Exercise and Hypertension
One of my colleagues at the Colorado Mesa University Monfort Family Human Performance lab is Carmine Grieco, PhD, an exercise physiologist. It has been interesting to hear Carmine’s perspective on Exercise is Medicine, as he has been involved at the research level and is very interested in the effects of exercise on chronic disease. Carmine and I wrote a four-part series for Personal Training Quarterly (PTQ) discussing the impact of exercise on chronic disease. For that series, we started with the impact of exercise on Type 2 Diabetes, exercise and the brain and now discussed exercise and hypertension - that article is below. Clearly, exercise should play a critical role in the overall treatment plan for patients. (Please note before reading: Patients with hypertension, diabetes and any other chronic disease or condition should first discuss a change in exercise levels or habits with their personal medical provider. This is informational only.)
Exercise and Hypertension
Carmine Grieco, PhD, CSCS
Michael Reeder, D.O.
Grieco CR and Reeder MT. (2016) Exercise and Hypertension - Part 3 Exercise and the Brain. Personal Training Quarterly, 4(3).
This article is the 3rd in a 4-part series which will explore the impact of exercise on a variety of diseases and conditions. As fitness professionals, we understand the positive effect exercise has on health and human performance. Despite the efficacy of exercise as both a preventive and treatment for so many diseases and conditions, standard medical interventions (notably medications) remain the “go to” medical option for most individuals. In fact, recent estimates by the National Center for Health Statistics suggest that nearly 50% of the U.S. population have used a prescription drug within the last 30 days (1). Therefore, the aim of this article series is to provide a context for understanding the efficacy of exercise as adjunct therapy and compare this to commonly prescribed treatments.
Hypertension, more commonly known as high blood pressure or the “silent killer”, is pervasive in the United States and represents a major public health problem. It is the most prevalent and preventable cardiovascular risk factor and one of the costliest to our health care system (2). The Centers for Disease Control and Prevention (CDC) estimate that nearly one out of every three adults in the United States have hypertension. African Americans are substantially more likely to have hypertension, with rates at 45.7 and 43%, for females and males, respectively (3). Importantly though, only about 80% of hypertensive adults are aware of their condition and, of those, only 48% achieve adequate control (4).
Hypertension is defined as having a resting systolic blood pressure (SBP) ≥140 mm Hg and/or a diastolic blood pressure (DBP) ≥90 mm Hg and/or taking antihypertensive medication (5). Hypertension is further classified according to severity, as follows (6):
Normal Blood Pressure
<120 mm Hg <80 mm Hg
120-139 mm Hg - 80-89 mm Hg
Stage I Hypertension
140-159 mm Hg - 90-99 mm Hg
Stage II Hypertension
>160 mm Hg - >100 mm Hg
>180 mm Hg - >110 mm Hg
High blood pressure (BP) levels are associated with a diversity of negative health outcomes, including an increased risk of stroke (7) and cardiovascular disease (8).). However, high BP is also a significant risk factor for renal disease, peripheral artery disease, heart failure, reductions in brain volume and Alzheimer’s disease (10,11). High BP, as a primary contributing cause, has led to approximately 360,000 deaths in the U.S. annually, or nearly 1,000 per day (2,3).
While the primary treatment for hypertension relies on medication, there are several non-pharmacological strategies, such as weight loss, sodium restriction, biofeedback and guided breathing exercises (9). However, of the non-pharmacological treatments, exercise (both aerobic and dynamic resistance) has the strongest evidence of efficacy (9). Regular exercise is an essential modifiable determinant of hypertension. “Therefore, strategies to increase physical activity are needed to decrease hypertension’s burden.”(12).
Aerobic ExerciseLifestyle interventions are important in treating hypertension as they have few side effects, are low cost and improve other cardiovascular (CVD) risk factors. Regular exercise has been shown to decrease arterial stiffness, and improve BP in hypertensive patients, especially aerobic exercise (13,14). Aerobic exercise has been shown to be effective in both prevention and treatment of hypertension by lowering BP and decreasing the progression from prehypertension to hypertension (15,16). Meta-analyses looking at the effects of exercise on BP conclude that aerobic exercise lowers both SBP and DBP 4-7mmHG (15,17), a decline which is similar to the decrease noted with the first-line anti-hypertensive medications.
The normal immediate response to aerobic exercise is a mild increase in SBP with no change or a slight decrease in DBP from decreased peripheral vascular resistance (19). The effects of regular exercise that contribute to this decrease in BP include the following: decrease in heart rate, decrease in systemic vascular resistance, increase in arterial compliance, and decrease in sympathetic input and increase in nitric oxide availability (16). Conversely an abnormal BP response during aerobic exercise would be a significant drop in SBP or failure of SBP to increase with increasing load (5).
Aerobic exercise exerts both an acute and chronic effect on BP. Acutely, a powerful physiological effect of aerobic exercise is post exercise hypotension (PEH). With PEH, the exerciser experiences an immediate decrease in BP of 5-7 mmHg with exercise bouts lasting 10 – 60 min at intensities from 40 to 100% of maximum oxygen consumption (17). Multiple studies have shown this decrease in BP may last as long as 24 hours. (20,21). This exercise-mediated reduction in BP is especially helpful during the day when BP is typically the most elevated (15). The chronic changes from regular exercise include reduced resting BP and decreased arterial stiffness
Aerobic exercise prescription should be individualized using the FITT principle (frequency, intensity, time and type) The level of medical screening prior to the exercise prescription will depend on the intensity of the exercises planned as well as the patients overall cardiovascular risk. Patients with other cardiovascular risk factors and/or stage 2 hypertension need more intensive screening prior to moderate-intensity (40-60% VO2max, 3-6 METS or walking at a moderate pace) exercise but not for light activity (<40% VO2max, MET < 3 or a slow walk). Absolute contraindications include recent myocardial infarction, heart block, heart failure and other recent cardiovascular events (23).
Frequency: The majority of professional medical societies, such as the American Heart Association (9), now recommend exercise on most if not every day of the week, which is important given the impact of the PEH phenomenon
Intensity: published guidelines all recommend adults with hypertension engage in moderate-intensity exercise (40-60% of VO2max or heart rate reserve) (9,15,24). Interestingly, some evidence also supports high-intensity interval training (HIIT) as an exercise modality. HIIT consists of periods of brief, high-intensity aerobic exercise separated by recovery periods. Several studies have shown the benefit of HIIT over continuous moderate-intensity exercise and the impact on CV risk factors, including hypertension (25,26). However, more recent studies have urged caution until further research has been completed (17,24,27).
Time: The general consensus is that at least 30 minutes a day with at least 150 minutes per week of aerobic exercise is appropriate for hypertensive patients. Research has suggested that exercise can be accumulated in a single bout or several accumulated episodes among adults with hypertension and still be effective in reducing BP (14). For exercise adherence, short bouts of aerobic exercise during the day may be an important strategy for hypertensive patients (17).
Type: many beneficial aerobic exercise modes are available: walking, running, swimming and biking. One important factor in selecting the specific type is exercise adherence.
Resistance Training and Hypertension
Normal BP response to exercise differs between aerobic and resistance training. While aerobic training elicits an intensity-dependent increase in SBP and a negligible effect on DBP, a normal response to dynamic resistance training can significantly increase both SBP and DBP. Moreover, those with hypertension may experience greater increases in SBP during exercise than normotensive individuals (28).
One study compared BP response to resistance exercise between normotensive and hypertensive individuals (28). The authors compared low- (three sets at 40% 1RM to exhaustion, with 45s rest between sets) and high-intensity (three sets at 80% 1RM, with 90s rest between sets) exercise, using seated knee extension, on intra-arterial pressure, during work and rest periods (28). Both normotensive and hypertensive individuals experienced substantial increases during low- and high-intensity training, but the hypertensive group was significantly higher with both low--intensity (SBP 227 vs. 179 mmHg) and high-intensity programs (SBP 215 vs. 176 mmHg). Moreover, while the normotensive group’s SBP returned to baseline values during the rest period of low-intensity exercise, the hypertensive group remained elevated. Interestingly, the greatest increase in BP for both groups occurred during the low-intensity exercise, likely a product of maximal effort with minimal rest between sets.
Currently, substantial evidence links aerobic training with both acute and chronic reductions in BP. However, evidence supporting resistance training as a therapeutic modality is not as robust as that for aerobic training. One major reason may be relative dearth of studies on resistance training for as a treatment for hypertensive populations (29). Nevertheless, the American College of Sports Medicine’s (ACSM) Position Stand on Exercise and Hypertension recommends resistance training as “an important component of a well-rounded exercise program” for the treatment of hypertension (15). However, the ACSM recommends aerobic exercise as the primary modality, with resistance training to “serve as an adjunct” modality (15). Likewise, the American Heart Association’s (AHA) Scientific Statement on alternative approaches to lowering BP recommends resistance training, stating, “The overall evidence suggests that dynamic resistance exercise can lower arterial BP by a modest degree.” The AHA cites the relative lack of large scale studies and goes on to conclude, “it is conceivable that resistance exercise may merit even stronger recommendations in the future.” (9).
A recent meta-analysis by MacDonald et al. helps to illustrate this issue (30). Using data from 71 interventions (in 64 published studies) the authors found a relatively modest reduction in BP (2-3 mmHg) attributed to moderate-intensity resistance training. There was, however, a notable difference in effect when accounting for study population. Studies using hypertensive populations saw a substantially larger reduction in SBP and DBP than studies with normotensive populations (6/5 vs. 0/1 mmHg), indicating hypertensive populations may benefit more from exercise training than normotensive populations.
The ACSM as well as the AHA recommend resistance training for adults with hypertension. Current exercise guidelines for resistance training, from the ACSM, include (5):
Intensity: 60-70% of 1RM (may progress to 80%). Older individuals or novice lifters should begin with 40-50% of 1RM
Time: 2-4 sets of 8-12 reps for major muscle groups
Type: Resistance machines, free weights and/or body weight exercises
While more research into the independent effect of resistance training on BP is warranted, particularly in hypertensive populations, clearly this form of training is efficacious.
Pharmacological Treatment of Hypertension
Practice guidelines established by the Eighth Joint National Committee (JNC8) recommend pharmacological treatment of high BP in adults <60 years begin when SBP ≥140 mm Hg and/or DBP ≥90 mm Hg (for adults >60 years the threshold of SBP is 150 mm Hg) (31). Lifestyle interventions (exercise, dietary change, weight loss, smoking cessation, etc.) are first-line treatments and should continue throughout the treatment plan. Four classes of medications are used for initial treatment of hypertension: thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). The initial treatment strategy recommends beginning with monotherapy (i.e. one drug) and progressing to combination therapy (multiple drugs), as necessary (31).
Effectiveness of antihypertensive drug therapy is similar across all four drug classes. For example, Bronsert et al. (32), in a meta-analysis comparing the effectiveness of antihypertensive drugs, stated, “There were small, clinically insignificant differences in BP reductions between the monotherapy classes.” Another meta-analysis, which compared the effectiveness of antihypertensive drugs in prevention of cardiovascular disease, concluded, “We find limited evidence of important differences between the various drug-classes” (33). These conclusions are in agreement with current JNC8 recommendations (31).
While it is beyond the scope of this paper to evaluate the myriad combinations of antihypertensive drugs and their combined effect on BP reduction, we present the following as a point of comparison to evaluate the effectiveness of drug therapy in relation to exercise therapy as a form of treatment for hypertension. A recent meta-analysis found a risk-adjusted average reduction in SBP of 13.6 and DBP of 7.9 mm Hg, while using drug monotherapy (32). Combination therapy (i.e. using more than one drug), as either fixed-dose combination (FDC; combining two active agents into a single pill) or free-equivalent combination (FEC; prescribing two or more active agents) performed slightly better, resulting in a risk-adjusted reduction in SBP of 17.3 and 12.0 mm Hg, respectively, with the risk-adjusted reduction in DBP of 10.1 and 6.0 mm Hg, respectively (Bronsert et al., 2013). (This paper is not an evaluation of medication treatment; please talk with your physician if you have any questions.)
Hypertension is a major public health concern, affecting nearly one out of every three adults in the U.S. (3). Reductions in BP are strongly associated with a decrease in vascular disease risk. In fact, Lewington et al. estimated that a SBP reduction of only 10 mmHg or a DBP reduction of 5 mmHg would result in 40% lower risk of death from stroke and 30% lower risk of death from ischemic heart disease (35). Indeed, even a modest reduction in BP translates into a clinically meaningful risk reduction in vascular events, such as stroke and ischemic heart disease (15,29).
Lifestyle modification, including exercise, is important for both preventing and treating hypertension. More recent guidelines for treating hypertension have increased emphasis on lifestyle factors, such as exercise. Exercise, particularly aerobic exercise, compares favorably to antihypertensive drug therapy, reducing BP by 5-7 mmHg. While further research into the effect of resistance training on BP is necessary, especially in hypertensive populations, recent work suggests that this form of training is efficacious and safe (23). Current guidelines from the ACSM provide a framework for fitness professionals to create an individualized exercise prescription. Exercise training should be an essential component of treatment recommendations for the hypertensive client/patient. As fitness professionals, it is important to educate and encourage clients with hypertension on the importance of exercise in their overall health.
Mozzafarian D, Benjamin EJ, Go AS, et al. Heart Disease and Stroke Statistics-2015 Update: a report from the American Heart Association. Circulation. e29-322, 2015.
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