Being male puts a patient at increased risk of getting cardiovascular disease (CVD) mostly because men get CVD approximately 10 years earlier then women. Increased risk begins at 55 for men and 65 for women. Hormonal factors are hypothesized to be responsible for this difference in risk. Overall risk of hypertension does differ appreciably between men and women. Because hypertension is an important modifiable risk factor one could argue that aggressive early detection and treatment in the male population could help to delay the progression of CVD
An estimated 70 million American adults have prehypertension, a blood pressure (BP) classification adopted in 2003 by Seventh Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of Hypertension (JNC7). Prehypertension describes a range of BP levels that had previously been categorized as normal or borderline: 120-139 mm Hg systolic and/or 80-89 mm Hg diastolic (see table 1).
JNC6 Classification (1997)
Blood Pressure (mm Hg)
JNC7 Classification (2003)
Prehypertension is not a disease category and drug therapy is not recommended. The exception is individuals who also have diabetes or kidney disease if lifestyle modification alone fails to reduce their BP to ≤130/80 mm Hg. To reduce BP and prevent or delay the onset of hypertension the JNC7 recommends lifestyle modifications that include weight loss, a healthy diet, limited alcohol intake, and aerobic exercise (30 minutes/day 6-7 days a week).
It is estimated that in patients with stage 1 hypertension and additional cardiovascular risk factors, achieving a sustained 12 mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated.
Table 2: Identifiable causes of hypertension
Drug-induced or related causes (see table 3)
Chronic kidney disease
Chronic steroid therapy and Cushing’s syndrome
Coarctation of the aorta
Thyroid or parathyroid disease
Causes of resistant hypertension
Improper BP Measurement
Identifiable Causes of Hypertension. (See table 2.)
Excess sodium intake
Volume retention from kidney disease
Inadequate diuretic therapy
Drug-Induced or Other Causes
Nonsteroidal anti-inflammatory drugs; cyclooxygenase 2 inhibitors
Cocaine, amphetamines, other illicit drugs
Sympathomimetics (decongestants, anorectics)
Cyclosporine and tacrolimus
Licorice (including some chewing tobacco)
Selected over-the-counter dietary supplements and medicines (e.g., ephedra, bitter orange, caffeine)
Excess alcohol intake
Effective Dietary Advice
Numerous epidemiological studies and intervention studies agree that the following foods either protect against CHD and stroke or are associated with less cardiovascular related mortality: 1) Whole grains: 2-3 servings/day 2) Legumes (including soy protein, peas, lentils, peanuts, beans) 2-3 servings/day 3) Wine/ alcohol 1-3 servings/day. For those without an alcohol problem I recommend one 4 oz glass of dry white or red wine per day. For those who weigh more than 180 lbs two 4 oz glasses may be consumed per day. 4) Fruits and vegetables: 1-2 servings of fruit, 5 or more servings of vegetables. 5) Nuts: 1-2 servings/day. Almonds, Brazil nuts, Cashews, Hazelnuts, Macadamia, Peanuts (really a legume), Pecans, Pine nuts, Pistachio, and Walnuts are all good choices. Raw, unsalted nuts are what you should buy. Nut butters are also good. Almonds are the highest in fiber and peanuts are the highest in protein. Walnuts are the only nut with appreciable amounts of omega-3 fats. 6) Fish: 2 servings minimum/week. I recommend fish oil supplements if at least two servings of fish per week are not consumed.
Of all the diets associated with lower blood pressure only the DASH diet has been studied extensively and shown to be effective as an intervention. The DASH diet is low in sodium (<2400 mg/day) and high in magnesium, potassium and calcium. Traditional diets such as the “Paleo diet” also mimic this mineral profile. In the United States sodium intake is roughly 4,200 milligrams per day (men) and 3,300 milligrams per day (women). It is the pattern of low sodium coupled with high potassium, magnesium and calcium that is most effective whereas individual mineral supplementation is not very effective.
The DASH diet is easily obtained online. In my office we use a modified version of the DASH diet. The modified version includes lower glycemic carbohydrate, healthier fats, whole grains and more fiber. Additionally we customize it for those needing to lose weight and conduct bioimpedance analysis to monitor fat and muscle mass. I also give patients a shopping list to take with them to the store.
Dark chocolate administration has been shown to lower blood pressure and improve insulin sensitivity in humans [i] and lately there has been a flurry of research on Cacoa as a constituent of dark chocolate and its effects on blood pressure, heart disease and diabetes. Cacao beans contain >600 plant chemicals, including antioxidant phytochemicals such as flavonoids, and high amounts of magnesium which could explain a beneficial role in heart disease prevention. A bar of chocolate supplies the recommended daily allowance of magnesium as well.
Arginine: Individuals with hypertension exhibit blunted epicardial and vascular dilation to endothelium-derived nitric oxide (EDNO) in the peripheral and coronary circulation. This likely contributes to altered vascular tone in hypertension. The amino acid L-arginine serves as the principal substrate for vascular NO production. Some but not all studies demonstrate a beneficial effect of acute and chronic L-arginine supplementation on EDNO production and endothelial function. Numerous studies of iv L-arginine in humans have shown that endothelial function is improved in patients with hypertension, hypercholesterolemia and diabetes. [ii] Recently, Preli et al. summarized the results of studies on the effect of oral L-arginine on the cardiovascular system in humans. In contrast to animal studies, the results from human studies have varied. Five of the 17 human studies showed no vascular health benefit from oral L-arginine supplementation. The remaining 12 studies demonstrated beneficial effect of oral L-arginine supplementation as evidenced by decreased platelet aggregation and adhesion, decreased monocyte adhesion or improved endothelium-dependent vasodilation. [iii] IV administration is more effective for acute blood pressure lowering.
A new sustained release form of arginine shows promise. At 2.1 g daily sustained release arginine lowered SBP in 10 individuals who were hypertensive (mean systolic reduction of 11 mm Hg) while normotensives had a mean systolic decrease of only 0.22 mm Hg. [iv]
Magnesium chelate (citrate, glycinate, malate): Some, but not all, trials show that magnesium supplements (350–500 mg per day) lower blood pressure. Magnesium appears to be particularly effective in people who are taking potassium-depleting diuretics probably because potassium depleting diuretics also deplete magnesium. Magnesium also has mild calcium channel blockade effects.
Coenzyme Q10: Coenzyme Q10 has been primarily used for the treatment of congestive heart failure but evidence also suggests utility in angina, diabetes, and hypertension. Langsjoen et al looked at the effect of CoQ10 on 424 patients with various cardiovascular diagnoses over an 8-year period to determine the effect of Co-Q10 on cardiovascular diseases. Coenzyme Q10 was added to each patient’s medical regimen. Patients were then monitored during regular clinic visits where various cardiologic studies were performed. The dosage range used in this analysis varied from 75 mg to 600 mg per day with the aim of producing a whole blood level greater than or equal to 2.10 micrograms/ml.
Patients were subdivided into 6 categories for the purposes of the analysis: those with idiopathic dilated cardiomyopathy, primary diastolic dysfunction, hypertension, ischemic cardiomyopathy, valvular heart disease, and mitral valve prolapse. In general, the investigators observed symptomatic improvements in occurrence of chest pain, fatigue, dyspnea, and palpitations. Overall, 247 (58.2%) patients demonstrated improvements. Patients with hypertension (P < .02) and mitral valve prolapse (P < .06) also showed some improvement in the left ventricular end diastolic dimension compared with baseline. Left ventricular wall thickness showed a significant improvement in all groups of patients except for patients with valvular heart disease (P < .05). This study, compared with others, enrolled a larger number of patients and had a longer follow-up period. Langsjoen et al also reported a significant decrease in the number of different cardiovascular drugs used: a 19% decrease in the use of digoxin, a 51% decrease in use of beta blockers, a 21% decrease in use of long-acting nitrates, a 61% decrease in the use of antiarrhythmic drugs, a 24% decrease in use of calcium channel blockers, a 32% decrease in the use of angiotensin-converting enzyme inhibitors, and a 37% decrease in the use of other antihypertensive drugs.[v]
Aged Garlic extract: Epidemiologic studies show an inverse correlation between garlic consumption and progression of cardiovascular disease and evidence from clinical trials points toward garlic having a role to play in either preventing or delaying cardiovascular disease. [vi] However, more research is still required. Since 1993, 9 studies have been published on the effects of various forms of garlic on blood pressure and 6 of the 9 studies showed a reduction in blood pressure. A metaanalysis published in 2001[vii] concluded that garlic has insignificant effects on blood pressure. Though effects on blood pressure are small garlic has other proven cardiovascular benefits including; inhibition of platelet aggregation, mild hypolipidemic effects, and reduction in oxidative stress.
[i] Grassi D, Lippi C, Necozione S, Desideri G, Ferri C. Short-term administration of dark chocolate is followed by a significant increase in insulin sensitivity and a decrease in blood pressure in healthy persons. Am J Clin Nutr 2004;81:611–4.
[ii] L-arginine and cardiovascular system. Pharmacol Rep. 2005 Jan-Feb;57(1):14-22. Review.
[iii] Preli RB, Klein KP, Herrington DM: Vascular effects of dietary L-arginine supplementation. Atherosclerosis, 2002, 162, 1–15.
[iv] Miller A. The effects of sustained-release-L-arginine formulation on blood pressure and vascular compliance in 29 healthy individuals.Altern Med Rev. 2006 Mar;11(1):23-9.
[v] Langsjoen H, Langsjoen P, Willis R, et al. Usefulness of coenzyme Q10 in clinical cardiology: A long-term study. Mol Aspects Med 1994;15(suppl):S165-S175.
[vi] Rahman K, Lowe GM. Garlic and cardiovascular disease: a critical review. J Nutr. 2006 Mar;136(3 Suppl):736S-740S. Review.
[vii] Ackermann RT, Mulrow CD, Ramirez G, Gardner CD, Morbidoni L, Lawrence VA. Garlic shows promise for improving some cardiovascular risk factors. Arch Intern Med. 2001;161:813–24.