Assessing the Existing Professional Exercise Recommendations for Hypertension: A Review and Recommendations for Future Research Priorities

Linda S. Pescatello; Hayley V. MacDonald; Garrett I. Ash; Lauren M. Lamberti; William B. Farquhar; Ross Arena; Blair T. Johnson

doi:10.1016/j.mayocp.2015.04.008

Review| Volume 90, ISSUE 6, P801-812, June 2015

Assessing the Existing Professional Exercise Recommendations for Hypertension: A Review and Recommendations for Future Research Priorities

Linda S. Pescatello, PhD
Linda S. Pescatello
Correspondence
Correspondence: Address to Linda S. Pescatello, PhD, Department of Kinesiology and Human Performance Laboratory, College of Agriculture, Health and Natural Resources, University of Connecticut, Gampel Pavilion Room 206, 2095 Hillside Rd, U-1110, Storrs, CT 06269-1110.
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Affiliations
Department of Kinesiology, University of Connecticut, Storrs, CT
Center for Health, Intervention, and Prevention, University of Connecticut, Storrs, CT
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Hayley V. MacDonald, MS
Hayley V. MacDonald
Affiliations
Department of Kinesiology, University of Connecticut, Storrs, CT
Center for Health, Intervention, and Prevention, University of Connecticut, Storrs, CT
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Garrett I. Ash, MSc
Garrett I. Ash
Affiliations
Department of Kinesiology, University of Connecticut, Storrs, CT
Center for Health, Intervention, and Prevention, University of Connecticut, Storrs, CT
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Lauren M. Lamberti, BS
Lauren M. Lamberti
Affiliations
Department of Kinesiology, University of Connecticut, Storrs, CT
Center for Health, Intervention, and Prevention, University of Connecticut, Storrs, CT
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William B. Farquhar, PhD
William B. Farquhar
Affiliations
Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE
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Ross Arena, PhD, PT
Ross Arena
Affiliations
Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL
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Blair T. Johnson, PhD
Blair T. Johnson
Affiliations
Center for Health, Intervention, and Prevention, University of Connecticut, Storrs, CT
Department of Psychology, University of Connecticut, Storrs, CT
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DOI:https://doi.org/10.1016/j.mayocp.2015.04.008

Abstract

The Eighth Joint National Committee guideline on the management of adult hypertension was recently released. Rather than recommending specific lifestyle modifications as in the Seventh Joint National Committee guideline, the Eighth Joint National Committee endorsed the recommendations of the American Heart Association/American College of Cardiology 2013 Lifestyle Work Group. The Lifestyle Work Group report included systematic reviews and meta-analyses of randomized controlled trials or controlled clinical trials from 2001 through 2011 of “fair to good” quality. In total, 11 reviews qualified for inclusion in the report, 6 of which included blood pressure (BP) as the primary outcome. Three reviews did not find significant reductions in BP, and BP status was not reported in 5. When BP was reported, only 22% of the patients had hypertension. Yet, the group concluded with a strength of evidence categorized as “high” that aerobic exercise training reduces BP by 1 to 5 mm Hg in individuals with hypertension and that the most effective exercise interventions on average included aerobic physical activity of moderate to vigorous intensity for at least 12 weeks, 3 to 4 sessions per week lasting 40 minutes per session. The exercise prescription recommendations of the Lifestyle Work Group deviate from those of other professional organizations and committees including the Seventh Joint National Committee, another American Heart Association scientific statement, the American College of Sports Medicine, the European Society of Hypertension/European Society of Cardiology, and the Canadian Health Education Program. The purposes of this review are to present the existing exercise recommendations for hypertension, discuss reasons for differences in these recommendations, discuss gaps in the literature, and address critical future research needs regarding exercise prescription for hypertension.

Abbreviations and Acronyms:

ACSM (American College of Sports Medicine), AHA (American Heart Association), BP (blood pressure), Ex Rx (exercise prescription), FITT (Frequency, Intensity, Time, and Type), JNC 8 (Eighth Joint National Committee), JNC 7 (Seventh Joint National Committee), PEH (postexercise hypotension), RCT (randomized clinical trial)

Article Highlights

▪
Exercise is recommended as a key lifestyle therapy for adults with high blood pressure (BP) for the prevention, treatment, and control of hypertension by the Seventh Joint National Committee, the Eighth Joint National Committee, the American Heart Association/American College of Cardiology Lifestyle Work Group, another American Heart Association scientific statement, the American College of Sports Medicine, the European Society of Hypertension/ European Society of Cardiology, and the Canadian Hypertension Education Program.
▪
A recurrent theme throughout this review is that there is a substantial lack of evidence on many issues surrounding BP treatment and management in adults with hypertension despite the considerable volume of literature in this area, including exercise prescription (Ex R_x) for hypertension.
▪
An Ex R_x is the process whereby the recommended physical activity program is designed in a systematic and individualized manner in terms of the Frequency (how often?), Intensity (how hard?), Time (how long?), and Type (what kind?), known as the FITT principle.
▪
The professional organizations and committees included in this review report a wide range in the magnitude of the BP reduction resulting from exercise training (ie, 1-9 mm Hg), and in 2 instances, the magnitude was not specified.
▪
There are many possible reasons for the variability in the magnitude of the BP reduction in response to exercise training in the sources discussed in this review, including (1) the review methodology used by the professional organizations and committees to arrive at their conclusions were often based on expert opinion, (2) the lower methodological quality of the exercise and hypertension literature in general, and (3) BP status is often not reported in exercise and hypertension studies, and when it is, most adults enrolled in exercise and hypertension studies do not have hypertension.
▪
Despite the current limitations and differences in the FITT of the recommended Ex R_x for hypertension, the consensus that can be taken from the level of agreement among the various professional recommendations is for adults with pre- to established hypertension to participate in 30 min/d or more of moderate-intensity aerobic exercise on most, if not all, days of the week to total 150 min/wk or more.

The long-awaited evidence-based guideline from the Eighth Joint National Committee (JNC 8) on the management of adult hypertension was recently released.

¹

James P.A.
Oparil S.
Carter B.L.
et al.

2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).

The JNC 8 guideline has generated considerable debate because it departs from established blood pressure (BP) classifications on which treatment was previously based.

²

Chobanian A.V.
Bakris G.L.
Black H.R.
et al.

National High Blood Pressure Education Program Coordinating Committee
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.

^,

³

McCarthy M.

New guidelines relax blood pressure goals.

^,

⁴

Murthy V.L.
Shah R.V.
Rubenfire M.
Brook R.D.

Comparison of the treatment implications of American Society of Hypertension and International Society of Hypertension 2013 and Eighth Joint National Committee guidelines: an analysis of National Health and Nutrition Examination Survey.

Furthermore, rather than recommending specific lifestyle modifications as was done by the Seventh Joint National Committee (JNC 7),

²

Chobanian A.V.
Bakris G.L.
Black H.R.
et al.

National High Blood Pressure Education Program Coordinating Committee
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.

JNC 8 supported the lifestyle modifications recommended by the American Heart Association (AHA)/American College of Cardiology 2013 Lifestyle Work Group.

⁵

Eckel R.H.
Jakicic J.M.
Ard J.D.
et al.

2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.

The Lifestyle Work Group considered evidence only from systematic reviews and meta-analyses published between 2001 and 2011 relating to physical activity and BP. The writing group acknowledged that because of limited resources and time, they could not review every study.

Although the group concluded that the strength of evidence for physical activity to lower BP was “high,” the exercise prescription (Ex R_x) for hypertension that they recommended differs from those of other professional organizations and committees including JNC 7,

²

Chobanian A.V.
Bakris G.L.
Black H.R.
et al.

National High Blood Pressure Education Program Coordinating Committee
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.

another recent AHA scientific statement,

⁶

Brook R.D.
Appel L.J.
Rubenfire M.
et al.

American Heart Association Professional Education Committee of the Council for High Blood Pressure Research, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity
Beyond medications and diet: alternative approaches to lowering blood pressure; a scientific statement from the American Heart Association.

the American College of Sports Medicine (ACSM),

⁷

Pescatello L.S.
Franklin B.A.
Fagard R.
Farquhar W.B.
Kelley G.A.
Ray C.A.

American College of Sports Medicine position stand: exercise and hypertension.

the European Society of Hypertension/European Society of Cardiology,

⁸

Mancia G.
Fagard R.
Narkiewicz K.
et al.

Task Force for the Management of Arterial Hypertension of the European Society of Hypertension and the European Society of Cardiology
2013 ESH/ESC Practice Guidelines for the Management of Arterial Hypertension.

and the Canadian Hypertension Education Program.

⁹

Dasgupta K.
Quinn R.R.
Zarnke K.B.
et al.

The 2014 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension.

The purposes of this review are to present the exercise recommendations for hypertension made by these professional organizations and committees, discuss reasons for the differences in these recommendations, present gaps in the literature, and address critical future research needs regarding the prescription of exercise for hypertension.

Overview of the JNC 8 Guideline

The JNC 8 panel members used rigorous, evidence-based methods guided by 3 critical questions to develop evidence statements and recommendations for BP treatment in adults with hypertension to meet user needs, especially those of primary care clinicians.

¹

James P.A.
Oparil S.
Carter B.L.
et al.

2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).

The 3 critical questions were judged by the panel to be those of the highest priority, and they related to hypertension management and addressed thresholds and goals for pharmacological treatment. The panel’s decision to rely solely on evidence from randomized clinical trials (RCTs) versus relying on the totality of evidence that could have been included in addition to RCTs, especially observational studies, systematic reviews, and meta-analyses as well as expert option, is one reason for the debate that has surrounded the release of the JNC 8 guideline.

³

McCarthy M.

New guidelines relax blood pressure goals.

Following fundamental scientific methods, higher-quality interventions suggest lower bias and higher validity.

¹⁰

Shadish W.R.
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Experimental and Quasi-Experimental Designs for Generalized Causal Inference.

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Panning for the gold in health research: incorporating studies' methodological quality in meta-analysis.

Yet, this “best evidence approach”

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often limits included studies to RCTs exclusively, and despite however strong their methodological quality, RCTs are but one dimension of the literature.

¹⁰

Shadish W.R.
Cook T.D.
Campbell D.T.

Experimental and Quasi-Experimental Designs for Generalized Causal Inference.

Google Scholar

^,

¹³

Rosenbaum P.R.

Observational Studies.

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^,

¹⁴

McAlister F.A.

The Canadian Hypertension Education Program—a unique Canadian initiative.

^,

¹⁵

Valentine J.C.

Judging the quality of primary research.

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Scientific discovery and its translation to clinical practice rely on the replication of findings from independent groups to ensure the robustness of the observed effects across relevant parameters. By gathering all relevant trials related to the underlying phenomenon, meta-analyses and systematic reviews are able to gauge the extent to which trials replicate each other’s findings and evaluate potential reasons for discrepancies among results, such as differences in study populations and the content of the experimental and control arms. Furthermore, even when internally valid RCTs (ie, when differences in study groups are due solely to the different treatments regimes) are included in evidence-based syntheses, the results may not be directly applicable to the populations, interventions, or specific outcomes in the guideline recommendations.

¹⁴

McAlister F.A.

The Canadian Hypertension Education Program—a unique Canadian initiative.

Of importance to this review, and a recurrent theme throughout, is the lack of evidence on many issues surrounding BP treatment and management in adults with hypertension despite the considerable volume of literature in this area.

¹⁶

Zanchetti A.

Evidence and wisdom: recommendations for forthcoming guidelines.

Another notable departure by JNC 8 from JNC 7 was the methodology used to make the lifestyle recommendations. The JNC 8 endorsed the evidence-based recommendations of the 2013 AHA/American College of Cardiology Lifestyle Work Group,

⁵

Eckel R.H.
Jakicic J.M.
Ard J.D.
et al.

2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.

whereas JNC 7 committee members made specific lifestyle recommendations based on a range of study designs as well as expert opinion.

²

Chobanian A.V.
Bakris G.L.
Black H.R.
et al.

National High Blood Pressure Education Program Coordinating Committee
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.

In contrast to the systematic review methodologies of JNC 8, which included only RCTs, the Lifestyle Work Group included only systematic reviews and meta-analyses of RCTs or controlled clinical trials published from 2001 through 2011 that achieved “fair to good” study quality.

⁶

Brook R.D.
Appel L.J.
Rubenfire M.
et al.

American Heart Association Professional Education Committee of the Council for High Blood Pressure Research, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity
Beyond medications and diet: alternative approaches to lowering blood pressure; a scientific statement from the American Heart Association.

^,

¹⁷

U.S. Preventive Services Task Force Procedure Manual. US Preventive Services Task Force website. http://www.uspreventiveservicestaskforce.org/Page/Name/procedure-manual. Published July 2008. Accessed September 11, 2014. AHRQ Publication 08-05118-EF.

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A total of 13 reports with physical activity and BP outcomes qualified for inclusion in their study, but 2 meta-analyses were excluded because of “poor” quality.

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^,

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Cornelissen V.A.
Fagard R.H.

Effect of resistance training on resting blood pressure: a meta-analysis of randomized controlled trials.

Thus, 9 meta-analyses,

²¹

Guo X.
Zhou B.
Nishimura T.
Teramukai S.
Fukushima M.

Clinical effect of qigong practice on essential hypertension: a meta-analysis of randomized controlled trials.

^,

²²

Jolly K.
Taylor R.S.
Lip G.Y.
Stevens A.

Home-based cardiac rehabilitation compared with centre-based rehabilitation and usual care: a systematic review and meta-analysis.

^,

²³

Kelley G.A.
Kelley K.S.
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Walking and resting blood pressure in adults: a meta-analysis.

^,

²⁴

Kelley G.A.
Sharpe Kelley K.

Aerobic exercise and resting blood pressure in older adults: a meta-analytic review of randomized controlled trials.

^,

²⁵

Lee M.S.
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Guo R.
Ernst E.

Qigong for hypertension: a systematic review of randomized clinical trials.

^,

²⁶

Murphy M.H.
Nevill A.M.
Murtagh E.M.
Holder R.L.

The effect of walking on fitness, fatness and resting blood pressure: a meta-analysis of randomised, controlled trials.

^,

²⁷

Taylor R.S.
Brown A.
Ebrahim S.
et al.

Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials.

^,

²⁸

Thomas D.E.
Elliott E.J.
Naughton G.A.

Exercise for type 2 diabetes mellitus.

^,

²⁹

Whelton S.P.
Chin A.
Xin X.
He J.

Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials.

1 systematic review that examined the effects of aerobic exercise,

³⁰

Asikainen T.M.
Kukkonen-Harjula K.
Miilunpalo S.

Exercise for health for early postmenopausal women: a systematic review of randomised controlled trials.

and 1 systematic review that examined the effects of resistance training

³¹

Gordon B.A.
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were included (Table 1 describes the sampled reviews, and Supplemental Tables 1 and 2 [available online at http://www.mayoclinicproceedings.org] describe the sampled reviews of the Lifestyle Work Group report in greater detail).

Table 1Reviews Included in the Lifestyle Work Group Report for the Eighth Joint National Committee: Summary of Features, Baseline Samples, and Intervention Characteristics (N=11)

^a

AET = aerobic exercise training; BP = blood pressure; BMI = body mass index; CET = concurrent exercise training; CR = cardiac rehabilitation; CT = controlled trial; DBP = diastolic BP; FITT = Frequency, Intensity, Time, and Type of the exercise intervention; HRmax = maximal heart rate; HTN = hypertension; k = number of interventions; MVC = maximum voluntary contraction; Med = medication; Multi-CR = multifaceted or comprehensive CR, including exercise, education, psychological and/or lifestyle components; NA = not available (unreported or missing information); NBP = normal BP; RCT = randomized controlled trial; 1-RM = one repetition maximum; RT = resistance training; SBP = systolic BP; T2DM = type 2 diabetes mellitus; VO2max = maximum oxygen consumption.

Review features ^b The Lifestyle Work Group5 searched for potentially relevant meta-analyses or reviews that focused on physical activity with BP or lipid outcome(s). In contrast, Johnson et al,32 included meta-analyses that examined the BP response to exercise as a primary outcome. Johnson et al, identified and later excluded 4 of the reviews included by the Lifestyle Work Group because it was a systematic review (not a meta-analysis)30 and 3 did not focus on BP as the primary outcome22,27,28; in addition to the reviews included in the Lifestyle Work Group’s sample, Johnson et al, identified 10 additional meta-analyses, 2 of which were excluded for “poor” quality.19,20 ^, ^c The publication type (meta-analysis or systematic review) and percentage of included trials (% trials) that reported BP outcomes are provided for each review. Meta-analyses included in the review on the methodological quality of meta-analyses examining the BP response to exercise32 appear in the table as boldface entries under the columns titled “Review features” and “Evidence rating.”		Patient clinical characteristics ^d Descriptive statistics for BMI (kg/m2), age (y), and resting BP (mm Hg) are presented as mean ± SD, median (minimum, maximum),29 or range (minimum-maximum) in the observed values.21		Features of the exercise intervention: level of supervision, FITT, duration, and attrition rate	Resultant BP change ^f Summary statistics for BP change (mm Hg) are presented as mean (lower, upper 95% CI) or mean ± SD. Downward arrows (↓) represent significant BP reductions (P≤.05). Double-headed arrows (↔) represent nonsignificant BP reductions (P>.05).	Evidence rating ^g The Lifestyle Work Group5 rated the strength of evidence using the National Heart, Lung, and Blood Institute quality scale.17 Johnson et al32 rated the strength of evidence as a percentage of items completely satisfied (18 items total) using the AMSTARExBP (an augmented version of the Assessment of Multiple Systematic Reviews or AMSTAR questionnaire).
Reference, year	No. of trials (RCTs)	No. of pts (women)	SBP/DBP (HTN) ^e % HTN represents the percentage of the total sample with HTN as reported by the meta-analysis or review or based on resting BP values (SBP ≥140 or ≥90 mm Hg).2			Lifestyle Work Group	AMSTARExBP scale
Aerobic exercise training
Guo et al, ²¹ Guo X. Zhou B. Nishimura T. Teramukai S. Fukushima M. Clinical effect of qigong practice on essential hypertension: a meta-analysis of randomized controlled trials. J Altern Complement Med. 2008; 14: 27-37 Crossref PubMed Scopus (51) Google Scholar 2008 Meta-analysis BP outcome (100% trials)	9 (100%), k=12 Qigong vs AET, k=2	157 (NA) BMI: NA Age: 30-70	Qigong: 143.6-169.7/93.0-104.3 (100%) AET: 140.9-166.2/93.1-107.1 (100%) BP Med: 42%-50% (k=5)	Qigong (N=76): supervision not reported; F: 2 sessions/d × 7 d/wk, I: NA, T: 15-60 min/d or 30-120 min/d, T: Guolin AET (N=81): supervision not reported; F: NA, I: NA, T: NA, T: jog, “exercise” Duration: 16-48 wk (Qigong and AET) Attrition: Qigong, 21%; AET, 18%	Qigong vs AET: SBP/DBP ↔ −1.5 (−7.0, 4.0)/ −1.6 (−4.9, 1.7)	Fair	61.1%
Lee et al, ²⁵ Lee M.S. Pittler M.H. Guo R. Ernst E. Qigong for hypertension: a systematic review of randomized clinical trials. J Hypertens. 2007; 25: 1525-1532 Crossref PubMed Scopus (88) Google Scholar 2007 Meta-analysis BP outcome (100% trials)	12 (100%), k=12 AET vs Qigong, k=2	1218 (28%) BMI: NA Age: 30-70	AET vs Qigong: SBP/DBP: NA (100%) BP Med: 58% (k=7)	Qigong (N=86): supervision not reported; F: 2-7 d/wk, I: NA, T: 60-120 min/d, T: NA AET (N=86): supervision not reported; F: 2-7 d/wk, I: NA, T: 120 min/d or 4-5 km/d, T: jog, “exercise” Duration: 16-48 wk (Qigong and AET) Attrition: NA	AET vs Qigong: SBP/DBP ↔ −1.4 (−2.6, 5.4)/ 1.5 (−1.0, 4.1)	Good	50.0%
Murphy et al, ²⁶ Murphy M.H. Nevill A.M. Murtagh E.M. Holder R.L. The effect of walking on fitness, fatness and resting blood pressure: a meta-analysis of randomised, controlled trials. Prev Med. 2007; 44: 377-385 Crossref PubMed Scopus (238) Google Scholar 2007 Meta-analysis *BP outcome* (38% trials)	24 (100%)	1128 (83%) BMI: 25.9±1.0 (k=20) Age: 51.6±12.7	AET: 127.0±11.7/ 77.7±4.5 (0%) BP Med: NA	AET (N=698): supervision not reported; F: 4.4 (2-7) d/wk, I: 70.1% (50%-86%) HR_max or 56.3% (45%-65%) VO_2max, T: 38.3±14.4 min/d or 188.8 (50-270) min/wk, T: walk Duration: 34.9±4.9 wk Attrition: 20% (0%-54%)	Total sample: SBP ↔ −1.1±2.2 DBP ↓ −1.5±0.8	Fair	61.1%
Jolly et al, ²² Jolly K. Taylor R.S. Lip G.Y. Stevens A. Home-based cardiac rehabilitation compared with centre-based rehabilitation and usual care: a systematic review and meta-analysis. Int J Cardiol. 2006; 111: 343-351 Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar 2006 Meta-analysis BP outcome (61% trials)	21 (100%), k=24	5047 (33%) Sedentary CR attendees BMI: NA Age: <75	SBP/DBP: NA BP Med: NA	Home-based (N=684): unsupervised; F: 1-5 d/wk, I: NA, T: NA, T: multi-CR (k=3) or exercise-only CR (k=2) Center-based (N=279): supervised; F: 1-3 d/wk, I: NA, T: NA, T: multi-CR (k=2) Duration: 6-24 wk (home- and center-based) Attrition: home-based, 7%-37%; center-based, 16%	Home-based: SBP ↓ −4.2 (−6.6, −1.5) Center-based: SBP ↓ −1.1 (−3.7, −6.0)	Good	50.0%
Thomas et al, ²⁸ Thomas D.E. Elliott E.J. Naughton G.A. Exercise for type 2 diabetes mellitus. Cochrane Database Syst Rev. 2006; : CD002968 PubMed Google Scholar 2006 Meta-analysis BP outcome (29% trials)	14 (100%)	377 (25%) Sedentary, T2DM/NA/ 40-65	SBP/DBP: NA BP Med: NA	AET, RT, and CET (k=3): supervised and unsupervised; F: 3-4 d/wk, I: 65%-75% VO_2max (AET); 50%-55% 1-RM or 70%-80% MVC (RT), T: 40-60 min/d (AET); 2-3 sets × 10-12 repetitions/set (∼55 min) (RT), T: AET + diet (k=1), RT + diet (k=1), circuit-RT (k=1), CET (k=1) Duration: 8-48 wk Attrition: 19% (CET group only)	Total sample: SBP/DBP ↔ −4.2 (−9.5, 1.1)/ −0.1 (−4.0, 3.0)	Good	66.7%
Asikainen et al, ³⁰ Asikainen T.M. Kukkonen-Harjula K. Miilunpalo S. Exercise for health for early postmenopausal women: a systematic review of randomised controlled trials. Sports Med. 2004; 34: 753-778 Crossref PubMed Scopus (274) Google Scholar 2004 Systematic review BP outcome (25% trials)	28 (100%)	2646 (100%) Sedentary, healthy, postmenopausal/26-33/50-65	SBP/DBP: NA (28.6%) BP Med: NA	NBP—AET (N=541; k=5): unsupervised; F: 2-5 d/wk, I: 40%-84% VO_2max, T: 30-60 min/d, T: walk/jog HTN—AET and CET (N=301; k=2): supervised; F: 3 d/wk, I: 79% VO_2max, T: 16 km/wk (AET); 30-55 min/d (CET) + 1 set × 7-15 repetitions/set, 8 exercises (CET), T: AET (walk/jog) + diet; CET + diet Duration: 12-48 wk (NBP and HTN) Attrition: 4%-33% (NBP and HTN)	Total sample: SBP/DBP ↓ NBP: SBP/DBP ↔ HTN: SBP/DBP ↔ or SBP ↓ −10.0	Good	60.0%
Taylor et al, ²⁷ Taylor R.S. Brown A. Ebrahim S. et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004; 116: 682-692 Abstract Full Text Full Text PDF PubMed Scopus (1657) Google Scholar 2004 Meta-analysis BP outcome (100% trials)	48 (100%), k=49	8940 (20%) Sedentary, CR attendees/NA/ 55 (48-71)	SBP/DBP: NA BP Med: NA	CR: supervision not reported; F: 3.7 d/wk, I: 76% VO_2max, T: 53 min/d, T: exercise-only CR (k=19); Multi-CR (k=10) Duration: 12 wk (1-120 wk) Attrition: NA	Total sample: SBP ↓ −3.2 (−5.4, −0.9) DBP ↔ −1.2 (−2.7, 0.3)	Good	66.7%
Whelton et al, ²⁹ Whelton S.P. Chin A. Xin X. He J. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med. 2002; 136: 493-503 Crossref PubMed Scopus (1430) Google Scholar 2002 Meta-analysis *BP outcome* (100% trials)	38 (100%), k=54	2419 (44% of trials, NA) BMI: 25.4 Age: 21-79	Total: 126.5 (101.0, 168.0)/ 77.0 (61.0, 104.0) (28%) BP Med: 7.4% (k=4)	AET: supervised (k=47) and unsupervised (k=7) F: NA, I: NA, T: NA, T: walk or jog, cycle, multiple or “other” Duration: 12 wk (3-96 wk) Attrition: NA	Total sample: SBP/DBP ↓ −3.8 (−5.0, −2.7)/ −2.6 (−3.4, −1.8) NBP (k=28): SBP/DBP ↓ −4.0 (−5.3, −2.7)/ −2.3 (−3.1, −1.5) HTN (k=15): SBP/DBP ↓ −4.9 (−7.2, −2.7)/ −3.7 (−5.7, −1.8)	Fair	70.6%
Kelley et al, ²³ Kelley G.A. Kelley K.S. Tran Z.V. Walking and resting blood pressure in adults: a meta-analysis. Prev Med. 2001; 33: 120-127 PubMed Google Scholar 2001 Meta-analysis *BP outcome* (100% trials)	47 (100%), k=72	2543 (49%)/ 25.6/ 47.4±15.6	Total: 129.0±15.0/ 82.0±10.0 (15%) BP Med: 15% (k=11)	AET: supervision not reported; F: 3±1 (1-5) d/wk, I: 67%±10% (45%-86%) VO_2max, T: 40±11 (25-60) min/d, T: walk, jog, cycle, dance and/or swim Duration: 23 wk (4-52 wk) Attrition: 16% (0%-60%)	Total sample: SBP/DBP ↓ −2.0 (−3.0, −1.0)/ −2.0 (−2.0, −1.0) NBP: SBP/DBP ↓ −2.0 (−3.0, −1.0)/ −1.0 (−2.0, −1.0) HTN: SBP/DBP ↓ −6.0 (−8.0, −3.0)/ −5.0 (−7.0, −3.0)	Fair	66.7%
Kelley et al, ²⁴ Kelley G.A. Sharpe Kelley K. Aerobic exercise and resting blood pressure in older adults: a meta-analytic review of randomized controlled trials. J Gerontol A Biol Sci Med Sci. 2001; 56: M298-M303 Crossref PubMed Scopus (94) Google Scholar 2001 Meta-analysis BP outcome (100% trials)	7 (100%), k=14	802 (NA) Healthy, ≥50 y 26.0±2.0/ 68.0±6.0	AET: 128.0±12.0/77.0±4.0 (14%) BP Med: 21% (k=3)	AET (N=563): supervision not reported; F: 3±1 (2-5) d/wk, I: 63%±5% (60%-70%) VO_2max, T: 40±11 (25-60) min/day, T: walk, jog, cycle, and/or dance Duration: 35 wk (16-52 wk) Attrition: 18% (0%-37%)	Total sample: SBP/DBP ↓ −2.0 (−4.0, −1.0)/ −1.0 (−2.0, 0.0)	Good	50.0%
Dynamic resistance training
Gordon et al, ³¹ Gordon B.A. Benson A.C. Bird S.R. Fraser S.F. Resistance training improves metabolic health in type 2 diabetes: a systematic review. Diabetes Res Clin Pract. 2009; 83: 157-175 Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar 2009 Systematic review BP outcome (42% trials)	24 (54.2%), k=10 CT=8 non-CT=3	662 (42%) Sedentary, T2DM/ 31.3±4.2 (k=1)/51-68	SBP/DBP: NA (30%) BP Med: NA	Dynamic RT (N=151; 35% women): supervised; F: 3 d/wk, I: NA, T: 1-3 sets × 8-15 repetitions/set (∼45 min), T: full-body RT using machine weights Duration: 2-16 wk Attrition: NA	HTN group: SBP/DBP ↓ SBP (k=3), DBP (k=1)	Fair	46.7%

a AET = aerobic exercise training; BP = blood pressure; BMI = body mass index; CET = concurrent exercise training; CR = cardiac rehabilitation; CT = controlled trial; DBP = diastolic BP; FITT = Frequency, Intensity, Time, and Type of the exercise intervention; HR_max = maximal heart rate; HTN = hypertension; k = number of interventions; MVC = maximum voluntary contraction; Med = medication; Multi-CR = multifaceted or comprehensive CR, including exercise, education, psychological and/or lifestyle components; NA = not available (unreported or missing information); NBP = normal BP; RCT = randomized controlled trial; 1-RM = one repetition maximum; RT = resistance training; SBP = systolic BP; T2DM = type 2 diabetes mellitus; VO_2max = maximum oxygen consumption.

b The Lifestyle Work Group

⁵

Eckel R.H.
Jakicic J.M.
Ard J.D.
et al.

2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.

searched for potentially relevant meta-analyses or reviews that focused on physical activity with BP or lipid outcome(s). In contrast, Johnson et al,

³²

Johnson B.T.
MacDonald H.V.
Bruneau Jr., M.L.
et al.

Methodological quality of meta-analyses on the blood pressure response to exercise: a review.

included meta-analyses that examined the BP response to exercise as a primary outcome. Johnson et al, identified and later excluded 4 of the reviews included by the Lifestyle Work Group because it was a systematic review (not a meta-analysis)

³⁰

Asikainen T.M.
Kukkonen-Harjula K.
Miilunpalo S.

Exercise for health for early postmenopausal women: a systematic review of randomised controlled trials.

and 3 did not focus on BP as the primary outcome

²²

Jolly K.
Taylor R.S.
Lip G.Y.
Stevens A.

Home-based cardiac rehabilitation compared with centre-based rehabilitation and usual care: a systematic review and meta-analysis.

^,

²⁷

Taylor R.S.
Brown A.
Ebrahim S.
et al.

Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials.

^,

²⁸

Thomas D.E.
Elliott E.J.
Naughton G.A.

Exercise for type 2 diabetes mellitus.

; in addition to the reviews included in the Lifestyle Work Group’s sample, Johnson et al, identified 10 additional meta-analyses, 2 of which were excluded for “poor” quality.

¹⁹

Cornelissen V.A.
Fagard R.H.

Effects of endurance training on blood pressure, blood pressure-regulating mechanisms, and cardiovascular risk factors.

^,

²⁰

Cornelissen V.A.
Fagard R.H.

Effect of resistance training on resting blood pressure: a meta-analysis of randomized controlled trials.

c The publication type (meta-analysis or systematic review) and percentage of included trials (% trials) that reported BP outcomes are provided for each review. Meta-analyses included in the review on the methodological quality of meta-analyses examining the BP response to exercise

³²

Johnson B.T.
MacDonald H.V.
Bruneau Jr., M.L.
et al.

Methodological quality of meta-analyses on the blood pressure response to exercise: a review.

appear in the table as boldface entries under the columns titled “Review features” and “Evidence rating.”

d Descriptive statistics for BMI (kg/m²), age (y), and resting BP (mm Hg) are presented as mean ± SD, median (minimum, maximum),

²⁹

Whelton S.P.
Chin A.
Xin X.
He J.

Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials.

or range (minimum-maximum) in the observed values.

²¹

Guo X.
Zhou B.
Nishimura T.
Teramukai S.
Fukushima M.

Clinical effect of qigong practice on essential hypertension: a meta-analysis of randomized controlled trials.

e % HTN represents the percentage of the total sample with HTN as reported by the meta-analysis or review or based on resting BP values (SBP ≥140 or ≥90 mm Hg).

²

Chobanian A.V.
Bakris G.L.
Black H.R.
et al.

National High Blood Pressure Education Program Coordinating Committee
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.

f Summary statistics for BP change (mm Hg) are presented as mean (lower, upper 95% CI) or mean ± SD. Downward arrows (↓) represent significant BP reductions (P≤.05). Double-headed arrows (↔) represent nonsignificant BP reductions (P>.05).

g The Lifestyle Work Group

⁵

Eckel R.H.
Jakicic J.M.
Ard J.D.
et al.

2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.

rated the strength of evidence using the National Heart, Lung, and Blood Institute quality scale.

¹⁷

U.S. Preventive Services Task Force Procedure Manual. US Preventive Services Task Force website. http://www.uspreventiveservicestaskforce.org/Page/Name/procedure-manual. Published July 2008. Accessed September 11, 2014. AHRQ Publication 08-05118-EF.

Google Scholar

Johnson et al

³²

Johnson B.T.
MacDonald H.V.
Bruneau Jr., M.L.
et al.

Methodological quality of meta-analyses on the blood pressure response to exercise: a review.

rated the strength of evidence as a percentage of items completely satisfied (18 items total) using the AMSTAR_ExBP (an augmented version of the Assessment of Multiple Systematic Reviews or AMSTAR questionnaire).

Open table in a new tab

Of the 11 systematic reviews and meta-analyses that were included, only 6 (55%) had BP as their primary outcome,

²¹

Guo X.
Zhou B.
Nishimura T.
Teramukai S.
Fukushima M.

Clinical effect of qigong practice on essential hypertension: a meta-analysis of randomized controlled trials.

^,

²³

Kelley G.A.
Kelley K.S.
Tran Z.V.

Walking and resting blood pressure in adults: a meta-analysis.

^,

²⁴

Kelley G.A.
Sharpe Kelley K.

Aerobic exercise and resting blood pressure in older adults: a meta-analytic review of randomized controlled trials.

^,

²⁵

Lee M.S.
Pittler M.H.
Guo R.
Ernst E.

Qigong for hypertension: a systematic review of randomized clinical trials.

^,

²⁶

Murphy M.H.
Nevill A.M.
Murtagh E.M.
Holder R.L.

The effect of walking on fitness, fatness and resting blood pressure: a meta-analysis of randomised, controlled trials.

^,

²⁹

Whelton S.P.
Chin A.
Xin X.
He J.

Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials.

and 4 (36%) focused on specific clinical populations, including patients with type 2 diabetes

²⁸

Thomas D.E.
Elliott E.J.
Naughton G.A.

Exercise for type 2 diabetes mellitus.

^,

³¹

Gordon B.A.
Benson A.C.
Bird S.R.
Fraser S.F.

Resistance training improves metabolic health in type 2 diabetes: a systematic review.

and patients undergoing cardiac rehabilitation.

²²

Jolly K.
Taylor R.S.
Lip G.Y.
Stevens A.

Home-based cardiac rehabilitation compared with centre-based rehabilitation and usual care: a systematic review and meta-analysis.

^,

²⁷

Taylor R.S.
Brown A.
Ebrahim S.
et al.

Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials.

A key point regarding these 11 reports is that BP status was often not reported (N=5, 45% of the trials), and when it was, the patients predominantly did not have hypertension (ie, only 22% had hypertension).

²²

Jolly K.
Taylor R.S.
Lip G.Y.
Stevens A.

Home-based cardiac rehabilitation compared with centre-based rehabilitation and usual care: a systematic review and meta-analysis.

^,

²⁶

Murphy M.H.
Nevill A.M.
Murtagh E.M.
Holder R.L.

The effect of walking on fitness, fatness and resting blood pressure: a meta-analysis of randomised, controlled trials.

^,

²⁷

Taylor R.S.
Brown A.
Ebrahim S.
et al.

Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials.

^,

²⁸

Thomas D.E.
Elliott E.J.
Naughton G.A.

Exercise for type 2 diabetes mellitus.

^,

³⁰

Asikainen T.M.
Kukkonen-Harjula K.
Miilunpalo S.

Exercise for health for early postmenopausal women: a systematic review of randomised controlled trials.

These methodological limitations may explain why only 8 of the 11 reviews observed significant BP reductions following exercise,

²²

Jolly K.
Taylor R.S.
Lip G.Y.
Stevens A.

Home-based cardiac rehabilitation compared with centre-based rehabilitation and usual care: a systematic review and meta-analysis.

^,

²³

Kelley G.A.
Kelley K.S.
Tran Z.V.

Walking and resting blood pressure in adults: a meta-analysis.

^,

²⁴

Kelley G.A.
Sharpe Kelley K.

Aerobic exercise and resting blood pressure in older adults: a meta-analytic review of randomized controlled trials.

^,

²⁶

Murphy M.H.
Nevill A.M.
Murtagh E.M.
Holder R.L.

The effect of walking on fitness, fatness and resting blood pressure: a meta-analysis of randomised, controlled trials.

^,

²⁷

Taylor R.S.
Brown A.
Ebrahim S.
et al.

Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials.

^,

²⁹

Whelton S.P.
Chin A.
Xin X.
He J.

Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials.

^,

³⁰

Asikainen T.M.
Kukkonen-Harjula K.
Miilunpalo S.

Exercise for health for early postmenopausal women: a systematic review of randomised controlled trials.

^,

³¹

Gordon B.A.
Benson A.C.
Bird S.R.
Fraser S.F.

Resistance training improves metabolic health in type 2 diabetes: a systematic review.

and they were of small to modest magnitude (approximately 1-5 mm Hg). In addition, other important variables that are known to influence the BP response to exercise, such as patient baseline characteristics (ie, body mass index, BP medication use) and intervention features (ie, attrition, level of exercise supervision) were generally poorly reported. Table 1 describes the exercise intervention features, and Supplemental Table 2 describes the exercise intervention details of the Lifestyle Work Group report in greater detail.

Exercise Recommendations for Hypertension

Exercise offers numerous health benefits and is considered safe in apparently healthy individuals as well as all patients with stable medical conditions. Accordingly, it is recommended as a key lifestyle therapy for adults with high BP for the prevention, treatment, and control of hypertension by all the professional committees and organizations listed in Table 2.

¹

James P.A.
Oparil S.
Carter B.L.
et al.

2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).

^,

²

Chobanian A.V.
Bakris G.L.
Black H.R.
et al.

National High Blood Pressure Education Program Coordinating Committee
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.

^,

⁵

Eckel R.H.
Jakicic J.M.
Ard J.D.
et al.

2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.

^,

⁶

Brook R.D.
Appel L.J.
Rubenfire M.
et al.

American Heart Association Professional Education Committee of the Council for High Blood Pressure Research, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity
Beyond medications and diet: alternative approaches to lowering blood pressure; a scientific statement from the American Heart Association.

^,

⁷

Pescatello L.S.
Franklin B.A.
Fagard R.
Farquhar W.B.
Kelley G.A.
Ray C.A.

American College of Sports Medicine position stand: exercise and hypertension.

^,

⁸

Mancia G.
Fagard R.
Narkiewicz K.
et al.

Task Force for the Management of Arterial Hypertension of the European Society of Hypertension and the European Society of Cardiology
2013 ESH/ESC Practice Guidelines for the Management of Arterial Hypertension.

^,

⁹

Dasgupta K.
Quinn R.R.
Zarnke K.B.
et al.

The 2014 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension.

An Ex R_x is the process whereby the recommended physical activity program is designed in a systematic and individualized manner in terms of the Frequency (how often?), Intensity (how hard?), Time (how long?), and Type (what kind?), otherwise known as the FITT principle.

³³

Google Scholar

Despite using systematic approaches, the recommended FITT of the Ex R_x varies across the professional committees and organizations (Table 2). We address areas of agreement and disagreement and comment on the level of evidence on which the various professional committees and organizations made their FITT Ex R_x recommendations.

Table 2Exercise Prescription Guidelines, Scientific Statements, and Recommendations for the Prevention, Treatment, and Control of Hypertension Made by Various Professional Committees and Organizations

^a

ACC = American College of Cardiology; ACSM = American College of Sports Medicine; AHA = American Heart Association; CHEP = Canadian Hypertension Education Program; ESC = European Society of Cardiology; ESH = European Society of Hypertension; Ex Rx = exercise prescription; FITT = Frequency, Intensity, Time, and Type of the exercise prescription; JNC 8 = Eighth Joint National Committee; JNC 7 = Seventh Joint National Committee; NHLBI = National Heart, Lung, and Blood Institute; RCT = randomized controlled trial; 1-RM = one repetition maximum; RT = resistance training; VO2reserve = oxygen uptake reserve.

The FITT of the Ex R_x	Professional committee/organization
The FITT of the Ex R_x	JNC 8 ¹ James P.A. Oparil S. Carter B.L. et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014; 311 ([published correction appears in JAMA. 2014;311(17):1809]): 507-520 Crossref PubMed Scopus (5873) Google Scholar and AHA/ACC Lifestyle Work Group ⁵ Eckel R.H. Jakicic J.M. Ard J.D. et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014; 63 ([published correction appears in J Am Coll Cardiol. 2014;63(25, pt B):3027-3028]): 2960-2984 Crossref PubMed Scopus (906) Google Scholar	JNC 7 ² Chobanian A.V. Bakris G.L. Black H.R. et al. National High Blood Pressure Education Program Coordinating Committee The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003; 289 ([published correction appears in JAMA. 2003;290(2):197]): 2560-2572 Crossref PubMed Scopus (16577) Google Scholar	AHA ⁶ Brook R.D. Appel L.J. Rubenfire M. et al. American Heart Association Professional Education Committee of the Council for High Blood Pressure Research, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity Beyond medications and diet: alternative approaches to lowering blood pressure; a scientific statement from the American Heart Association. Hypertension. 2013; 61: 1360-1383 Crossref PubMed Scopus (406) Google Scholar	ACSM ⁷ Pescatello L.S. Franklin B.A. Fagard R. Farquhar W.B. Kelley G.A. Ray C.A. American College of Sports Medicine position stand: exercise and hypertension. Med Sci Sports Exerc. 2004; 36: 533-553 Crossref PubMed Scopus (1311) Google Scholar	ESH/ESC ⁸ Mancia G. Fagard R. Narkiewicz K. et al. Task Force for the Management of Arterial Hypertension of the European Society of Hypertension and the European Society of Cardiology 2013 ESH/ESC Practice Guidelines for the Management of Arterial Hypertension. Blood Press. 2014; 23: 3-16 Crossref PubMed Scopus (525) Google Scholar	CHEP ⁹ Dasgupta K. Quinn R.R. Zarnke K.B. et al. The 2014 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol. 2014; 30: 485-501 Abstract Full Text Full Text PDF PubMed Scopus (205) Google Scholar
Frequency (how often?)	3-4 sessions/wk ≥12 wk	Most days of the week	Most days of the week	Most, preferably all, days of the week	5-7 d/wk	4-7 d/wk in addition to habitual daily activity
Intensity (how hard?)	Moderate to vigorous ^b Moderate intensity is defined as 40% to <60% VO2reserve or an intensity that causes noticeable increases in heart rate and breathing; vigorous or high intensity is defined as ≥60% VO2reserve or an intensity that causes substantial increases in heart rate and breathing.	None specified	Moderate to high, >40%-60% of maximum	Moderate 40%-<60% of VO_2reserve	Moderate ^b Moderate intensity is defined as 40% to <60% VO2reserve or an intensity that causes noticeable increases in heart rate and breathing; vigorous or high intensity is defined as ≥60% VO2reserve or an intensity that causes substantial increases in heart rate and breathing.	Moderate ^b Moderate intensity is defined as 40% to <60% VO2reserve or an intensity that causes noticeable increases in heart rate and breathing; vigorous or high intensity is defined as ≥60% VO2reserve or an intensity that causes substantial increases in heart rate and breathing.
Time (how long?)	40 min/session	≥30 min/d	150 min/wk	30-60 min continuous or accumulated in bouts ≥10 min each	≥30 min/d	Accumulation of 30-60 min/d
Type (what kind?) Primary	Aerobic	Aerobic	Aerobic	Aerobic	Aerobic	Dynamic exercise (aerobic)
Evidence rating	“High” ^c The NHLBI5 rating system grades the strength of the evidence (Evidence Statement) and the strength of the recommendation(s) (Evidence Recommendation); adapted from the US Preventive Services Task Force.17 ^, ^d The Lifestyle Work Group rated the Evidence Statement for aerobic exercise to lower BP as “high”i; the Evidence Recommendation for the Ex Rx (or FITT) to lower BP was rated grade Bc or “moderate”; corresponding to class IIa level of evidence Ae. Grade B ^c The NHLBI5 rating system grades the strength of the evidence (Evidence Statement) and the strength of the recommendation(s) (Evidence Recommendation); adapted from the US Preventive Services Task Force.17 ^, ^d The Lifestyle Work Group rated the Evidence Statement for aerobic exercise to lower BP as “high”i; the Evidence Recommendation for the Ex Rx (or FITT) to lower BP was rated grade Bc or “moderate”; corresponding to class IIa level of evidence Ae. Class IIa level of evidence A ^e Classification of recommendations and level of evidence per AHA guideline criteria.6,18,34		Class 1 level of evidence A ^e Classification of recommendations and level of evidence per AHA guideline criteria.6,18,34	Evidence category A, ^f NHLBI grading of evidence.35 ^, ^g The strength of evidence was rated: evidence category Bf for the immediate effects of aerobic exercise or postexercise hypotension; evidence category Af for aerobic exercise to lower BP; evidence category Bf for the recommended aerobic Ex Rx (or FITT) to lower BP. evidence category B ^f NHLBI grading of evidence.35 ^, ^g The strength of evidence was rated: evidence category Bf for the immediate effects of aerobic exercise or postexercise hypotension; evidence category Af for aerobic exercise to lower BP; evidence category Bf for the recommended aerobic Ex Rx (or FITT) to lower BP.	Class 1 level of evidence A-B ^h ESC recommendations.36	Grade D ⁱ CHEP graded recommendations by the underlying evidence14 using grade A (strongest evidence, based on high-quality studies) to grade D (weakest evidence, based on low-power imprecise studies or expert opinion alone). ^, ^j CHEP assigned grade Di to “higher intensity exercise is not more effective.”
Adjuvant			Dynamic RT	Dynamic RT 2-3 d/wk Moderate 60%-80% 1-RM, 8-12 repetitions	Dynamic RT 2-3 d/wk	Dynamic, Isometric, or Handgrip RT
Evidence rating			Class IIa level of evidence B ^e Classification of recommendations and level of evidence per AHA guideline criteria.6,18,34	Evidence category B ^f NHLBI grading of evidence.35 ^, ^k The strength of evidence was rated evidence category Ch for the immediate effects of dynamic resistance exercise or postexercise hypotension.		Grade D ⁱ CHEP graded recommendations by the underlying evidence14 using grade A (strongest evidence, based on high-quality studies) to grade D (weakest evidence, based on low-power imprecise studies or expert opinion alone).
BP reduction (mm Hg)	1-5	4-9		5-7 among those with hypertension	2-3 overall; 5-7 among those with hypertension
Review methodology	Meta-analyses and systematic reviews of RCTs or controlled clinical trials from 2001-2011	Nonsystematic literature review including a range of study types. Recommendations made by consensus	An initial search that identified a meta-analysis or review within the past 6 y; a second systematic review from 2006-2011 followed	Systematic literature review including a range of study types. Recommendations made by consensus	Extensive literature review of RCTs and meta-analyses of RCTs as highest priority; other data were considered if appropriate scientific caliber	Systematic literature review using PubMed/ MEDLINE of RCTs and systematic reviews of RCTs up to 2013; aided by the Cochrane Collaboration. Recommendations made by consensus

a ACC = American College of Cardiology; ACSM = American College of Sports Medicine; AHA = American Heart Association; CHEP = Canadian Hypertension Education Program; ESC = European Society of Cardiology; ESH = European Society of Hypertension; Ex R_x = exercise prescription; FITT = Frequency, Intensity, Time, and Type of the exercise prescription; JNC 8 = Eighth Joint National Committee; JNC 7 = Seventh Joint National Committee; NHLBI = National Heart, Lung, and Blood Institute; RCT = randomized controlled trial; 1-RM = one repetition maximum; RT = resistance training; VO_2reserve = oxygen uptake reserve.

b Moderate intensity is defined as 40% to <60% VO_2reserve or an intensity that causes noticeable increases in heart rate and breathing; vigorous or high intensity is defined as ≥60% VO_2reserve or an intensity that causes substantial increases in heart rate and breathing.

c The NHLBI

⁵

Eckel R.H.
Jakicic J.M.
Ard J.D.
et al.

2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.

rating system grades the strength of the evidence (Evidence Statement) and the strength of the recommendation(s) (Evidence Recommendation); adapted from the US Preventive Services Task Force.

¹⁷

U.S. Preventive Services Task Force Procedure Manual. US Preventive Services Task Force website. http://www.uspreventiveservicestaskforce.org/Page/Name/procedure-manual. Published July 2008. Accessed September 11, 2014. AHRQ Publication 08-05118-EF.

Google Scholar

d The Lifestyle Work Group rated the Evidence Statement for aerobic exercise to lower BP as “high”

ⁱ

CHEP graded recommendations by the underlying evidence14 using grade A (strongest evidence, based on high-quality studies) to grade D (weakest evidence, based on low-power imprecise studies or expert opinion alone).

; the Evidence Recommendation for the Ex R_x (or FITT) to lower BP was rated grade B

^c

The NHLBI5 rating system grades the strength of the evidence (Evidence Statement) and the strength of the recommendation(s) (Evidence Recommendation); adapted from the US Preventive Services Task Force.17

or “moderate”; corresponding to class IIa level of evidence A

^e

Classification of recommendations and level of evidence per AHA guideline criteria.6,18,34

.

e Classification of recommendations and level of evidence per AHA guideline criteria.

⁶

Brook R.D.
Appel L.J.
Rubenfire M.
et al.

American Heart Association Professional Education Committee of the Council for High Blood Pressure Research, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity
Beyond medications and diet: alternative approaches to lowering blood pressure; a scientific statement from the American Heart Association.

^,

¹⁸

American Heart Association. Methodology Manual and Policies From the ACCF/AHA Task Force on Practice Guidelines. American Heart Association website. http://my.americanheart.org/idc/groups/ahamah-public/@wcm/@sop/documents/downloadable/ucm_319826.pdf. Published June 2010. Accessed September 11, 2014.

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Gibbons R.J.
Smith S.
Antman E.

American College of Cardiology/American Heart Association clinical practice guidelines, Part I: where do they come from?.

f NHLBI grading of evidence.

³⁵

Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults—the evidence report: National Institutes of Health.

g The strength of evidence was rated: evidence category B

^f

NHLBI grading of evidence.35

for the immediate effects of aerobic exercise or postexercise hypotension; evidence category A

^f

NHLBI grading of evidence.35

for aerobic exercise to lower BP; evidence category B

^f

NHLBI grading of evidence.35

for the recommended aerobic Ex R_x (or FITT) to lower BP.

h ESC recommendations.

³⁶

Writing ESC guidelines. European Society of Cardiology website. http://www.escardio.org/guidelines-surveys/esc-guidelines/about/Pages/rules-writing.aspx. Accessed September 11, 2014.

Google Scholar

i CHEP graded recommendations by the underlying evidence

¹⁴

McAlister F.A.

The Canadian Hypertension Education Program—a unique Canadian initiative.

using grade A (strongest evidence, based on high-quality studies) to grade D (weakest evidence, based on low-power imprecise studies or expert opinion alone).

j CHEP assigned grade D

ⁱ

CHEP graded recommendations by the underlying evidence14 using grade A (strongest evidence, based on high-quality studies) to grade D (weakest evidence, based on low-power imprecise studies or expert opinion alone).

to “higher intensity exercise is not more effective.”

k The strength of evidence was rated evidence category C

^h

ESC recommendations.36

for the immediate effects of dynamic resistance exercise or postexercise hypotension.

Open table in a new tab

Frequency

As Table 2 shows, all professional committees/organizations recommend exercising on most, if not all, days of the week with the exception of the Lifestyle Work Group that recommended 3 to 4 sessions per week for at least 12 weeks. Our group, among many others, has reported that the reason exercise should be recommended on most, preferably all, days of the week is because BP is lower on the days people exercise compared with the days they do not exercise, a physiologic response termed postexercise hypotension (PEH).

⁷

Pescatello L.S.
Franklin B.A.
Fagard R.
Farquhar W.B.
Kelley G.A.
Ray C.A.

American College of Sports Medicine position stand: exercise and hypertension.

^,

³³

Google Scholar

^,

³⁷

Pescatello L.S.
Guidry M.A.
Blanchard B.E.
et al.

Exercise intensity alters postexercise hypotension.

Postexercise hypotension is the sustained reduction in BP that occurs immediately after an isolated bout of exercise and persists for up to 24 hours after the bout.

Furthermore, there is emerging evidence supporting the notion that the BP reductions that result from aerobic exercise training are largely due to the immediate response related to recent exercise or PEH.

³⁸

Pescatello L.S.
Kulikowich J.M.

The aftereffects of dynamic exercise on ambulatory blood pressure.

^,

³⁹

Liu S.
Goodman J.
Nolan R.
Lacombe S.
Thomas S.G.

Blood pressure responses to acute and chronic exercise are related in prehypertension.

^,

⁴⁰

Hecksteden A.
Grütters T.
Meyer T.

Association between postexercise hypotension and long-term training-induced blood pressure reduction: a pilot study.

Yet, despite a large body of literature on PEH and its clinical utility as antihypertensive therapy, only the ACSM has addressed the distinction between the BP response to short-term or PEH and long-term or exercise training, and provided graded evidence for the antihypertensive effects of this seemingly important phenomenon.

⁷

Pescatello L.S.
Franklin B.A.
Fagard R.
Farquhar W.B.
Kelley G.A.
Ray C.A.

American College of Sports Medicine position stand: exercise and hypertension.

Another reason for the recommendation of exercising on most, if not all, days of the week is that adults with hypertension are often overweight to obese, and a high frequency/volume of exercise is often needed to achieve the caloric expenditure required for weight loss and maintenance of that weight loss.

⁴¹

Donnelly J.E.
Blair S.N.
Jakicic J.M.
Manore M.M.
Rankin J.W.
Smith B.K.

American College of Sports Medicine
American College of Sports Medicine position stand: appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults.

Intensity

Although not specified by JNC 7,

²

Chobanian A.V.
Bakris G.L.
Black H.R.
et al.

National High Blood Pressure Education Program Coordinating Committee
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.

there appears to be a general consensus for recommending moderate-intensity exercise as antihypertensive therapy by the Lifestyle Work Group,

⁵

Eckel R.H.
Jakicic J.M.
Ard J.D.
et al.

2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.

AHA,

⁶

Brook R.D.
Appel L.J.
Rubenfire M.
et al.

American Heart Association Professional Education Committee of the Council for High Blood Pressure Research, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity
Beyond medications and diet: alternative approaches to lowering blood pressure; a scientific statement from the American Heart Association.

ACSM,

⁷

Pescatello L.S.
Franklin B.A.
Fagard R.
Farquhar W.B.
Kelley G.A.
Ray C.A.

American College of Sports Medicine position stand: exercise and hypertension.

European Society of Hypertension/European Society of Cardiology,

⁸

Mancia G.
Fagard R.
Narkiewicz K.
et al.

Task Force for the Management of Arterial Hypertension of the European Society of Hypertension and the European Society of Cardiology
2013 ESH/ESC Practice Guidelines for the Management of Arterial Hypertension.

and Canadian Hypertension Education Program.

⁹

Dasgupta K.
Quinn R.R.
Zarnke K.B.
et al.

The 2014 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension.

Nonetheless, the Lifestyle Work Group and AHA also endorse vigorous or high-intensity exercise. Since the publication of the ACSM position stand in 2004, the body of literature substantiating the cardiovascular health benefits of vigorous-intensity exercise has grown.

³³

Google Scholar

^,

⁴²

Swain D.P.
Franklin B.A.

Comparison of cardioprotective benefits of vigorous versus moderate intensity aerobic exercise.

^,

⁴³

Ciolac E.G.
Guimarães G.V.
D'Àvila V.M.
Bortolotto L.A.
Doria E.L.
Bocchi E.A.

Acute effects of continuous and interval aerobic exercise on 24-h ambulatory blood pressure in long-term treated hypertensive patients.

^,

⁴⁴

Garber C.E.
Blissmer B.
Deschenes M.R.
et al.

American College of Sports Medicine Position Stand: quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults; guidance for prescribing exercise.

These new findings suggest that exercise intensity is an important determinant of the magnitude of the BP reductions that result from exercise,

⁴⁵

Eicher J.D.
Maresh C.M.
Tsongalis G.J.
Thompson P.D.
Pescatello L.S.

The additive blood pressure lowering effects of exercise intensity on post-exercise hypotension.

that is, the higher the intensity, the greater the magnitude of the BP reduction. Nonetheless, further investigation is warranted to determine the benefit to risk ratio of exercising at vigorous intensity to lower BP in adults with hypertension because this population is predisposed to a transient increase in cardiovascular risk on sudden, vigorous physical exertion.

⁷

Pescatello L.S.
Franklin B.A.
Fagard R.
Farquhar W.B.
Kelley G.A.
Ray C.A.

American College of Sports Medicine position stand: exercise and hypertension.

^,

³³

Google Scholar

^,

⁴⁶

Thompson P.D.
Franklin B.A.
Balady G.J.
et al.

American College of Sports Medicine
Exercise and acute cardiovascular events: placing the risks into perspective; a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology.

Time

There is a broad consensus for performing aerobic exercise for 30 min/d or more on most, if not all, days of the week to achieve a total of approximately 150 min/wk. Emerging evidence reveals that aerobic exercise conducted both continuously and interspersed in shorter intervals throughout the day (eg, three 10-minute bouts) are effective in lowering BP throughout the day.

⁴³

Ciolac E.G.
Guimarães G.V.
D'Àvila V.M.
Bortolotto L.A.
Doria E.L.
Bocchi E.A.

Acute effects of continuous and interval aerobic exercise on 24-h ambulatory blood pressure in long-term treated hypertensive patients.

^,

⁴⁷

Guidry M.A.
Blanchard B.E.
Thompson P.D.
et al.

The influence of short and long duration on the blood pressure response to an acute bout of dynamic exercise.

^,

⁴⁸

Ciolac E.G.
Guimarães G.V.
D'Àvila V.M.
Bortolotto L.A.
Doria E.L.
Bocchi E.A.

Acute aerobic exercise reduces 24-h ambulatory blood pressure levels in long-term-treated hypertensive patients.

^,

⁴⁹

Jones H.
Taylor C.E.
Lewis N.C.
George K.
Atkinson G.

Post-exercise blood pressure reduction is greater following intermittent than continuous exercise and is influenced less by diurnal variation.

^,

⁵⁰

Angadi S.S.
Weltman A.
Watson-Winfield D.
et al.

Effect of fractionized vs continuous, single-session exercise on blood pressure in adults.

^,

⁵¹

Miyashita M.
Burns S.F.
Stensel D.J.

Accumulating short bouts of running reduces resting blood pressure in young normotensive/pre-hypertensive men.

^,

⁵²

Bhammar D.M.
Angadi S.S.
Gaesser G.A.

Effects of fractionized and continuous exercise on 24-h ambulatory blood pressure.

Because not having the time to exercise is often a major deterrent, interspersing shorter bouts of aerobic exercise throughout the day offers promise as a behavioral strategy to keep more people exercising.

³³

Google Scholar

Future research should evaluate this supposition. As such, discussions between clinicians and patients should focus on an exercise program that will optimize the likelihood of long-term adherence; patients should be active and engaged participants in developing their exercise program.

Type

There is also broad consensus with a strong rating of evidence that the primary type of exercise prescribed for the prevention, treatment, and control of hypertension should be aerobic. This recommendation is made because aerobic exercise training has consistently been found to lower BP, and although dynamic resistance training also reduces resting BP, it does so with a smaller effect than aerobic training (ie, the magnitude of the BP reduction is less).

⁷

Pescatello L.S.
Franklin B.A.
Fagard R.
Farquhar W.B.
Kelley G.A.
Ray C.A.

American College of Sports Medicine position stand: exercise and hypertension.

Nonetheless, the existing body of evidence on resistance training reveals a dearth of studies focused on adults with hypertension, and these studies vary widely in their conclusions,

⁵

Eckel R.H.
Jakicic J.M.
Ard J.D.
et al.

2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.

^,

⁶

Brook R.D.
Appel L.J.
Rubenfire M.
et al.

American Heart Association Professional Education Committee of the Council for High Blood Pressure Research, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity
Beyond medications and diet: alternative approaches to lowering blood pressure; a scientific statement from the American Heart Association.

^,

⁹

Dasgupta K.
Quinn R.R.
Zarnke K.B.
et al.

The 2014 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension.

^,

³⁸

Pescatello L.S.
Kulikowich J.M.

The aftereffects of dynamic exercise on ambulatory blood pressure.

^,

⁵³

Carlson D.J.
Dieberg G.
Hess N.C.
Millar P.J.
Smart N.A.

Isometric exercise training for blood pressure management: a systematic review and meta-analysis.

yielding a weak to moderate rating of evidence as shown in Table 2.

Furthermore, despite the strong rating of evidence, there are substantial shortcomings in our knowledge about the BP benefits of aerobic exercise training. These deficits include, but are not limited to, whether certain patient clinical characteristics, exercise intervention features, and biomarkers predict the degree of the BP response. Moreover, studies using home and ambulatory BP monitoring are rare, which is a major void in the literature because these methods are most predictive of cardiovascular disease outcomes.

⁵⁴

Omboni S.
Guarda A.

Impact of home blood pressure telemonitoring and blood pressure control: a meta-analysis of randomized controlled studies.

^,

⁵⁵

Ostchega Y.
Berman L.
Hughes J.P.
Chen T.C.
Chiappa M.M.

Home blood pressure monitoring and hypertension status among US adults: the National Health and Nutrition Examination Survey (NHANES), 2009-2010.

^,

⁵⁶

Pickering T.G.
Hall J.E.
Appel L.J.
et al.

Recommendations for blood pressure measurement in humans and experimental animals, Part 1: Blood pressure measurement in humans; a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research.

^,

⁵⁷

Pickering T.G.
Miller N.H.
Ogedegbe G.
et al.

Call to action on use and reimbursement for home blood pressure monitoring: executive summary; a joint scientific statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association.

In addition, these methods enable measurement of BP under conditions of daily living versus the simulated confines of the laboratory and thus have the ability to capture the most clinically meaningful information about the antihypertensive benefits of exercise.

Resultant BP Reductions

There is a wide range in the observed magnitude of the BP reduction resulting from exercise training (ie, 1-9 mm Hg), and in 2 instances, the magnitude was not specified (Table 2).

⁶

Brook R.D.
Appel L.J.
Rubenfire M.
et al.

American Heart Association Professional Education Committee of the Council for High Blood Pressure Research, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity
Beyond medications and diet: alternative approaches to lowering blood pressure; a scientific statement from the American Heart Association.

^,

⁹

Dasgupta K.
Quinn R.R.
Zarnke K.B.
et al.

The 2014 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension.

There are many possible reasons for the reported variability in the magnitude of the BP reduction in response to exercise training, as discussed subsequently.

Reasons for Different FITT Ex R_x Recommendations

Because it was unclear how well meta-analyses examining the effects of exercise on BP satisfied contemporary standards, our group conducted and published a systematic review of the methodological quality of meta-analyses on the BP response to exercise that used BP as the primary outcome.

³²

Johnson B.T.
MacDonald H.V.
Bruneau Jr., M.L.
et al.

Methodological quality of meta-analyses on the blood pressure response to exercise: a review.

The full search details have been reported elsewhere,

³²

Johnson B.T.
MacDonald H.V.
Bruneau Jr., M.L.
et al.

Methodological quality of meta-analyses on the blood pressure response to exercise: a review.

but briefly, our literature search was inclusive, encompassing all meta-analyses from the earliest coverage until 2013, a search that yielded 33 meta-analyses. On average, the study quality of this literature was fair, with numerous methodological deficiencies including (1) detail of the search strategies was insufficient for replication of the search, (2) only half of the meta-analyses integrated duplicate study selection and data extraction, and (3) the majority failed to document the quality of the included studies or examine whether study quality influenced the primary result (ie, magnitude of the BP change).

As expected, meta-analyses routinely found that exercise significantly reduced BP. Yet, the overall study quality was “fair”; only half identified patient or FITT characteristics of the Ex R_x that influenced the BP reductions, and when they were identified, findings often conflicted across meta-analyses. For these reasons, the FITT Ex R_x recommendations listed in Table 2 are questionable, especially when the evidence on which they were made was generally of lower quality or missing, the literature searches that were performed to generate these recommendations were not completely inclusive or up-to-date, and the recommendations made about the specifics of the FITT of the Ex R_x (with the exception of type) were largely based on expert opinion.

Although our meta-review included 33 meta-analyses of controlled exercise trials that had BP as the primary outcome, only 4 of these 33 were included to make the recommendations of the Lifestyle Work Group.

²³

Kelley G.A.
Kelley K.S.
Tran Z.V.

Walking and resting blood pressure in adults: a meta-analysis.

^,

²⁴

Kelley G.A.
Sharpe Kelley K.

Aerobic exercise and resting blood pressure in older adults: a meta-analytic review of randomized controlled trials.

^,

²⁶

Murphy M.H.
Nevill A.M.
Murtagh E.M.
Holder R.L.

The effect of walking on fitness, fatness and resting blood pressure: a meta-analysis of randomised, controlled trials.

^,

²⁹

Whelton S.P.
Chin A.
Xin X.
He J.

Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials.

These 4 meta-analyses achieved only low to moderate quality on our review’s methodological quality scale.

³²

Johnson B.T.
MacDonald H.V.
Bruneau Jr., M.L.
et al.

Methodological quality of meta-analyses on the blood pressure response to exercise: a review.

Another important deficiency within the exercise and hypertension literature is that despite its volume, examinations of the antihypertensive effects of exercise are often limited by small sample sizes that include a relatively large number of people without hypertension.

⁵

Eckel R.H.
Jakicic J.M.
Ard J.D.
et al.

2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.

^,

⁶

Brook R.D.
Appel L.J.
Rubenfire M.
et al.

American Heart Association Professional Education Committee of the Council for High Blood Pressure Research, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity
Beyond medications and diet: alternative approaches to lowering blood pressure; a scientific statement from the American Heart Association.

^,

⁷

Pescatello L.S.
Franklin B.A.
Fagard R.
Farquhar W.B.
Kelley G.A.
Ray C.A.

American College of Sports Medicine position stand: exercise and hypertension.

^,

³²

Johnson B.T.
MacDonald H.V.
Bruneau Jr., M.L.
et al.

Methodological quality of meta-analyses on the blood pressure response to exercise: a review.

Because the magnitude of BP reductions in response to exercise is a function of initial values such that adults with the highest resting BP experience the largest BP reductions following exercise,

³⁸

Pescatello L.S.
Kulikowich J.M.

The aftereffects of dynamic exercise on ambulatory blood pressure.

inclusion of individuals without hypertension to make Ex R_x recommendations for those with hypertension would serve to underestimate the effectiveness of exercise as antihypertensive lifestyle therapy. In addition, important moderators such as medication use, body mass index, or the level of exercise supervision were underreported in the studies we reviewed or were not examined for their potential influence on the BP outcomes. Collectively, these observations reveal important limitations of the available evidence in formulating Ex R_x recommendations for hypertension. From our analysis of the current body of evidence, we concluded that little is known about the optimal exercise dose and for which groups exercise works best as antihypertensive therapy.

³²

Johnson B.T.
MacDonald H.V.
Bruneau Jr., M.L.
et al.

Methodological quality of meta-analyses on the blood pressure response to exercise: a review.

Gaps in the Literature and Future Research Needs in Ex R_x for Hypertension

Hypertension is the most prevalent, modifiable, and costly cardiovascular disease risk factor.

⁵⁸

Mozaffarian D.
Benjamin E.J.
Go A.S.
et al.

American Heart Association Statistics Committee and Stroke Statistics Subcommittee
Heart disease and stroke statistics—2015 update: a report from the American Heart Association.

All professional guidelines and scientific statements recommend exercise as a cornerstone lifestyle therapy for the prevention, treatment, and control of hypertension (Table 2). Nonetheless, only 30% of primary care physicians recommend exercise as lifestyle therapy to their patients.

⁵⁹

Barnes P.M.
Schoenborn C.A.

Trends in adults receiving a recommendation for exercise or other physical activity from a physician or other health professional.

This statistic is problematic for several reasons. First, there are many health benefits that result from regular exercise participation with an extremely low risk of adverse effects. Second, a recent meta-analysis of major exercise and drug trials found no statistically detectable difference between exercise and drug interventions in mortality outcomes for coronary heart disease and prediabetes, and physical activity interventions were actually more effective for secondary prevention of stroke mortality.

⁶⁰

Naci H.
Ioannidis J.P.

Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study.

Third, if a patient is taking medication for high BP and their BP is responsive to the antihypertensive effects of exercise, the possibility exists that regular exercise participation may be a way to reduce medication use.

⁷

Pescatello L.S.
Franklin B.A.
Fagard R.
Farquhar W.B.
Kelley G.A.
Ray C.A.

American College of Sports Medicine position stand: exercise and hypertension.

^,

²⁹

Whelton S.P.
Chin A.
Xin X.
He J.

Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials.

^,

⁶¹

Hamer M.

The anti-hypertensive effects of exercise: integrating acute and chronic mechanisms.

These observations in addition to the reviews in Table 2 speak to the value of exercise as antihypertensive lifestyle therapy. However, our review found substantial gaps in the literature that need to be addressed so that the BP-lowering benefits of exercise can be better understood. Until these issues are resolved, we are unable to address an important challenge that health care professionals face in Ex R_x for hypertension—finding ways to tailor exercise interventions to maximize the antihypertensive benefits of exercise so that more people with hypertension will exercise to lower their BP and more clinicians will recommend exercise as antihypertensive lifestyle therapy to their patients.

A key literature gap that the current review has identified is that there remains the need for well-designed, adequately powered, and controlled short-term (ie, PEH) and long-term (ie, training) exercise intervention studies with BP as the primary outcome measured under ambulatory conditions and at home in populations with hypertension, particularly those that have been underrepresented to date (eg, African Americans and other racial/ethnic groups). These studies should also be designed to examine important factors that influence the BP response to exercise including patient clinical characteristics (eg, sex, race/ethnicity, medication use, adiposity, and the cardiometabolic profile), features of the exercise intervention (eg, FITT and adherence), and mechanistic underpinnings (eg, heritable, inflammatory, and vasoactive factors) so that a more personalized Ex R_x can be recommended to maximize the effectiveness of exercise as antihypertensive therapy.

Meta-analyses are often the pillars of position stands, scientific statements, and clinical recommendations and guidelines, yet to date, they have contributed less than optimally to the understanding of how exercise influences resting BP, which factors produce greater BP-lowering effects, especially the dose of exercise (or FITT) needed to elicit the effect, and other important study and population features. Thus, new meta-analyses should be undertaken that more fully satisfy contemporary methodological standards. Meta-analyses that adhere to higher-quality standards will serve to improve the strength of the evidence on which exercise guidelines and recommendations to lower BP in those with hypertension are made. In this way, policymakers and health care professionals can be more confident that the Ex R_x recommendations they are making to their patients and clients are based on an inclusive literature of the best available science.

Conclusion

A recurrent theme of the current review is that despite the volume of literature on exercise and hypertension, the available evidence on which recommendations regarding Ex R_x for hypertension can be made is limited and of less than optimal quality. In addition, the patient clinical characteristics, exercise intervention features, and biomarkers that predict the degree of the BP response to exercise have for the most part not been identified, which calls into question the existing FITT Ex R_x recommendations (Table 2). Clearly, there is a need for well-designed, high-quality RCTs, which will be incorporated into future systematic reviews and meta-analyses, to address these questions. Despite the current limitations and differences in the FITT of the recommended Ex R_x (Table 2), the consensus that can be taken from the level of agreement among various professional recommendations shown in Table 2 is for adults with pre- to established hypertension to participate in 30 min/d or more of moderate-intensity aerobic exercise on most, if not all, days of the week to total 150 min/wk or more. Lastly, health care professionals who are charged with Ex R_x for patients with hypertension should consider the effect that some antihypertensive medications can have on the BP and heart rate response to physical exertion and when appropriate, modify the FITT of the Ex R_x accordingly.

Acknowledgments

The authors thank Jonathan C. Rinciari for his assistance with data extraction and the content of Tables 1 and 2 and Supplemental Tables 1 and 2.

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Grant Support: This work was supported by the University of Connecticut Research Foundation and University of Connecticut’s Center for Health, Intervention, and Prevention.

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DOI: https://doi.org/10.1016/j.mayocp.2015.04.008

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Assessing the Existing Professional Exercise Recommendations for Hypertension: A Review and Recommendations for Future Research Priorities

Abstract

Abbreviations and Acronyms:

Overview of the JNC 8 Guideline

Exercise Recommendations for Hypertension

Frequency

Intensity

Time

Type

Resultant BP Reductions

Reasons for Different FITT Ex Rx Recommendations

Gaps in the Literature and Future Research Needs in Ex Rx for Hypertension

Conclusion

Acknowledgments

Supplemental Online Material

References

Article info

Footnotes

Identification

Copyright

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Reasons for Different FITT Ex R_x Recommendations

Gaps in the Literature and Future Research Needs in Ex R_x for Hypertension