Nonpharmacologic Strategies for Managing Hypertension
http://www.100md.com
《美国家庭保健医生杂志》
Ohio State University College of Medicine, Columbus, Ohio
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends lifestyle modification for all patients with hypertension or prehypertension. Modifications include reducing dietary sodium to less than 2.4 g per day; increasing exercise to at least 30 minutes per day, four days per week; limiting alcohol consumption to two drinks or less per day for men and one drink or less per day for women; following the Dietary Approaches to Stop Hypertension eating plan (high in fruits, vegetables, potassium, calcium, and magnesium; low in fat and salt); and achieving a weight loss goal of 10 lb (4.5 kg) or more. Alternative treatments such as vitamin C, coenzyme Q10, magnesium, and omega-3 fatty acids have been suggested for managing hypertension, but evidence for their effectiveness is lacking. (Am Fam Physician 2006;73:1953-6, 1957-8. Copyright ? 2006 American Academy of Family Physicians.)
Despite all that is known about its adverse health consequences, high blood pressure still is poorly controlled in the United States.1-5 Only about one third of patients with hypertension have achieved the National High Blood Pressure Education Program goal of 140/90 mm Hg or lower.1 With the mainstay of hypertensive therapy in the United States being pharmacotherapy, interventions such as lifestyle and dietary modification often are overlooked. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)1 recommends lifestyle modification for all patients with hypertension (i.e., blood pressure of 140/90 mm Hg or higher) or prehypertension (i.e., blood pressure of 120/80 to 139/89 mm Hg), a new category developed by JNC 7 to draw attention to earlier intervention. Although some lifestyle modifications may seem to offer only minimal blood pressure-lowering effects, they should not be discounted. A reduction in systolic blood pressure of 5 mm Hg has been associated in observational studies with reductions of 14 percent in mortality caused by stroke, 9 percent in mortality caused by heart disease, and 7 percent in all-cause mortality.6 In addition, a weight loss of 10 lb (4.5 kg), a realistic goal for most individuals who are overweight, can reduce or prevent hypertension.7
note: All recommendations are rated C because, although there is good evidence that they lower blood pressure, there is no direct evidence of mortality or morbidity benefit from clinical trials.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1874 or http://www.aafp.org/afpsort.xml.
Recommended Lifestyle Modifications
Five lifestyle modifications are recommended by JNC 7 for reducing blood pressure: (1) reducing sodium intake, (2) increasing exercise, (3) moderating alcohol consumption, (4) following the Dietary Approaches to Stop Hypertension (DASH) eating plan (Table 1),8-10 and (5) losing weight.1 These modifications have been proven to reduce blood pressure, although their direct impact on morbidity and mortality is not yet known.
DASH = dietary approaches to stop hypertension.
Low sodium intake was a later addition to the plan.
Information from references 8 through 10.
sodium reduction
In the Trial Of Nonpharmacologic interventions in the Elderly (TONE) study,11 patients were randomized to a low-sodium diet (80 mEq per L [1.9 g; 80 mmol per L] per day) or usual care (i.e., no study-related counseling in lifestyle change). The intervention group had a 2.8 mm Hg greater reduction in systolic blood pressure than the control group. A later study12 assessed the impact on blood pressure of three levels of daily sodium intake: 150, 100, and 50 mEq per L (3.6, 2.4, and 1.2 g; 150, 100, and 50 mmol per L), representing a typical American diet, the upper end of recommended intake, and a limited intake, respectively. Results demonstrated a graded blood pressure response, with a correlation between greater reduction in blood pressure and lower sodium consumption. The recommended sodium intake is less than 100 mEq per L per day for all patients with hypertension or prehypertension.1,12
exercise
Aerobic exercise has positive effects on blood pressure whether or not a person has hypertension, producing average reductions of 4 mm Hg in systolic blood pressure and 3 mm Hg in diastolic blood pressure.13 Physicians should help patients find an activity that they enjoy, because enjoyment will increase their adherence. If a patient finds it difficult to make time to exercise, one suggestion might be a brisk walk at lunch, which helps break up the day and requires no additional time commitment. Physicians also could suggest that patients listen to books on tape while walking, which may help to maintain interest level. It is recommended that patients with prehypertension or hypertension exercise for 30 minutes on most days of the week.1
limiting alcohol consumption
Limiting alcohol consumption is an important lifestyle modification for reducing blood pressure. One meta-analysis14 indicated a dose-response relationship between decreased alcohol consumption and blood pressure reduction. Pooled results showed reductions of 3 mm Hg in systolic blood pressure and 2 mm Hg in diastolic blood pressure for patients in the alcohol reduction groups (average reduction of 67 percent from an average intake of three to six drinks per day at baseline).14 As part of a comprehensive lifestyle program, men should have no more than two alcoholic drinks per day and women no more than one per day.1,14
dietary changes
The DASH eating plan outlines a diet rich in fruits and vegetables; high in low-fat dairy products, potassium, magnesium, and calcium; and low in total saturated fats (Table 1).8-10 Following this plan has been shown to produce mean reductions of 6 mm Hg in systolic blood pressure and 3 mm Hg in diastolic blood pressure,12 and combining the plan with a reduction in sodium intake produces additional blood pressure reduction.12
In the PREMIER clinical trial,15 researchers assessed the impact on blood pressure of comprehensive lifestyle changes (i.e., reduced sodium intake, increased activity, moderate alcohol consumption, and weight loss) in addition to the DASH eating plan, compared with lifestyle changes alone or usual care (i.e., advice only). Participants in the lifestyle changes only group had a greater reduction in blood pressure than those in the usual care group, and this was further enhanced with the addition of the DASH eating plan. This was the first trial to demonstrate that all recommended lifestyle changes can be combined to reduce blood pressure successfully.
Potassium and sodium fluctuate antagonistically-a decrease in potassium leads to sodium retention, whereas an increase in potassium leads to sodium excretion, thereby promoting diuresis and natriuresis.16 Although the mechanism by which a diet low in potassium contributes to increased blood pressure is not known, it has been estimated that, in persons with essential hypertension, a diet low in potassium results in a systolic increase of 7 mm Hg because of increased sodium retention.17 Additionally, potassium supplementation appears to play an enhanced role in individuals with an initially high sodium intake.6 A meta-regression analysis of randomized trials that assessed blood pressure response to changes in potassium and sodium intake showed that increased intake of potassium could play a major role in the prevention of hypertension.18 Increased potassium resulted in a reduction of 2.42 mm Hg in systolic blood pressure and a drop of 1.57 mm Hg in diastolic blood pressure.18 Current recommendations, however, are to obtain adequate potassium intake through a healthy diet.1 Some of the organizations that provide helpful information about and support for the implementation of lifestyle modifications are listed in Table 2.
REFERENCES
1. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-52.
2. American Heart Association. Heart disease and stroke statistics-2004 update. Dallas, Tex.: American Heart Association, 2003.
3. Fields LE, Burt V, Cutler JA, Hughes J, Roccella EJ, Sorlie P. The burden of adult hypertension in the United States 1999 to 2000: a rising tide. Hypertension 2004;44:398-404.
4. Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA 2003;290:199-206.
5. Berlowitz DR, Ash AS, Hickey EC, Friedman RH, Glickman M, Kader B, et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med 1998;339:1957-63.
6. Whelton PK, He J, Appel LJ, Cutler JA, Havas S, Kotchen TA, et al. Primary prevention of hypertension: clinical and public health advisory from the National High Blood Pressure Education Program. JAMA 2002;288:1882-8.
7. He J, Whelton PK, Appel LJ, Charleston J, Klag MJ. Long-term effects of weight loss and dietary sodium reduction on incidence of hypertension. Hypertension 2000;35:544-9.
8. Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, et al. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med 1997;336:1117-24.
9. Vollmer WM, Sacks FM, Ard J, Appel LJ, Bray GA, Simons-Morton DG, et al. Effects of diet and sodium intake on blood pressure: subgroup analysis of the DASH-sodium trial. Ann Intern Med 2001;135:1019-28.
10. National Heart, Lung, and Blood Institute. The DASH eating plan. Bethesda, Md.: U.S. Department of Health and Human Services, 2003. Accessed online November 3, 2005, at: http://www.nhlbi.nih.gov/health/public/heart/hbp/dash.
11. Whelton PK, Appel LJ, Espeland MA, Applegate WB, Ettinger WH Jr, Kostis JB, et al. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of nonpharmacologic interventions in the elderly (TONE) [published correction appears in JAMA 1998;279:1954]. JAMA 1998;279:839-46.
12. Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. N Engl J Med 2001;344:3-10.
13. Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med 2002;136:493-503.
14. Xin X, He J, Frontini MG, Ogden LG, Motsamai OI, Whelton PK. Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 2001;38:1112-7.
15. Appel LJ, Champagne CM, Harsha DW, Cooper LS, Obarzanek E, Elmer PJ, et al. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA 2003;289:2083-93.
16. Gallen IW, Rosa RM, Esparaz DY, Young JB, Robertson GL, Batlle D, et al. On the mechanism of the effects of potassium restriction on blood pressure and renal sodium retention. Am J Kidney Dis 1998;31:19-27.
17. Krishna GG, Kapoor SC. Potassium depletion exacerbates essential hypertension. Ann Intern Med 1991;115:77-83.
18. Geleijnse JM, Kok FJ, Grobbee DE. Blood pressure response to changes in sodium and potassium intake: a metaregression analysis of randomized trials. J Hum Hypertens 2003;17:471-80.
19. Cryer PE, Haymond MW, Santiago JV, Shah SD. Norepinephrine and epinephrine release and adrenergic mediation of smoking-associated hemodynamic and metabolic events. N Engl J Med 1976;295:573-7.
20. Benowitz NL, Hansson A, Jacob P III. Cardiovascular effects of nasal and transdermal nicotine and cigarette smoking. Hypertension 2002;39:1107-12.
21. Yamagishi K, Iso H, Kitamura A, Sankai T, Tanigawa T, Naito Y, et al. Smoking raises the risk of total and ischemic strokes in hypertensive men. Hypertens Res 2003;26:209-17.
22. Kurth T, Kase CS, Berger K, Schaeffner ES, Buring JE, Gaziano JM. Smoking and the risk of hemorrhagic stroke in men. Stroke 2003;34:1151-5.
23. Schneider RH, Staggers F, Alexander CN, Sheppard W, Rainforth M, Kondwani K, et al. A randomised controlled trial of stress reduction for hypertension in older African Americans. Hypertension 1995;26:820-7.
24. Canter PH, Ernst E. Insufficient evidence to conclude whether or not transcendental meditation decreases blood pressure: results of a systematic review of randomized clinical trials. J Hypertens 2004;22:2049-54.
25. Schneider RH, Alexander CN, Staggers F, Rainforth M, Salerno JW, Hartz A, et al. Long-term effects of stress reduction on mortality in persons > or = 55 years of age with systemic hypertension. Am J Cardiol 2005;95:1060-4.
26. Canter PH. The therapeutic effects of meditation. BMJ 2003;326: 1049-50.(RANDY WEXLER, M.D., M.P.H)
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends lifestyle modification for all patients with hypertension or prehypertension. Modifications include reducing dietary sodium to less than 2.4 g per day; increasing exercise to at least 30 minutes per day, four days per week; limiting alcohol consumption to two drinks or less per day for men and one drink or less per day for women; following the Dietary Approaches to Stop Hypertension eating plan (high in fruits, vegetables, potassium, calcium, and magnesium; low in fat and salt); and achieving a weight loss goal of 10 lb (4.5 kg) or more. Alternative treatments such as vitamin C, coenzyme Q10, magnesium, and omega-3 fatty acids have been suggested for managing hypertension, but evidence for their effectiveness is lacking. (Am Fam Physician 2006;73:1953-6, 1957-8. Copyright ? 2006 American Academy of Family Physicians.)
Despite all that is known about its adverse health consequences, high blood pressure still is poorly controlled in the United States.1-5 Only about one third of patients with hypertension have achieved the National High Blood Pressure Education Program goal of 140/90 mm Hg or lower.1 With the mainstay of hypertensive therapy in the United States being pharmacotherapy, interventions such as lifestyle and dietary modification often are overlooked. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)1 recommends lifestyle modification for all patients with hypertension (i.e., blood pressure of 140/90 mm Hg or higher) or prehypertension (i.e., blood pressure of 120/80 to 139/89 mm Hg), a new category developed by JNC 7 to draw attention to earlier intervention. Although some lifestyle modifications may seem to offer only minimal blood pressure-lowering effects, they should not be discounted. A reduction in systolic blood pressure of 5 mm Hg has been associated in observational studies with reductions of 14 percent in mortality caused by stroke, 9 percent in mortality caused by heart disease, and 7 percent in all-cause mortality.6 In addition, a weight loss of 10 lb (4.5 kg), a realistic goal for most individuals who are overweight, can reduce or prevent hypertension.7
note: All recommendations are rated C because, although there is good evidence that they lower blood pressure, there is no direct evidence of mortality or morbidity benefit from clinical trials.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1874 or http://www.aafp.org/afpsort.xml.
Recommended Lifestyle Modifications
Five lifestyle modifications are recommended by JNC 7 for reducing blood pressure: (1) reducing sodium intake, (2) increasing exercise, (3) moderating alcohol consumption, (4) following the Dietary Approaches to Stop Hypertension (DASH) eating plan (Table 1),8-10 and (5) losing weight.1 These modifications have been proven to reduce blood pressure, although their direct impact on morbidity and mortality is not yet known.
DASH = dietary approaches to stop hypertension.
Low sodium intake was a later addition to the plan.
Information from references 8 through 10.
sodium reduction
In the Trial Of Nonpharmacologic interventions in the Elderly (TONE) study,11 patients were randomized to a low-sodium diet (80 mEq per L [1.9 g; 80 mmol per L] per day) or usual care (i.e., no study-related counseling in lifestyle change). The intervention group had a 2.8 mm Hg greater reduction in systolic blood pressure than the control group. A later study12 assessed the impact on blood pressure of three levels of daily sodium intake: 150, 100, and 50 mEq per L (3.6, 2.4, and 1.2 g; 150, 100, and 50 mmol per L), representing a typical American diet, the upper end of recommended intake, and a limited intake, respectively. Results demonstrated a graded blood pressure response, with a correlation between greater reduction in blood pressure and lower sodium consumption. The recommended sodium intake is less than 100 mEq per L per day for all patients with hypertension or prehypertension.1,12
exercise
Aerobic exercise has positive effects on blood pressure whether or not a person has hypertension, producing average reductions of 4 mm Hg in systolic blood pressure and 3 mm Hg in diastolic blood pressure.13 Physicians should help patients find an activity that they enjoy, because enjoyment will increase their adherence. If a patient finds it difficult to make time to exercise, one suggestion might be a brisk walk at lunch, which helps break up the day and requires no additional time commitment. Physicians also could suggest that patients listen to books on tape while walking, which may help to maintain interest level. It is recommended that patients with prehypertension or hypertension exercise for 30 minutes on most days of the week.1
limiting alcohol consumption
Limiting alcohol consumption is an important lifestyle modification for reducing blood pressure. One meta-analysis14 indicated a dose-response relationship between decreased alcohol consumption and blood pressure reduction. Pooled results showed reductions of 3 mm Hg in systolic blood pressure and 2 mm Hg in diastolic blood pressure for patients in the alcohol reduction groups (average reduction of 67 percent from an average intake of three to six drinks per day at baseline).14 As part of a comprehensive lifestyle program, men should have no more than two alcoholic drinks per day and women no more than one per day.1,14
dietary changes
The DASH eating plan outlines a diet rich in fruits and vegetables; high in low-fat dairy products, potassium, magnesium, and calcium; and low in total saturated fats (Table 1).8-10 Following this plan has been shown to produce mean reductions of 6 mm Hg in systolic blood pressure and 3 mm Hg in diastolic blood pressure,12 and combining the plan with a reduction in sodium intake produces additional blood pressure reduction.12
In the PREMIER clinical trial,15 researchers assessed the impact on blood pressure of comprehensive lifestyle changes (i.e., reduced sodium intake, increased activity, moderate alcohol consumption, and weight loss) in addition to the DASH eating plan, compared with lifestyle changes alone or usual care (i.e., advice only). Participants in the lifestyle changes only group had a greater reduction in blood pressure than those in the usual care group, and this was further enhanced with the addition of the DASH eating plan. This was the first trial to demonstrate that all recommended lifestyle changes can be combined to reduce blood pressure successfully.
Potassium and sodium fluctuate antagonistically-a decrease in potassium leads to sodium retention, whereas an increase in potassium leads to sodium excretion, thereby promoting diuresis and natriuresis.16 Although the mechanism by which a diet low in potassium contributes to increased blood pressure is not known, it has been estimated that, in persons with essential hypertension, a diet low in potassium results in a systolic increase of 7 mm Hg because of increased sodium retention.17 Additionally, potassium supplementation appears to play an enhanced role in individuals with an initially high sodium intake.6 A meta-regression analysis of randomized trials that assessed blood pressure response to changes in potassium and sodium intake showed that increased intake of potassium could play a major role in the prevention of hypertension.18 Increased potassium resulted in a reduction of 2.42 mm Hg in systolic blood pressure and a drop of 1.57 mm Hg in diastolic blood pressure.18 Current recommendations, however, are to obtain adequate potassium intake through a healthy diet.1 Some of the organizations that provide helpful information about and support for the implementation of lifestyle modifications are listed in Table 2.
REFERENCES
1. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-52.
2. American Heart Association. Heart disease and stroke statistics-2004 update. Dallas, Tex.: American Heart Association, 2003.
3. Fields LE, Burt V, Cutler JA, Hughes J, Roccella EJ, Sorlie P. The burden of adult hypertension in the United States 1999 to 2000: a rising tide. Hypertension 2004;44:398-404.
4. Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA 2003;290:199-206.
5. Berlowitz DR, Ash AS, Hickey EC, Friedman RH, Glickman M, Kader B, et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med 1998;339:1957-63.
6. Whelton PK, He J, Appel LJ, Cutler JA, Havas S, Kotchen TA, et al. Primary prevention of hypertension: clinical and public health advisory from the National High Blood Pressure Education Program. JAMA 2002;288:1882-8.
7. He J, Whelton PK, Appel LJ, Charleston J, Klag MJ. Long-term effects of weight loss and dietary sodium reduction on incidence of hypertension. Hypertension 2000;35:544-9.
8. Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, et al. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med 1997;336:1117-24.
9. Vollmer WM, Sacks FM, Ard J, Appel LJ, Bray GA, Simons-Morton DG, et al. Effects of diet and sodium intake on blood pressure: subgroup analysis of the DASH-sodium trial. Ann Intern Med 2001;135:1019-28.
10. National Heart, Lung, and Blood Institute. The DASH eating plan. Bethesda, Md.: U.S. Department of Health and Human Services, 2003. Accessed online November 3, 2005, at: http://www.nhlbi.nih.gov/health/public/heart/hbp/dash.
11. Whelton PK, Appel LJ, Espeland MA, Applegate WB, Ettinger WH Jr, Kostis JB, et al. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of nonpharmacologic interventions in the elderly (TONE) [published correction appears in JAMA 1998;279:1954]. JAMA 1998;279:839-46.
12. Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. N Engl J Med 2001;344:3-10.
13. Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med 2002;136:493-503.
14. Xin X, He J, Frontini MG, Ogden LG, Motsamai OI, Whelton PK. Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 2001;38:1112-7.
15. Appel LJ, Champagne CM, Harsha DW, Cooper LS, Obarzanek E, Elmer PJ, et al. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA 2003;289:2083-93.
16. Gallen IW, Rosa RM, Esparaz DY, Young JB, Robertson GL, Batlle D, et al. On the mechanism of the effects of potassium restriction on blood pressure and renal sodium retention. Am J Kidney Dis 1998;31:19-27.
17. Krishna GG, Kapoor SC. Potassium depletion exacerbates essential hypertension. Ann Intern Med 1991;115:77-83.
18. Geleijnse JM, Kok FJ, Grobbee DE. Blood pressure response to changes in sodium and potassium intake: a metaregression analysis of randomized trials. J Hum Hypertens 2003;17:471-80.
19. Cryer PE, Haymond MW, Santiago JV, Shah SD. Norepinephrine and epinephrine release and adrenergic mediation of smoking-associated hemodynamic and metabolic events. N Engl J Med 1976;295:573-7.
20. Benowitz NL, Hansson A, Jacob P III. Cardiovascular effects of nasal and transdermal nicotine and cigarette smoking. Hypertension 2002;39:1107-12.
21. Yamagishi K, Iso H, Kitamura A, Sankai T, Tanigawa T, Naito Y, et al. Smoking raises the risk of total and ischemic strokes in hypertensive men. Hypertens Res 2003;26:209-17.
22. Kurth T, Kase CS, Berger K, Schaeffner ES, Buring JE, Gaziano JM. Smoking and the risk of hemorrhagic stroke in men. Stroke 2003;34:1151-5.
23. Schneider RH, Staggers F, Alexander CN, Sheppard W, Rainforth M, Kondwani K, et al. A randomised controlled trial of stress reduction for hypertension in older African Americans. Hypertension 1995;26:820-7.
24. Canter PH, Ernst E. Insufficient evidence to conclude whether or not transcendental meditation decreases blood pressure: results of a systematic review of randomized clinical trials. J Hypertens 2004;22:2049-54.
25. Schneider RH, Alexander CN, Staggers F, Rainforth M, Salerno JW, Hartz A, et al. Long-term effects of stress reduction on mortality in persons > or = 55 years of age with systemic hypertension. Am J Cardiol 2005;95:1060-4.
26. Canter PH. The therapeutic effects of meditation. BMJ 2003;326: 1049-50.(RANDY WEXLER, M.D., M.P.H)