Certain alternative approaches – notably aerobic exercise and resistance training – reduce blood pressure and can be considered adjunctive to standard dietary and medical therapies for hypertension, according to an American Heart Association scientific statement published April 22 in Hypertension.
The evidence supporting biofeedback techniques, isometric handgrip exercise, and device-guided slow breathing is not as strong, but these approaches also are likely effective at reducing blood pressure by a small amount. For other alternative therapies such as meditation, yoga, relaxation therapy, stress-reduction techniques, and acupuncture, the evidence to date is insufficient to support their use as adjunctive treatments for HT.
Dr. Robert Brook
These are the main conclusions of the AHA scientific statement that aims to "provide an up-to-date assessment of the evidence supporting the blood pressure lowering efficacy of several alternative approaches." The statement also provides practical recommendations for clinicians to incorporate these alternative approaches into their practices, said Dr. Robert D. Brook, chair of the writing committee, and his associates.
They reviewed the literature published during the past 6 years and identified 124 studies of behavioral therapies, 105 of noninvasive procedures and devices, and 773 of exercise-based regimens for reducing blood pressure.
The overall quality of these studies was not good. Most were observational, and even the randomized clinical trials often were flawed by inadequate randomization methods, the use of suboptimal control groups, small sample sizes, and short follow-ups. Many of the reviewed studies also had selection, compliance, and other biases.
Overall, the committee found that "it is reasonable for all patients with BP levels higher than 120/80 mm Hg to consider a trial of alternative approaches as adjuvant methods to help lower BP." However, since no alternative modality can reliably decrease BP by 20/10 mm Hg or more, patients "who require this magnitude of BP reduction should employ alternative approaches only after they are first treated with appropriate pharmacologic strategies," according to the statement.
"It should also be emphasized that most alternative approaches reduce systolic BP only by 2-10 mm Hg. Hence, only a minority of patients will be successful in reaching goals using these treatment modalities alone when BP is 10/5 mm Hg above target."
Of all the alternative therapies, dynamic aerobic exercise was found to have the highest level of evidence that it decreases blood pressure, along with the greatest potential for improving other cardiovascular health factors such as lipid levels and glucose levels. "Numerous observational cohorts also suggest that aerobic exercise may reduce CV risk in a dose-dependent manner," Dr. Brook and his associates noted.
Therefore aerobic exercise "should be considered the primary alternative modality to help reduce BP," according to the statement.
Resistance training also had a high level of evidence that it lowers blood pressure, and also was associated with additional cardiovascular benefits, so it also is "highly recommended by our review." Most patients "should start with aerobic or resistance exercise (alone or together) as the first alternative approach unless contraindicated or they are unwilling or unable to exercise."
If this isn’t sufficiently effective, clinicians should next consider recommending device-guided deep breathing or isometric handgrip exercise. These two approaches had a greater weight of evidence supporting their efficacy and were more practical to use in a real-world setting than were the remaining alternative therapies, said Dr. Brook, associate professor of medicine at the University of Michigan, Ann Arbor, and his colleagues.
Biofeedback also is supported by a moderate level of evidence.
It is not yet established how long trials of various alternative therapies should be given before the clinician can decide whether they have been effective. "However, 3 months is a reasonable time frame given that most of the approaches reduced BP among the studies within this period, when they were effective," the investigators said.