Acupuncture for Lowering Blood Pressure Systematic Review

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Acupuncture for Hypertension articles, auricular acupuncture blood pressure and hypertension r espectively and various factors including study quality high. Reference lists from the original articles and reviews were exam vs low as assessed with modified Oxford scale country where. ined for additional studies and no language restrictions were the study was conducted China vs non China control type. imposed Studies meeting the following criteria were included sham vs medication vs no treatment medication medica. i An RCT ii Patients were diagnosed as hypertensive with tion vs no medication and acupuncture style individualized. a systolic BP SBP 140 mm Hg and or a diastolic BP DBP vs standard Study outcome was defined as positive when. 90 mm Hg or used antihypertensive drugs iii Patients in the acupuncture was significantly more effective than the control. experiment group were treated with acupuncture electroacu and as nonpositive when acupuncture was not significantly. puncture EA or auricular acupuncture more than once with different from or not so effective as the control. or without antihypertensive drugs iv Placebo sham or active. control procedure was used Studies were excluded wherein any Results. complementary and alternative therapies of which the efficacy is Study characteristics. not yet established e g herbal medicine were adopted as con Eleven RCTs met the inclusion criteria4 10 11 16 23 Figure 1. trols v A change in SBP and or DBP was an outcome of the seven studies were conducted in China 4 16 19 22 23 two in. trial Studies were excluded if they were nonrandomized studies Germany 10 20 and one each in the United States11 and in. and or involving other forms of acupuncture such as transcuta Korea 21 Table 1 shows the basic characteristics of the included. neous electrical nerve stimulation or laser acupuncture studies In total 847 patients 468 in the acupuncture group. The following data were extracted independently by two of 379 in the control group participated The number of subjects. the authors SYK and HJP first author s name year of publica in each group ranged from 7 to 83 in the acupuncture groups. tion details of participants and trial design sample size blind mean s d 39 0 21 6 and 7 to 77 in the controls 34 5. ing intervention procedures and withdrawals and dropouts 19 5 Most studies 91 except one20 included both men. The net changes in SBP and DBP and or mean BP before and and women The mean age was 56 3 7 31 ranging from 40. after acupuncture treatment as available were also extracted to 72 The median BP at baseline was 158 94 mm Hg and 21. as main outcome measures We contacted corresponding of the patients in the acupuncture groups were taking anti. authors via e mail and asked to provide further information hypertensive medication In majority of the included studies. if necessary the patients had essential hypertension three studies involved. patients with mild arterial hypertension 20 mild or moderate. Methodological quality assessment A modified Oxford scale arterial hypertension 10 or BP within or higher than the prehy. was used to assess the methodological quality of the included pertension category 21 BP was measured at various time points. studies 12 13 Points were awarded as follows if the study was from 1 week to 12 months with various methods including. randomized add one point add an additional point for appro 24 h ambulatory BP monitoring mercury sphygmomanom. priate randomization and deduct one point for inappropriate eter and automated sphygmomanometer. randomization if the subject was blinded to the intervention. i e the control procedure was indistinguishable from real acu Acupuncture treatment and control characteristics. puncture add one point if the outcome assessor was blinded Participants received 15 to 30 min per session acupuncture. to the intervention add one point if the study described with treatments 5 to 30 times median 17 for mean 5 4 weeks rang. drawals and dropouts add one point Subject blinding was ing 1 to 8 weeks median 5 7 weeks Although two acupunc. assumed when the control intervention was indistinguishable ture modalities were tested i e manual acupuncture 10 11 16 23. from acupuncture even if the word blinding did not appear and magnetic needle acupuncture 4 the acupuncture tech. in the report A point for assessor blinding was only given if niques greatly varied across the studies in terms of acupoint. specified in the text The highest possible score was 5 and trials. with 4 points were considered to be of high quality whereas. Potentially relevant studies, trials with 3 points were defined as of low quality identified and screened for. retrieval n 112 Studies excluded n 101,Case report n 20. Data analysis Only studies providing changes in BP were Uncontrolled n 49. Not randomized n 6, considered for meta analysis Meta analyses were performed Compared with traditional chinese medicine n 15. using Cochrane Collaboration Review Manager 5 and het Compared with another form of acupuncture n 8. Evaluating transient effects of acupuncture n 2, erogeneity was sought using I2 statistic 14 which describes the Potentially appropriate RCTs.
to be included in this review Duplicate data n 1, percentage of the total variability in study estimates that is due. to heterogeneity rather than chance 15 Mean effect size was cal RCTs included in systematic review but. culated using a random effects model as we assume that each excluded from meta analysis because of. study is assessing different acupuncture treatment and thus insufficient outcome reporting n 7 or as it. compared with active medication n 1, different effects 2 test or two tailed Fisher s exact test SPSS. for Windows ver 12 0 Chicago IL was used to examine Studies included in meta. analysis n 3, any statistically significant associations between direction. of study outcome positive vs nonpositive for SBP and DBP Figure 1 Study flow diagram RCT randomized controlled trial. AMERICAN JOURNAL OF HYPERTENSION VOLUME 22 NUMBER 1 january 2009 123. articles Acupuncture for Hypertension,Table 1 Characteristics of included studies. No of No of, Mean age No of Duration patients Baseline patients Baseline.
Author Country Acu Con Qualitya Style session wk drug b BPc Type drug b BPc Comments. Flachskampf10 Germany 59 58 4 IND 22 6 83 78 131 81 Sham identical 77 78 129 80 F u 3 and 6 mo. needling at,nonacupoints, Yin21 South 52 54 5 IND 17 8 21 100 137 84 Sham 20 100 133 82 Co breathing. Korea nonpenetrating and easy walking,sham needles exercise for both. at the same groups, Macklin11 United 57 56 53 5 IND STD 12 5 9 3 64 64 150 93 Sham superficial 64 0 148 94 F u every 2 to 10. States 0 0 150 93 needling at wk and 4 6 9 and,nonacupoints 12 mo. manipulation, Jin16 China 72 69 1 STD 5 1 30 100 169 84 Tailored 30 100 165 83 Acupuncture.
antihypertensive group also,drugs received tailored. antihypertensive, Wang17 China 55 52 2 STD 28 4 30 0 170 104 Metoprolol 30 100 174 105. 10 mg per day, Jiang4 China 57 58 1 STD with 18 3 30 100 159 92 Captopril 30 100 157 94 Acupuncture. MNA 12 5 25 mg t i d group also,received captopril. Zhao23 China 40 46 2 STD 30 5 7 30 0 164 96 Lifestyle 30 0 161 98 Acupuncture. intervention group also,received lifestyle,intervention.
Chen18 China 64 65 1 STD 14 2 35 0 166 87 Nifedipine 35 100 164 90. 10 20 mg t i d, Kraft20 Germany 50 3 STD 12 6 wk 2 7 0 148 94d Sham superficial 7 0 150 94d. cycles needling at,nonacupoints,deqi elicited, Yin22 China ND 1 STD 21 6 48 0 171 107 Reserpine 30 100 168 106 F u 2 wk. 1 2 tablets t i d, Dan19 China 58 58 1 IND 15 3 26 0 149 95 Nifedipine 26 100 147 95. 10 mg t i d, Acu acupuncture BP blood pressure Co co intervention Con control DBP diastolic blood pressure F u follow up IND individualized acupuncture MNA magnetic needle acupuncture. mo months ND no data reported SA sham acupuncture SBP systolic blood pressure STD standardized acupuncture wk week t i d three times a day. aModified Oxford scale bPercentage of patients on antihypertensive drugs cMean SBP DBP dMedian. selection manipulation or stimulation methods and frequency sham needle at the same acupoints 21 identical needling at. and duration of the treatment sessions Few studies provided nonacupoints10 or superficial needling at nonacupoints 11 20. detailed information about the practitioner s experience or Acupuncture was compared with antihypertensive medi. expertise treatment rationale and reproducible description cation in six studies4 16 19 22 and with no treatment in one. of the intervention without which the intervention s validity is study 23 In two studies breathing and easy walking exercise21. limited The most frequently used acupoints were LR3 7 stud and lifestyle interventions including restricted smoking and. ies out of 11 LI11 7 studies GB20 7 studies followed by alcohol intake weight reduction low sodium and calorie. ST36 6 studies and ST40 6 studies with a great variation intake exercise and relaxation23 were concomitantly given. in combination of selected acupoints In 4 of the 11 included. studies the acupuncture group also had antihypertensive Methodological quality. medication 4 10 16 21 Only two sham controlled studies were awarded the maximum. Regarding control groups three types of control pro points of 5 on the modified Oxford scale 11 21 One RCT received. cedures were used sham acupuncture antihypertensive four points as it was not assessor blinded10 and another study. medications and no treatment Defining sham acupuncture got three points for being randomized subject blinding and. as a procedure designed to be indistinguishable from real reporting of withdrawals and dropouts 20 The other seven. acupuncture 4 sham controlled studies used nonpenetrating included studies suffered from poor methodological quality of. 124 January 2009 VOLUME 22 NUMBER 1 AMERICAN JOURNAL OF HYPERTENSION. Acupuncture for Hypertension articles,Table 2 Findings of included studies.
Type of Acupuncture Control Acupuncture Control, Control Author Outcomes Intergroup difference Mean 95 CI Mean 95 CI Mean 95 CI Mean 95 CI. Acu plus Med Flachskampf10 1 24 h BP at 6 wk 1 SBP DBP each P 0 001 1 5 8 3 1 2 0 4 1 3 5 2 1 1 1 3. vs Sham Acu 2 Daytime BP at 6 wk 2 SBP DBP each P 0 001 2 7 9 4 2 2 1 4 2 4 5 2 2 1 1 2. 3 Nighttime BP at 6 wk 3 SBP P 0 049 DBP 3 3 6 0 3 0 3 2 3 1 3 1 3 1 1 3. 4 Peak exercisea BP at 4 SBP DBP each P 0 05 4 5 11 2 4 1 7 6 4 1 4 2 4 1 6 3. Yin21 BP at 8 wk SBP P 0 013 DBP P 0 049 15 20 9 4 11 3 7 11 3 1 6 4. Acu vs Sham Macklin11 BP at 10 wk SBP P 0 90 DBP P 0 16 4 7 0 4 8 0 4 6 2 3 5 1. Acu Kraft20 b 1 BP at 10 wk 1 SBP DBP each P 0 05,2 24 h BP at 10 wk 2 SBP DBP each P 0 05. 3 Daytime BP at 10 wk 3 SBP DBP each P 0 05,4 Nighttime BP at 10 wk 4 SBP DBP each P 0 05. Acu plus Med Jin16 1 BP at 1 wk 1 SBP DBP each P 0 05 1 31 NA 1 27 NA 1 8 NA 1 8 NA. vs Med 2 Global symptom 2 P 0 05,3 Headache vertigo and 3 Each P 0 05. 4 insomnia, Jiang4 BP at 3 wk SBP DBP each P 0 05 21 NA 12 NA 16 NA 9 NA.
Acu vs Med Wang17 1 BP at 4 wk 1 SBP DBP each P 0 05 1 7 9 4 1 7 9 5 1 14 15 13 1 12 14 11. 2 Improvement of 2 P 0 05,3 Headache vertigo and 3 Each P 0 05. 4 Tinnitus and insomnia 4 Each P 0 05,5 Serum TNF 5 P 0 05. 6 Plasma ET 6 P 0 05, Chen18 BP at 2 wk SBP P 0 05 DBP P 0 05 30 NA 35 NA 9 NA 15 NA. Yin22 BP at 6 wk SBP DBP each P 0 05 35 NA 26 NA 16 NA 14 NA. Dan19 1 24 h BP at 3 wk 1 SBP DBP each P 0 05 1 20 NA 1 20 NA 1 11 NA 4 1 11 NA. 2 Myocardial oxygen 2 P 0 01,consumption,3 Symptom relieving 3 P 0 05. Acu vs no Zhao23 1 BP at 5 7 wk 1 SBP P 0 05 DBP P 0 05 1 35 NA 1 22 NA 1 15 NA 1 10 NA. treatment 2 Fasting insulin 2 P 0 05,3 Insulin sensitivity 3 P 0 05.
4 Body mass index 4 P 0 01,5 Waist hip ratio 5 P 0 01. Acu acupuncture BP blood pressure DBP diastolic blood pressure ET endothelin HR heart rate IND individualized acupuncture Med antihypertensive drugs mo months NA not. applicable data not available SA sham acupuncture SBP systolic blood pressure STD standardized acupuncture wk week. aExercise at the maximal comparable workload bThe data of BP changes were not available. one or two points Regarding the credibility of a sham control c ontrol interventions and the outcome reporting In some. only one of the three sham controlled trials checked the suc studies BP changes were not reported instead they reported. cess of subject blinding 11 mean BP before and after acupuncture treatment some even. without s d or s e Changes in BP and summarized outcomes. BP outcomes and associated factors are tabulated Tables 1 and 2 Overall 4 of 11 studies yielded. As with RCTs of acupuncture in other areas the included a significant BP reduction10 18 21 23 and the other 7 studies. studies greatly varied in terms of baseline BP acupuncture and showed no difference between acupuncture and control in. AMERICAN JOURNAL OF HYPERTENSION VOLUME 22 NUMBER 1 january 2009 125. articles Acupuncture for Hypertension, either SBP or DBP changes High quality trials showed con in SBP and DBP with s d were available for meta analysis. flicting results in two trials acupuncture was superior to one study was again excluded as it compared acupuncture. sham10 21 and in the other study acupuncture was not signifi with active medication 17 leaving three sham controlled tri. cantly different from sham 11 Although both groups were given als involving four different acupuncture groups for the final. Acupuncture for Lowering Blood Pressure Systematic Review and Meta analysis Hyangsook Lee1 2 Song Yi Kim 1 and automated sphygmomanometer acupuncture treatment and control characteristics Participants received 15 to 30 min per session acupuncture treatments 5 to 30 times median 17 for mean 5 4 weeks rang ing 1 to 8 weeks median 5 7 weeks Although two acupunc ture modalities were

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