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Tuesday, April 01, 2008

Relaxation Tops Didactic Lifestyle Advice for Blood Pressure Control

While we have been promoting relaxation and related relaxation therapies for multiple decades, now it may be coming back in vogue amidst MSM (mainstream medicine); remember those old books from the 60s and 70s about reversing heart disease with biofeedback?

* Medical News: Hypertension

By Charles Bankhead, Staff Writer, MedPage Today
Published: March 31, 2008

Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine.

BOSTON, March 31 -- Recalcitrant systolic hypertension may respond better to a form of relaxation training than to lectures on lifestyle interventions, investigators here found.

The two types of nondrug interventions reduced blood pressure to a similar degree, Randall Zusman, M.D., of Massachusetts General Hospital and Harvard, and colleagues, reported in April issue of the Journal of Alternative and Complementary Medicine.

However, patients who engaged in relaxation training were more than twice as likely to discontinue antihypertensive therapy and maintain blood pressure control.

"If a practice that takes only 15 to 20 minutes a day can help decrease patients' dependence on antihypertensive medications -- reducing often-unpleasant side effects and the considerable costs of these drugs -- we could not only improve their quality of life by lower direct and indirect health costs by billions of dollars," said Dr. Zusman.

Systolic hypertension is the most prevalent form of high blood pressure in older adults, accounting for 65% to 75% of hypertension among those 60 and older. Moreover, systolic hypertension poses a greater risk of cardiovascular disease in older individuals than does diastolic hypertension or hyperlipidemia, the authors noted.

Antihypertensive drugs, though effective, often cause side effects in older patients that affect compliance, making nonpharmacologic interventions attractive, the authors continued. Stress management techniques that elicit a relaxation response have demonstrated efficacy in essential hypertension but had not been examined in patients with systolic hypertension.

Dr. Zusman and colleagues evaluated relaxation response training in a randomized comparison with lifestyle intervention in 122 patients with systolic hypertension. All patients were 55 or older, had systolic blood pressure of 140 to 159 mm Hg, diastolic blood pressure less than 90 mm Hg, and were being treated with at least two antihypertensive drugs.

The patients' mean age was 67, and baseline blood pressure averaged 146.3/77.3 mm Hg in the relaxation training arm and 145.3/77.6 in the control arm. Half of the patients in the investigational group were taking three or more antihypertensive drugs versus 30% in the control group.

The primary outcome was systolic blood pressure at eight weeks. Patients who reduced their systolic blood pressure to lower than 140 mm Hg and had at least a 5-mm Hg reduction in systolic blood pressure could enter a second eight-week phase of intervention with supervised elimination of antihypertensive medication.

Patients assigned to relaxation training attended weekly hour-long sessions that included instruction, practice, and education related to relaxation response. Additionally, they listened to a 20-minute relaxation response audiotape daily.

The lifestyle modification group attended weekly sessions that consisted of education and discussion related to nondrug interventions to manage stress and hypertension. They were asked to listen to a series of 20-minute audiotapes about various aspects of lifestyle modification.

After the end of the first eight-week phase of the study, systolic blood pressure had decreased by an average of 9.4 mm Hg in the relaxation training group and 8.8 mm Hg in the lifestyle modification group. Blood pressure changes in both groups were statistically significant compared with baseline (P<0.0001) but there was no difference between groups (P=0.75). Diastolic blood pressure decreased 1.5 and 2.4 mm Hg (P= 0.05 and 0.01, respectively) without group difference (P=0.48).

The authors reported that 44 patients in the relaxation response group and 36 in the control group qualified for supervised medication elimination. By intention-to-treat analysis, 14 (32%) patients in the relaxation training group maintained blood pressure control after discontinuing one or more antihypertensive drugs compared with 5 (14%) in the control group.

After controlling for baseline differences between the two groups, those in the relaxation training group were four times more likely to eliminate one or more medications versus the control group (OR 4.3, 95% CI 1.2 to 15.9, P=0.03).

Reviewing limitations of the study, the authors cited differences in antihypertensive drug regimens, variation in dose-response to medications, brief period of follow-up, lack of monitoring of lifestyle interventions, and absence of a placebo control.

Despite the limitations, the authors concluded that the study demonstrated the feasibility and efficacy of relaxation response training to manage systolic hypertension. They suggested that the approach also is feasible for prehypertensive patients and might prevent the patients' progression to overt hypertension.

The study was supported by the CDC and NIH. The authors reported no disclosures.

Primary source: Journal of Alternative and Complementary Medicine
Source reference:
Dusek JA, et al "Stress management versus lifestyle modification on systolic hypertension and medication elimination: A randomized trial" J Altern Complement Med 2008; 14: 129-138.

Add Your Knowledge™ From Moss Posner, md - Apr 01, 2008
The significance of this study cannot be overestimated: Systolic hypertension of the elderly is, as mentioned, more dangerous, and also harder to control by conventional medication, which is effective in treatment of diastolic hypertension. In the elderly, this effect is not only dangerous, but usually accompanied by no substantial lowering of systolic pressure. As a result, and particularly in those elderly with substantial systolic elevation and normal or depressed diastolic pressures, we have been unable to offer safe treatment--or any treatment for that matter. The very fact that relaxation can have a substantial effect selectively on systolic hypertension, and that it is even superior to life-style modification (proven effective in diastolic hypertension) in the ultimate success in reducing or eliminating medication opens up a whole new realm of possible causes and insights into the pathophysiology. Are specific neuroreceptor sites affected, and if so, which, and by what mechanism? Is this endorphin-mediated? Proposed use of fMRI in investigation is tantalizing. As in the title of the old song...

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