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Xavier University

Ateneo de Cagayan

The Comparison between Pharmacologic and Non-pharmacologic Management of


Hypertensive Patients

Research Paper

Presented to:
Christine Salvador
Instructor

Presented by:
Octubre, Karenn Joy C.
Pagute, Demelyn J.
English 27- NG

March 2012

Sentence Outline

Title: The Comparison between Pharmacologic and Non-pharmacologic Management of


Hypertensive Patients.

Thesis statement: Non-pharmacologic intervention is more effective compared to


pharmacologic intervention in the management of hypertension.

I.

The most common worldwide disease afflicting humans is hypertension.

II.

The comparison between pharmacologic and non-pharmacologic intervention used


in the management of hypertension based on its advantages and disadvantages.
A. What are different pharmacologic interventions used to manage
hypertension?
B. What are the different non-pharmacologic interventions used to manage
hypertension?
C. What are the advantages and disadvantages of each intervention?

III.

Non-pharmacologic intervention is more effective compared to pharmacologic


intervention because of it offers more advantages and less disadvantages.

INTRODUCTION

Hypertension is defined as systolic blood pressure greater than 140mmHg and a


diastolic greater than 90mmHg over a sustained period of time. It is also known as high
blood pressure. There are two types of hypertension, the primary which is the reason for
the elevation in blood pressure is unknown, and secondary which high blood pressure
results from an identified cause such as sedentary lifestyle, high fat diet, and genetics.
Hypertension is sometimes called the silent killer because people who had high blood
pressure are sometimes unaware of their elevated blood pressure and have no
accompanying signs and symptoms, such as dizziness, palpatations, nape pain, and
alterations in speech and vision (Smeltzer & Bare, 2010).
Major risk factors of having hypertension include smoking, dyslipidemia, diabetes
mellitus, impaired renal function, obesity, physical inactivity, age over 55 years for men
and 65 years for women, and a family history of cardiovascular disease. Some of these
risk factors can be controlled or prevented by an individual such as smoking, obesity, and
physical inactivity. Having hypertension would lead to serious complications such as heart
failure, stroke, chronic kidney disease, peripheral arterial disease, retinopathy, and even
death. So, prompt identification of the disease condition and treatment is very important
(Smeltzer & Bare, 2010).
Hypertension is the number one attributable risk factor for death throughout the
world. According to the Control for disease control (CDC, 2006), about one out of three
U.S. adults have high blood pressure. High blood pressure is a major risk factor for heart
disease, stroke, congestive heart failure, and kidney diseases. In 2006, hypertension was
listed as a primary contributing cause of death for 326, 000 Americans and hypertension
also cost United States $76.6 billion in health care services, medications, and missed
days of work.

In the Philippines, hypertension is the fifth leading cause of morbidity (DOH, 2005),
accounting for 448 per 100,000 population and sixty-one deaths per 100,000 Filipinos.
According to the Philippine Society of Hypertension (2006), one out of five adult Filipinos
is hypertensive and not even aware of the condition, while 90 percent of the countrys
population has one or more of the risk factors that contributes to high blood pressure.
These reveal that most Filipinos are at high risk of having hypertension which could be
very fatal if left untreated.
Furthermore, because of the alarming number of cases having hypertension and
number of people who died from it, the researchers were motivated to study about
hypertension and what are its different treatments and managements.

Hypertensive

people can lower their blood pressures into safety zone with the use of medications
(pharmacologic therapy) or with lifestyle modification (non-pharmacologic interventions).
In this study, the will researchers compare the two interventions that can effectively
manage hypertension. The researchers will provide evidences on which intervention is
more effective in the management of hypertension basing on the advantages and
disadvantages of each intervention. Based on having more advantages and less
disadvantages, the researchers will be able to determine the most effective intervention.
The main aim of this study is to gain knowledge on what are the different treatment plans
of hypertension and to compare which is more effective from the two variables. The
findings of this study will be beneficial not only the hypertensive patients for whom the
treatment plans are indicated, but as well as the health care providers through giving their
patients appropriate intervention. And also, findings of this study can also serve as basis
for future researchers to conduct another study related to hypertension and its
management.

CHAPTER 1
Hypertension is the number one attributable risk factor for death throughout the
world. According to the Control for disease control (CDC, 2006), about one out of three
U.S. adults have high blood pressure. High blood pressure is a major risk factor for
heart disease, stroke, congestive heart failure, and kidney diseases. In 2006,
hypertension was listed as a primary contributing cause of death for 326, 000
Americans and hypertension also cost United States $76.6 billion in health care
services, medications, and missed days of work. In the Philippines, hypertension is the
fifth leading cause of morbidity (DOH, 2005), accounting for 448 per 100,000 population
and sixty-one deaths per 100,000 Filipinos. According to the Philippine Society of
Hypertension (2006), one out of five adult Filipinos is hypertensive and not even aware
of the condition, while 90 percent of the countrys population has one or more of the risk

factors that contributes to high blood pressure. This reveals that most Filipinos are at
high risk of having hypertension, which could be very fatal if left untreated.
Smeltzer and Bare (2010) said that blood pressure is the product of cardiac
output multiplied by peripheral resistance. Cardiac output is the product of the heart rate
multiplied by the stroke volume. In normal circulation, pressure is transferred from the
heart muscle to the blood each time the heart muscle contracts and then pressure is
exerted by the blood as it flows through the blood vessels. Hypertension can result from
an increase in cardiac output, an increase in peripheral resistance, or both.
Hypertension is a multifactorial condition. Smeltzer and Bare (2010) stated that because
hypertension is a sign, it is most likely to have many causes, just as fever has many
causes. For hypertension to occur there must be a change in one or more factors
affecting peripheral resistance or cardiac output. These factors include excess sodium
intake, fewer nephrons, stress, genetic alteration, obesity, and endothelial factors. In
addition, increased sympathetic nervous system activity, increased renal absorption of
sodium, chloride, and water, increased activity of the rennin-angiostensin-aldosterone
system, decreased vasodilation, and resistance to insulin action are some of the causes
of hypertension. In addition, major risk factors for hypertension includes smoking,
dyslipidemia, diabetes mellitus, impaired renal function, obesity, physical inactivity, age
older than 55 years for men and 65 years for women, and family history of
cardiovascular disease.
Physical examination may reveal no abnormalities other than elevated blood
pressure. However, retinal changes and papilledema (swelling of the optic disk) may be
seen. Coronary artery disease with angina and myocardial infarction are common

consequence of hypertension. Increased in blood urea nitrogen and serum creatinine


levels may indicate pathologic changes in the kidneys. Cerebrovascular involvement
may lead to stroke or transient ischemic attack, manifested by alterations in vision and
speech, dizziness, weakness, a sudden fall, or transient or permanent paralysis on one
side (Smeltzer & Bare, 2010).
Hypertension (high blood pressure) is a sustained elevation of systemic blood
pressure to a level that places the patient at increased risk for target organ damage. It
has been called the silent disease because there may be no initial symptoms. When left
untreated, hypertension can lead to heart disease, kidney disease and stroke. There is
no cure; therefore lifestyle modifications and pharmacological therapy are necessary for
blood pressure (pressure against the flow of blood to or from the arteries or veins
outside the chest) control. Treatment of hypertension must continue throughout life,
making non-compliance a significant problem (Daniels, 2007).
Constant, excessive high blood pressure, called hypertension, can damage the
fragile inner lining of the blood vessels and cause a disruption of blood flow to the
tissues. It also puts a tremendous strain on the heart muscle, increasing myocardial
oxygen consumption and putting the heart muscle itself at risk. Hypertension can be
caused by neurostimulation of the blood vessels that causes them to constrict and to
raise pressure or by increased volume in the system. In most cases, its cause is not
known, and drug therapy to correct it is aimed at changing one or more of the normal
reflexes that control vascular resistance or the force of cardiac muscle contraction
(Karch, 2008).

Hypertension has no symptoms; it is difficult to diagnose and treat and is often


called as a silent killer. All of the drugs used to treat hypertension have adverse
effects, many of which are seen as unacceptable by otherwise healthy people. Nurses
face a different challenge trying to convince patients to comply with their drug regimens
when they experience adverse effects and do not see any positive effects on their
bodies (Karch, 2008).
If hypertension is controlled, the patients risk of cardiovascular and disease is
reduced. The risk of developing cardiovascular complications is directly related to the
patients degree of hypertension. Lowering the degree can lower the risk. The Seventh
Joint National Committee on Prevention, Detection, Evaluation and Treatment of
Hypertension, from the National Institute of Health, has established a stepped care
approach to treating hypertension that has proved effective in national studies (Karch,
2008).
The goal of hypertension treatment is to prevent complications and death by
achieving and maintaining the arterial blood pressure at 140/90mmHg or lower. The
medications used for treating hypertension decreased peripheral resistance, blood
volume, or the strength and rate of myocardial contraction (Smeltzer & Bare, 2010).
The classes of antihypertensive drugs include diuretics, sympatholytics and other
components of drugs. Diuretics can enhance the effects of other hypotensive drugs and
it reduces blood pressure if taken alone. Under of which includes three categories
thiazide, loop diuretics and potassium sparing diuretics. In thiazide diuretics, there are
two ways or mechanism to reduce blood pressure: reduction of blood volume and
reduction of arterial resistance. Loop diuretics promote vasodilation and reduce blood

volume. Potassium- sparing diuretics conserve the potassium in the body and balance
the potassium level. For the sympatholytics, there are five categories: beta blockers,
alpha blockers, alpha/beta blockers, centrally acting alpha2 agonist and adrenergic
neuron blocker. These subcategories have a common effect which is to suppress and
prevent sympathetic effects on the body by causing vasodilation to constricted arteries
(Lehne, 2007).
The drugs currently available for treatment of hypertension work in one of two
ways, reduction of the systemic vascular resistance (SVR) or decrease the volume of
circulating blood. Vasodilating drugs increase the diameter of the arterioles, by various
mechanisms. Pharmacological therapy usually begins with a diuretic. It is divided into
several classes: loop, potassium sparing, thiazide and aldosterone receptor blockers.
Diuretics promote the excretion of water (decrease the blood volume) and electrolytes
by increasing the renal GFR (Karch, 2008).
Drugs used to treat hypertension work to alter the normal reflexes that control the
blood pressure. Treatment for essential hypertension does not cure the disease but is
aimed to maintaining the blood pressure within normal limits to prevent the damage that
hypertension has caused. Not all patients respond the same way to antihypertensive
drugs, because different factors may contribute to each persons hypertension (Karch,
2008).

CHAPTER 2
According to Gottlieb (2000), most people with hypertension can lower their
blood pressures into safety zone without resorting to drugs. There are alternative
remedies presented that can bring blood pressure down to a healthier level. According
to Dr. Whitaker, the number one recommendation for hypertensive patients is water
remedy. Fifteen glasses of water a day is required for hypertensive patients because it
mimics the effects of medication. Water helps the entire system and arteries to relax.
Other alternatives are potassium-rich foods which lowers the level of sodium in the
body. Exercise at least four times a week within thirty minutes to decrease stress as well
as relaxes the artery walls and also increase the intake of fish oil, garlic, and
magnesium gluconate which is said to lower the blood pressure.

Smeltzer and Bare (2010) stated that studies show that diets high in fruits,
vegetables, and low-fat dairy products can lower elevated blood pressure. The Dietary
Approaches to Stop Hypertension (DASH) diet can lower blood pressure in people who
follow it. Lifestyle modifications to prevent and mange hypertension includes weight
reduction, adopt DASH diet, dietary sodium restriction, physical activity, and moderation
of alcohol consumption. Maintain a normal body weight with a body mass index of 18.524.9 kg/m2. Consume a diet rich in fruits, vegetables, and low-fat diet with a reduced
content of saturated fat and total fat. Dietary sodium intake should be no more than
100mmol/day or 2.4 g sodium.
According to Silverberg (1990), weight reduction, alcohol restriction, mild salt
restriction, eating a vegetarian diet and increasing aerobic exercise will generally lower
the blood pressure in patients with essential hypertension. Eating a diet rich in
potassium and reducing caffeine intake may also be helpful in reducing the pressure,
but increasing the fiber or calcium intake will generally be ineffective. Reducing fat
intake from the usual 40% of total calories to 25-30% may reduce hypertension directly
or by weight reduction. Smoking, when combined with excessive caffeine or alcohol
intake may have an additive effect on blood pressure. Monotherapy with such
behavioral techniques as self-monitoring of blood pressure, biofeedback, meditation,
yoga, progressive muscular relaxation or cognitive therapy may reduce the blood
pressure to a variable degree, and combinations of these treatments may be even more
successful.
A solid body of evidence shows that men and women of all age groups who are
physically active have a decreased risk of developing high blood pressure. Findings

from multiple studies indicate that exercise can lower blood pressure as much as some
drugs can. People with mild and moderately elevated blood pressure who exercises 30
to 60 minutes three to four days per week (walking, jogging, cycling, or a combination)
may be able to significantly decrease their blood pressure. In addition, blood pressure
increases when a person is under emotional stress and tension, but whether or not
psychological interventions aimed at stress reduction can decrease blood pressure in
patients with hypertension is not clear. Nevertheless, recent studies suggest that
ancient relaxation methods that include controlled breathing and gentle physical activity,
such as yoga, Qigong, and Tai Chi, are beneficial. People with mild hypertension who
practiced these healing techniques daily for two to three months experienced significant
decreases in their blood pressure, had lower levels of stress hormones, and were less
anxious. Also, the results of a recent small study suggest that a daily practice of slow
breathing (15 minutes a day for 8 weeks) brought about a substantial reduction in blood
pressure. However, these findings need to be confirmed in larger and better-designed
studies before these ancient healing techniques are recommended as effective nonpharmacological approaches to treating hypertension. Still, possible benefits, coupled
with minimal risks, make these gentle practices a worthwhile activity to incorporate into
a healthy lifestyle (webmd.com).
Bhatt (2007) stated that lifestyle modification, previously termed nonpharmacologic

therapy, has

an

important

role

in

hypertensive

as

well

as

nonhypertensive individuals. In hypertensive individuals, lifestyle modification is


recommended as initial therapy in stage 1 hypertension (for up to 12 months in those
without other risk factors and for up to 6 months in those with other risk factors) before

initiation of drug therapy and as an adjunct to medication in persons already on drug


therapy. In those with medication-controlled blood pressure, lifestyle modifications can
help reduce drug dosage or, in some cases, even stop drug therapy. In normotensives,
lifestyle modifications can reduce the incidence of hypertension and also lower endorgan damage. Non-pharmacologic measures should be part of routine management of
hypertension. It is emphasized that simple advice from physicians can have a positive
influence on patients' motivation to make lifestyle changes.
Enriquez (2004) said that there are alternative treatments on how to keep ones
heart healthy. This includes diet, exercise, stress management, and attitude. In the diet,
counting the calories and choosing healthy food can make ones heart stay healthy and
functioning. Medical science has shown that high levels of cholesterol, saturated fats
and homocysteine are detrimental to cardiovascular system and can result to heart
attack or stroke. On the other hand, regular physical and mental health benefits,
including a sound and healthy heart. Exercise does not need to be intense or long i9n
duration. As simple as brisk walking, it strengthens the cardiovascular system, helping o
protect a person from hypertension. Furthermore, stress management can have
beneficial effects on your heart. As long as one stays calm and relaxes, it lowers the
heart rate and blood pressure. And lastly, people with positive attitudes are healthier
than those with negative attitudes according to a study conducted by Dr. GrossarthMaticek in Heildelburg, Germany. Having a positive attitude controls intense emotions,
thus, controlling the heart rate and blood pressure.
Meditation has been applied to an array of both healthy and harmful activities
that is hard to get consistent agreement about its impact on health. It offers a wide

range of practices to take away stressful events. It also helps in relaxing the body that is
overworked. Sitting comfortably, focusing on thoughts, minimizing distractions, and
focus on own breathing are forms of meditation. To some extent, with practice people
can consciously relax the muscle and learn to control other bodily functions which are
not usually under their control. Clinical studies have shown and confirmed that
meditation can provide short-term results in reducing stress, relieving pain, and
reducing blood pressure (Mathuna & Larimore, 2001).

CHAPTER 3
The classes of antihypertensive drugs include diuretics, sympatholytics and other
components of drugs. Diuretics can enhance the effects of other hypotensive drugs and
it reduces blood pressure if taken alone. Under of which includes three categories
thiazide, loop diuretics and potassium sparing diuretics. In thiazide diuretics, there are
two ways or mechanism to reduce blood pressure: reduction of blood volume and
reduction of arterial resistance. Loop diuretics promote vasodilation and reduce blood
volume. Potassium- sparing diuretics conserve the potassium in the body and balance
the potassium level. For the sympatholytics, there are five categories: beta blockers,
alpha blockers, alpha/beta blockers, centrally acting alpha2 agonist and adrenergic
neuron blocker. These subcategories have a common effect which is to suppress and

prevent sympathetic effects on the body by causing vasodilation to constricted arteries


(Lehne, 2007).
However, long-term adherence or compliance with antihypertensive drug therapy
is poor. It has been estimated that within the first year of treatment 16-50% of
hypertensive discontinue their anti-hypertensive medications. Even among those who
remain on therapy long term, missed medication doses are common. Epidemiological
studies have shown that drug-treated hypertensive have higher blood pressures than
age, gender and body mass index-matched normotensives. In addition, drug treated
hypertensive men and women who achieve blood pressure normalization are less likely
to die over a 9-5-year period than those whose blood pressure remains elevated while
taking anti-hypertensive drugs. Thus, one reason for less than optimal reduction of
blood pressure-related cardiovascular-renal risk in drug treated hypertensive is
inadequate blood pressure lowering. Side effects that are perceived as secondary to
anti-hypertensive medication have correlated with non-adherence to anti-hypertensive
drug regimens in several previous studies. Thus, the magnitude of expected medication
side effects should be an important consideration when prescribing anti-hypertensive
drug therapy. It can be difficult to know, at least with any degree of confidence, if side
effects occurring during anti-hypertensive drug therapy are actually caused by the
prescribed medications because there is overlap between clinical symptoms attributable
to hypertension and drug-induced side effects. Some of the side effects of hypertension
medications can be life-threatening, so it is important to consider the possible side
effects when choosing a course of treatment for hypertension. Not all medications are
right for everyone (Flack, 1996).

Bhatt (2007) stated lifestyle modifications can help reduce drug dosage or, in
some cases, even stop drug therapy. In normotensives, lifestyle modifications can
reduce the incidence of hypertension and also lower end-organ damage. Nonpharmacologic measures should be part of routine management of hypertension. It is
emphasized that simple advice from physicians can have a positive influence on
patients' motivation to make lifestyle changes. In addition, these non-pharmaceutical
approaches have a proven efficacy in the reduction and prevention of high blood
pressure. But they require substantial perseverance and will-power to comply with. You
should know how much effort is required to follow dietary restrictions or to stop smoking
recommendations.

Low

compliance

with

these

recommendations

is

usually

accompanied by low compliance with drug therapy. For people who want to be healthy
and prevent or at least control this dangerous disease, there is good news. Nonpharmaceutical recommendations really work according to Alifimoy (2005) because it
will definitely reduce your risk of having hypertension by following them.
However, Ramsay (1994) said that hypertensive patients may be shifted from just
above some arbitrary intervention level to just below it by non-pharmacological
treatment, and the perceived benefits of non-pharmacological management may be
offset by an increased risk of vascular complications related to suboptimal blood
pressure control. Moreover even simple measures such as moderate sodium restriction
may affect some aspects of quality of life adversely. Non-pharmacological measures
should generally be regarded as useful adjuncts to antihypertensive drug therapy rather
than alternatives to it.

CONCLUSION
The study was about the two interventions used in the management of
hypertension. The two interventions were compared as for the nature of the treatment
plan and its advantages and disadvantages. Based on the gathered data, the
researchers concluded that non-pharmacologic intervention is more effective compared
to pharmacologic intervention in the management of hypertension. Bhatt (2007) stated
that lifestyle modifications can help reduce drug dosage or, in some cases, even stop
drug therapy. These lifestyle modifications include the DASH diet, weight reduction,
smoking cessation, and active lifestyle shows significant decrease in having the risk
factor of having hypertension (Smeltzer and Bare, 2010). In connection, Bhatt (2007)
said that these non-pharmaceutical approaches have a proven efficacy in the reduction

and prevention of high blood pressure. But they require substantial perseverance and
will-power to comply with. In non-pharmacological approach, it will not offer any side
effects affecting the body unlike in the pharmacological approach. Eventhough that
pharmacologic therapy offers direct reduction of blood pressure, the medication itself,
still causes other side effects.
According to Flack, (1996), side effects that are perceived as secondary to antihypertensive medication have correlated with non-adherence to anti-hypertensive drug
regimens in several previous studies. Thus, the magnitude of expected medication side
effects should be an important consideration when prescribing anti-hypertensive drug
therapy. Some of the side effects of hypertension medications can be life-threatening,
so it is important to consider the possible side effects when choosing a course of
treatment for hypertension. Furthermore, non-pharmacological intervention in the
management of hypertension does not have any side effects, thus, it is safe. In addition,
relaxation techniques such as meditation is effective in lowering the blood pressure
because it will relax the muscle and learn to control other bodily function which provide
results in reducing blood pressure without any unnecessary discomforts (Mathuna &
Larimore, 2001).

Reference List:
Alfimov, A. (June 18, 2005). Five secrets of high blood pressure treatment.
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Complementary alternative treatments for hypertension. Retrieved February 12,
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Daniels, R et.al. (2007).

Contemporary medical-surgical nursing . USA:

Thompson Corp.
Enriquez, C. C. (2004). The healthy life. United States of America: Whitaker
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Flack, J. et al. (1996). Side effects of hypertensive medications. Retrieved
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Lehne, R. (2007). Pharmacology for nursing care. Canada:Elsevier Inc.
Mathuna, D. O., & Larimore, W. (2001). Alternative medicine: The Christian
handbook. Michigan: Zondervan Publishing House.
Ramsay, L. et al.(1994). Non-pharmacologic management as adjunct to
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