Exercise and Hypertension

SUMMARY Hypertension (HTN), one of the most common medical disorders, is associated with an increased incidence of all-cause and cardiovascular disease (CVD) mortality. Lifestyle modifications are advocated for the prevention, treatment, and control of HTN, with exercise being an integral component. Exercise programs that primarily involve endurance activity prevent the development of HTN and lower blood pressure (BP) in adults with normal BP and those with HTN. The BP lowering effects of exercise are most pronounced in people with HTN who engage in endurance exercise with BP decreasing approximately 5–7 mm Hg after an isolated exercise session (acute) or following exercise training (chronic). Moreover, BP is reduced for up to 22 h after an endurance exercise bout (e.g., postexercise hypotension), with the greatest decreases among those with the highest baseline BP. The proposed mechanisms for the BP lowering effects of exercise include neurohumoral, vascular, and structural adaptations. Decreases in catecholamines and total peripheral resistance, improved insulin sensitivity, and alterations in vasodilators and vasoconstrictors are some of the postulated explanations for the antihypertensive effects of exercise. Emerging data suggest genetic links to the BP reductions associated with acute and chronic endurance exercise. Nonetheless, definitive conclusions regarding the mechanisms for the BP reductions following endurance exercise cannot be made at this time. Individuals with controlled HTN and no CVD or renal complications may participate in an exercise program or competitive athletics, but should be evaluated, treated, and monitored closely. Preliminary peak or symptom-limited exercise testing may be warranted, especially for men over 45 and women over 55 yr planning a vigorous exercise program (i.e., ≥ 60% V̇O2R, oxygen uptake reserve). In the interim, while formal evaluation and management are taking place, it is reasonable for the majority of patients to begin moderate intensity exercise training (40–<60% V̇O2R) such as walking. When pharmacologic therapy is indicated in physically active people it should, ideally: a) lower BP at rest and during exertion; b) decrease total peripheral resistance; and, c) not adversely affect exercise capacity. For these reasons, angiotensin converting enzyme (ACE) inhibitors (or angiotensin II receptor blockers in case of ACE inhibitor intolerance) and calcium channel blockers are currently the drugs of choice for recreational exercisers and athletes who have HTN. Exercise remains a cornerstone therapy for the primary prevention, treatment, and control of HTN. The optimal training frequency, intensity, time, and type (FITT) need to be better defined to optimize the BP lowering capacities of exercise, particularly in children, women, older adults, and certain ethnic groups. Based upon the current evidence, the following exercise prescription is recommended for those with high BP: Frequency: on most, preferably all, days of the week Intensity: moderate-intensity (40–<60% of V̇O2R) Time: ≥ 30 min of continuous or accumulated physical activity per day Type: primarily endurance physical activity supplemented by resistance exercise INTRODUCTION Since the 1970s, significant technological and pharmacotherapeutic advances have been made in the treatment and control of cardiovascular disease (CVD) and its associated risk factors. Yet, hypertension (HTN) remains a major public health problem in the United States, with 58.4 million (28.7%) Americans aged 18 yr or older having HTN (systolic blood pressure [SBP] ≥ 140 and/or diastolic blood pressure [DBP] ≥ 90 mm Hg) (11,39,107,137). HTN prevalence is increasing whereas awareness of the condition and control rates is suboptimal (39,107,137). The positive relationship CVD risk and blood pressure (BP) with a BP as as mm Hg and for Hg with normal BP at 55 yr of a risk of HTN The BP of or mm Hg) been to the public health of BP and HTN for people are and effects associated with and with CVD risk factors. For these reasons, the on and of the the of Hypertension and the such as physical activity for the and treatment of HTN. the blood pressure and the treatment for HTN pressure for adults aged 18 and and of this is to an of the current of on exercise and HTN with to and HTN. The of are those by the and of the of on the effects of physical on the BP of exercise in this such as those on blood insulin sensitivity, and are not in this of this are the and of exercise testing in HTN and CVD and the of acute effects of one bout of and chronic effects of a training endurance and resistance exercise on exercise prescription and for with HTN, mechanisms for the effects of acute and chronic exercise, and the current of on exercise and HTN an BP with to to whereas in the and decreases pressure with In HTN defined as ≥ 140 and/or ≥ 90 mm or being on antihypertensive The prevalence of HTN is to be and in the United HTN with and is among men women at but the is in older HTN is the of yr and HTN and CVD and HTN is associated with an increased incidence of all-cause and CVD peripheral and renal with high normal BP or mm Hg) rates of cardiovascular as with those with optimal and mm is the pressure is an of CVD and particularly in older patients with isolated HTN to be at particularly high CVD risk controlled have effects of antihypertensive therapy in patients with and have older patients with isolated HTN treatment therapy reduced CVD by in patients with hypertension and by in patients with isolated and for and and and for is not BP by regarding CVD of patients with HTN in the have normal BP by or The of HTN (or isolated is better that of it remains the risk of HTN is to the risk of HTN in with normal BP in the or with antihypertensive therapy the complications of HTN, of patients with HTN are treatment, and a of these have normal BP to the of to be to control CVD of HTN of HTN in with normal BP is that be to this of HTN, and physical activity and are of HTN. HTN been to be associated with an BP during and/or after exercise. In a of a significant and risk for HTN during a in those with a exercise BP by in a of to men and Individuals with an exercise BP at baseline to HTN over the yr with a normal exercise BP but the no significant after In the who for yr after baseline exercise an but not to exercise a significant and of HTN in men and women, with of and of HTN with who In those who HTN at to have an exercise BP BP at in the after exercise testing and a BP after acute exercise HTN The of exercise BP in in not to the of exercise testing to HTN of a of exercise and the of an BP not the not for in the and BP during exercise have particularly with to exercise testing is for reasons, BP may or exercise BP to the of HTN in with normal BP. of CVD the of exercise BP for or the incidence of CVD In the in baseline to during exercise and and total and at a of but not to the of CVD and In during a exercise to all-cause and CVD in men and women the exercise BP not the of BP in men but exercise resistance to resistance at most to during exercise as a of structural in those with The not in an in BP of a of The of and is by the is associated with a in patients and in with chronic to In the of exercise BP on the is associated with a in and a in patients with CVD and/or whereas the may be in patients on and the associated The of exercise BP regarding CVD complications on the and and is Exercise training and the of HTN. The of physical activity and the incidence of HTN have been in a of In vigorous exercise in the HTN. and intensity of baseline physical activity associated with the risk of HTN in men In of and physical activity associated with a in the risk for HTN In the in the incidence of HTN lower in men in the highest of activity as with men in the active In of the in women significant and the of physical activity and the risk of HTN Moreover, physical activity not associated with HTN in the in have physical and HTN. with physical a risk of for the development of HTN with after for and BP. in men the risk of HTN, after for and in the with the most of physical activity and at baseline are associated with a reduced incidence of HTN in and these after The in women and the one in not significant the of data definitive conclusions regarding the of and Exercise training in the treatment and management of HTN. have the of training on BP in adults, but have not been of a control or is BP may decrease over to the to the and to to the active or control or the of the training and should be controlled are for the current but a on in most BP not by a or an data on BP are of BP. of the of on physical and HTN the of endurance training on BP been in a of of controlled of the and the of the 18 to yr of training one to per but of the training programs exercise session 30 to min and in of the and in training intensity in the to of oxygen uptake BP decreases in to exercise the of training on BP among may in baseline of the training and BP In and controlled of the baseline BP of the the decreases of mm Hg mm Hg and mm Hg In of in baseline BP in the ≥ 140 or ≥ 90 mm Hg) the BP decrease after for control and for significant and mm Hg the BP significant and mm Hg in the in baseline BP of antihypertensive reductions in in mm Hg) mm Hg) and and the training the BP decrease greatest in the to the of the training or no effects of exercise frequency, and of training on the BP in these it no of exercise intensity or that a lower intensity associated with a in BP. controlled BP to the of exercise training h BP to and BP. on controlled and BP is not or by exercise training the current of the controlled is on BP and on BP in the that not day BP. mm The in BP significant and mm Exercise BP. In controlled BP during exercise at a of BP during exercise at an of in exercise mm Hg and The decrease in and to mm Hg and training BP in with normal BP and in those with HTN. The decrease in BP to be pronounced in in training BP and BP at a among are by the of the exercise training that frequency, intensity, time, and and the to an in BP after exercise. yr reduced BP for h after to of the and reductions in BP after a bout of endurance exercise, and the decrease in BP control after a session of exercise as postexercise in and and older men and women, with the greatest BP reductions in those with HTN When BP is in the and are reduced an of and mm a of mm Hg for after the exercise session acute decreases in BP are the health of having BP during the day BP is at its highest The on exercise and HTN on to that time, the of to be in the BP with those BP the decreases in BP be of BP is a of CVD In that better the BP a during of Moreover, this of the associated with such as and the For these reasons, and to BP the day reductions to be approximately mm Hg or those by the reductions in to among adults with HTN been to for up to 22 h after an exercise bout The that the to the in BP after exercise to be the exercise for those who are in greatest need of its is to better those who most exercise as antihypertensive to the of of the exercise prescription on and intensity, are data suggest the of is of these factors. is a with BP reductions with exercise as as min and exercise as as and/or exercise to a or is at this time. The by the of exercise to programs may be an acute with the BP reductions as the training program and acute and chronic endurance exercise BP to exercise not lower BP in approximately of with HTN The BP exercise that should be in on a to the decreases in BP with BP especially in with normal to high normal of a baseline to BP and a control session of rest to for in the of the BP to for and of BP with BP to for the of HTN in the of BP exercise BP among people with HTN for a major of the data on of the acute exercise BP of the exercise and definitive conclusions cannot be made at this time. Exercise effects and controlled the effects of chronic and resistance training on BP in adults have in that and exercise, the effects of chronic resistance training on and in and adults In the resistance training programs the recommended by the significant decreases of approximately mm Hg for and BP as a of resistance decreases to reductions of approximately and for and these may not be a a of as as mm Hg in been to disease by by and all-cause by The of data on the effects of resistance training on BP this may be of CVD and training to BP in and effects controlled adults with and 90 mm Hg have the effects of exercise training on and In one reduced by an of approximately mm Hg and by approximately mm Hg as a of for at of with a rest of at of and for 45 with a rest for significant reductions of approximately and mm Hg for and controlled have the effects of exercise on and in and adults and significant reductions to mm Hg in and to mm Hg in as a of of exercise for in significant reductions for no control data for or a by and the effects of of exercise at of for in significant reductions of approximately mm Hg for with no significant reductions for the of controlled are to the effects of exercise on and and in The exercise BP in adults with BP. effects of resistance exercise. are of no or controlled that have the acute effects of resistance exercise on BP in have the acute effects of resistance exercise on BP the effects of min of resistance exercise on postexercise BP. significant decrease in for up to h after the session whereas no significant reductions for the effects of 30 min of resistance exercise on BP in for up to h after the no significant for a significant in at and min after the and at min after a the BP for up to h after resistance exercise in and men and BP in the after h of no exercise. The exercise session of of on with a rest significant in BP among the groups. that resistance exercise on BP for up to h after the exercise of Exercise are currently no to a regarding the acute effects of exercise on BP in controlled with the effects of chronic exercise on BP in and adults yr of and older have to a that on the effects of exercise for and in and and adults exercise, yr of and older a significant of approximately mm Hg for and a of approximately mm Hg for these reductions in may a are for the older of the the for physical activity in older adults have the acute effects of endurance exercise in older adults, have that for up to 22 of the exercise intensity endurance exercise BP in older is no to the that BP alterations and older in older and controlled the effects of chronic exercise on and in and have to that a total of and and and exercise, decreases of approximately and mm Hg for and as a of exercise training data to the primarily in resistance In the and with HTN, no 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these are the of acute and chronic endurance exercise on BP among Americans with HTN. of controlled the effects of exercise training on BP in and adults with and decreases in whereas reductions in in with and on of and of and the acute exercise BP and women with high normal to HTN and to be in the of the public health and medical treatment of these is to and the BP to endurance exercise, particularly among people of and the of a need for ethnic in the BP to acute and chronic resistance exercise. no to the ethnic in the BP to chronic and acute exercise The evaluation of a with HTN a and physical for and of major risk and CVD complications Based on the of BP and the of risk and the is in risk or The of a evaluation on the intensity of the exercise and on the CVD and In patients with HTN to engage in or exercise ≥ 60% a peak or symptom-limited exercise with may be In men in the the risk of major CVD reduced as patients up to vigorous but the risk increased in active particularly in the of risk or symptom-limited exercise testing is indicated in patients with of CVD such as or In men or women in risk or and with BP mm Hg or who engage in to moderate physical activity 60% is no need for testing the patients in risk or with hypertension ≥ mm may exercise testing in moderate-intensity exercise (40–<60% V̇O2R) but not for or activity In patients with CVD such as or exercise testing is and vigorous exercise training V̇O2R) is in medical to be on the of or exercise such as and should be controlled the of exercise In the interim, while formal evaluation and management are taking place, it is reasonable for the majority of patients to begin moderate-intensity exercise training (40–<60% V̇O2R) such as walking. up should be as in the on and for for Americans chronic exercise may to the development of CVD and its cardiovascular associated with exercise have been in the medical and the physical activity may acute or in the for and is to that and exercise, by increasing and and time, 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as The in the most and of Exercise for and and and in are the most for those with HTN. When the exercise for this to the on this Frequency: most, preferably all, days of the and are in BP may be per week data suggest that is no of exercise and BP reductions a bout of exercise an acute in BP that (e.g., or to the reductions in BP exercise training should be to or exercise. 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In reduced of and angiotensin II after training have been in exercise training not and angiotensin II current that the not to the lowering of BP after are to to lower BP after to receptor by is after training exercise been to decrease in is a been to in HTN in have reduced to after training exercise training the to and HTN with are and is upon the of Exercise training been to and in and an blood to after of in with HTN that reductions in BP. are with and these improved is an training to peripheral resistance in HTN. adaptations. in in in to exercise training include (i.e., increased and/or of and and (i.e., data are the effects of training on the or of and is in in endurance the most in this is the resistance of isolated and the alterations in (i.e., increased that the total of resistance suggest a to lower peripheral resistance and BP. data endurance have in training these and the and have after training in training not to in isolated In may to the antihypertensive of exercise, but are The antihypertensive effects of exercise training may be associated with genetic factors. on BP have been at rest and during exercise. of these data have been by the genetic for approximately of the in after exercise of that may to this and the for and in BP at rest and during exercise after an endurance training program in men and women the no and with the reduced during exercise those for the an and physical training on and exercise BP these in may be in that with for in BP. In to be a genetic to BP to exercise the The for these may be to the of BP in normal and genetic and or should in this of exercise. The for is and is most one (i.e., older suggest that the acute decrease in BP is to reductions in peripheral resistance mechanisms have been proposed to the decrease in peripheral and after exercise. in after exercise have been in and is reduced by acute exercise remains the and are for and in acute exercise, is associated with a of the