Article

Regular exercise as an adjunct to antihypertensive therapy

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American Journal of Emergency Medicine

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Regular exercise as an adjunct to Antihypertensive therapy

For the sake of completeness, the observational study which in- cluded interviews of Hypertensive patients regarding their views on as- pects of hypertension [1] should have included in-depth discussions with those patients regarding their awareness of the beneficial effects of regular exercise. Among patients with hypertension, one benefit of exercise might be the opening up of the possibility of weaning the pa- tient off thiazide diuretics, or using exercise, instead of thiazide di- uretics, as an adjunct to Antihypertensive medication.

Although thiazide monotherapy generates a fall in systolic blood pressure(SBP)and diastolic blood pressure(DBP) this fall is comparable to the fall in those parameters generated by regular aerobic exercise. In the Cochrane Review of thiazide antihypertensive monotherapy chlorthalidone 12.5-15 mg/day monotherapy generated a mean fall in SBP by 10.1 mmHg (95% Confidence Interval 6.3 to 13.9 mmHg), and a fall in DBP by 2.6 mmHg (95%CI 0 to 5.1 mmHg). Chlorthalidone 25 mg/day generated a fall in SBP by 13.6 mmHg (95% CI 11.3 to 16.0 mmHg), and a fall in DBP by 4 mmHg (95% CI 2.3 to 5.7 mmHg). In the same review hydrochlorothiazide 12.5 mg/day generated a mean fall in SBP by 6.3 mmHg (95% CI 5.3 to 7.2 mmHg) and a fall in DBP by 3.1 mmHg (95% CI 2.5 to 3.7 mmHg). At the 25 mg/day dose the SBP fell by a mean value of 8.0 mmHg(95% CI 7.- to 9.0 mmHg), and the DBP fell by 3.3 mmHg (95% CI 2.8 to 3.8 mmHg) [2]. The “down- side” of thiazide use is that both chlorthalidone, 12.5-25 mg/day [3] and hydrochlorothiazide, 25 mg/day [4,5] activate the renin aldosterone an- giotensin system(RAAS), with the attendant risk of myocardial fibrosis [6], and, hence, diastolic heart failure.

According to a narrative review of 27 Randomised controlled trials on individuals with hypertension, comparable falls in SBP and DBP can be achieved by regular aerobic exercise. That review showed that regular medium to high intensity aerobic activity reduces the systolic blood pressure by a mean of 11 mmHg and the diastolic blood pressure by a mean value of5 mmHg. The type of exercise included walking, jogging, swimming, and cycling [7]. Even hypertension which persists at 140/ 90 mmHg or more in spite of 3 antihypertensive medications (so-called “resistant” hypertension) can be ameliorated by regular aerobic exercise [8]. In the latter study 50 subjects with resistant hypertension were ran- domly allocated to participate or not participate in an 8-12 week tread- mill exercise program which was well tolerated by all the subjects. Exercise significantly (P = 0.03) decreased daytime ambulatory SBP and DBP by, on average, 6 mmHg and 3 mmHg, respectively [8].

Regular exercise also reduces myocardial stiffness, thereby mitigat- ing the risks of subsequent diastolic heart failure [9]. In the latter study sixty one (48% male) healthy participants(all in sedentary occu- pations) of mean age 53 were randomly allocated to either 2 years exer- cise training (n = 34) or attention control (control = 27). In each subject measurements were made of left parameters of left ventricular stiffness. Maximal oxygen uptake was measured to quantify changes in fitness. Fifty three subjects completed the study. Adherence to

prescribed exercise was 88% on average. As a result of exercise training left ventricular stiffness was significantly (P = 0.0018) reduced in com- parison with its pre-existing value. This parameter did not change in the control group. Exercise also significantly (P b 0.001) increased the left ventricular end-diastolic volume, whereas pulmonary capillary wedge pressure was unchanged. The consequence was a significant (P = 0.007) increase in stroke volume for any given filling pressure. The au- thors concluded that regular exercise could reduce the risk of future heart failure with preserved ejection fraction by mitigating the risk of myocardial stiffness attributable to sedentary lifestyle [9].

In view of the fact that the blood pressure lowering effect of regular aerobic exercise is comparable to the antihypertensive effect of thiazide diuretics, some hypertensive patients might benefit from a regime whereby regular exercise was substituted for thiazide diuretics. Alterna- tively, instead of add-on thiazides, exercise could be used as “add on” therapy if hypertension is not adequately controlled either with angio- tensin converting enzyme inhibitors (or angiotensin receptor blockers) and/or calcium channel blockers. That strategy would mitigate the risk of RAAS-related myocardial stiffness, and also confer the additional ben- efit of reversing any pre-existing myocardial stiffness.

Finally, if resort to thiazide “add on” therapy proves to be inescap-

able, low-dose chlorthalidone 6.25 mg/day or low-dose controlled- release hydrochlorothiazide 12.5 mg/day would be worthy of consider- ation, over and above the use of “add on” exercise. In 12-week compar- ative, double-blind, outpatient study which enrolled 54 patients with stage 1 hypertension were randomised to chlorthalidone 6.25 mg/day (n = 16), hydrochlorothiazide(HCTZ) 12.5 mg/day (n = 18), or HCTZ-CR (n = 20). In that study both chlorthalidone and HCTZ-CR sig- nificantly (P b 0.01) reduced 24 h ambulatory blood pressure [10]. The magnitude of RAAS activation at those doses would be worthy of interest.

Acknowledgment

I have no funding, and no conflict of interest.

Oscar M.P. Jolobe, MRCP(UK) Manchester Medical Society, Simon Building, Brunswick Street, Manchester M13 9PL, United Kingdom of Great Britain and Northern Ireland.

E-mail address: [email protected].

27 November 2018

https://doi.org/10.1016/j.ajem.2018.12.032

References

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    0735-6757/(C) 2018

    Musini VM, Nazer M, Bassett K, Wright JM. Blood pressure-lowering efficacy of monotherapy with thiazide diuretics for primary hypertension (review). Cochrane Libr Cochrane Database Syst Rev 2014;5:CD003842. https://doi.org/10.1002/ 14651858.CD003824.pub2.

  2. Menon DV, Arbique D, Wang Z, Adams-Huet B, Auchus RJ, Vongpatanasin W. Differ- ential effects of chlorthalidone versus spironolactone on muscle sympathetic nerve activity in hypertensive patients. J Clin Endocrinol Metab 2009;94:1361-6.
  3. Ambrosioni E, Borghi C, Costa FV. Captopril and hydrochlorothiazide: rationale for their combination. Br J Clin Pharmacol 1987;23:43S-50S.
  4. Ubaid-Girioli S, Ferreira-Melo SE, Souza A, Nogueira EA, Yugar-Toledo JC, Coca A,

    et al. Aldosterone escape with diuretic or angiotensin-converting enzyme inhibi- tor/angiotension II receptor blocker Combination therapy in patients with mild to moderate hypertension. J Clin Hypertens 2007;9:770-4.

    Gekle M, Grossmann C. Actions of aldosterone in the cardiovascular system: the good, the bad, and the ugly? Pflugers Archiv Eur J Physiol 2009;458:231-46.

  5. Borjesson M, Onerup A, Lundqvist S, Dahlof B. physical activity and exercise lower blood pressure in individuals with hypertension: narrative review of 27 RCTs. Br J Sports Med 2016;50:356-61.
  6. Dimeo F, Pagonas N, Seibert F, Arndt R, Zidek W, Westhoff TH. Aerobic exercise re- duces blood pressure in resistant hypertension. Hypertension 2012;60:653-8.
  7. Howden EJ, Sarma S, Lawley JS, Opondo M, Cornwell W, Stoller D, et al. Reversing the Cardiac effects of sedentary aging in middle age-a randomized controlled trial. Impli- cations for heart failure prevention. Circulation 2018. https://doi.org/10.1161/ CIRCULATIONAHA.117.030617.
  8. Pareek AK, Messerli FH, Chandurkar NB, Dharmadhikari SK, Godbole AV, Kshirsagar PP, et al. Efficacy of low-dose chlorthalidone and hydrochlorothiazide as assessed by 24-h ambulatory Blood pressure monitoring. JACC 2016;67:379-89.

    The authors respond: public health intervention in the ED for hypertension

    We thank Mr. Oscar M. Jolobe for the interest in our article. Exercise is certainly a highly beneficial activity, and an emergency department visit does indeed present an opportunity for promoting such Prevention strategies. Emergency departments are increasingly being asked to de- ploy public health interventions such as HIV testing with risk reduction counseling, and Mental health and substance abuse screening among others. We posit that substantial barriers remain to achieving the be- havior change required to improve health outcomes through a brief in- tervention. There is a considerable need for research, practice, and Policy change to balance the competing missions of acute care and pub- lic health, identify the resources required for emergency departments to adopt a public health mission, and promote linkage to more appropriate venues for longitudinal interventions needed to achieve sustained be- havior change.

    W. Tyler Winders, MD*

    Department of Emergency Medicine, Medical University of South Carolina,

    United States of America

    Corresponding author.

    E-mail address: [email protected].

    Kimberly Hart, MA Christopher Lindsell, PhD

    Department of Emergency Medicine, Vanderbilt University, Nashville, TN,

    United States of America E-mail address: [email protected].

    Michael Lyons, MD, MPH Opeolu Adeoye, MD

    Department of Emergency Medicine, University of Cincinnati, Cincinnati,

    OH, United States of America E-mail address: [email protected], [email protected]

    15 December 2018

    https://doi.org/10.1016/j.ajem.2018.12.033

    cranial CT of nontrauma emergency department patients

    I have greatly enjoyed reading the recently published article by Covino et al. [1]. In this retrospective study, the authors evaluated 1156 patients presenting to the ED for neurological deficit, postural in- stability, acute headache, altered mental status, seizures, confusion, diz- ziness, vertigo, syncope, and pre-syncope. The authors built a score for positive cranial computed tomography prediction by using a logistic re- gression model on clinical factors significant at univariate analysis. I congratulate the authors for their successful article. However, I have some concerns about article. First, this study was retrospective and did not include ED patients who did not undergo cranial computed to- mography. Therefore, it must be stressed that the true effect of applying these Clinical predictors cannot be assessed. There is need for prospec- tive validation of the clinical predictor variables that identified in this consecutive series of ED patients with nontraumatic neurologic symp- toms who did undergo cranial computed tomography. Second, as a re- sult of the retrospective nature of this study, patient assessment and documentation of clinical findings were not standardized. Finally, owing to the retrospective design of the study, there was no standardi- zation of the terminology contained within the computed tomography requisitions.

    Arsal Acarbas

    Mugla University, Faculty of Medicine, Department of neurosurgery,

    Turkey E-mail address: [email protected].

    6 December 2018

    https://doi.org/10.1016/j.ajem.2018.12.058

    References

    [1] Covino M, Gilardi E, Manno A, Simeoni B, Ojetti V, Cordischi C, et al. A new Clinical score for cranial computed tomography in emergency department non-trauma pa- tients: definition and first validation. Am J Emerg Med 2018. https://doi.org/10. 1016/j.ajem.2018.09.032 [Epubahead of print, pii: S0735-6757(18)30767-8].

    The author responds: The need for prospective studies of cranial CT for ED head trauma patients

    Dear Sir,

    I sincerely appreciate your interest in our work, and I thank you for the questions about our paper. In our study we retrospectively reviewed clinical data of 1156 patients presented to our ED for several clinical condition non-related to trauma, and build a score for positive cranial CT scan prediction in the ED setting. We furtherly validated our score on a prospective population of 508 patients.

    Our data confirmed that risk stratification could reasonably reduce head CT utilization in the emergency department patients, keeping high standards of sensitivity.

    In the first point of your letter you underline that the true effect of applying this clinical predictor could not be assessed since we did not include patients that did not undergo CT scan. However since the pur- pose of our work was to give a tool to emergency physicians to reduce just urgent head CT scan in the ED, we think that the design of our study is adequate to our endpoint. Furthermore it would be very diffi- cult to design a study were every patient should undergo a urgent head CT scan regardless of clinical evaluation and physician judgement. So, in our opinion, the true incidence of any head CT rule cannot be mathematically estimated at 100% in the real world.

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