Cardio Compass: Guiding Your Journey to Heart & Hypertension Health
| Advanced Concepts in Cardiovascular Physiology and Rehabilitation | |
|---|---|
| Course: | KIN 500C |
| Instructor: | Dr. Darren Warburton |
| Email: | darren.warbuton@ubc.ca |
| Office: | Lower Mall Research Station |
Original Contributors: Ethan Ashley-Cheetham, Ali Hosseinzadeh, Meredith Levorson, Anna Turner
The authors acknowledge that this UBC Wiki page was created on the traditional, ancestral, and unceded territory of the hən̓q̓əmin̓əm̓ speaking xʷməθkʷəy̓əm (Musqueam) Peoples.
The people of this delta describe their traditions as a Living Culture (Musqueam Indian Band, 2024).
We would like to recognize that we are but temporary guests continuing the cycle of knowledge sharing on these lands, which, still today, remain part of the living history of the xʷməθkʷəy̓əm.
Background
Hypertension is a chronic condition that occurs when blood pressure (BP) is consistently high over long periods of time. BP is the force of blood pressing against the walls of blood vessels as it circulates (Public Health Agency of Canada, 2010).
Hypertension presents the most risk when unmanaged. While other atherogenic conditions, such as dyslipidaemia, obesity, and hyperglycaemia, are all associated with an elevated risk for developing cardiovascular disease (CVD), a diagnosis of hypertension exaggerates this risk almost two-fold. (Petrie et al., 2018). CVD is a leading preventable cause of death in Canada, second only to cancer in annual mortalities (Statistics Canada, 2021).
This page intends to provide an overview of hypertension to educate patients, providers, and caregivers on the risks, signs and symptoms of this "silent killer" (Hegde et al., 2024). It provides diagnosis and measurement strategies to increase awareness and empower patients to take charge of their health. Lastly, this page explores various preventative measures and interventions to help support heart health and wholistic wellbeing.
Symptoms
The clinical presentation of hypertension varies depending on the underlying pathophysiology. Hypertension is known as the “silent killer” due to its asymptomatic nature in most cases (Hegde et al., 2024; Iqbal & Jamal, 2024). Severe episodes of hypertension can lead to headaches, chest pain, nosebleeds, dizziness, blurred vision and buzzing in the ears (Kowalski et al., 2023).
Diagnosis
Diagnosis of hypertension involves the use of a BP-measuring device called a sphygmomanometer (BP cuff) to determine the force of blood against the vessel walls as it circulates. A sphygmomanometer consists of three parts (InformedHealth.org, 2019):
- A flexible, wearable cuff that inflates with air,
- A manometer (pressure meter), which measures the pressure of air in the cuff, and
- A stethoscope, to listen to the sound of blood passing through the brachial artery (the major artery found in the upper arm).
Sphygmomanometers can be manual or electronic, stationary or portable.
An individual's BP is considered normal when the systolic blood pressure (SBP) (higher) reading is 120 mmHg or less, and the diastolic blood pressure (DBP) (lower) reading is 80 mmHg or less.
According to American College of Cardiology (ACC), the categorizations of BP are defined as normal, elevated, stage I hypertension, and stage II hypertension (Table 1) (Whelton et al., 2022).
Table 1. Definition of hypertension according to the ACC (Whelton et al., 2022).
| Condition | Characteristic |
| Normal | SBP less than 120 mmHg and DBP less than 80 mmHg |
| Elevated | SBP between 120-129 mmHg and DBP less than 80 mmHg |
| Stage I Hypertension | SBP between 130-139 mmHg or DBP between 80-89 mmHg. |
| Stage II Hypertension | SBP of 140 mmHg or higher or DBP of 90 mmHg or higher |
To be diagnosed with hypertension, multiple readings are required. Typically, at least three resting measurements on at least two separate health care visits (Brown & Haydock, 2012; InformedHealth.org, 2019). BP must be measured on multiple occasions because BP fluctuates over the day due to things like physical exertion or stress. BP readings taken by a physician are sometimes misleading because visiting the doctor can be a nervous experience for some people (Brown & Haydock, 2012).
To get the most accurate reading possible, BP is measured while seated on a chair, with both feet planted on the ground, and after waiting about three minutes to allow the patient and their circulatory system to relax (Brown & Haydock, 2012). The patient's hand should rest on a table at roughly the same height as their heart, with their palm facing up (Brown & Haydock, 2012; InformedHealth.org, 2019). The BP cuff is placed around their upper arm and aligned with their brachial artery. The device used should have validated accuracy and should be properly calibrated and maintained (Brown & Haydock, 2012; InformedHealth.org, 2019). If this is the patient's first reading, their BP will be measured on both arms to compare the readings from each arm. The arm that produces the highest BP reading is used for diagnosing hypertension (InformedHealth.org, 2019).
Beyond the magnitude of SBP and DBP readings, several risk factors should be considered when diagnosing a patient with hypertension. Patients should be screened for the following risk factors by clinical assessment and laboratory testing (Brown & Haydock, 2012):
- a family history of CVD,
- a high-risk socioeconomic group, geographical region or ethnic group,
- a sedentary lifestyle,
- diabetes,
- smoking,
- alcoholism, and
- lipid profile.
Out-of-Office Measurement
Hypertension Canada is a staunch advocate of out-of-office measurements in the diagnosis of hypertension. Due to the aforementioned stress-inducing process of physician-administered BP measurement, out-of-office measures are preferred to avoid misdiagnosis (Hypertension Canada, 2020; Rabi et al., 2020).
Blood Pressure Monitoring at Home
At-home BP monitoring should be considered for patients with a history of hypertension, prehypertension, or any of the following conditions (Hypertension Canada, 2020; Rabi et al., 2020):
- Diabetes mellitus,
- Chronic kidney disease,
- Suspected nonadherence to intervention, and
- Masked hypertension.
In all of these cases, healthcare professionals should ensure that patients who engage in at-home BP monitoring have received training in how to properly administer a BP test, and have demonstrated a capacity to self-administer such tests (Hypertension Canada, 2020).
Ambulatory Blood Pressure Monitoring
A measurable difference between clinic and ambulatory pressures has been demonstrated in clinical studies. This difference is, on average, 12/7 mmHg (Brown & Haydock, 2012).
The currently accepted minimum thresholds for hypertension diagnosis based on ambulatory BP monitoring (ABPM) consist of 24‐hour, daytime, and nighttime averages (O'Brien et al., 2018):
- For 24-hour ABPM averages, the minimum threshold is 130/80 mmHg.
- For daytime (awake) ABPM, the threshold for hypertension is 135/80 mmHg.
- For nighttime (asleep) ABPM, the minimum threshold is for hypertension 120/70 mmHg.
Etiology
The causes of hypertension are categorized into primary and secondary hypertension.
Primary Hypertension
Primary hypertension (also known as essential hypertension) is the most common type of hypertension. Although primary hypertension does not have a known cause (Iqbal & Jamal, 2024), high sodium intake and a higher sensitivity to sodium due to genetic predispositions have been proposed to be potential mechanisms for its development (Sanders, 2009). Other modifiable risk factors including smoking, alcohol use, obesity and a sedentary lifestyle can indirectly lead to primary hypertension (Oparil et al., 2019).
Secondary Hypertension
Secondary hypertension is increased BP secondary to a known cause (Hegde et al., 2024). In individuals with secondary hypertension, treating the main cause often cures the hypertension as well (Hegde et al., 2024). The mechanism behind secondary hypertension can vary. Some conditions that could lead to secondary hypertension include renal parenchymal disease (such as diabetic nephropathy, interstitial renal parenchymal diseases, and polycystic kidney disease), endocrine disorders (such as primary aldosteronism), renovascular disorders (renal artery stenosis) and preeclampsia (Hegde et al., 2024). These conditions alter BP by altering cardiac output or peripheral vascular resistance (Hegde et al., 2024).
Pathophysiology
The pathophysiology behind hypertension is multifaceted. BP is determined based on the cardiac output (heart rate and stroke volume) and peripheral vascular resistance (Figure 1) (Oparil et al., 2019). These factors are regulated by elements of neurohormonal systems such as the renin-angiotensin-aldosterone system (RAAS), natriuretic peptides, endothelium, the sympathetic nervous system and the immune system (Hall et al., 2024). Dysfunction of these regulatory elements can either directly or indirectly (damaging the organs such as kidneys) cause hypertension (Oparil et al., 2019; Hall et al., 2024). Therefore, the communication axis between the kidneys, blood vessels and the autonomic nervous system plays a major role in hypertension pathology.
Kidneys are major regulators of BP through their ability to secrete and reabsorb fluids and sodium (Hall et al., 2024). The increased reabsorption of fluids and sodium leads to increased cardiac output and BP. Kidneys are also responsible for renin production, an enzyme that cleaves angiotensinogen to produce angiotensin II, a strong vasoconstrictor (Oparil et al., 2019; Hall et al., 2024). Abnormal increased secretion of renin, and increased reabsorption of sodium caused by the dysfunction of sodium hydrogen exchanger-3 transporters are two examples of how kidneys are involved in hypertension pathology (Oparil et al., 2019; Hall et al., 2024).
Constriction and dilations of the blood vessels play a crucial role in BP modulation. Vasoconstriction usually occurs in response to sympathetic nervous system activation and secretion of angiotensin II, while the main mediator of vasodilation is nitric oxide (Hall et al., 2024). These factors directly control peripheral vascular resistance and BP. Endothelial dysfunctions are one of the underlying mechanisms of hypertension (Hall et al., 2024). Reduced expression and secretion of nitric oxide, damage to the endothelium and development of atherosclerosis, arterial stiffening and chronic vasoconstriction play roles in hypertension pathogenesis (Drożdż et al., 2023; Hall et al., 2024)
The autonomic nervous system has a direct influence on BP management. Via its sympathetic branch, the heart rate, peripheral vascular resistance and stroke volume can increase (Joyner et al., 2010). In individuals with hypertension, the sympathetic outflow and catecholamine-mediated vasoconstriction increase (Hall et al., 2024). The sympathetic nervous system can also modulate the function of kidneys and promote the reabsorption of water and sodium (Sata et al., 2018). Figure 2 summarizes the relationship between the kidney, peripheral vessels, and the autonomic nervous system regarding hypertension pathogenesis.
Epidemiology
Prevalence in Canadian Population
Despite the abundant available literature, diverse strategies for management, and widespread availability of community-based intervention programs (Hypertension Canada, 2016), diagnoses of hypertension are disproportionately prevalent in rural and remote regions of Canada (Statistics Canada, 2022).
The disproportionate prevalence of atherogenic conditions like hypertension in low-income, low-education, and rural groups has been well-documented since the distribution of the Canadian Heart Health Surveys (CHHS)[5] in the late 1980s and early 1990s; a correlation that persists in the more recent Canadian Health Measures Survey (CHMS) (Hypertension Canada, 2016; Statistics Canada, 2022). According to Statistics Canada, a rural region is defined as an area with less than 1,000 inhabitants and a population density of less than 400 people per square kilometre (Statistics Canada, 2022)
In addition to experiencing increased rates of atherogenic conditions, rural populations in Canada are sicker on average, less affluent than their urban counterparts, and less well-served by healthcare providers (Garasia & Dobbs, 2019). Almost one-fifth (17.8%)(Statistics Canada, 2022) of Canadians fall into the category of rural residents, yet this population is served cumulatively by only 8% of registered practicing physicians (Garasia & Dobbs, 2019).
In Canada, hypertension frequency increases with age, ranging from a prevalence of 10% for adults between 20 and 44 years old, to over 70% among adults over 80 (Hypertension Canada, 2016). Population prevalence of hypertension has been steadily increasing, from a reported 19.6% in the 2009-2011 CHMS to 22.6% in the 2012-2013 edition (Padwal et al., 2016). Increased sodium intake and lack of physical activity are the primary factors driving this increased prevalence across all age groups (Hypertension Canada, 2016). Notably, when comparing all rural and urban regions in Canada, the proportion of individuals aged 65 and above is higher in rural communities (23.2%) than urban centres (18.0%) (Statistics Canada, 2022). Similarly, the proportion of children younger than 14 is also higher in rural (16.8%) compared with urban (15.4%) regions (Statistics Canada, 2022).
Moreover, Indigenous Canadians, individuals of lower socioeconomic status, and people living in the territories are at greater risk of developing hypertension regardless of age or sex and are less likely to receive treatment when diagnosed (Hypertension Canada, 2016). Additionally, young males with hypertension are less likely to be aware of their diagnosis and consequently less likely to seek treatment (Hypertension Canada, 2016). According to Statistics Canada, there are proportionally more young males (25 years old) compared to females living in rural (114:100) compared to urban (110:100) regions (Statistics Canada, 2022).
Sex Differences
It has been well established that the prevalence of hypertension is generally higher in young and middle-aged men compared to women, independent of race and ethnicity (Sandberg & Ji, 2012; Connelly et al., 2022). The elevated risk in males typically occurs until approximately age 60, where the prevalence shifts to be greater in females. This is in part due to the influence of estrogen on regulating the vascular system and inhibiting vascular remodeling, a protective effect which is reversed when estrogen levels decline after menopause in women (Madsen et al., 2018). The sex-based risk stratifications are also proposed to be related to differences in chromosomes, obesity prevalence, renal sympathetic activation, and immune system profiles, although these mechanisms are not entirely understood (Reckelhoff, 2023).
Given the risk of hypertension is affected by sex, it is important to assess the differences in terms of the specific presentation of and experiences with the condition between men and women. While the symptomatology does not differ significantly between the sexes, there are notable differences in the complications and risks associated with a hypertension diagnosis in males compared to females. Research has revealed that women with hypertension may be at elevated risk for adverse cardiovascular outcomes in comparison to men with the condition, even in younger cohorts (age 25-39). For example, several studies have found that in hypertensive populations, females have a higher relative risk of myocardial infarction, with this risk estimated to be up to 80% (Millet et al., 2018).
Further, when contrasted with normotensive individuals, hypertensive females who are prescribed with BP-lowering medication are significantly more likely to experience myocardial infarction compared to hypertensive males. This elevated risk in females has also been observed with ischemic stroke and development of left ventricular hypertrophy, despite having a lower incidence of these events due to the lower overall prevalence of hypertension in women (Millett et al., 2018; Lee et al., 2020; Madsen et al., 2019; Izzo et al., 2017).
Females also appear to experience these elevated cardiovascular risks at lower BP thresholds than their male counterparts. For example, a recent review revealed that the risk for CVD increases by 25% per 10 mmHg increase in SBP in females, compared to 15% in males (Connelly et al., 2022). This risk discrepancy can be observed in the approximately 0.6 higher hazard ratio (HR) for incident CVD in females compared to males (2.3 vs 1.7) at a SBP of 150-159 mmHg, and a 1.5 higher HR (3.5 vs 2) at a SBP ≥ 160 mmHg (Connelly et al., 2022). These sex-specific risk thresholds are proposed to be due to differences in anatomy, such as smaller arterial diameter in females, as well as variability in vascular physiology between the sexes (Ji et al., 2021).
Given the stark differences in hypertension presentation and BP thresholds between males and females, it is important that clinical approaches to prevention, diagnosis, and treatment for CVD are sex-specific.
Comorbidities
A diagnosis of hypertension is often associated with elevated risks for a plethora of additional health conditions, which can exacerbate its effects and increase the likelihood of developing CVD.
Hypertension and Diabetes
A common comorbidity amongst individuals with hypertension is diabetes mellitus; the risk for this overlap is stratified according to age, sex, diabetes diagnosis (type and duration), race, body mass index, and medical history, among other factors (Al-Azzam et al., 2020). Additionally, the linkage between diabetes and hypertension is largely attributed to the similarity in their risk factors, which include dyslipidemia, sedentarism, insulin resistance, obesity, genetic predispositions, and age, as well as their associations with CVD through pathways of vascular inflammation, arterial remodelling, atherosclerosis, and endothelial dysfunction (Figure 3; Petrie et al., 2018).
There are numerous mechanisms by which the presence of diabetes induces the subsequent development of hypertension. First, due to the insulin resistance-induced hyperinsulinemia and hyperglycemia associated with diabetes, individuals with the condition exhibit increased circulatory fluid volume which subsequently causes elevations in BP (Ohishi, 2018). Moreover, diabetes is known to cause significant vascular remodeling. These alterations to the vasculature result in increases in peripheral artery resistance, providing an additional pathway by which the systemic BP is elevated (Ohishi, 2018). Individuals with diabetes also commonly have impaired vascular endothelial cells and increased vascular reactivity, which cause increased oxidative stress and subsequently contribute to the development of hypertension in this population (Lago et al., 2007; Ohishi, 2018).
The coexistence of hypertension and diabetes significantly increases the risk for other comorbidities, including ischemic cerebrovascular disease, CVD, retinopathy, and neuropathy. (Lago et al., 2007; Oparil et al., 2003). The overlap between diabetes and hypertension is of particular concern in children due to their elevated susceptibility for end-organ disease (Lago et al., 2007). Moreover, the presence of diabetes prior to a pregnancy is also a significant risk factor for preeclampsia, which will be discussed in the following section.
Hypertension during Pregnancy
Hypertension is of great concern when it occurs during a pregnancy as it may pose a significant threat to both the mother and the fetus. Hypertensive disorders of pregnancy, which include gestational hypertension, chronic hypertension, and preeclampsia, are common in Canada, affecting approximately 7% of all pregnancies (Butalia et al., 2018). In addition to experiencing the typical symptoms associated with hypertension, a female who is pregnant and has hypertension may face serious complications such as cerebral hemorrhage, placental abruption, acute renal failure, and hepatic failure (National Institutes of Health, 2000). It is important to distinguish that chronic hypertension describes a condition of hypertension present prior to the 20th week of gestation, whereas gestational hypertension is diagnosed when a woman who has not been previously hypertensive has elevated BP for the first time midway through her pregnancy (National Institutes of Health, 2000).
Preeclampsia
Preeclampsia, as defined by the American College of Obstetrics and Gynecology (ACOG), is a placental disease in which hypertension and proteinuria occur approximately 20 weeks into the gestational period in an individual who was previously normotensive (Rana et al., 2019). It is considered one of the most high-risk conditions of pregnancy as it can rapidly progress from moderate symptoms to severe complications which may result in morbidity and mortality of both the mother and the fetus (Rana et al., 2019; Sorensen et al., 2003). In addition to a previous history of the condition and/or chronic hypertension, other risk factors for preeclampsia include obesity, nulliparity, advanced maternal age, renal disease, pregestational diabetes mellitus, and use of assisted reproductive technologies (Paré et al., 2014; Rana et al., 2019).
A critical factor which distinguishes preeclampsia from chronic or gestational hypertension is that preeclampsia is a systemic condition with potentially life-threatening complications that can occur independent of increases in BP. In addition to increasing the risk for developing the condition during subsequent pregnancies, a preeclampsia diagnosis has a multitude of chronic morbidities. It has been proposed that the endothelial damage induced by preeclampsia can have severe repercussions on a woman’s cardiovascular health, greatly elevating her risk of long-term hypertension, cerebrovascular disease, peripheral arterial disease, coronary artery disease, congestive heart failure, and death (Brouwers et al., 2018; Newstead et al., 2007; Rana et al., 2019). Moreover, women who have been diagnosed with preeclampsia are at a 4.7-fold risk of end-stage renal disease (Vikse et al., 2008), 4-fold risk of stroke (Bushnell et al., 2011), and 3-fold risk of later in life vascular dementia (Basit et al., 2018).
The pathogenesis of preeclampsia typically involves two stages. In the first trimester, abnormal placentation, which is driven by a host of genetic, maternal/environmental, and immunological factors, represents the initiation of the pathogenic pathway leading to preeclampsia. By inhibiting normal trophoblast transformation and producing narrow maternal vessels, abnormal placentation subsequently results in placental ischemia, the mechanism that is thought to induce placental dysfunction and ultimately contribute to the development of preeclampsia (Rana et al., 2019; Romero & Chaiworapongsa, 2013). As a result of placental dysfunction early on in the pregnancy, an excess of antiangiogenic proteins and other inflammatory mediators are released into the maternal circulation (Rana et al., 2019). These factors are proposed to trigger a cascade of pathological changes in the late second and third trimesters, leading to the manifestation of this potentially fatal placental disease.
Preventative Measures
Given the multifaceted nature of hypertension, a multidimensional preventative approach is needed to achieve the optimum outcome. Addressing the modifiable risk factors of hypertension including smoking cessation, weight loss, increased amount of physical activity and lower amount of stress, can reduce the risk of developing hypertension (Rippe, 2019). Improving the health literacy of the population and patient education are other factors that could contribute to the prevention of hypertension (Du et al., 2018). Closely monitoring the BP of individuals who are at a high risk of developing hypertension can also contribute to prevention and better management of hypertension.
Pharmacological Interventions
Management of hypertension involves pharmacological and non-pharmacological intervention. Pharmacological interventions include angiotensin-converting enzyme inhibitors (ACEi), calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs), and thiazide diuretics (usually thiazides) (Table 2) (Campbell et al., 2022; Iqbal & Jamal, 2024). According to the ACC, antihypertensive medications should be initiated when an individual's BP is constantly above 140/90 mmHg with the aim of bringing the BP down to 130/80 mmHg or lower (Whelton et al., 2022).
Table 2. Summary of medication groups used for hypertension management and their mechanism of action.
| Medication Group | Mechanism |
| Angiotensin-converting enzyme inhibitors | Inhibition of conversion of angiotensin I to angiotensin II, which is a potent vasodilator. Increase Bradykinin (Wright et al., 2018). |
| Calcium channel blockers | Inhibition of calcium entrance to the vascular smooth muscle cells and myocardial cells, reducing the heart rate, and aldosterone production (Wright et al., 2018). |
| Angiotensin receptor blockers | Blocking of angiotensin II AT1 receptors, causing vasodilation and reduction in aldosterone production (Wright et al., 2018). |
| Thiazide diuretics | Inhibition of sodium and chloride reabsorption in the kidney (Wright et al., 2018). |
Pharmacological intervention without a specific indication would require the practitioner to consider the cost, side effects, and potential medication contraindications (BC Ministry of Health, 2023). In these cases, a monotherapy combination of first-line drugs such as low-dose thiazides and thiazide-like diuretics, CCBs, ACEi, or ARBs is indicated (BC Ministry of Health, 2023). Pharmacological intervention for hypertension with a specific indication requires a specific first-line drug (BC Ministry of Health, 2023).
Physical Activity
Regular physical activity (PA) is widely recognized as a cornerstone in the management and prevention of hypertension (MacDonald & Pescatello, 2019). Hypertension is a fatal risk factor for developing CVD and other comorbidities. It has been established that hypertension is closely linked to an inactive lifestyle, thus providing support for the importance of regular physical activity and exercise for prevention and management (Alpsoy, 2020). Introducing exercise into an individual's life supports overall cardiovascular health and long-term survival of normotensive and hypertensive individuals. For individuals identified at risk of hypertension, exercise can slow the progression of symptoms and prevent the development of hypertension (Alpsoy et al., 2013). Exercise is recommended for normotensive and hypertensive individuals because of the preventative and therapeutic effect it has on the body (Alpsoy, 2020; Esmailiyan et al., 2023; Sakamoto, 2020)
Benefit of Exercise on Hypertension
A low to moderate increase in one's level of physical activity can vastly improve health outcomes. Simply reducing sedentary behaviours has the potential to reduce the relative risk of developing a plethora of chronic medical conditions (Warburton & Bredin, 2016). Physical activity includes body movements that result in an expenditure of energy above the resting levels of skeletal muscles (Caspersen et al., 1985). These are often unstructured activities such as routine cleaning, gardening, and running errands. The lifestyle changes prescribed in the prevention and management of hypertension are typically activities that fall into the category of exercise. Activities that are planned, structured, repetitive, and done with the intention of improving or maintaining one's health are considered exercise (Caspersen et al., 1985).
Previous studies examining the effect of cardiac rehabilitation programs highlight the benefits of physical activity and exercise for CVD patients. Physical activity has been identified as a tool to improve most of the cardiovascular factors in CVD patients, even in situations where no improvement in BP is observed (Esmailiyan et al., 2023). Not only was exercise capacity and health-related quality of life improved from these programs, but patients also demonstrated reduced risk of hospitalization, reduced CV-related mortality, and increased prevalence of smoking cessation in smoker CVD patients (Esmailiyan et al., 2023).
Types of Exercise For Hypertensive Care
There is support for several different types of exercise for the treatment of hypertension. Largely, the literature focuses on three categories of exercise, aerobic exercise, resistance training and isometric training.
Aerobic Training
This type of exercise includes regular purposeful movement of the joints and large muscle groups such as cycling, swimming, dancing, speed-walking, jogging and running (Rabi et al., 2020). Single bouts of aerobic exercise produce an acute period of postexercise hypotension (PEH) (Millar & Goodman, 2014). This reduction in BP can last up to 22 hours after the end of an exercise session (Ghadieh & Saab, 2015). The PEH seems to be largely affected by exercise duration and type, with less emphasis on intensity than previously thought (MacDonald & Pescatello, 2019). Consistent aerobic exercise also demonstrates lasting benefits such as lower resting BP and decreased BP reactivity to stressors (MacDonald & Pescatello, 2019).
Resistance Training
This type of training is performed against an opposing force with the goal of increasing muscle strength (MacDonald & Pescatello, 2019). Examples of resistance training for the treatment of hypertension are dynamic exercises such as weightlifting and circuit training with implements such as free weights or resistance training machines (Ghadieh & Saab, 2015).
Isometric Exercise
Isometric training is a type of resistance training that focuses on sustained static contraction of the muscles, without joint movement or changes in muscle length (Ghadieh & Saab, 2015). There is a lack of evidence surrounding isometric training for hypertensive individuals. Isometric handgrip and isometric leg exercises have been examined, but there are no exercise guidelines for isometric resistance training for hypertensive individuals (MacDonald & Pescatello, 2019). The effect on resting BP is relatively small, however, the health risks for high-risk CV patients have yet to be examined thoroughly (Ghadieh & Saab, 2015).
Exercise Recommendations
Current Hypertension Canada guidelines recommend 30-60 minutes of moderate-intensity (3.0-6.0 MET) aerobic exercise 4-7 days per week. The 30-minute goal can be done through continuous exercise or accumulated through 10-minute sessions (Ghadieh & Saab, 2015; MacDonald & Pescatello, 2019). These recommendations are in addition to the activities of daily living. Moderate-intensity exercise improves individuals' relative risk ratio. Resistance training is also recommended in conjunction with aerobic training, but not in place of dynamic aerobic exercise (Rabi et al., 2020).
It is noted that while more vigorous activity is not a contraindication for most hypertensive individuals, higher intensities of aerobic/dynamic exercise are not shown to be more effective for the treatment of hypertension (Rabi et al., 2020). Weight training or the use of resistance training does not adversely affect BP for nonhypertensive or hypertensive individuals with SBP/DBP of 140-159/90-99 mmHg.
Before partaking in exercise, it is essential for individuals to complete pre-participation screening and/or exercise testing. This includes the Physical Activity Readiness Questionnaire (PAR-Q or PAR-Q+), the Electronic Physical Activity Readiness Medical Examination (ePARmed-X), and/or consultation with a clinician or trained exercise professional (Bredin et al., 2013; Warburton et al., 2011). This information can help determine a baseline for safe and effective exercise prescription (Millar & Goodman, 2014; Wang et al., 2017).To promote health behaviour change, adherence should be routinely evaluated by physicians and exercise professionals to ensure compliance and reassess BP targets and exercise goals (Ghadieh & Saab, 2015; Rabi et al., 2020).
Following American College of Sports Medicine (ACSM) prescription guidelines, exercise should follow the FITT principle, noting the frequency, intensity, time and type of exercise being completed. Prescriptions should be gradually modified and especially in the case of hypertensive patients, substantial increases in intensity should be avoided (American College of Sports Medicine, 2018). Another safety concern for individuals partaking in exercise can be the effects of antihypertensive drug treatment. Certain medications can lead to sudden decrease in BP after stopping exercise, so its important to conclude exercise sessions gradually with a proper cool-down period, allowing BP and heart rate to return to baseline levels (American College of Sports Medicine, 2018).
Exercise Programming with Indigenous Communities
The reliance in the literature of Western ways of knowing currently stands in the way of accepting Indigenous knowledge as credible evidence for informing health practices (Josewski et al., 2023). A frequently mentioned obstacle to continued support for land-based healing is the lack of ‘evidence’ demonstrating improved health and wellbeing benefits of traditional land-based healing interventions. Literature is dominated by a focus on evidence-based practice and the scientific method to produce guidelines with an appropriate amount of rigour, generalizability and applicability to patient populations (Josewski et al., 2023). The evidence in support of land-based practices often comes from self-report measures and single case studies, creating a challenge for practitioners when compared to the objective measurements of deficit-based assessments typically used in Western biomedical models (Josewski et al., 2023). Not culturally relevant or sensitive programs fail to incorporate mental, emotional, physical, and spiritual health into the physical activity experiences (Akbar, 2023; Salloum & Warburton, 2019). This reliance on the Western approach further limits the ability to understand and address the community-specific needs, challenges, values, and perspectives used by Indigenous peoples for wholistic health and wellbeing practices (Ahmed et al., 2021).
The 2021 systematic review by Ahmed, Zuk and Tsuji highlights the importance of including all aspects of wholistic wellbeing in physical activity interventions. Spiritual health in particular is often excluded from PA interventions as it can be a difficult concept for practitioners to grasp and incorporate across PA settings (Lewis et al., 2022; Salloum & Warburton, 2019). Western health contexts typically do not recognize spiritual health as a component of health. An important aspect of restoring traditional practices and spiritual connection includes being on the land and participating in land-based activities (Akbar, 2023). The most impactful intervention strategies incorporate community engagement, physical health, spiritual health, emotional health, mental health, and land-based practices, representing a truly wholistic approach to healing (Ahmed et al., 2021).
It has only recently become practiced In Western approaches to health to acknowledge the impact that Indigenous culture, identity, and lifestyle have on well-being (Ahmed et al., 2021). Indigenous communities are fundamentally interconnected with their land and recognizing this is crucial to promoting Indigenous well-being. Daily acts of living such as substinence activities, ceremonial practices, knowledge transfer from Elders, expressions of culture and life, and facing challenges creating motivation, were all activities viewed as synonymous with health (Ahmed et al., 2021). Effective exercise interventions in Indigenous communities demonstrate lasting impact at various levels throughout the community. Incorporating support from local leadership and integrating cultural traditions can modify engagement with risk behaviours and improve health and fitness (Teufel-Shone et al., 2009).
Nutrition
Nutrition plays a crucial role in managing hypertension. Modifications in dietary factors are an effective strategy for controlling BP.
Sodium and Hypertension
Sodium (Na+) is an essential nutrient found in most foods and commonly added as seasoning in the form of salt. In common table salt and food, Na+ is bound with chloride (Cl-) to form sodium chloride (NaCl). Na+ and Cl- are required in small amounts to maintain extracellular volume and plasma osmolality (Sacks et al., 2001). Humans have demonstrated the capacity to survive on as little as 200 mg of Na+ daily (Standing Committee, 2005), with current health guidelines recommending the consumption of 1,500 mg of Na+ per day to maintain good health (Sacks et al., 2001).
Excessive salt intake causes excessive reabsorption of Na+ and abnormal secretion of renin, which increases blood volume in your body and results in hypertension. Despite recommendations to limit salt intake, Canadians consume, on average, 2,760 mg of Na+ per day, which is well above the recommended daily maximum of 2,300 mg (Health Canada, 2017). Average daily Na+ intakes by age and sex are in Table 3.
Table 3. Average daily sodium intakes (in mg) of Canadians, by age and sex group (Health Canada, 2017).
| Average Daily Sodium Intake (mg) | |||
|---|---|---|---|
| Age Groups (years) | Children | Males | Females |
| 1 to 3 | 1,530 | ||
| 4 to 8 | 2,160 | ||
| 9 to 13 | 2,740 | 2,410 | |
| 14 to 18 | 3,320 | 2,350 | |
| 19 to 30 | 3,420 | 2,270 | |
| 31 to 50 | 3,020 | 2,270 | |
| 51 to 70 | 2,820 | 2,030 | |
| 71+ | 2,440 | 1,950 | |
Potassium and Hypertension
Potassium (K+) helps to balance the amount of Na+ in your cells (Houston & Harper, 2008). Westernized diets typically include low levels of K+, which, combined with excessive salt intake, results in the accumulation of Na+ in the blood, increasing blood volume and resulting in hypertension (Ellison & Terker, 2015; Houston & Harper, 2008).
The distal convoluted tubules (DCTs) in the kidneys regulate the body's homeostasis of Na+ and K+ through the action of the thiazide-sensitive NaCl cotransporter (NCC). When there's a low intake of K+ in the diet, NCCs become more active, resulting in the reabsorption of Na+ and Cl- from the urine back into the bloodstream (Ellison & Terker, 2015).
K+ plays a regulatory role in the activity of NCCs. When K+ levels are adequate, they suppress the activity of NCCs, causing less Na+ reabsorption and resulting in lower BP. But when K+ levels are low, NCC becomes more active, contributing to Na+ retention and higher BP (Ellison & Terker, 2015).
Calcium and Hypertension
Calcium plays a role in regulating vascular smooth muscle contraction, impacting blood vessel constriction and dilation. Inadequate calcium intake disrupts calcium homeostasis, which causes calcium depletion from all membrane storage sites (Houston & Harper, 2008). This state of calcium deprivation results in the activation of the parathyroid gland and increased calcitriol synthesis, both of which act as calcium-preserving pathways (Villa-Etchegoyen et al., 2019).
Increases in parathyroid gland activity result in the release of parathyroid hormone. Parathyroid hormone acts to conserve intracellular calcium in smooth muscle, which results in the vasoconstriction of vascular muscles (Villa-Etchegoyen et al., 2019).
Similarly, an increase in calcitriol synthesis triggered by low calcium levels and the release of parathyroid hormone contributes to hypertension by signalling for increased intracellular calcium storage, which also contributes to a systemic state of vasoconstriction (Villa-Etchegoyen et al., 2019).
Magnesium and Hypertension
Magnesium is involved in many processes in the body, including playing a role in BP regulation. Magnesium has been theorized to lower BP by naturally impeding calcium channel function (Houston & Harper, 2008).
Specifically, magnesium impedes the activation of Transglutaminase 2 (TG2) by competitively binding with calcium (Jeong, 2020). When TG2 is activated, it contributes to cellular apoptosis, autophagy, inflammation, and extracellular matrix formation, which plays a role in the pathogenesis of a variety of diseases, such as cancer, cataracts, celiac disease, fibrotic diseases, including cystic fibrosis, renal fibrosis, and pulmonary fibrosis, and increased vascular stiffness (Jeong, 2020).
In addition to regulating the sensitivity of TG2 to Ca2+, magnesium competes with sodium for binding sites on vascular smooth muscle cells, binds to potassium cooperatively, induces endothelial-dependent vasodilation and BP reduction, and increases prostaglandin (Houston & Harper, 2008).
Magnesium increases prostaglandin by playing the role of an essential cofactor for the delta-6-desaturase enzyme, which is the rate-limiting step in converting linoleic acid to gamma-linolenic acid. Gamma-linolenic acid is a precursor for prostaglandin e1, which is a vasodilator. Low magnesium states lead to insufficient prostaglandin e1, causing vasoconstriction and increased BP (Houston & Harper, 2008).
Recent meta-analyses suggest that magnesium is more effective in reducing BP when administered naturally, as a combination of magnesium, potassium, and calcium, than when given alone through supplementation (Houston & Harper, 2008).
Fibre and Hypertension
Dietary fibre, such as those in fruits, vegetables, and whole grains, can help lower BP (Tejani & Dhillon, 2023). Several underlying mechanisms may contribute to reductions in BP when dietary fibre intake is higher.
One mechanism concerns the insolubility of fibrous carbohydrates, like beta-glucans and pectins, which, due to their indigestibility, form viscous gels in the gastrointestinal tract (Tejani & Dhillon, 2023). These viscous gels can slow down carbohydrate digestion, which delays glucose absorption. A more steady release of glucose during digestion prevents spikes in blood sugar, which can help modulate insulin sensitivity and improve glycemic control, which plays a role in BP regulation (Tejani & Dhillon, 2023).
Further, fermentation of dietary fibre by gut microbiota results in short-chain fatty acids (SCFAs) synthesis, hypothesized to contribute to BP reduction. Proposed mechanisms for the action of SCFAs include vasodilatory effects through the relaxation of blood vessel walls or modulation of the renin-angiotensin-aldosterone system (RAAS) (Tejani & Dhillon, 2023).
Additionally, consuming dietary fibre contributes to good gut microbiome health, which may play a role in modulating BP (Tejani & Dhillon, 2023).
Fish Oil and Hypertension
Fish oil, rich in omega-3 fatty acids, has been shown to lower BP in hypertensive individuals. Fatty acids are integral components of cell membranes and influence their physical properties and functions, such as ion transport, receptor interactions, cell signalling and gene expression (Engler, 2017).
The three omega-3 fatty acids primarily found within fish oils are alpha-linolenic acid (ALA), docosahexaenoic acids (DHA) and eicosapentaenoic acids (EPA). EPA, in particular, plays a significant role in bioactive eicosanoid synthesis (lipid-based signalling molecules which play a role in innate immune responses), which results in cardioprotective anti-inflammatory, anti-thrombotic and vasodilatory effects (Engler, 2017).
A recent meta-analysis determined that administering 3.9 grams/day of EPA resulted in a 4.51 mmHg reduction in SBP and a 3.05 mmHg reduction in DBP (Mozaffarian, 2007). Results from this study also showed that this was as effective or more effective than other lifestyle interventions, such as physical activity and restricting alcohol and sodium to lower BP in hypertensive populations not taking anti-hypertensive medications (Engler, 2017; Mozaffarian, 2007).
DASH Diet
The DASH diet, which stands for Dietary Approaches to Stop Hypertension, is the leading diet recommended by the American Heart Association for the non-pharmacological management of hypertension. Early research conducted by the National Institute of Health revealed that a DASH diet intervention alone could decrease SBP by 6 to 11 mmHg in both normotensive and hypertensive individuals (Challa et al., 2023). Further, compared with a standard American diet, the DASH diet has shown to be beneficial in significantly improving insulin sensitivity, inflammation, oxidative stress, fasting glucose, and total cholesterol, alterations which are critical in mitigating the pathophysiology of hypertension (Siervo et al., 2015). Following this research, DASH has been advocated as an optimal nutritional approach, alongside other lifestyle modifications, for the management of high BP.
As mentioned, a critical dietary contributor to hypertension is high sodium intake. To reduce this exposure, a primary recommendation within the DASH diet is limiting sodium consumption to less than 1,500 mg/day (Challa et al., 2023). The diet also prioritizes the consumption of fresh fruits and vegetables, ideally 4-5 servings per day of low glycemic index fruits (e.g. berries, apples, peaches) and green leafy vegetables (e.g. kale and broccoli). Third, DASH recommends significantly limiting the intake of saturated fats (e.g. fatty meats, full-fat dairy products) and instead consuming 2-3 servings per day of unsaturated (i.e. “healthy”) fats, from sources like olive oil, avocado, nuts, seeds, and omega-3 rich fish. In terms of protein, individuals following the DASH diet should primarily select plant-based protein sources, as well as lean meat, eggs, and low-fat dairy products. Finally, increasing the intake of protective micronutrients such as calcium, magnesium, and potassium is crucial in the management of hypertension. These nutrients, which can be sufficiently obtained by consuming a DASH-focused diet, are imperative in the reduction of BP and prevention of endothelial dysfunction (Houston et al., 2008).
Nutrition Programming with Indigenous Communities
As with physical activity, Western ways of knowing impede our acceptance of Indigenous knowledge as a credible source of informed nutritional practice (Devereaux & Black, n.d.; Josewski et al., 2023). Western academic research into nutrition focuses heavily on the physical effects of macronutrient content and serving size and overlooks the mental, spiritual, and emotional relationship individuals share with food. Crucially, when working with Indigenous communities, it is necessary to acknowledge how certain foods can be associated with traumatic memories, such as an experience with the Residential School System (Devereaux & Black, n.d.). Indeed, many of the Western dietary practices, such as portion restriction and diet prescription, emulate the experience of Residential Schools for survivors and their families.
It is also critical to recognize that while Western literature details a great understanding of the biochemical processes of macronutrients in patients with hypertension, Indigenous cultures contain millennia of knowledge from a period when atherogenic conditions were nonexistent within Indigenous communities (Kattelmann et al., 2009). Many traditional diets across Turtle Island consisted of large and small game, fish and seafood, wild plants and berries, and fungi; foods high in macronutrients which have cardioprotective and hypotensive effects (Devereaux & Black, n.d.; Kattelmann et al., 2009). For example, fish, particularly cold-water fish like herring, eulachon, and salmon, are rich in Omega-3 fatty acids, rosehips and Saskatoon berries are a fair source of calcium and fibre, and wild game is rich in protein and iron, which is essential for muscle growth and maintaining energy levels (Johnson, n.d.). Examples of common traditional foods and their nutrition content are shown in Table 4.
Table 4. Common traditional Indigenous foods, major nutritional content, and regions found (Johnson, n.d.).
| Food | Major Nutrient (non-exhaustive) | Nutrient Content | Region Found (British Columbia) |
|---|---|---|---|
| Salmon | Omega-3 Fatty Acids | Good Source (provides 15-24% of daily need) | Coastal seawaters and inlets, migrate seasonally along major rivers and streams |
| Eulachon | Calcium | Good Source (provides 15-24% of daily need) | Coastal seawaters and inlets, migrate seasonally along major rivers and streams |
| Clams | Calcium | Fair Source (provides 5-14% of daily need) | Along the shorelines of seawaters and inlets |
| Moose | Protein | Excellent Source (provides 25% or more of daily need) | Interior and Northern regions |
| Deer | Iron | Excellent Source (provides 25% or more of daily need) | Throughout many regions |
| Giant Kelp | Iron | Excellent Source (provides 25% or more of daily need) | Along the shorelines of seawaters and inlets |
| Saskatoon Berries | Calcium | Fair Source (provides 5-14% of daily need) | Interior and Northern regions |
| Elderberries | Iron | Fair Source (provides 5-14% of daily need) | Interior and Northern regions |
| Rosehips | Calcium | Fair Source (provides 5-14% of daily need) | Throughout many regions |
A nutrition intervention with Indigenous patients with hypertension is a journey of reciprocal learning and collaboration. A two-eyed seeing approach (Forsyth et al., 2014), which combines evidence-informed clinical practice with the demonstrated history of Indigenous wholistic food health practices, should shape conversations around the positive physical, spiritual, mental, and emotional impacts of traditional foods (Devereaux & Black, n.d.). Lastly, nutrition interventions with Indigenous peoples should consist of an open dialogue which prioritizes the strengths of the individual, as well as their community and their environment (Devereaux & Black, n.d.).
Hypertension Resources
Here are some resources to support heart health and contribute to successful management and prevention of hypertension:
Traditional Indigenous Food Resources:
Traditional_Food_Fact_Sheets.pdf (fnha.ca)
FNHA-ISPARC-Food-is-Medicine-Recipe-Book.pdf (fnha.ca)
VIHA-Setting-The-Table-For-A-Healthy-Food-Conversation.pdf (fnha.ca)
Public Health Resources:
https://www.nccih.ca/docs/emerging/RPT-Womens-Heart-Health-Diffey-Fontaine-Schultz-EN.pdf
https://hypertension.ca/public/recommended-devices
References
Ahmed, F., Zuk, A. M., & Tsuji, L. J. S. (2021). The Impact of Land-Based Physical Activity Interventions on Self-Reported Health and Well-Being of Indigenous Adults: A Systematic Review. International Journal of Environmental Research and Public Health, 18(13), Article 13. https://doi.org/10.3390/ijerph18137099
Akbar, L. (2023). Health and Wellness Impacts of Being on the Land for Indigenous Peoples in North America—ProQuest. https://www.proquest.com/openview/862df928fdd418ac4fb5c5ef7878a68d/1?pq-origsite=gscholar&cbl=18750&diss=y
Al-Azzam, N., Al-Azzam, S., Elsalem, L., & Karasneh, R. (2020). Hypertension prevalence and associated factors among patients with diabetes: A retrospective cross-sectional study from Jordan. Annals of medicine and surgery, 61, 126-141. https://doi.org/10.1016/j.amsu.2020.12.038
Alpsoy, S. (2020). Exercise and Hypertension. In J. Xiao (Ed.), Physical Exercise for Human Health (pp. 153–167). Springer. https://doi.org/10.1007/978-981-15-1792-1_10
Alpsoy, Ş. (2020). Exercise and hypertension. Physical exercise for human health, 153-167. https://doi.org/10.1007/978-981-15-1792-1_10
Alpsoy, S., Oran, M., Topcu, B., Akyuz, A., Akkoyun, D. C., & Degirmenci, H. (2013). Effect of lifestyle modifications on diastolic functions and aortic stiffness in prehypertensive subjects: A prospective cohort study. Anadolu Kardiyoloji Dergisi/The Anatolian Journal of Cardiology. https://doi.org/10.5152/akd.2013.139
American College of Sports Medicine. (2018). ACSM’s guidelines for exercise testing and prescription (D. Riebe, J. K. Ehrman, G. Liguori, & M. Magal, Eds.; 10th edition). Wolters Kluwer.
Basit, S., Wohlfahrt, J., & Boyd, H. A. (2018). Pre-eclampsia and risk of dementia later in life: nationwide cohort study. Bmj, 363. https://doi.org/10.1136/bmj.k4109
BC Ministry of Health. (2023). Hypertension—Diagnosis and Management—Province of British Columbia. Hypertension - Diagnosis and Management; Province of British Columbia.https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines /hypertension
Bredin, S. S. D., Gledhill, N., Jamnik, V. K., & Warburton, D. E. R. (2013). PAR-Q+ and ePARmed-X+: New risk stratification and physical activity clearance strategy for physicians and patients alike. Canadian Family Physician, 59(3), 273–277.
Brouwers, L., van der Meiden‐van Roest, A. J., Savelkoul, C., Vogelvang, T. E., Lely, A. T., Franx, A., & van Rijn, B. B. (2018). Recurrence of pre‐eclampsia and the risk of future hypertension and cardiovascular disease: a systematic review and meta‐analysis. BJOG: An International Journal of Obstetrics & Gynaecology, 125(13), 1642-1654. https://doi.org/10.1111/1471-0528.15394
Brown, M. J., & Haydock, S. (2000). Pathoaetiology, epidemiology and diagnosis of hypertension. Drugs, 59, 1-12. https://doi.org/10.2165/00003495-200059002-00001
Bushnell, C., & Chireau, M. (2011). Preeclampsia and stroke: risks during and after pregnancy. Stroke research and Treatment, 2011.https://doi.org/10.4061/2011/858134
Butalia, S., Audibert, F., Côté, A. M., Firoz, T., Logan, A. G., Magee, L. A., Mundle, W., Rey, E., Rabi, D. M., Daskalopoulou, S. S., Nerenberg, K. A., & Hypertension Canada (2018). Hypertension Canada's 2018 guidelines for the management of hypertension in pregnancy. The Canadian journal of cardiology, 34(5), 526–531. https://doi.org/10.1016/j.cjca.2018.02.021
Campbell, N. R. C., Paccot Burnens, M., Whelton, P. K., Angell, S. Y., Jaffe, M. G., Cohn, J., Espinosa Brito, A., Irazola, V., Brettler, J. W., Roccella, E. J., Maldonado Figueredo, J. I., Rosende, A., & Ordunez, P. (2022). 2021 World Health Organization guideline on pharmacological treatment of hypertension: Policy implications for the region of the Americas. Lancet Regional Health - Americas, 9, 100219. https://doi.org/10.1016/j.lana.2022.100219
Caspersen, C. J., Powell, K. E., & Christenson, G. M. (1985). Physical activity, exercise, and physical fitness: Definitions and distinctions for health-related research. Public Health Reports, 100(2), 126–131.
Challa, H. J., Ameer, M. A., & Uppaluri, K. R. (2023). DASH diet to stop hypertension. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482514/
Connelly, P. J., Currie, G., & Delles, C. (2022). Sex Differences in the Prevalence, Outcomes and Management of Hypertension. Current hypertension reports, 24(6), 185–192. https://doi.org/10.1007/s11906-022-01183-8
Devereaux, F. & Black, K. (n.d.). Setting the table for healthy food conversation. Retrieved April 16 2024, from https://www.fnha.ca/WellnessSite/WellnessDocuments/VIHA-Setting-The-Table-For-A-Healthy-Food-Conversation.pdf
Drożdż, D., Drożdż, M., & Wójcik, M. (2023). Endothelial dysfunction as a factor leading to arterial hypertension. Pediatric nephrology (Berlin, Germany), 38(9), 2973–2985. https://doi.org/10.1007/s00467-022-05802-z
Du, S., Zhou, Y., Fu, C., Wang, Y., Du, X., & Xie, R. (2018). Health literacy and health outcomes in hypertension: An integrative review. International journal of nursing sciences, 5(3), 301–309. https://doi.org/10.1016/j.ijnss.2018.06.001
Ellison, D. H., & Terker, A. S. (2015). Why your mother was right: how potassium intake reduces blood pressure. Transactions of the American Clinical and Climatological Association, 126, 46. PMID: 26330658
Engler, M. M. (2017). Role of dietary omega-3 fatty acids in hypertension. Ann Nurs Pract, 4(1), 1077. https://www.healthyliving.gr/wp-content/uploads/2017/11/Role-of-Dietary-Omega-3-Fatty-Acids-in-Hypertension.pdf
Esmailiyan, M., Amerizadeh, A., Vahdat, S., Ghodsi, M., Doewes, R. I., & Sundram, Y. (2023). Effect of Different Types of Aerobic Exercise on Individuals With and Without Hypertension: An Updated Systematic Review. Current Problems in Cardiology, 48(3), 101034. https://doi.org/10.1016/j.cpcardiol.2021.101034
Garasia, S., & Dobbs, G. (2019). Socioeconomic determinants of health and access to health care in rural Canada. University of Toronto Medical Journal, 96(2). Retrieved April 16 2024 from https://jps.library.utoronto.ca/index.php/utmj/issue/view/2375
Ghadieh, A. S., & Saab, B. (2015). Evidence for exercise training in the management of hypertension in adults. Canadian Family Physician, 61(3), 233–239.
Health Canada. (2017). Sodium intake of Canadians in 2017. Retrieved April 16 2024, from https://www.canada.ca/content/dam/hc-sc/documents/services/publications/food-nutrition/sodium-intake-canadians-2017/2017-sodium-intakes-report-eng.pdf
Hegde, S., Ahmed, I., & Aeddula, N. R. (2024). Secondary Hypertension. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK544305/
Houston, M. C., & Harper, K. J. (2008). Potassium, magnesium, and calcium: their role in both the cause and treatment of hypertension. The Journal of Clinical Hypertension, 10(7), 3-11. https://doi.org/10.1111/j.1751-7176.2008.08575.x
Howley, E. T. (2001). Type of activity: Resistance, aerobic and leisure versus occupational physical activity. Medicine and Science in Sports and Exercise, 33(6 Suppl), S364-9; discussion S419-20. https://doi.org/10.1097/00005768-200106001-00005
Hypertension Canada. (2016). Hypertension in Canada. Retrieved April 16 2024, from https://hypertension.ca/wp-content/uploads/2018/12/HTN-Fact-Sheet-2016_FINAL.pdf
Hypertension Canada. (2020). Criteria for diagnosis of hypertension and guidelines follow-up. Retrieved April 16 2024, from https://hypertension.ca/guidelines/diagnosis-assessment/diagnosis-assessment-diagnosis/
InformedHealth.org. (2019). What is blood pressure and how is it measured? Institute for Quality and Efficiency in Health Care (IQWiG). Retrieved April 16 2024 from: https://www.ncbi.nlm.nih.gov/books/NBK279251/
Iqbal, A. M., & Jamal, S. F. (2024). Essential Hypertension. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK539859/
Izzo, R., Losi, M. A., Stabile, E., Lönnebakken, M. T., Canciello, G., Esposito, G., Barbato, E., De Luca, N., Trimarco, B., & de Simone, G. (2017). Development of left ventricular hypertrophy in treated hypertensive outpatients: The Campania Salute Network. Hypertension (Dallas, Tex. : 1979), 69(1), 136–142. https://doi.org/10.1161/HYPERTENSIONAHA.116.08158
Jeong, E. M., Lee, K. B., Kim, G. E., Kim, C. M., Lee, J. H., Kim, H. J., ... & Kim, I. G. (2020). Competitive binding of magnesium to calcium binding sites reciprocally regulates transamidase and GTP hydrolysis activity of transglutaminase 2. International journal of molecular sciences, 21(3), 791. https://doi.org/10.3390%2Fijms21030791
Ji, H., Niiranen, T. J., Rader, F., Henglin, M., Kim, A., Ebinger, J. E., ... & Cheng, S. (2021). Sex differences in blood pressure associations with cardiovascular outcomes. Circulation, 143(7), 761-763. https://doi.org/10.1161/CIRCULATIONAHA.120.049360
Josewski, V., de Leeuw, S., & Greenwood, M. (2023). Grounding Wellness: Coloniality, Placeism, Land, and a Critique of “Social” Determinants of Indigenous Mental Health in the Canadian Context. International Journal of Environmental Research and Public Health, 20(5), Article 5. https://doi.org/10.3390/ijerph20054319
Johnson, S. (n.d.). First nations traditional foods fact sheets. Retrieved April 16 2024, from https://www.fnha.ca/Documents/Traditional_Food_Fact_Sheets.pdf
Joyner, M. J., Charkoudian, N., & Wallin, B. G. (2010). Sympathetic nervous system and blood pressure in humans: individualized patterns of regulation and their implications. Hypertension (Dallas, Tex. : 1979), 56(1), 10–16. https://doi.org/10.1161/HYPERTENSIONAHA.109.140186
Kowalski, S., Goniewicz, K., Moskal, A., Al-Wathinani, A. M., & Goniewicz, M. (2023). Symptoms in Hypertensive Patients Presented to the Emergency Medical Service: A Comprehensive Retrospective Analysis in Clinical Settings. Journal of Clinical Medicine, 12(17), 5495. https://doi.org/10.3390/jcm12175495
Lago, R. M., Singh, P. P., & Nesto, R. W. (2007). Diabetes and hypertension. Nature Clinical Practice Endocrinology & Metabolism, 3(10), Article 10. https://doi.org/10.1038/ncpendmet0638
Lee, H., Yano, Y., Cho, S. M. J., Park, J. H., Park, S., Lloyd-Jones, D. M., & Kim, H. C. (2020). Cardiovascular risk of isolated systolic or diastolic hypertension in young adults. Circulation, 141(22), 1778-1786. https://doi.org/10.1161/CIRCULATIONAHA.119.044838
Lewis, M. E., Smith, J., Wildcat, S., Anderson, A., & Walls, M. L. (2022). The Health Effects of a Cherokee Grounded Culture and Leadership Program. International Journal of Environmental Research and Public Health, 19(13), Article 13. https://doi.org/10.3390/ijerph19138018
MacDonald, H. V., & Pescatello, L. S. (2019). Exercise and Blood Pressure Control in Hypertension. In P. Kokkinos & P. Narayan (Eds.), Cardiorespiratory Fitness in Cardiometabolic Diseases: Prevention and Management in Clinical Practice (pp. 137–168). Springer International Publishing. https://doi.org/10.1007/978-3-030-04816-7_8
Madsen, T. E., Howard, G., Kleindorfer, D. O., Furie, K. L., Oparil, S., Manson, J. E., ... & Howard, V. J. (2019). Sex differences in hypertension and stroke risk in the REGARDS study: a longitudinal cohort study. Hypertension, 74(4), 749-755. https://doi.org/10.1161/HYPERTENSIONAHA.119.12729
Millar, P. J., & Goodman, J. M. (2014). Exercise as medicine: Role in the management of primary hypertension. Applied Physiology, Nutrition, and Metabolism, 39(7), 856–859. https://doi.org/10.1139/apnm-2014-0006
Millett, E. R., Peters, S. A., & Woodward, M. (2018). Sex differences in risk factors for myocardial infarction: cohort study of UK Biobank participants. BMJ, 363. https://doi.org/10.1136/bmj.k4247
Mozaffarian D. (2007). Fish, n-3 fatty acids, and cardiovascular haemodynamics. Journal of cardiovascular medicine (Hagerstown, Md.), 8 Suppl 1, S23–S26. https://doi.org/10.2459/01.JCM.0000289279.95427.e2
Musqueam Indian Band. (2024). Our story. Retrieved April 16 2024, from https://www.musqueam.bc.ca/our-story/
National Institutes of Health. (2000). Working Group Report on High Blood Pressure in Pregnancy. Bethesda, MD: National Institutes of Health. NIH Publication no. 00-3029.
Newstead, J., Von Dadelszen, P., & Magee, L. A. (2007). Preeclampsia and future cardiovascular risk. Expert review of cardiovascular therapy, 5(2), 283-294. https://doi.org/10.1586/14779072.5.2.283
O'Brien, E., White, W. B., Parati, G., & Dolan, E. (2018). Ambulatory blood pressure monitoring in the 21st century. The Journal of Clinical Hypertension, 20(7), 1108-1111. https://doi.org/10.1111%2Fjch.13275
Ohishi, M. (2018). Hypertension with diabetes mellitus: physiology and pathology. Hypertension Research, 41, 389-393. https://doi.org/10.1038/s41440-018-0034-4
Oparil, S., Acelajado, M. C., Bakris, G. L., Berlowitz, D. R., Cífková, R., Dominiczak, A. F., Grassi, G., Jordan, J., Poulter, N. R., Rodgers, A., & Whelton, P. K. (2018). Hypertension. Nature reviews. Disease primers, 4, 18014. https://doi.org/10.1038/nrdp.2018.14
Oparil, S., Zaman, M. A., & Calhoun, D. A. (2003). Pathogenesis of hypertension. Annals of internal medicine, 139(9), 761–776. https://doi.org/10.7326/0003-4819-139-9-200311040-00011
Padwal, R. S., Bienek, A., McAlister, F. A., Campbell, N. R., & Outcomes Research Task Force of the Canadian Hypertension Education Program. (2016). Epidemiology of hypertension in Canada: an update. Canadian Journal of Cardiology, 32(5), 687-694. https://doi.org/10.1016/j.cjca.2015.07.734
Paré, E. , Parry, S. , McElrath, T. F. , Pucci, D. , Newton, A. & Lim, K. (2014). Clinical risk factors for preeclampsia in the 21st century. Obstetrics & Gynecology, 124 (4), 763-770. doi: 10.1097/AOG.0000000000000451.
Petrie, J. R., Guzik, T. J., & Touyz, R. M. (2018). Diabetes, hypertension, and cardiovascular disease: clinical insights and vascular mechanisms. The Canadian journal of cardiology, 34(5), 575–584. https://doi.org/10.1016/j.cjca.2017.12.005
Public Health Agency of Canada. (2010). Report from the Canadian chronic disease surveillance system: Hypertension in Canada, 2010. Retrieved April 16 2024, from https://www.phac-aspc.gc.ca/cd-mc/cvd-mcv/ccdss-snsmc-2010/pdf/CCDSS_HTN_Report_FINAL_EN_20100513.pdf
Rabi, D. M., McBrien, K. A., Sapir-Pichhadze, R., Nakhla, M., Ahmed, S. B., Dumanski, S. M., Butalia, S., Leung, A. A., Harris, K. C., Cloutier, L., Zarnke, K. B., Ruzicka, M., Hiremath, S., Feldman, R. D., Tobe, S. W., Campbell, T. S., Bacon, S. L., Nerenberg, K. A., Dresser, G. K., … Daskalopoulou, S. S. (2020). Hypertension Canada’s 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children. Canadian Journal of Cardiology, 36(5), 596–624. https://doi.org/10.1016/j.cjca.2020.02.086
Rana, S., Lemoine, E., Granger, J., & Karumanchi, S. A. (2019). Preeclampsia: pathophysiology, challenges, and perspectives. Circulation Research, 124(7), 1094–1112. https://doi.org/10.1161/CIRCRESAHA.118.313276
Reckelhoff J. F. (2023). Mechanisms of sex and gender differences in hypertension. Journal of human hypertension, 37(8), 596–601. https://doi.org/10.1038/s41371-023-00810-4
Rippe J. M. (2018). Lifestyle Strategies for Risk Factor Reduction, Prevention, and Treatment of Cardiovascular Disease. American journal of lifestyle medicine, 13(2), 204–212. https://doi.org/10.1177/1559827618812395
Romero, R., & Chaiworapongsa, T. (2013). Preeclampsia: a link between trophoblast dysregulation and an antiangiogenic state. The Journal of clinical investigation, 123(7), 2775-2777. 10.1172/JCI70431
Sacks, F. M., Svetkey, L. P., Vollmer, W. M., Appel, L. J., Bray, G. A., Harsha, D., ... & Cutler, J. A. (2001). Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. New England journal of medicine, 344(1), 3-10. https://doi.org/10.1056/NEJM200101043440101
Sakamoto, S. (2020). Prescription of exercise training for hypertensives. Hypertension Research, 43(3), 155–161. https://doi.org/10.1038/s41440-019-0344-1
Salloum, M., & Warburton, D. E. R. (2019). Importance of Spiritual Wellbeing in Community-Based Health Interventions in Indigenous Peoples in BC. The Health & Fitness Journal of Canada, 12(1), Article 1. https://doi.org/10.14288/hfjc.v12i1.264
Sandberg, K., & Ji, H. (2012). Sex differences in primary hypertension. Biology of Sex Differences, 3(1), 7. https://doi.org/10.1186/2042-6410-3-7
Sanders, P. W. (2009). Dietary Salt Intake, Salt Sensitivity, and Cardiovascular Health. Hypertension, 53(3), 442–445. https://doi.org/10.1161/HYPERTENSIONAHA.108.120303
Sata, Y., Head, G. A., Denton, K., May, C. N., & Schlaich, M. P. (2018). Role of the Sympathetic Nervous System and Its Modulation in Renal Hypertension. Frontiers in medicine, 5, 82. https://doi.org/10.3389/fmed.2018.00082
Siervo, M., Lara, J., Chowdhury, S., Ashor, A., Oggioni, C., & Mathers, J. C. (2015). Effects of the Dietary Approach to Stop Hypertension (DASH) diet on cardiovascular risk factors: a systematic review and meta-analysis. British Journal of Nutrition, 113(1), 1-15. https://doi.org/10.1017/S0007114514003341
Sorensen, T. K., Williams, M. A., Lee, I. M., Dashow, E. E., Thompson, M. L., & Luthy, D. A. (2003). Recreational physical activity during pregnancy and risk of preeclampsia. Hypertension, 41(6), 1273-1280. https://doi.org/10.1161/01.HYP.0000072270.82815.91
Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Panel on Dietary Reference Intakes for Electrolytes, & Water. (2005). Dietary reference intakes for water, potassium, sodium, chloride, and sulfate. National Academies Press. https://doi.org/ 0.17226/10925
Statistics Canada. (2021). The Daily — Deaths. Retrieved April 16 2024 from https://www150.statcan.gc.ca/n1/daily-quotidien/230828/dq230828b-eng.htm
Statistics Canada. (2022) Population growth in Canada’s rural areas, 2016 to 2021. Retrieved April 16 2024, from https://www12.statcan.gc.ca/census-recensement/2021/as-sa/98-200-x/2021002/98-200-x2021002-eng.cfm
Statistics Canada. (2022). Annual demographic estimates, rural and urban areas: Interactive dashboard. Retrieved April 16 2024 from https://www150.statcan.gc.ca/n1/pub/71-607-x/71-607-x2021030-eng.htm
Statistics Canada. (2022). Canadian Health Measures Survey (CHMS). Retrieved April 16 2024, from https://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=5071
Sui, X., Sarzynski, M. A., Lee, D., & Kokkinos, P. F. (2017). Impact of Changes in Cardiorespiratory Fitness on Hypertension, Dyslipidemia and Survival: An Overview of the Epidemiological Evidence. Progress in Cardiovascular Diseases, 60(1), 56–66. https://doi.org/10.1016/j.pcad.2017.02.006
Tejani, V. N., Dhillon, S. S., Damarlapally, N., Usman, N. U. B., Winson, T., Roy, P. B., & Panjiyar, B. K. (2023). The relationship between dietary fiber intake and blood pressure worldwide: a systematic review. Cureus, 15(9). https://doi.org/10.7759%2Fcureus.46116
Teufel-Shone, N. I., Fitzgerald, C., Teufel-Shone, L., & Gamber, M. (2009). Systematic Review of Physical Activity Interventions Implemented with American Indian and Alaska Native Populations in the United States and Canada. American Journal of Health Promotion, 23(6_suppl), S8–S32. https://doi.org/10.4278/ajhp.07053151
Vikse, B. E., Irgens, L. M., Leivestad, T., Skjærven, R., & Iversen, B. M. (2008). Preeclampsia and the risk of end-stage renal disease. New England Journal of Medicine, 359(8), 800-809. 10.1056/NEJMoa0706790
Villa-Etchegoyen, C., Lombarte, M., Matamoros, N., Belizán, J. M., & Cormick, G. (2019). Mechanisms involved in the relationship between low calcium intake and high blood pressure. Nutrients, 11(5), 1112. https://doi.org/10.3390/nu11051112
Wang, L., Ai, D., & Zhang, N. (2017). Exercise Dosing and Prescription-Playing It Safe: Dangers and Prescription. In J. Xiao (Ed.), Exercise for Cardiovascular Disease Prevention and Treatment: From Molecular to Clinical, Part 2 (pp. 357–387). Springer. https://doi.org/10.1007/978-981-10-4304-8_19
Warburton, D. E. R., & Bredin, S. S. D. (2016). Reflections on Physical Activity and Health: What Should We Recommend? Canadian Journal of Cardiology, 32(4), 495–504. https://doi.org/10.1016/j.cjca.2016.01.024
Warburton, D. E. R., Gledhill, N., Jamnik, V. K., Bredin, S. S. D., McKenzie, D. C., Stone, J., Charlesworth, S., & Shephard, R. J. (2011). Evidence-based risk assessment and recommendations for physical activity clearance: Consensus Document 2011. Applied Physiology, Nutrition, and Metabolism = Physiologie Appliquee, Nutrition Et Metabolisme, 36 Suppl 1, S266-298. https://doi.org/10.1139/h11-062
Whelton, P. K., Carey, R. M., Mancia, G., Kreutz, R., Bundy, J. D., & Williams, B. (2022). Harmonization of the American College of Cardiology/American Heart Association and European Society of Cardiology/European Society of Hypertension Blood Pressure/Hypertension Guidelines: Comparisons, Reflections, and Recommendations. European Heart Journal, 43(35), 3302–3311. https://doi.org/10.1093/eurheartj/ehac432
Whelton, P. K., Carey, R. M., Mancia, G., Kreutz, R., Bundy, J. D., & Williams, B. (2022). Harmonization of the American College of Cardiology/American Heart Association and European Society of Cardiology/European Society of Hypertension Blood Pressure/Hypertension Guidelines: Comparisons, Reflections, and Recommendations. Circulation, 146(11), 868–877. https://doi.org/10.1161/CIRCULATIONAHA.121.054602
Wilson, C. R., Rourke, J., Oandasan, I. F., & Bosco, C. (2020). Progress made on access to rural health care in Canada. Canadian Family Physician, 66(1), 31-36. PMCID: PMC7012120
Wright, J. M., Musini, V. M., & Gill, R. (2018). First-line drugs for hypertension. The Cochrane database of systematic reviews, 4(4), CD001841. https://doi.org/10.1002/14651858.CD001841.pub3