The Effect of Acupuncture Therapy on Reducing Blood Pressure in Hypertension Patients: Meta-Analysis
DOI:
https://doi.org/10.26911/jepublichealth.2021.06.01.12Abstract
Background: Acupuncture is a traditional Chinese medicine for treating ailments, including diseases of the cardiovascular system, such as hypertension. Acupuncture modulates neurohumoral regulatory systems and cardio vascular function. This study aims to estimate the effectiveness of acupuncture therapy in reducing blood pressure in hyper tensive patients.
Subjects and Method: This was a systematic review and meta-analysis, with PICO, namely Population= hypertension cases aged 20-80 years. Intervention= acupuncture therapy. Comparison= Sham/ Placebo/ No Treatment Acupuncture. Outcome = Blood pressure. The articles used in this study were obtained from several databases including Google Scholar, MEDLINE/ PubMed, Science Direct, Hindawi, BMC, Europe PMC and Springer Link. These articles were collected for 1 month. The key words to search for articles were as follows: “acupuncture”, “hypertension”, “randomized controlled trial”, “hypertension randomized controlled trial”, “acupuncture randomized controlled trial”, “acupuncture for primary hypertension”, “acupuncture for hypertension essential” AND “acupuncture for blood pressure”. The articles included in this study are full text articles with a randomized con trolled trial study design. Articles were collected using PRISMA flow diagrams and analyzed using the Review Manager application (RevMan) 5.3.
Results: A total of 9 articles were reviewed in this meta-analysis. Articles are from Boston, Germany, Korea, China, India and Taiwan. The study showed that acupuncture therapy was able to reduce systolic blood pressure with the Standardized Mean Different by 0.54 compared to sham acupuncture /placebo/no treatment (SMD= 0.54; 95% CI= -1.04 to -0.04; p<0.05). Acupuncture reduced diastolic blood pressure 0.49 units (SMD= 0.49; 95% CI= -0.99 to 0.02; p>0.05) compared to sham acupuncture/ placebo, but it was statistically non significant.
Conclusion: Acupuncture can reduce systolic blood pressure, but it is less significant in reducing diastolic blood pressure in hyper tensive patients.
Keywords:
acupuncture, hypertension, high blood pressureCorrespondence
Faricha Indra Hapsari. Masters Program in Public Health, Universitas Sebelas Maret. Jl. Ir. Sutami 36A, Surakarta57126, Central Java. Email: farichaindrah @gmail.com Mobile: +6285647075776.
BACKGROUND
Hypertension or high blood pressure is a pathophysiological condition of the body where there is an increase in blood pressure above 140 mmHg systolic pressure and 90 mmHg diastolic pressure on two measure ments with an interval of 5 minutes in a state of sufficient rest/quiet (Yulanda, 2017).
The World Health Organization (WHO) in 2015 showed that around 1.13 billion people in the world suffer from hypertension and the number continues to increase every year. It is estimated that in 2025 people with hypertension will reach 1.5 billion with a total mortality of 9.4 million people due to hypertension and complications (Ministry of Health, 2018).
Complications of disease by hyper tension cause more severe damage, such as stroke, coronary heart disease, left ventri cular hypertrophy (heart muscle), kidney failure, several other diseases related to blood vessels, to death (Rodiah, 2013). Considering that there are various compli cations from hypertension cases, and the side effects of using anti-hypertensive drugs, there are many complementary treatment options to lower BP safely in hypertensive patients such as acupuncture. Acupuncture is one of the traditional Chi nese medicine to treat diseases, including those related to the cardio vascular system, such as hypertension (Liu et al., 2015).
Acupuncture modulates the neuro humoral regulatory system and cardio-vascular function (Li et al., 2015). Acupunc ture can reduce BP in hypertensive patients by decreasing plasma renin, aldo-sterone, and angiotensin II activity, increasing sodium secretion and changing plasma norepinephrine, serotonin, and endorphin levels (Wang et al., 2013). This study aimed to assess and esti mate the effectiveness of acupuncture therapy in reducing BP in hypertensive patients based on the results of previous similar studies.
SUBJECTS AND METHOD
1.Study Design
This research is a systematic review and meta-analysis. This study uses secondary data in the form of data obtained from previous studies. The question posed by the researcher this time was the effect of acu puncture therapy on reducing blood pressure in hypertensive patients. The study was conducted by searching and selecting data from the results of tests conducted on all ethnicities, races and locations. The time of the selected test results is in the period 2001-2021. Article searches are carried out for a maximum of one month. The PICO used is as follows: Population= hypertension cases aged 20-80 years. Intervention= acupuncture therapy. Comparison= Sham/ Placebo/ Not Treatment with Acupuncture. Outcome= Blood pressure. The articles used in this study were obtained from several data bases, including Google Scholar, MED LINE/ PubMed, Science Direct, Hindawi, BMC, Europe PMC and Springer Link. These articles were collected for 1 month. The keywords to search for articles were as follows: “acupuncture”, “hypertension”, “randomized controlled trial”, “acupunc ture for hypertension”, “hypertension randomized controlled trial”, “acupuncture randomized controlled trial”, “acupuncture for primary hypertension ”, “acupuncture for hypertension essential” AND “acupunc ture for blood pressure”. The articles included in this study are full text articles with a randomized controlled trial study design.
2.Population and Sample
Inclusion Criteria:
a.Full paper article with Randomized Controlled Trial (RCT)
b.The article has an appropriate title and is related to the effect of acupuncture on reducing BP in hypertensive patients
c.Articles published in English and/or Indonesian
d.Include the results of the study in the form of the number of respondents, the mean value and the standard deviation (SD) value
e.The intervention in the experimental group was acupuncture (with inserting needle)
f.Sham/placebo acupuncture, non-acu puncture hypertensive treatment (life style modification, medication) and non-treatment were allowed in the control group.
Exclusion Criteria:
a.Research conducted with non-RCT studies
b.RCT research using acupressure, herbs, moxibustion and transcutaneous electri cal acupoint stimulation in the experi mental group kelompok
c.Articles published before 2001
d.Research subjects suffer from secondary hypertension or non-essential hyper tension.
3.Study Variables
The dependent variable is a decrease in blood pressure in hypertensive patients. The independent variables in this study were acupuncture therapy and Sham/ placebo Acupuncture.
4.Data Analysis
Previous articles were collected using PRISMA flow diagrams and analyzed using Review Manager (RevMan) 5.3 application.
RESULTS
This meta-analysis analyzed 9 primary studies from 3 continents, namely the Asian continent, covering countries: South Korea, China, India, and Taiwan. Continental Europe, including Germany, and South America, including Boston.
Figure 1. PRISMA flow diagram
The article search process has been carried out by searching for articles through a database based on the PRISMA flow diagram and can be seen in Figure 1.
The assessment of the quality of the articles used in this study is shown in table 1. In this instrument there are 12 questions (assessment items), if the answer is (Yes) it will be given a score of 1 and if the answer is (No) it will be given a score of 0 (CEBMa, 2014) .
The result is the research quality score is between the numbers 11-12. This indicates that the research article has good quality for meta-analysis.
There are 9 Randomized Controlled Trial (RCT) studies as a source of data in a systematic review and meta-analysis on the effectiveness of acupuncture in reducing blood pressure in hypertensive patients. An overview of the PICO (Population, Inter vention, Comparison, Outcome) used in this study can be seen in table 2.
Table 1. Research Quality Assessment (Critical Appraisal)
Scoring Items
Study | Relevance of goals and problems | Relevance of methods and problems | Sufficiency and validity of the sample | Randomized intervention | Blinding | Comparable cases and controls | No bias | Data analysis is relevant and valid | Relevance effect size | 95% CI reporting | Confounding factors reported | Results can be applied | Total |
Maklin et al (2006) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 12 |
Flachskampf et al (2007) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 12 |
Yin et al (2007) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 12 |
Park et al (2010) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 11 |
Kim et al (2012) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 11 |
Liu et al (2015) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 12 |
Zheng et al (2019) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 12 |
Maheshkumar et al (2020) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 11 |
Huang et al (2020) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 11 |
Note: Yes = 1, No = 0
Table 2. Description of the primary studies included in the meta-analysis
Author | Country (Conti nent) | Sample | P (Popula tion) | I (Inter vention) | C (Compa rison) | O (Out come) |
Maklin et al. (2006) | Boston (South America) | 192 | Essential hyper tension patient | Acupunc ture | Sham Acupunc ture | Blood pressure |
Flachskampfet al. (2007) | Germany (Europe) | 160 | Essential hyper tension patient | Acupunc ture | Sham Acupuncture | Blood pressure |
Yin et al., (2007) | South Korea (Asia) | 41 | Essential hyper tension patient | Acupunc ture | Sham Acupuncture | Blood pressure |
Park et al., (2010) | South Korea (Asia) | 15 | Essential hyper tension patient | Acupunc ture | Sham Acupuncture | Blood pressure |
Kim et al., (2012) | South Korea (Asia) | 33 | Essential hyper tension patient | Acupunc ture | Sham Acupuncture | Blood pressure |
Liu et al., (2015) | South Korea (Asia) | 30 | Essential hyper tension patient | Acupunc ture | No intervention | Blood pressure |
Zheng et al., (2019) | China (Asia) | 428 | Essential hyper tension patient | Acupunc ture | Sham Acupuncture | Blood pressure |
Maheshkumar et al., (2020) | Iran (Asia) | 90 | Essential hyper tension patient | Acupunc ture | Sham Acupuncture | Blood pressure |
Huang et al., (2020) | Taiwan (Asia) | 70 | Essential hyper tension patient | Acupunc ture + anti hyper ten sion | anti hyper tension | Blood pressure |
1.Forest Plot Systolic
Figure 2. Forest plot of systolic blood pressure
2.Funnel Plot Systolic
Figure 3. Funnel plot of systolic blood pressure
The interpretation of the results of the meta-analysis can be seen in Figure 2, for the forest plot of systolic blood pressure and Figure 3, for the funnel plot of systolic blood pressure. Based on the results of the analysis using RevMan 5.3 software, it is known that there is high heterogeneity (= 92%; p < 0.001) so that the distribution of data is declared heterogeneous (Random Effect Model). Acupuncture therapy was able to reduce systolic blood pressure with Standardized Mean Different (SMD) by 0.54 compared to sham acupuncture (p= 0.04). Based on Figure 3, it does not show any publication bias which is indicated by the symmetrical right and left plots. SE value<0.5.
3.Forest Plot Diastolic
Gambar 4. Forest plot diastolic blood pressure
4.Funnel Plot Diastolic
Figure 5. Funnel plot of diastolic blood pressure
The interpretation of the results of the meta-analysis can be seen in Figure 4, for the forest plot of diastolic blood pressure and Figure 5, for the funnel plot of diastolic blood pressure. Based on the results of the analysis using RevMan 5.3 software, it is known that there is high heterogeneity (I2=92%; p<0.001) so that the distribution of data is declared heterogeneous (Random Effect Model). Acupuncture therapy was less effective in reducing diastolic blood pressure with Standardized Mean Different (SMD) by 0.49 compared to sham acupuncture (p=0.06).
A funnel plot is a plot that describes the size of the effect of each study on an estimate of its accuracy which is usually the standard error. Figure 5 shows the exist ence of publication bias which is indicated by the asymmetry of the right and left plots. SE value < 0.5.
DISCUSSION
The systematic review and meta-analysis of this study raised the topic of the effect of acupuncture on lowering blood pressure in hypertensive patients. The independent variable in this study was acupuncture and the dependent variable in the study was hypertension. This meta-analysis study uses research article sources that have con trolled for confounding factors. Confound ing factors are factors that cannot be avoided in research, can be controlled and affect the results of invalid studies (Murti, 2018). This study controls confounding factors that can be seen from the inclusion and exclusion in this study. There were 9 articles that passed the inclusion and exclusion criteria from a number of primary studies that were included in this study.
The results of a meta-analysis from a Randomized Controlled Trial (RCT) study showed that acupuncture was able to signi ficantly reduce systolic blood pressure, but acupuncture was not significant in reducing diastolic blood pressure, so it can be colla borated with other treatment therapies to achieve blood pressure targets and control blood pressure. This is in line with the research of Zhao et al. (2019) which states that acupuncture combined with medical treatment (antihypertensive drugs) is better in reducing SBP, DBP, increasing effective ness and overcoming TCM syndrome in hypertensive patients. Therefore, acupunc ture is recommended as an additional therapy for medical treat ment, so that the use of antihypertensive drugs can be done with smaller doses to avoid side effects of antihypertensive drugs, so that adherence to taking antihyper tensive drugs can be optimized (Zhang et al., 2014).
Acupuncture is safe in lowering blood pressure in cases of pre-eclampsia in labor and postpartum, if performed by experts and professionals. Handling cases of hyper tension in the elderly with acupunc ture therapy combined with pharmaco logical therapy has proven to be more effectiv e than using only pharmacological therapy (Lazuardi et al., 2018).
Acupuncture has minor side effects such as pain, bleeding, minimal hematoma but in a large sample there were no deaths or permanent injuries from acupuncture (Lee et al., 2009). Therefore, acupuncture is proven to be safe and can be used in the treatment of hypertension.
The limitation in this study is search bias because in this study only 7 electronic databases were used, namely Google Scholar, MEDLINE/PubMed, Science Direct, Hindawi, BMC, Europe PMC and Springer Link, thus ignoring other search sources. Language bias because in this study only articles in English and Indo nesian were used. The articles used are only articles that have been published, thus ignoring the articles that have not been published.
It is hoped that further researchers can conduct research related to the effecti veness of acupuncture in hypertensive patients with a larger sample, wider langu age used, and with different research loca tions for the development of further similar research. Essential hypertension is a chro nic cardiovascular disease, so the long-term effect of treatment is of great concern to patients. A longer follow-up period is recommended to determine the long-term effectiveness of acupuncture.
AUTHOR CONTRIBUTION
Faricha Indra Hapsari as the main researcher is the executor of the research, collecting related articles, conducting research, data analysis, data processing and writing research manuscripts. Setyo Sri Rahardjo played a role in preparing the research framework, research design and writing research manuscripts. Hanung Prasetya plays a role in developing ideas, processing research data, and preparing research manuscripts.
FUNDING and sponsorship
This study is self-funded.
CONFLICT OF INTEREST
There is no conflict of interest in this study.
ACKNOWLEDGEMENT
We would like to thank the database pro viders, namely Google Scholar, MEDLINE/ PubMed, Science Direct, Hindawi, BMC, Europe PMC and Springer Link.
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Published
2021-07-11
Issue
Vol. 6 No. 1 (2021)
Section
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