Nonpharmacological Treatment of Hypertension
Alvin P. Shapiro
University of Pittsburgh School of Medicine
The health benefit from lowering blood pressure in hypertensive patients has been a major clinical research accomplishment of the last four decades. In the late 1940s and 1950s, the efforts were primarily diagnostic and therapy was limited to reassurance, hope, and prayer. Pharmacological studies at that time were concerned with evaluating ac ute effects of potent drugs such as the ganglionic blocking agents and the veratrum alkaloids and their applications to therapy were limited because of their potent side effects. High blood pressure reduction, with such drastic measures as fever therapy and sympathectomy, were employed in some severe situations as well as nitrates, orally and parenterally. Clinics did follow hypertensive patients closely and were impressed bY the variability of blood pressure and by the value of supportive therapy-mainly reassurance, hospitalization, and lifestyle changes- in reducing blood pressure and even occasionally reversing or delaying consequences of the disease. Reiser, Rosenbaum, and Ferris (195 l), in fact, reported a small group of patients in whom malignant hypertension was ameliorated in this fashion, at least for a brief period of time. Nonpharmacological therapy was the order of the day, by default, because specific drugs to treat hypertension were not available. Indeed, it was preferable to speak of the drugs that began to emerge in the 1950s as “hypotensive” agents and not as “antihypertensive” drugs.
Pharmacological therapy of malignant hypertensionake progress in the 1950s with the advent of combinations of long acting ganglionic blocking agents, the vasodilator drug hydralazine, and the diuretics of the thiazide genre. With these agents, the malignant phase of the disease could be reverted to a more benign course, but their use in the more modest forms of hypertension and in those with mild disease was inhibited by their disturbing side effects, which interfered in many ways with patient comfort and lifestyle. Orthostatic symptoms, difficulty in urination, constipation, headaches, impotence- both libidinous and erectile failure -were all very real problems in their use. And, although these could be tolerated in patients with the malignant and most severe phases of hypertension, it was difficult to justify their administration in the asymptomatic mild hypertensive. There was uncertainty as to whether life expectancy was shortened even in the individual with modest degrees of hypertension (i.e., diastolics of 100 to 115 mm Hg) and it was generally felt that with mild hypertension (i.e., diastolics of 90 to 105 mm Hg) who constituted about two thirds of the hypertensive population, the risk of death and even of significant morbidity was minimal. Accordingly, it was justifiable to view this approach with reassurance and supportive therapy, often accompanied by admonitions for weight control and a low salt diet as a method of management. These measures did result in significant lowering of blood pressure, as shown for example in studies from the 1951 group in Cincinnati (Reiser et al., 195 1). Beyond the supportive therapy that was offered to patients, there were reports of significant lowering of blood pressure with more extensive psychotherapy, including psychoanalysis. These now historic events illustrate that the idea of treating hypertension with behavioral techniques is not a new concept, but rather one that physicians relied on before the advent of current pharmacological treatment.
Research has come full circle over the last 30 years. Pharmacological therapy first showed its value in the nonmalignant