AHA声明：替代疗法或有助于降压

　　《高血压》杂志(Hypertension)4月22日发表的美国心脏协会(AHA)科学声明显示，某些替代疗法(特别是有氧运动和抗阻训练)有助于降低血压，可以考虑作为高血压标准饮食和药物治疗的辅助手段。此外，虽然支持生物反馈技术、等量握拳运动和仪器引导缓慢呼吸的证据强度不高，但这些方法也可能有效地小幅降低血压。对于冥想、瑜伽、放松疗法、减压技术、针灸等其他替代疗法，到目前为止所获得的证据还不足以支持其作为高血压的辅助治疗。

　　作为这份AHA科学声明起草委员会的主任，美国密歇根大学的Robert D. Brook博士及其同事称，这份声明旨在“评估支持多种替代疗法降压效果的最新研究证据”。该声明还为临床医生提供了实用的推荐意见，以便其将这些替代疗法用于临床实践当中。

Robert Brook博士

　　Brook博士及其同事对过去6年内发表的文献进行了回顾性分析，找到了124项有关行为疗法的研究，105项涉及无创操作和仪器的研究，还有773项基于运动锻炼的降压方案研究。

　　这些研究的总体质量不太高，以观察性研究为主，即便是临床随机试验往往也存在随机方法不完善、对照组的使用不理想、样本量小、随访时间短等问题。而且，许多研究还存在选择、依从以及其他偏倚。

　　总的来说，起草委员会发现“血压高于120/80 mmHg的所有患者都应该考虑尝试替代疗法，将后者作为辅助降压手段”。不过，由于目前还没有一种替代治疗方案能可靠地将血压降低≥20/10 mmHg，因此“需要达到这一降压幅度的患者应该先接受合理的药物治疗策略，之后再采用替代疗法”。“还要强调的是，大部分替代疗法只能将收缩压降低2~10 mmHg。因此，只有那些血压仅比正常值高10/5 mmHg的少数患者可以只采用这些替代治疗方案来实现达标。”

　　Brook博士及其同事指出，在所有替代疗法中，支持动态有氧运动降压效果的证据强度是最高的，而且有氧运动也最有可能改善其他心血管健康因素，比如血脂水平和血糖水平。“大量观察性队列研究还表明，有氧运动降低心血管风险的作用可能呈剂量依赖性。”因此，这份声明称有氧运动“应被视为辅助降压的主要替代治疗方法”。

　　支持抗阻训练降压效果的证据强度也较高，而且还与其他心血管效益相关，因此“也被强烈推荐”。大部分患者“都应该将有氧或抗阻运动(单个或联合)作为首选的替代疗法，除非存在禁忌证或者不愿意或不能运动”。

　　如果有氧或抗阻运动的降压效果还不够，临床医生下一步可以考虑建议患者接受仪器引导缓慢呼吸或等量握拳运动。与剩余的其他替代疗法相比，这两种方法的降压效果支持证据更强，在实际生活中也更加实用。

　　支持生物反馈降压效果的证据强度为中度。

　　研究者表示，目前还不能确定应该尝试替代疗法多久临床医生才能确定其是否有效。“不过，3个月是比较合理的，因为在这些研究中大多数替代疗法都是在3个月内就表现出了降压效果。”

与血压相关的拓展阅读：

• Stroke：超高龄患者的运动和认知能力影响对血压与卒中之间的相关性
• Lancet：利尿剂并不是对肥胖高血压患者合理的治疗方案
• JAMA：常用高血压药物能造福更多心衰患者
• 良好的血糖和血压控制有益于延长糖尿病患者生存期
• 高血压患者治疗时HDL低预示新发糖尿病风险更高
• 未控制高血压仍为急性主动脉夹层最显著危险因素
更多信息请点击：有关血压更多资讯

Alternative therapies may help lower blood pressure
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.
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. {nextpage}
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.