet) to combat this preventable medical condition, they fall short of utilizing the best available peer-reviewed, evidence-based scientific and medical literature available on nutrition and hypertension treatment. The typical result is improvement in blood pressure levels in patients who adopt these dietary guidelines BUT a continuation of their hypertension or the need for medications to control their hypertension.

I will discuss more about the evidence on diet and hypertension later, but first let’s take a look at various medications used to manage this condition.

What Medications are Used to Treat Hypertension?

There are five main classes of drugs used to treat hypertension.10 Below is a list of each class, an explanation of how the medications work, their success rates (in terms of morbidity and mortality outcomes), and common potential side effects/black box warnings of the medications within that class if such warnings exist. Success rates are given in terms of absolute risk reduction numbers.

These five classes of medications are not the only classes of drugs used to treat hypertension, but most patients will be put on one or more of these classes of medications when utilizing pharmacological therapy to manage their condition.

[Note #1– Please notice the choice of the word ‘manage’ in the previous sentence, as it is worth a reminder that medications do not target the cause of high blood pressure, and instead only work to better control hypertension with lifelong adherence to taking them as prescribed.]

[Note #2 – If you need help understanding how statistics are reported in studies including absolute risk reduction vs. relative risk reduction then please read my article – 3 Questions to Always Ask Your Doctor or Pharmacist]

1) Thiazide-type Diuretics [Chlorthalidone, hydrochlorothiazide (HCTZ)]

This is typically the first and safest class of drugs used in the treatment of hypertension. They are commonly referred to as ‘water pills’. Some patients may only need a thiazide diuretic as their only medication for high blood pressure, but the majority of people will need at least two medications to reach blood pressure goals in the absence of a major dietary and lifestyle change.

How they work – Thiazide diuretics inhibit the kidney from reabsorbing sodium and chloride, which, in turn, reduces the amount of water reabsorbed back into the body and increases urination.11 Less water means less volume in the blood, which means less work on the heart and a lower blood pressure. Of all the classes of medications this class is the best at removing excess water from the body.

Success rate/Risk reduction
  • Chlorthalidone provides a 3% absolute risk reduction in cardiovascular death rates over an average of a 14.3-year period.16
  • Chlorthalidone has been proven to be the most effective thiazide-type diuretic by offering more effective blood-pressure-lowering effects than HCTZ.17 However, despite this current evidence, HCTZ is still more commonly prescribed in the United States for patients with high blood pressure.

 Possible side effects12,13 – Thiazide-type diuretics may cause low potassium levels (hypokalemia), low sodium levels (hyponatremia), high blood sugar levels (hyperglycemia), increase in cholesterol levels, increase in uric acid levels (gout), and erectile dysfunction.

2) Angiotensin Converting Enzyme Inhibitors (ACE inhibitors) [lisinopril, enalapril, benazepril, ramipril, fosinopril, quinapril, captopril, trandolapril, perindopril, moexipril]

ACE inhibitors are commonly used as the second drug of choice in many patients with hypertension, especially diabetics, heart failure patients, and in chronic kidney disease. These are typically used in addition to a thiazide diuretic.

How they work – ACE inhibitors work in multiple ways to reduce blood pressure including increasing dilation of the blood vessels (i.e. reducing resistance the heart has to pump against), increasing excretion of sodium and water in the urine (i.e. lowering blood volume), and by decreasing the overall workload on the heart each time it pumps.11

Success rate/Risk reduction
  • Ramipril provides a 2.4% absolute risk reduction in heart attacks and 1.8% absolute risk reduction in death over a 5-year period.19
  • Enalapril provides a 1% absolute risk reduction in death over a 37-month period.19
  • Perindopril provides a 2% absolute risk reduction in either cardiovascular death, cardiac arrest, or heart attacks over a 4.2-year period.20

 Possible side effects13-15 – ACE inhibitors may cause dry cough (5-20%), dizziness, headache, hypokalemia, acute kidney failure, and angioedema (occurs in 0.1%-1% - severe swelling of the lips, eyes, face, and other parts of the body).

Black box warning18 – ACE inhibitors, when used in the second and third trimester of pregnancy, can cause possible birth defects and fetal death. This class of drugs is contraindicated in pregnancy.

3) Angiotensin Receptor Blockers (ARBs) [valsartan, telmisartan, irbesartan, losartan, candesartan, eprosartan, olmesartan, azilsartan]

ARBs are typically reserved for patients who cannot tolerate an ACE inhibitor. The most common reason for this is due to the development of a chronic, dry cough. Like ACE inhibitors, they are commonly used in patients with heart failure, chronic kidney disease, and diabetics.

How they work – ARBs work in multiple ways, similar to ACE inhibitors, to reduce blood pressure including dilation of blood vessels, increasing excretion of sodium and water in the urine, and decreasing the workload on the heart each time it pumps.11

Success rate/Risk reduction
  • Candesartan provides a 2% absolute risk reduction in death and 4% absolute risk reduction in hospitalizations for congestive heart failure over a 38-month period.20
  • Valsartan provides a 2.59% absolute risk reduction in developing atrial fibrillation (a serious heart arrhythmia) over a 2-year period.11

 Possible side effects – ARBs may cause upper respiratory tract infections (6-9%), dizziness (3-4%), cough (2.8%-4%), sinusitis (3%), fatigue (2-4%), diarrhea (2.4-3%), viral infections (2-3%), musculoskeletal pain (1-3%), abdominal pain (2%), and upset stomach (1.3-2%).21

Black box warning18 – ARBs, when used in the second and third trimester of pregnancy, can cause possible birth defects and fetal death. This class of drugs is contraindicated in pregnancy.

4) Beta-Blockers [carvedilol, atenolol, metoprolol, labetolol, propranolol, bisoprolol, acebutolol, betaxolol, nadolol, penbutolol, pindolol, bucindolol]

Beta-blockers are not recommended as first-line agents for high blood pressure, instead they are added to existing antihypertensive therapy for most patients. They are typically used in special patient populations such as those with heart failure, diabetics, and those who have suffered a recent heart attack.

How they work – Beta-blockers work in various ways. Different beta-blockers may have more than one method of decreasing blood pressure, but, in general, beta-blockers decrease the amount of blood pumped out of the heart each time it pumps, thereby decreasing the workload on the heart. Beta-blockers can also increase excretion of sodium and water out of the kidney.11

Success rate/Risk reduction
  • Carvedilol provides a 3% absolute risk reduction rate in death over a 1.3-year period.19
  • Meta-analysis of nine randomized, placebo-controlled trials of beta-blockers (bucindolol, carvedilol, bisoprolol, and metoprolol) including 14,594 patients showed a 3.4% absolute risk reduction in death over a 1-year period, and a 4% absolute risk reduction in hospitalizations for heart failure (no timeframe provided).22
  • Meta-analysis of four randomized, placebo-controlled trials on beta-blockers showed a 0.5% absolute risk reduction in stroke and 0.7% absolute risk reduction in total cardiovascular disease.26

 Possible side effects – Beta-blockers may cause diarrhea (3.8%), dizziness (3.7%), bradycardia (3.3% - i.e. slow heart rate), high blood sugar levels (2.7%), and intermittent claudication (1.5% - i.e. burning, aching, or cramping feeling in the legs when active).23

Black box warning24 – Metoprolol, atenolol, propranolol, and nadolol can cause severe chest pain, heart attacks, and heart arrhythmias upon abrupt discontinuation in patients being treated for coronary heart disease.

5) Calcium Channel Blockers (CCBs) [amlodipine, felodipine, nifedipine, clevidipine, isradipine, nisoldipine, nitrendipine, diltiazem, verapamil]

CCBs are not recommended as first-line agents for hypertension. They are typically used as second-choice agents in addition to existing antihypertensive therapy. CCBs can be broken up into two separate subgroups—dihydropyridines (all CCBs ending in ‘dipine’) and non-dihydropyridines (verapamil and diltiazem). Specific CCBs are used for special patient populations such as those with diabetes, angina (chest pain), certain types of heart arrhythmias (atrial fibrillation), high risk of coronary heart disease, and African Americans.

How they work – Dihydropyridine CCBs work by relaxing the walls of blood vessels, thereby reducing pressure in the arteries that the heart has to pump against. Diltiazem and verapamil can also relax arterial walls reducing blood pressure, but also work directly on heart muscle. Diltiazem and verapamil reduce the workload on the heart each time it pumps by reducing the force with which it pumps at, and they also decrease the heart rate.11

Success rate/Risk reduction
  • Nitrendipine provides a 2.9% absolute risk reduction in stroke over a 5-year period.25
  • Meta-analysis of ten randomized, placebo-controlled trials of CCBs including 43,534 patients showed a 1.4% absolute risk reduction of stroke (no timeframe given).27

 Possible side effects13,28-30 – CCBs, particularly the dihydropyridines, may cause dizziness, low blood pressure (especially right after standing up), headache, flushing, peripheral edema (swelling of extremities), and gingival hyperplasia (overgrowth of gum tissue). Verapamil can cause constipation. Diltiazem and verapamil may worsen congestive heart failure. Nifedipine and isradipine may increase cardiovascular death and disability.

What Diet and Lifestyle Interventions Are Used in the Treatment Hypertension?

Diet and lifestyle patterns play a huge role in the development of hypertension. As mentioned in the beginning of this article, hypertension is a “nutritional-hygienic disease”. The food you put into your body (and to a lesser degree how active you are) will determine whether or not you develop high blood pressure.

The official recommendation from the medical community is to adopt the DASH diet to treat hypertension. DASH stands for Dietary Approaches to Stop Hypertension. The DASH diet includes fruits, vegetables, whole grains, legumes, low- or non-fat dairy, lean meats, nuts and seeds, and small amounts of fats and sweets. The average drop in blood pressure for hypertensive patients on the DASH diet is 11.4/5.5 mmHg.31 While this is an improvement over the Standard American Diet (SAD), the DASH diet still includes foods (dairy, lean meats, and sweets/junk foods) that promote heart disease, cancer, diabetes, and other chronic diseases.

So is there a better way to treat high blood pressure with diet without promoting heart disease, cancer, diabetes, and other chronic diseases?

Yes, there is!

Multiple studies have shown that the adoption of a low-fat, whole foods, plant-based diet with low sodium intake both significantly improves blood pressure and reduces chronic disease rates.

John McDougall, MD has published two such studies that I am aware of using a low-fat, low-salt, starch-based (vegan) diet to reverse hypertension. The first was in 1995 and included exercise. During this 12-day intensive live-in program blood pressures dropped an average of 17/13 mmHg for the 500 men and women participating in the study.32,33

Dr. McDougall published a second study in 2014 using the same diet and exercise program. After a 7-day intensive lifestyle live-in program patients with hypertension reduced their average blood pressure readings by 18/11 mmHg.34

Alan Goldhamer, DC from True North Health Clinic has also published studies showing dramatic reductions in blood pressures using a medically supervised water-only fasting program followed by a switch to a low-fat, low-sodium, whole foods, plant-based (vegan) diet. The entire program lasted anywhere from 18-22 days. The average drop in blood pressure readings for pre-hypertensive patients was 20/7 mmHg.32 The average drop in blood pressure readings for hypertensive patients was 37/13 mmHg, and for those patients with stage 3 hypertension (> 180/110 mmHg) the average drop in blood pressure was 60/17 mmHg.35 These results make these the most successful studies ever published in the medical literature on lowering blood pressure and reversing hypertension with diet and lifestyle.

There are no negative side effects from adopting this type of low-fat, low-sodium, whole foods, plant-based (vegan) diet. There are only positive effects in weight reduction, cholesterol reduction, and overall improved general health.

So how do medications stack up against these diets? For a comparative perspective, average blood pressure lowering effects of the different medication classes mentioned in this article are below:36,37 
  • Beta-blockers and/or diuretic – 13/6 mmHg
  • ACE inhibitors – 5/2 mmHg
  • ARBs – 8/5 mmHg
  • Calcium channel blockers – 10/5 mmHg

 It is clear that not only does the proper diet (low-fat, low-sodium, whole food, plant-based) work better at reversing hypertension, but it also provides additional benefits in terms of preventing and reversing numerous chronic diseases like heart disease, cancer, diabetes, and autoimmune disorders without any negative side effects.38-41 It’s a win-win-win situation.


Hypertension is a common condition in Western societies affecting nearly one-third of the population, with another third of the population being pre-hypertensive. Modern medicine resorts to prescription medications all too quickly to remedy this situation instead of having a truly meaningful discussion on the most effective way to treat this condition.

The answer, of course, lies in the root cause of the condition itself—the food! By making a significant changes in our Western-style diet we can beat hypertension and prevent the disastrous consequences that come of it. Adopting a low-fat, low-salt, plant-based diet comprised of whole foods is key in doing this.

Ultimately, the decision is yours. You have to every right to choose whatever path you feel is best for you. I’m honored to have the opportunity to present the information needed for you to do this in life.

May life bless you with many years of health and happiness as you embark on your journey towards a better you!

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by Dustin Rudolph, PharmD
Clinical Pharmacist

Check out Dustin Rudolph's book The Empty Medicine Cabinet to start your journey towards better health. This step-by-step guide leads you through many of today's common chronic diseases (heart disease, obesity, diabetes, cancer, and more), giving you the facts on foods versus medications in treating these medical conditions. The book also contains an easy-to-follow guide on how to adopt a whole foods, plant-based diet as a part of an overall lifestyle change, producing the best possible health outcomes for you and your family. Hurry and get your copy today!

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Photo credit: Wikimedia Commons - Yaddah (heart diagram), (all other images)

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