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Fast dose titration leads to controlled blood pressure.

Rapid dose titration is said to lower blood pressure better than using the traditional method of adjusting dosage over several months. The dosage adjustment is made at a hypertension clinic where the patient is seen for 3–4 days. Home BP measurement is an important part of the treatment plan.

Application of Project ImPACT in the Pharmacy

Time Management: Many community pharmacists are now saying: “Sounds wonderful, but who has the time?” Not surprisingly, two critical, time-saving components in this study of care in the pharmacy were scheduling patient appointments and staffing. The average time spent with patients on their initial visit was 45 minutes (range 30–60 minutes), and that on follow-up visits was 22 minutes (range 10–30 minutes). No doubt pharmacists found ways to streamline these visits as they gained experience. Furthermore, these visits were often arranged by appointment, during mid-afternoons, early evenings and other slow times in the pharmacy. Additionally, pharmacists learned to organize the time they had available and to be creative in integrating the service into the flow of the pharmacy department. Pharmacists can also make optimal use of pharmacy technicians. For example, technicians can be taught to obtain the lipid profile with the desktop analyzer and provide the results to pharmacists for interpretation and counseling.

The Collaborative Care Model: In order for pharmacists to be effective purveyors of health education, disease prevention, and disease management, both they and physicians need to fully understand and embrace a collaborative care model. Collaboration means just that…working together to achieve common goals for the patient. This model deploys pharmacists to help support, encourage, and carry out physician-prescribed care. It does not replace the physician nor supplant his/her care plan. It takes full advantage of the pharmacist’s skill level, service capacity, and extensive know-ledge base. Unfortunately, as the healthcare market becomes more competitive and restrictive, primary care physicians could feel threatened by the pharmacist’s collaborative services. This happened in some cases during the early days of Project ImPACT. But initial suspicion quickly turned to strong professional support once physicians experienced first-hand how the pharmacists’ collaborative services complemented their own. Given the alarming number of hypercholesterolemic patients and their undertreatment, attention given to helping patients persist and comply with therapy is desperately needed to successfully manage this debilitating disease state.

Communication Links: The success of the collaborative care model concept depends upon quick, efficient dissemination of information. During the study, pharmacists recorded their findings and recommendations at the conclusion of each patient’s visit and transmitted this information via phone calls and faxes to the patient’s physician. Ideally, this communication should take place electronically and the feasibility of an electronic health record is being explored. Such a computerized record is envisioned to contain personal, claims transaction, clinical encounter, and quality event data. If a community pharmacy could electronically link itself with healthcare providers, a seamless flow of patient care information between pharmacists and physicians could truly be accomplished.

Opportunities for Reimbursement: An important extrapolation from this study is the issue of reimbursement for services. Even though reimbursement was not a study measure, participating pharmacists were encouraged to place a value for their services and either charge patients directly or seek compensation from third parties. The results were encouraging. An average assigned value per visit was $55; counseling services were $28 and lipid profiles were $27. Of the 232 patients who were asked for payment, 174 (75%) paid an average of $35 per visit. Of the 121 third party payers billed for services, 64 (53%) paid an average of $30 per visit. Compensation was more frequently received for lab services (i.e., the lipid profile) than counseling services, but as third parties learn more about the impact of pharmacists’ consulting services, interest in compensating pharmacists based on successfully maintaining patients at their treatment goal has grown. Interestingly, two project sites executed contracts with managed care organizations to deliver services to their health plan beneficiaries — one a fee-for-service arrangement and the other capitation. Therefore, the collaborative care model presents real opportunities for financial compensation, especially if it is successful in helping patients attain and maintain their treatment goals.

Discussion

Project ImPACT: Hyperlipidemia offers a contemporary view of the importance of pharmacists as providers of health promotion, disease prevention, and disease management. Pharmacists are in a unique position to support and empower patients to achieve therapeutic outcomes in the management of hypercholesterolemia and various other disease states. Pharmacists are ideally positioned to make the collaborative practice model work because of: 1) the growing self-care movement in which patients are taking increasing responsibility for their health, including asking more questions of all healthcare providers; 2) their accessibility to both patients and providers; 3) their ability to provide an advanced level of care; 4) their information management capabilities; 5) their motivation to expand care; 6) their education and training in the area of patient-focused disease management services; and 7) their understanding of how to be a team player.

The results of Project ImPACT should not be underestimated. In spite of effective treatment, which has been proven to reduce coronary artery disease events, most patients with a high CHD risk are not receiving treatment and those who are, are not being treated to goal. This project demonstrates that collaborative care provided by a community pharmacist can have a dramatic impact on treatment success. Project pharmacists produced a two- to four-fold improvement over existing systems in getting hyperlipidemic patients to treatment goals. There is nothing in the literature quite as powerful as these results. Not even interventions aimed at improving the impact of physicians themselves have been as successful. This project unquestionably presents pharmacists with a huge opportunity. The challenge is to take the next step.

Patients are not the only beneficiaries of pharmacists’ collaborative care — so are the pharmacists. Pharmacists involved in Project ImPACT were highly satisfied with their own professional role and 85% rated their relationship with patients very satisfying. The majority of project pharmacists also perceived that their patients and physicians highly valued their services. Perhaps even more telling is that the majority of pharmacists participating in the project (25 of the 26 sites) indicated that they planned to continue to provide these services.

Conclusion

Lipid-lowering goals are difficult to attain for patients with hyperlipidemia. A collaborative care approach that involves pharmacists in community settings working together with primary care providers to support and encourage patients can be instrumental in getting patients to their lipid goals. Project ImPACT offers a sound model for pharmacists. At the end of the day, involvement by pharmacists with hyperlipidemic patients presents a win-win situation: an enhanced quality of life for the patient and improved job satisfaction for the pharmacist.

Project ImPACT: Hyperlipidemia

Project ImPACT: Hyperlipidemia is a recently completed community pharmacy-based demonstration project. ImPACT is an acronym for Improve Persistence And Compliance with Therapy. The study began in March 1996 and concluded October 1999. There were four core objectives: 1) improve patient persistence and compliance with lipid-lowering therapy; 2) increase communication and the flow of clinical information among patients, pharmacists, and physicians; 3) improve the cholesterol levels of individual patients over time; and 4) increase the population of patients who reach and maintain their NCEP lipid goals.

A total of 26 pharmacy practice sites in 12 states participated in the study. These sites were chosen based on criteria that addressed the readiness of the pharmacy to provide basic pharmaceutical care services. Readiness was determined by the availability of a private or semiprivate area for patient consultation; technician support; a documentation system for recording, tracking, and reporting patient care interventions; experience with patient-focused disease state management programs; demonstrated communication skills; and the ability to implement point-of-care testing technologies. Fourteen of the pharmacies were independent, three were professional chain stores, one was a chain grocery, two were home health stores, four were clinic pharmacies, and two were managed care or health maintenance organization pharmacies.

Patients were identified through referrals by local physicians, project pharmacists, other healthcare providers, or by self-referral. They were either newly diagnosed with hyperlipidemia or already receiving lipid-lowering drugs but not yet at their target lipid goal. A fasting lipid profile was performed using the LDX Analyzer (Cholestech, Hayward, CA), which requires only a fingerstick blood sample, and results were obtained within five minutes. Initiation of lifestyle modification and pharmacologic therapy was then undertaken by the patient’s physician based on the lipid results. Pharmacists communicated clinical progress — in the areas of cholesterol test results, current health status, coronary artery disease risk, and NCEP goal achievement — to the patients as well as their physicians. Patients were seen monthly for the first three months and quarterly thereafter, and fasting lipid profiles were obtained during each visit. The practice archetype designed for the project was a collaborative care model that allowed flexibility in staffing and types of resources available at the various participating pharmacies. This practice model also established a process for the seamless flow of care data between the patient, pharmacist, and physician. And most importantly, the collaborative care structure organized methods for pharmacists to document, interpret, and report their lipid management interventions.

One of the endpoints of this study, persistence, was defined as a patient who started on medication during the study and remained on the medication as of his or her last study visit. A second study endpoint, compliance, was determined through an evaluation of the number of missed doses for each lipid-lowering medication and of refill timing. Any patient who missed five or more days of medication or who missed a scheduled refill visit by more than five days was judged to be noncompliant for that visit. Compliance as a percentage was calculated by dividing the number of visits at which patients were compliant by the total number of patient visits.

Results: A total of 574 patients were enrolled in the study. Of the 397 patients who completed the two-year study, 345 (86.9%) patients were treated with lipid-lowering medications and lifestyle modifications. The remaining 52 patients (13.1%) focused on lifestyle modifications only (diet and exercise) in an effort to reach target cholesterol goals. The distribution of lipid-lowering drugs used was 89% statins, 5% niacin, 4% fibrates, and 2% bile acid resins. Of the 345 patients started on medication, the medication persistence rate was 93.6%. Of the 2,817 documented visits for patients on medication, the per-visit medication compliance rate was 90.1%. Average fasting lipid levels for patients at the beginning and end of the study are shown in Table 2.

In the primary and secondary prevention groups, NCEP goal achievement at the end of the study was 67.4% and 47.5%, respectively. Furthermore, 248 of all 397 patients (62.5%) were at or below goal as of their last full lipid profile, representing up to a 100% improvement over goal-attaining rates reported in the literature (Figure 1). Finally, of the 346 pharmacist-recommended interventions, physician acceptance of their recommendations was 76.6%.

Figure 1

Persistence, Compliance, and Treatment to NCEP Goal in Dyslipidemic Patients (N=397)

There was a time when heart disease was considered a “man’s disease.” However, we now know that women are just as likely to be afflicted, especially after reaching the age of menopause. Coronary artery disease (CAD) is the number one killer of American women and men. Another way to interpret this startling statistic is that about every 29 seconds an American will suffer a coronary event, and about every minute someone will die from one. CAD is also the leading cause of premature, permanent disability in the United States labor force. The direct and indirect cost of coronary artery disease for the year 2000 was estimated at $118 billion.

Risk Factors for coronary artery disease

Many risk factors are involved in the development of CAD. Age, gender, smoking history, physical inactivity, obesity, hypertension, family history of premature coronary artery disease events (e.g., heart attack), diabetes, and cholesterol level are among the most important. Whereas a person cannot control his or her age, gender, or family history, he or she can control tobacco use, amount of physical activity, weight, blood pressure, blood sugar, and blood cholesterol levels. Of these, controlling cholesterol levels may be among the easiest, given the efficacy of the cholesterol-lowering drugs currently available. The second report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II) affirms that an elevated low-density lipoprotein (LDL)-cholesterol level significantly increases the risk of CAD, and therefore makes its reduction a primary target for controlling hyperlipidemia. Close to 100 million American adults have borderline or high cholesterol levels. Furthermore, more than 50 million adults have an LDL-cholesterol level that is high enough to qualify them for treatment. Desirable LDL-cholesterol levels based on risk factors and primary and secondary prevention status can be found in Table 1.

Lowering Cholesterol Levels

The primary key to reducing cardiovascular morbidity and mortality in patients with clinically apparent coronary artery disease — as well as in patients without CAD — is to lower elevated LDL-cholesterol levels. Clinical trials have conclusively demonstrated this. Additionally, patients with low HDL-cholesterol also have a high CAD risk. Recent clinical trials in these patients also demonstrate that reducing LDL-C will reduce coronary artery disease events. These trials all point to the same conclusion: lowering elevated LDL-C levels to treatment goals reduces heart attacks and other CAD events.

One pharmacological approach that is highly effective in lowering LDL-cholesterol is the use of “statins” — HMG-CoA reductase inhibitors (e.g., atorvastatin/Lipitor, cerivastatin/Baycol, fluvastatin/ Lescol, lovastatin/Mevacor, pravastatin/Pravachol, and simvastatin/Zocor). The Scandinavian Simvastatin Survival Study Group (4S) was one of the first studies designed to test the hypothesis that lowering cholesterol with a statin would improve survival of patients with coronary artery disease. The results were impressive: Over 5 years, simvastatin significantly reduced LDL-cholesterol levels, and increased HDL-cholesterol levels, as compared with placebo. The 6-year probability of survival in the simvastatin group was 91.3% compared to 87.6% for those patients on placebo, but there was a 42% reduction in coronary deaths, which accounted for the improvement in survival. Subsequent randomized, placebo-controlled trials with other statins have showed that reducing LDL-cholesterol significantly decreased risk of CAD events in both primary and secondary populations.

Treatment and Compliance Issues

Despite the clear demonstration that lowering LDL-cholesterol improves cardiovascular risk, most adults who are eligible for cholesterol-lowering therapy do not receive it, including over half of those who qualify for drug therapy. The discouraging statistics continue. The compliance rate for patients with hyperlipidemia, even those with clinically apparent coronary artery disease, is dismal — only 40% to 60% remain on their lipid-lowering medication therapy after one year. As any good pharmacist knows, it does not matter how well drug studies are performed, how conclusive their results, or how superior a drug may be; if the patient does not swallow the pill it will not make a difference. Furthermore, too often studies do not address compliance issues; compliance is taken for granted. A recent study asked whether compliance rates reported in clinical trials reflect rates in primary care settings. Not surprising to healthcare providers, the answer was an emphatic “No.” Discontinuation of medications is much less in clinical trials than in routine practice.

In addition to the undertreatment of hyperlipidemia and noncompliance with antihyperlipidemic medication, there is a third area of concern — the number of patients taking lipid-lowering agents who are not reaching treatment goals. In primary care settings, successful attainment of NCEP goals ranges from only 8% to 38%.These numbers are disheartening. Even if patients could be appropriately identified for treatment and receive appropriate intervention, they will not obtain the full therapeutic benefit if they do not comply with therapy. What can be done? What healthcare professional can make an impact in these three troubling areas? Answer: the pharmacist.

Patient Counseling
Pharmacists can take on a variety of roles in the management of lipid disorders. Several reports have described pharmacists’ involvement in the management of dyslipidemias. Particularly in the community setting, pharmacists are uniquely positioned to assist with screening, managing, and educating patients with lipid disorders. Typically, pharmacists’ activities include interviewing patients to assess medical histories, ascertaining risk factors and other pertinent information, assessing lipid profiles, tressing the treatment, and providing patient education and follow-up.

Hypertension and Diabetes Risk Factors in the African American Population
The high prevalence of hypertension and diabetes in African Americans increases their risk for CHD. The presence of cholesterol abnormalities (i.e., increased LDL, triglycerides, and decreased HDL) in conjunction with these two major risk factors puts this population at an even greater risk for cardiovascular morbidity and mortality. It is imperative that pharmacists recognize this population as one requiring special considerations with regard to monitoring and counseling. Hypertension appears to increase with the prevalence of certain lifestyles. In the rural South (as well as in other areas), certain cultural food preferences still exist. For example, chitterlings, salt back, pickled pig parts, fat back, sweet potato pie, and boiled peanuts are major components of many African American diets. Many of these foods are high in fat and sodium, and low in potassium. Diets high in fried foods and low in fruits, vegetables, and grains pose significant challenges for the patient with dyslipidemia, making lifestyle modifications more critical. The assistance of a dietitian may be particularly useful for recommending low-fat, low-sodium alternatives to the patient.

To prevent hypertension, African Americans should increase consumption of high-potassium foods (such as fresh fruits and vegetables), use low-fat dairy products, and avoid salt. The Dietary Approaches to Stop Hypertension (DASH) diet is particularly effective in significantly lowering high blood pressure in African Americans. This diet is low in cholesterol, high in dietary fiber, potassium, calcium, and magnesium, and moderately high in protein, and has been shown to lower blood pressure even when an individual’s weight and salt intake remained constant. One major obstacle facing many African Americans in the treatment of hypertension, is the cost of medications. Many of the newer medications are more effective and have fewer side effects than older medications, but they are costly. In addition, many African Americans do not receive proper medical care until hypertension has been present for some time. This results in otherwise avoidable damage to the kidneys and other organs. It may also account for the high rate of hypertension-related morbidity and mortality that exists among African Americans.

It should also be taken into consideration that African Americans tend to respond differently than other populations to treatment for high blood pressure. Because African Americans experience higher rates of diabetes, renal insufficiency and heart failure, they may benefit more from aggressive treatments to lower blood pressure.

Conclusion
Dyslipidemia is a major risk factor in the development of coronary heart disease. This risk factor, as well as other risk factors, can be altered through pharmacologic, dietary and other lifestyle modifications. Cultural norms affecting health among African Americans do exist and should not be overlooked by healthcare providers. Increased awareness by the pharmacist and the use of culturally sensitive information and materials can greatly enhance patient understanding and adherence to the prescribed regimen.
Pharmacists have a responsibility to assist in the management of lipid disorders. This can be accomplished by developing individual or collaborative practices in various healthcare settings. Pharmacists interested in strengthening their skills in this area can enroll in courses offered by several organizations.

Heart disease is the leading cause of death among adults in the United States. Specifically, coronary heart disease (CHD) is the single largest killer of American males and females. Seven million Americans suffer from CHD, and about a half million people die each year from heart attacks caused by CHD. One out of two men, and one out of three women will develop heart disease sometime in their life. CHD is also the leading cause of death among African Americans, affecting this population disproportionately when compared to whites. In 1996 CHD death rates were 120.2 per 100,000 for white males, 125.4 for black males, 58.9 for white females, and 80.0 for black females. For those aged 35–74, the age-adjusted death rate from CHD for black women is nearly 72% higher than that of white women.

Both epidemiologic and clinical trials have documented the prevalence of lipid disorders, and have proven that elevated levels of low-density lipoprotein (LDL) cholesterol and decreased levels of high-density lipoprotein (HDL) are associated with an increased risk of CHD. (Pharmacists should be aware that certain diseases and medications are also capable of affecting cholesterol levels. Therefore, patient medication profiles and medical histories should be reviewed thoroughly to rule out these possible secondary causes of dyslipidemia.) In addition to elevated cholesterol, other risk factors for CHD have been identified:

• Age: Male 45 years or older; female 55 years or older, or experiencing premature menopause without estrogen replacement therapy
• Family history: History of premature CHD (definite myocardial infarction or sudden death before age 55 in father or other male first-degree relative, or before age 65 in mother or other female first-degree relative)
• Current cigarette smoking
• Hypertension (blood pressure 140/90 mmHg or greater) or taking antihypertensive medicine
• Diabetes mellitus

Management of Elevated Cholesterol
The National Cholesterol Education Program (NCEP) of the National Heart, Lung and Blood Institute (NHLBI) has established guidelines for the prevention and treatment of lipid disorders. According to the NCEP guidelines, all patients at least 20 years of age should have an initial cholesterol measurement. It is recommended that the initial laboratory test measure both total and HDL cholesterol. The American Diabetes Association (ADA) recommends that diabetic patients receive a complete lipid profile (i.e., LDL, HDL and triglycerides) annually. Further evaluation of the patient is based on the results of these initial tests. The goals of lipid-lowering interventions vary depending on whether the focus is primary or secondary prevention of CHD. In primary prevention the goal is to prevent the onset of CHD; secondary prevention focuses on avoiding further CHD events. Treatment should be modeled after NCEP recommendations. These guidelines include nonpharmacologic, lifestyle modifications (e.g., diet, exercise, smoking cessation), and pharmacologic measures. Table 1 outlines the LDL treatment goals based on the number of CHD risk factors present.

Lifestyle Modification: Dietary therapy is the first line of treatment for elevated cholesterol levels. NCEP recognizes dietary modification as the cornerstone in the management of dyslipidemia. The general goal of dietary therapy is to reduce elevated serum cholesterol while maintaining a nutritionally appropriate eating pattern. A reduction in saturated fat and cholesterol in the diet, as well as regular physical activity, are two important lifestyle changes that pharmacists must emphasize to patients. Dietary therapy is a two-step process. Step I begins the process of reducing intake of saturated fat and cholesterol. The diet should involve an intake of 10% of total calories from saturated fat, 30% or less of calories from total fat, and 300 mg or less of cholesterol per day (Table 2). If the goals of therapy are not achieved with Step I, patients should be advanced to the Step II diet. Step II requires further reduction in saturated fat and cholesterol. For this step, a registered dietitian should assist with management.

Both physical activity and weight reduction are considered essential components in the nonpharmacologic management of elevated serum cholesterol. A program of physical activity for at least 20 minutes three times weekly provides significant cardiovascular benefit. The benefits of physical activity include an increase in HDL and a decrease in weight, especially for obese and overweight patients. It may also lead to a reduction in triglyceride levels. Patients should be advised to consult their physician prior to initiating an exercise program.
Smoking cessation should also be encouraged. Pharmacists should have information available, and be able to direct patients to local smoking cessation programs. They should be knowledgeable about the various smoking cessation aids available (e.g., nicotine gum and patches).

Pharmocologic Measures: The goal of drug therapy is to reduce the LDL cholesterol to below 160 mg/dL or to below 130 mg/dL if two other risk factors are present. Drug therapy is considered for the adult patient who has an LDL cholesterol level of 190 mg/dL or greater without two other risk factors; or 160 mg/dL or greater with two other risk factors. Table 3 outlines the NCEP guidelines for treatment, and Table 4 summarizes patient counseling information specific to each lipid-lowering agent available.

Suspicious? Resentful? Cynical?

If those three words describe your personality, you may have more of a problem than just the lack of friends. Researchers at Arizona State University in Tempe have proven that people with hostile dispositions also have greater increases in diastolic blood pressure (the second number in a blood pressure reading).

A higher diastolic pressure means that the vessels in the body are under increased pressure even when the heart is between beats, a situation than can contribute to heart disease and stroke.

At the beginning of the study, the researchers designated 80 males and females as either high or low in hostility after taking a test measuring their suspiciousness, cynicism, mistrust, and resentment. Then each volunteer participated in a one-on-one discussion of capital punishment with a person who was trained to remain calm while presenting a point-of-view that disagreed with the volunteer’s.

The blood pressure of those who had been categorized as high-hostile began rising even before the conversation started, and they continued to have higher blood pressure readings than those categorized as low-hostile. This could mean, according to researchers, that people with hostile attitudes have high levels of mistrust and anticipate trouble in interpersonal relationships—even before they have proof that there is reason for suspicion.

Another factor that raised blood pressure of the people in the high-hostile group, according to researchers, was the need to control the situation between the person conducting the conversation and themselves.

Men and women whose scores placed them in the high-hostile group had similar increases in blood pressure.

Researchers examined the attitudes of nearly 1,100 men. The investigators from Brown University School of Medicine in Providence, Rhode Island, found that those with hostile attitudes were more likely to be overweight, especially in the upper part of the body which is a greater risk factor for heart disease than extra weight carried in the hips and legs. The subjects also were more likely to exhibit insulin resistance, often a precursor of diabetes.

A hostile attitude in this second study also appeared to be linked to lower income and educational status.

Systolic blood pressure should be considered “the major criterion for diagnosis, staging, and therapeutic management of hypertension, especially in middle-aged and older Americans”, according to a clinical advisory issued by Coordinating Committee of the National High Blood Pressure Education Program (NHBPEP).

“We’ve been focusing on diastolic through the years, but we now know that systolic blood pressure is a better predictor of future cardiovascular events such as heart attacks, strokes, and heart failure, and that treating it reduces those risks,” says Dr. Edward Roccella, NHBPEP coordinator.

“As people age, there’s a tendency for systolic blood pressure to rise, while diastolic pressure declines [after age 55]“, he explains. This is related to arteriosclerosis, a stiffening of the arteries that accompanies ageing, and may lead to increased blood pressure. “We used to think [increasing blood pressure] was a natural part of ageing. That gave rise to the erroneous belief that a systolic BP of 100 plus your age was acceptable.” Regardless of age, the Sixth Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommended blood pressure (BP) goal is 140 over 90 mm Hg; achieving it may be a long-term challenge for older people.

Because diastolic BP tends to fall in older people, its predictive and diagnostic capabilities in that population are greatly reduced compared with systolic BP. For instance, the proportion of participants in the NHLBI’s Framingham Heart Study correctly identified as candidates for antihypertensive therapy was 91% using systolic BP alone, compared with 22% using only diastolic pressure. The diagnostic power was further increased in people over 60.

Isolated systolic hypertension (ISH) (systolic 140 mm Hg or above, diastolic less than 90 mm Hg) is the most common form of high blood pressure, note advisory authors. About two-thirds of hypertensive people over age 60 have isolated systolic hypertension, yet less than a quarter of hypertensive Americans over 70 years of age have managed to meet recommended BP goals. While systolic hypertension is notably more difficult to manage than diastolic pressure, it’s well worth the effort.

Dr. Roccella cites the Systolic Hypertension in the Elderly Program (SHEP) study, in which 4,736 individuals over 60 years of age with isolated systolic hypertension were randomized to receive thiazide diuretic-based treatment, with or without beta-blockers, or placebo. After five years, those receiving treatment had an overall systolic BP reduction from 171 to 142 mmHg. Heart attacks were reduced by 27%, strokes by 37%, and heart failure by 55%; as well, trends toward improvement in depression and dementia scores were noted. “Even more astounding, if you’ve had a previous heart attack, lowering your blood pressure can reduce the chance of developing heart failure by 90%,” he said.
Lifestyle changes alone may make the difference, he says. Lose some weight, walk daily, eat a high-fiber, low-salt diet, and if you drink alcohol, do so moderately. “If that fails to bring BP down to goal, stick with it, because it could improve the effectiveness of medications.”

Researchers may have discovered one of the secrets of the Mediterranean diet: olive oil! The scientific community agrees that olive oil, high in monounsaturated fatty acids (MUFA) and antioxidants, helps reduce levels of total and LDL cholesterol thereby reducing risk of cardiovascular disease. And a new study shows that a diet high in MUFA from olive oil can also help reduce blood pressure levels.

Diet and blood pressure

Researchers have known for some time that the characteristics of a Mediterranean-type diet are important in controlling blood pressure levels. These characteristics include:

- high fiber intake,
- high fruit and vegetable intake,
- high MUFA and low saturated fat intake and,
- low sodium and high potassium, magnesium and calcium intake.

It may be that one or a combination of these factors helps decrease blood pressure levels. And since high blood pressure is a risk factor for stroke, the third leading causes of death in the United States, olive oil may reduce the incidence of stroke.

MUFA vs. PUFA

Ferrara and his colleagues designed a study to look at the effects of a diet high in monounsaturated fatty acids vs. diets high in polyunsaturated fatty acids (PUFA). Twenty-three people with mild to moderate hypertension (10 males and 13 females, ages 25-70 years) were randomly assigned to either a diet high in MUFA using extra-virgin olive oil, or high in polyunsaturated fatty acids using sunflower oil for six months. Both diets contained less total and saturated fat than the subjects’ usual diets. Their usual diets contained 34% total fat and 11% saturated fat, while the study diets contained 26% total fat and 6% saturated fat. After the initial six-month study period, the groups switched to the other type of diet. Both types of diets contained similar amounts of calories, saturated fat, cholesterol, fiber and minerals (sodium, potassium, magnesium and calcium). The only significant difference in the two study diets was the amount of MUFA vs. PUFA.

Ferrara and his colleagues found that while on the extra-virgin olive oil diet, subjects reduced the amount of antihypertensive medication necessary to control blood pressure levels by 48%, vs. only a 4% reduction on the sunflower oil diet. In addition, eight subjects on the extra-virgin olive oil diet required no antihypertensive medications; all subjects on the sunflower oil diet required antihypertensive medication. The authors conclude that a diet lower in total fat and saturated fat that contains higher amounts of MUFA can lower blood pressure levels and reduce or eliminate the need for medications in people with hypertension.

Possible role of olive oil in reducing blood pressure

So why does olive oil lower blood pressure? One possible reason is its polyphenol content. Polyphenols are potent antioxidants which help arteries dilate, thereby reducing blood pressure. Ten grams of extra-virgin olive oil contains five mg of polyphenols; sunflower oil has no polyphenols.

Our recommendations

There are numerous health benefits to replacing saturated and polyunsaturated fatty acids with monounsaturated fatty acids such as olive and canola oil. Switching from polyunsaturated oils such as sunflower, safflower, soybean, and corn to oils high in monounsaturated fatty acids such as olive oil and canola oil leads to decreased risk of stroke by lowering blood pressure levels; and also helps decrease risk of heart attack by lowering total and LDL cholesterol levels. Use olive or canola oil in cooking or salad dressings, and look for margarine-like spreads based on olive or canola oil to use on toast, vegetables, and potatoes to reap the heart-healthy benefits.

Remember that while replacing saturated fats with MUFAs is a step towards improved heart health, moderation remains important. Also, if you follow a very low fat diet and still have high blood pressure, consider adding one to three tablespoons of olive oil to your daily food choices and monitor your blood pressure for any changes.