<h2>Practice points</h2><ul><li>Coenzyme Q10 (CoQ10) may significantly reduce elevated blood pressure (BP) and is well tolerated</li><li> Fish oil may modestly reduce elevated BP and has multiple other cardiovascular benefits. Dosage should be based on EPA+DHA, not total fish oil</li><li>Magnesium supplementation may be beneficial for some patients at risk of deficiency, although evidence is mixed </li></ul><h2>Description</h2><ul><li>Responsible for more deaths and disease than any other biomedical risk factor worldwide1 </li><li>The major risk factor for stroke and coronary heart disease (CHD) and a major contributor to congestive heart failure, chronic kidney disease, and their progression1</li></ul><h2>Risk Factors2</h2><ul><li>Obesity (BMI &gt;25)</li><li>Chronic stress</li><li>Poor diet, high salt and alcohol intake</li><li>Age</li><li>Physical inactivity</li></ul>

<h2>Primary recommendations</h2><h2>COQ101</h2>Mechanism of action<ul><li>Antioxidant7</li><li> Improves endothelial function7</li></ul>Research<ul><li> Deficiency noted in hypertensive patients</li><li> Randomised controlled trials (RCTs) and meta-analyses find significant antihypertensive activity9</li><li> Treated or untreated hypertensives may have reductions in systolic blood pressure (SBP) of 11-17 mmHg and and diastolic blood pressure (DBP) 7-10 mmHg12,13</li></ul>Dosage<ul><li>100-150 mg/d7</li></ul>Adverse effects<ul><li>Extremely well tolerated7</li></ul>Key interactions <ul><li>Anticoagulants and antiplatelet agents: May increase or decrease drug effect. Clinical trial found no interaction, case reports exist of changes to INR. Avoid concomitant use11</li><li>Antihypertensive drugs: May increase drug effect and have an additive hypotensive effect. Use with caution under supervision of a healthcare professional 11</li><li>Beta-blocker adrenergic agents: CoQ10 levels may be decreased by these drugs. Assess nutrient status and supplement if indicated11</li><li>HMG-CoA-reductase inhibitors: CoQ10 may decrease myalgia associated with statin use11</li></ul><h2>Omega-3 fatty acids</h2>Mechanism of action<ul><li>Improve endothelial function10</li><li>Lower vascular resistance10</li></ul>Research<ul><li>Several meta-analyses have found a modest effect of omega-3s on BP7</li><li>Found to be as effective as other lifestyle interventions for lowering BP in untreated hypertensives10</li><li>A meta-analysis found a mean dose of EPA+DHA 3.8 g/d</li><li>Reduced SBP by 4.51 mmHg and DBP 3.05 mmHg in untreated hypertensives</li><li>Reduced SBP by 1.25 mmHg and DBP 0.62 mmHg in normotensives10</li></ul>Dosage<ul><li>Dosing should be based on EPA+DHA, not total fish oil. ≥2 g/d EPA+DHA10</li></ul>Adverse effects<ul><li>Omega-3 fatty acids are very well tolerated. Up to 3 g/d EPA+DHA is generally recognised as safe (GRAS)6</li></ul>Key interactions <ul><li>Antihypertensive drugs: May have additive hypotensive effect depending on fish oil dose. BP should be monitored when patient is on high dose fish oil11</li><li>Anticoagulant and antiplatelet agents: High doses of fish oil (&gt;3 g/day omega-3 fatty acids) may increase the risk of bleeding with these drugs. There is conflicting data multiple clinical trials have found no increase in risk of bleeding with antiplatelet or anticoagulant drugs, however there are some studies that suggest an interaction, particularly at higher doses. Use with caution under supervision of a HCP and monitor11</li><li>Chemotherapeutic agents: May decrease drug effect. Avoid concomitant use11</li></ul> For more information on key interactions visit: <a href="~/link.aspx?_id=4471DACF65C148EA8FD82B23FD6712D4&_z=z">https://www.blackmoresinstitute.org/interactions</a>

Primary

<h2>Secondary recommendations</h2><h2>Magnesium</h2>Mechanism of action<ul><li>Modulates vascular tone and reactivity7</li></ul>Research<ul><li>Low magnesium is associated with higher blood pressure14</li><li>Deficiency occurs only in some hypertensive patients14</li><li>Mixed findings on hypotensive effects in supplementation studies14</li></ul>Dosage<ul><li>May benefit some individuals with low magnesium levels, at a dose of 360-600 mg/d7</li></ul>Adverse effects<ul><li>High doses may cause diarrhoea. Take in divided doses to decrease risk7</li></ul>Key interactions <ul><li>Amphotericin-B: May decrease blood levels of nutrient. Assess nutrient status and supplement if indicated11</li><li>Antiarrhythmic drugs: Mg may have additive antiarrhythmic effect. Use with caution under supervision of a HCP and monitor11</li><li>Anticoagulant and antiplatelet agents: Mg may reduce the efficacy of warfarin. Avoid concomitant use11</li><li>Antihypertensive drugs (calcium channel blockers): Mg may have additive hypotensive effect. Use with caution under supervision of a HCP and monitor11</li><li>Biphosphonates: Bisphosphonates may form complexes with multivalent cations such as Mg. Avoid concomitant use11</li><li>Digoxin, chlorpromazine, penicillamine, tetracycline, nitrofurantoin and quinolone antibiotics: May decrease drug effect, separate medication and Mg by at least 2 hours11</li><li>Gabapentin: May decrease drug effect.11 Avoid concomitant use</li><li>Loop and thiazide diuretics: May decrease blood levels of nutrient. Assess nutrient status and supplement if indicated11</li><li>Proton pump inhibitors: PPIs may cause hypomagnesaemia if taken long-term (usually &gt;1 year). Assess nutrient status and supplement if indicated11</li><li>Proguanil: May decrease drug effect. Avoid concomitant use11</li><li>Rocuronium: May have additive inhibitory effects on acetylcholine release. Use with caution under supervision of a HCP and monitor11</li></ul> For more information on key interactions visit: <a href="~/link.aspx?_id=4471DACF65C148EA8FD82B23FD6712D4&_z=z">https://www.blackmoresinstitute.org/interactions</a>

Secondary

<h2>Diet and lifestyle</h2><h2> </h2><h2>Engage in physical activity</h2>Regular aerobic exercise can lower SBP by an average of 4 mm Hg and DBP by an average of 2.5 mmHg. Aim for 30 minutes of moderate-intensity physical activity on most, if not all, days of the week.1<h2>Maintain a healthy body weight</h2>Every 1% reduction in body weight lowers SBP by an average of 1 mmHg. Weight loss of 10 kg can reduce SBP by 6–10 mmHg.1<h2>Quit smoking</h2>Refer patients to Quitline (13 QUIT).1<h2>Decrease alcohol consumption</h2>Reducing consumption can lower SBP by 3.8 mmHg in patients with hypertension.3 Hypertensive patients should limit intake to a maximum of 1 standard drink per day for women and 2 for men, with at least 2 alcohol-free days per week.1<h2>Reduce salt</h2>High dietary sodium is linked to increased incidence of stroke and risk of death due to CHD. Reducing intake to 1700 mg sodium/d can lower SBP by 4-5 mmHg in patients with hypertension. Limit salt intake to ≤4 g/d.3<h2>Increase potassium-rich foods</h2>Increasing dietary potassium by 2100 mg/d may reduce BP by 4-8 mmHg in hypertensive patients. Increase fruit, vegetables, legumes, plain unsalted nuts. Avoid in patients with impaired renal function and those taking potassium-sparing diuretics.1,3<h2>DASH eating plan</h2>DASH(Dietary Approaches to Stop Hypertension)4 rich in potassium, calcium, magnesium, fibre and protein; low sodium, sweets, sugary beverages, red meats, saturated and trans fats.Increase vegetables, fruits, fat-free/low-fat dairy, whole grains, fish, poultry, beans, seeds, nuts and vegetable oils. For more information visit http://www.nhlbi.nih.gov/health/health-topics/topics/dash/ <h2>Include fish and garlic</h2>Higher fish intake is associated with lower risk of CHD mortality, total CHD and stroke.5,6,7 Omega-3s from fish reduce serum triglycerides and may modestly reduce BP.5,6,7 2-3 serves of oily fish per week are recommended for supporting general health,5 however higher quantities (2-4 g/d EPA+DHA) may be required to decrease blood pressure in hypertensive patients 6,7,10 2 meta-analyses conducted in 2008 found garlic may reduce SBP by 8 or 16 mmHg, and DBP by 7 or 9 mmHg.8,9 Aim to consume 2-5 g/d fresh or 480-960 mg/d aged garlic extract standardised to S-allylcysteine 4.8 mg/d.7

Diet & lifestyle

<h2>References</h2>1. Australian Heart Foundation. Guide to management of hypertension 2008. Updated 2010. 2. Sarris J, Wardle J. Clinical Naturopathy 2e. An evidence-based guide to practice. Chatswood: Elsevier, 2014 3. Huang N. Lifestyle management of hypertension. Australian Prescriber 2008;31(6):150-53. 4. US Department of Health &amp; Human Services. Dash eating plan. Accessed 02/02/2016 http://www.nhlbi.nih.gov/health/healthtopics/topics/dash/ 5. Australian Heart Foundation. Position Statement. Fish, fish oils, n-3 polyunsaturated fatty acids and cardiovascular health. 20086. Natural Medicines 2016. Fish oil professional monograph. https://naturalmedicines.therapeuticresearch.com/databases/food,-herbs-supplements/professional.aspx?productid=993 7. Braun L, Cohen M. Herbs and Natural Supplements. 4th edition. Chatswood: Elsevier, 2015. 8. Reid K, Frank OR, Stock NP, Fakler P, Sullivan T. Effect of garlic on blood pressure: a systematic review and meta-analysis. BMC Cardiovasc Disorder 2008;8:13 9. Reinhardt KM, Coleman CI, Teevan C, Vachhani P, White CM. Effects of garlic on blood pressure in patients with and without systolic hypertension: a meta-analysis. Ann Pharmacol 2008;42:1766-71 10. Miller PE, Van Elswyk M, Alexander DD. Long-chain omega-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid and blood pressure: a meta-analysis of randomised controlled trials. Am J Hypertens 2014;27(7):885-96. 11. Blackmores Institute 2015. Complementary Medicines Interactions Guide 7th ed. 12. Rosenfeldt F, Haas S, Krum H, Hadj A, Ng K, Leong J, Hohgson J, Watts G.Coenzyme Q10 in the treatment of hypertension: a meta-analysis of the clinical trials. J Human Hypertens 2007;21:297-306 13. Ho MJ, Bellusci A, Wright JM. Blood pressure lowering effi cacy of coenzyme Q10 for primary hypertension. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD007435. DOI: 10.1002/14651858.CD007435.pub2. 14. Oregon State University, Linus Pauling Micronutrient Information Center 2016 Magnesium http://lpi.oregonstate.edu/mic/minerals/magnesium 15. Sontia BS, Touyz. Role of magnesium in hypertension. Arch Biochem Biophys 2007;458:33-39

Hypertension

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