Professional Documents
Culture Documents
This paper aims to review evidence on the effect of exercise on cardiovascular (CV) risk in people with hypertension. Regular exercise is one of the most important
activities for primary prevention of hypertension 1 and
improving long-term survival. 2 Benefits of exercise
extend to people with hypertension, 3 as well as those
with related morbidity (such as diabetes,4 renal dysfunction 5 or depression6,7) or chronic disease relatively
separate from hypertension including cancer, 8 airway
disease,9 and osteoarthritis, 10 to name a few. Many
chronic diseases share the risk factor of physical inactivity, which is ranked among the top 10 contributors to
the global burden of disease.11 Thus, increasing exercise
levels in the general population is a valuable aspiration
with major health and economic gains.12 Beyond exercise alone, a CV risk reduction program for individuals
with hypertension should optimally also include smoking cessation, weight reduction, alcohol moderation,
and attention to diet such as that recommended with
the Dietary Approaches to Stop Hypertension, 13 which
has been shown to lower blood pressure (BP)14,15 and
improve all-cause survival. 16 Thorough analysis of treating and preventing hypertension with diet is addressed
by Appel etal. 17
Evidence for the benefits of regular exercise is irrefutable and increasing physical activity levels should be a major goal at all levels of health
care. People with hypertension are less physically active than those
without hypertension and there is strong evidence supporting the
blood pressurelowering ability of regular exercise, especially in hypertensive individuals. This narrative review discusses evidence relating
to exercise and cardiovascular (CV) risk in people with hypertension.
Comparisons between aerobic, dynamic resistance, and static resistance exercise have been made along with the merit of different exercise
volumes. High-intensity interval training and isometric resistance training appear to have strong CV protective effects, but with limited data in
hypertensive people, more work is needed in this area. Screening recommendations, exercise prescriptions, and special considerations are
provided as a guide to decrease CV risk among hypertensive people
who exercise or wish to begin. It is recommended that hypertensive
Sharman etal.
Figure 1. Summary of some of the cardiometabolic beneficial effects of regular exercise. increase or improvement; decrease or improvement;
*borderline improvement.
Sharman etal.
Table1. Chronic responses to aerobic and resistance training in people with hypertension
Variable
Aerobic (endurance)
Resistance (dynamic)
Resistance (static)
Large decrease
No changea
Large decrease
Large decrease
Small decrease
Large decrease
Decrease
No change
Decrease
Body weight
Decrease
No change
Waist circumference
Decrease
Decrease
Decrease
Blood glucose
Decrease
Total cholesterol
No change
Low-density lipoprotein
No change
High-density lipoprotein
Increase
Triglycerides
Borderline decrease
Heart rate
Decrease
No change
Small decrease
Blood pressure
Summary data from multiple meta-analyses, review articles,25,26,31,37,41,4648 and large well-conducted clinical trials involving people with high
blood pressure.49 Dashed line indicates no, or minimal, available data to draw conclusions regarding training effects.
aSignificant effect for patients with prehypertension,50 but small to no significant effect for patients with hypertension.48 Examples of aerobic
training include running, cycling, swimming, or rowing. Examples of dynamic resistance training include push-ups, abdominal crunches, or
shoulder presses. Examples of static resistance training include holding the position of hand grip using a dynamometer, plank bridges, or wall sit.
Since an acute bout of exercise causes temporary physiological stress,29 there remains the possibility that excessive
exercise volume combined with little recovery time could tip
the balance toward harmful effects. Indeed, some data suggest
an asymptote at which more intense exercise training provides
little incremental benefit59 or even a U-shaped association
in which events increase among the most highly trained.60
Similarly, a higher incidence of myocardial infarction was
shown in The British Regional Heart Study among men exercising at the highest levels when compared with moderate levels,61 and higher rates of CV disease and hypertension were
also found among the most active men in the Michigan State
University Longevity Study.62 In patients with manifest coronary heart disease, daily strenuous exercise conferred higher
mortality risk (on par with exercising only 14 times/month),
and this was independent of numerous covariates including
hypertension status.63 However, the premise that extreme
exercise may portend an increased risk of CV events remains
highly controversial64,65 and there are a number of studies
that suggest that longevity may be increased among athletes
undertaking the very highest volumes of intense exercise.66,67
150 American Journal of Hypertension 28(2) February 2015
Little is known regarding the causes underlying associations between chronically higher exercise volume and higher
CV risk in some epidemiological studies. However, homeostatic imbalance across multiple organ systems occurs with
overtraining and this can result in muscle trauma, inflammation, oxidative stress,68 adrenal gland dysfunction,69 and
immunosuppression.70 The heart may be particularly vulnerable to overtraining as chronically high exercise volume is
associated with adverse cardiac remodeling (especially atrial
enlargement and left ventricular hypertrophy), functional
abnormality (favoring damage to the right ventricle),71 and
arrhythmias (especially atrial fibrillation and complex ventricular tachyarrhythmias).7274 The role of BP exposure on
these adverse heart outcomes is unknown. Overall, these
data imply that regular exercise is a potent elixir for CV and
general health in which moderate doses may be just as efficacious as more extreme doses.
EXERCISE PRESCRIPTION RECOMMENDATIONS
Resting SBP > 200mm Hg or DBP > 110mm Hg is a relative contraindication to exercise stress testing and an excessive BP response to exercise (defined as SBP > 250mm Hg
or DBP > 115mm Hg) is a relative indication to terminate
exercise.57 In the absence of major comorbidities, patients
with hypertension (stage 2 or below)75 should be encouraged
Lipid
exercise training.76 Ideally, this evaluation will involve outof-office BP measures such as 24-hour ambulatory BP79 or
home BP monitoring80 to confirm BP status. Finally, recent
data suggest that it may be necessary to promote incentives
for staff to maintain participant adherence to lifestyle/exercise programs in the primary care setting.81
HIGH-INTENSITY INTERVAL TRAINING
Figure2. Adjusted all-cause mortality hazard ratio for people engaging in low-volume physical activity compared with inactive people. There was
significantly lower risk of all-cause mortality, regardless of sex, age, self-reported health, hypertension, or cardiovascular disease risk. Hazard ratios (HRs)
are relative to health outcomes in the inactive group. From Wen etal.53 with permission from Elsevier.
Sharman etal.
Figure3. Recommendations regarding exercise prescription for people with hypertension adapted from ref.76 Before adding exercise to a treatment
plan, people with severe uncontrolled hypertension based on clinic blood pressure (systolic 180mm Hg and/or diastolic 110mm Hg) should firstly
be evaluated by their doctor (preferably with addition of out-of-clinic blood pressure measures to confirm blood pressure control). Abbreviations: HR,
heart rate; HRR, heart rate reserve; METs, metabolic equivalents; RPE, rating of perceived exertion; 1-RM, one repetition maximal. *includes high-intensity
exercise.
and DBP, VO2max, total peripheral resistance, and left ventricular systolic and diastolic function.85 Young normotensive women with a family history of hypertension engaging
in HIIT showed greater improvements in VO2max, as well
as metabolic and hormonal factors related to hypertension
compared with moderate intensity exercise.86 Even small
doses of HIIT before meals, touted as exercise snacks (6-
damage9597 and thirdly, EIH predicts CV events and mortality independent from resting BP, with the strongest signal for
increased risk manifest at light-to-moderate intensity aerobic exercise.98 Although submaximal exercise BP cut points
denoting elevated risk from EIH are yet to be determined, it
may be in the region of SBP 150mm Hg at the equivalent
intensity of stage 2 of the Bruce treadmill protocol (5 metabolic equivalents), as this threshold has been shown as the
strongest predictor of left ventricular hypertrophy in a large
sample of people with prehypertension.99 Interpretation of
BP during more intense exercise is difficult. In normotensive
athletes, BP increases substantially during exercise of high
intensity but in a manner proportional to workload such that
the P/Q (BP/cardiac output) ratio remains normal and left
ventricular wall stress increases are modest.100 Furthermore,
in hypertensive athletes, BP during high-intensity exercise
does not correlate well with resting BP.101
To our knowledge, there is no evidence that EIH increases
risk for adverse events during the exercise bout where the
EIH is observed. Indeed, several studies in people with
higher BP or resistant hypertension have shown that regular
aerobic exercise (over 2- to 6-month intervention) will significantly reduce submaximal intensity exercise BP,102104 as
well as reduce the propensity toward EIH at maximal intensity (as per conventionally used cut points of 210mm Hg
for men and 190mm Hg for women) in people at higher
risk for EIH,105 including treated hypertensives.106 Thus, it
is unfounded for clinicians to discourage regular exercise or
suggest that exercise may be dangerous, in people with EIH.
On the contrary, regular exercise should be beneficial for
these people. Akey message from the presentation of EIH is
that it should be regarded as an indication to undertake outof-clinic BP monitoring to confirm true underlying BP107
and respond with treatment accordingly.
SPECIAL CONSIDERATIONS
Even in people with apparently normal resting BP, exerciseinduced hypertension (EIH) is probably indicative of underlying hypertension that has failed detection using resting
BP screening methods. Evidence to support this (although
not yet definitive) comes firstly from the high prevalence of
masked hypertension (normal clinic BP but elevated 24-hour
ambulatory BP) among people with EIH.93,94 Secondly,
EIH is associated with hypertensive-related end-organ
Recommendation
Frequency
3 times/week
Duration
40 minutes (includes 10-minute warm-up and 5-minute cool down at 60% peak heart rate)
Exercise intensity
Rest/recovery intensity
Interval times
44 minutes
Recovery times
33 minutes
aFor
people using beta blocker medication, this should be a rating of perceived exertion (RPE) 1517 on the Borg 620 scale. Adapted from
ref. 83 with permission from BMJ Publishing Group Ltd.
Sharman etal.
Table3. Selected considerations regarding exercise in people with hypertension
Factor
Antihypertensive medications
Consideration
Response
Increases BP
taking alpha blockers, calcium channel blockers, or vasodilating drugs, as well as in elderly people.57,76 The potential for
hypotensive-related adverse effects may be mitigated with an
extended cool down period of light activity and avoidance of
suddenly stopping exercise. Beta blockers and diuretics can
alter thermoregulation during exercise,37,76,108 which has led
to a precautionary call to those taking these medications to
limit exercise intensity in hot or humid weather, as well as
ensuring adequate hydration and use of clothing to encourage cooling.37
Exposure to fine particulate matter (<2.5 m in diameter) from automotive and other sources of air pollution is
recognized as a trigger of CV-related events and mortality.
Populations at increased risk include the elderly and those with
preexisting coronary artery disease; however, people with diabetes, women, and also those who are obese (for which there is
higher prevalence of hypertension) may also be vulnerable.109
Since the magnitude of CV risk is related to the duration,
intensity and frequency of particulate matter exposure, activities that increase exposure, such as exercising alongside busy
roadways, should be avoided. Instead people should exercise in
areas with lower ambient pollutant concentration, which may
include parks, recreation areas, and quiet roads.110
Acute CV events induced by exercise occur more commonly in older people with atherosclerotic disease or
younger people with congenital or hereditary heart disease.84
There is a slight risk of sudden cardiac death occurring during, or within 30 minutes of, unaccustomed vigorous exercise such as racquet sports or heavy yard work, although the
absolute risk only approximates 1 death per 1.51 million episodes of exertion.111 Serious events occur rarely in healthy
individuals112 and may be more frequent in people of older
age, or with diabetes or hypertension.111 Then again, vigorous exercise itself, when performed habitually, is protective
against sudden death and CV events,111,112 which reinforces
the notion that the health benefits of regular physical activity
far outweigh the risks.113 People with hypertension starting
154 American Journal of Hypertension 28(2) February 2015
an exercise program may wish to consult an expert in exercise prescription for chronic and complex diseases such as
a qualified Exercise Physiologist. This is especially relevant
to higher risk patients or those wishing to partake in highintensity physical activity. A summary of special exercise
considerations is presented in Table3.
SUMMARY AND CONCLUSION
There is incontrovertible evidence that exercise is a cornerstone therapy for the prevention, treatment, and control
of hypertension.31 In people with hypertension, aerobic and
resistance exercise promote general health and improvement
in CV risk factors, including major BP-lowering effects and
reduced future incident CV events and mortality. The comparative health effects of aerobic vs. resistance training have
not been fully elucidated in people with hypertension, but
where BP lowering is a major goal of exercise, then aerobic
activity appears to be the preferred method to achieve this.
There are promising data on the CV protective effects of
HIIT and isometric resistance training, but with only limited data available in people with hypertension, more work
is needed in this area. Exercise volume thresholds at which
maximum benefits are derived are difficult to determine,
although only a small but consistent weekly quantity of
moderate exercise can have significant health benefits owing
to the graded inverse relationship between exercise volume
and adverse clinical outcomes. The benefits of regular physical activity outweigh the risks and should be recommended
for the majority of people with hypertension.
Acknowledgments
References
1. Whelton PK, He J, Appel LJ, Cutler JA, Havas S, Kotchen TA, Roccella
EJ, Stout R, Vallbona C, Winston MC, Karimbakas J. Primary prevention of hypertension: clinical and public health advisory from
The National High Blood Pressure Education Program. JAMA 2002;
288:18821888.
2. Blair SN, Kampert JB, Kohl HW III, Barlow CE, Macera CA,
Paffenbarger RS Jr, Gibbons LW. Influences of cardiorespiratory fitness
and other precursors on cardiovascular disease and all-cause mortality
in men and women. JAMA 1996; 276:205210.
3. Sharman JE, Stowasser M. Australian association for exercise and
sports science position statement on exercise and hypertension. J Sci
Med Sport 2009; 12:252257.
4. Hordern MD, Dunstan DW, Prins JB, Baker MK, Singh MA, Coombes
JS. Exercise prescription for patients with type 2 diabetes and pre-diabetes: a position statement from Exercise and Sport Science Australia. J
Sci Med Sport 2012; 15:2531.
5. Smart NA, Williams AD, Levinger I, Selig S, Howden E, Coombes JS,
Fassett RG. Exercise & Sports Science Australia (ESSA) position statement on exercise and chronic kidney disease. J Sci Med Sport 2013;
16:406411.
6. Rethorst CD, Wipfli BM, Landers DM. The antidepressive effects
of exercise: a meta-analysis of randomized trials. Sports Med 2009;
39:491511.
7. Cooney GM, Dwan K, Greig CA, Lawlor DA, Rimer J, Waugh FR,
McMurdo M, Mead GE. Exercise for depression. Cochrane Database
Syst Rev 2013; 9:CD004366.
8. Hayes SC, Spence RR, Galvao DA, Newton RU. Australian Association
for Exercise and Sport Science position stand: optimising cancer outcomes through exercise. J Sci Med Sport 2009; 12:428434.
9. Morton AR, Fitch KD. Australian association for exercise and sports
science position statement on exercise and asthma. J Sci Med Sport
2011; 14:312316.
10. Fransen M, McConnell S, Bell M. Exercise for osteoarthritis of the hip
or knee. Cochrane Database Syst Rev 2003; 3; CD004286.
11. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H,
Amann M, Anderson HR, Andrews KG, Aryee M, Atkinson C, Bacchus
LJ, Bahalim AN, Balakrishnan K, Balmes J, Barker-Collo S, Baxter A,
Bell ML, Blore JD, Blyth F, Bonner C, Borges G, Bourne R, Boussinesq
M, Brauer M, Brooks P, Bruce NG, Brunekreef B, Bryan-Hancock C,
Bucello C, Buchbinder R, Bull F, Burnett RT, Byers TE, Calabria B,
Carapetis J, Carnahan E, Chafe Z, Charlson F, Chen H, Chen JS, Cheng
AT, Child JC, Cohen A, Colson KE, Cowie BC, Darby S, Darling S,
Davis A, Degenhardt L, Dentener F, Des Jarlais DC, Devries K, Dherani
M, Ding EL, Dorsey ER, Driscoll T, Edmond K, Ali SE, Engell RE,
Erwin PJ, Fahimi S, Falder G, Farzadfar F, Ferrari A, Finucane MM,
Flaxman S, Fowkes FG, Freedman G, Freeman MK, Gakidou E, Ghosh
S, Giovannucci E, Gmel G, Graham K, Grainger R, Grant B, Gunnell
D, Gutierrez HR, Hall W, Hoek HW, Hogan A, Hosgood HD III, Hoy
D, Hu H, Hubbell BJ, Hutchings SJ, Ibeanusi SE, Jacklyn GL, Jasrasaria
R, Jonas JB, Kan H, Kanis JA, Kassebaum N, Kawakami N, Khang YH,
Khatibzadeh S, Khoo JP, Kok C, Laden F, Lalloo R, Lan Q, Lathlean T,
Leasher JL, Leigh J, Li Y, Lin JK, Lipshultz SE, London S, Lozano R, Lu
Y, Mak J, Malekzadeh R, Mallinger L, Marcenes W, March L, Marks
R, Martin R, McGale P, McGrath J, Mehta S, Mensah GA, Merriman
TR, Micha R, Michaud C, Mishra V, Mohd Hanafiah K, Mokdad AA,
Morawska L, Mozaffarian D, Murphy T, Naghavi M, Neal B, Nelson
PK, Nolla JM, Norman R, Olives C, Omer SB, Orchard J, Osborne R,
Ostro B, Page A, Pandey KD, Parry CD, Passmore E, Patra J, Pearce N,
Sharman etal.
27. Taylor-Tolbert NS, Dengel DR, Brown MD, McCole SD, Pratley RE,
Ferrell RE, Hagberg JM. Ambulatory blood pressure after acute exercise in older men with essential hypertension. Am J Hypertens 2000;
13:4451.
28. Pagonas N, Dimeo F, Bauer F, Seibert F, Kiziler F, Zidek W, Westhoff
TH. The impact of aerobic exercise on blood pressure variability. J Hum
Hypertens 2014; 28:367371.
29. Radak Z, Chung HY, Koltai E, Taylor AW, Goto S. Exercise, oxidative
stress and hormesis. Ageing Res Rev 2008; 7:3442.
30. Dawson EA, Green DJ, Cable NT, Thijssen DH. Effects of acute exercise
on flow-mediated dilatation in healthy humans. J Appl Physiol 2013;
115:15891598.
31. Fagard RH, Cornelissen VA. Effect of exercise on blood pressure control
in hypertensive patients. Eur J Cardiovasc Prev Rehabil 2007; 14:1217.
32. Meredith IT, Friberg P, Jennings GL, Dewar EM, Fazio VA, Lambert
GW, Esler MD. Exercise training lowers resting renal but not cardiac
sympathetic activity in humans. Hypertension 1991; 18:575582.
33. Grassi G, Seravalle G, Calhoun DA, Mancia G. Physical training
and baroreceptor control of sympathetic nerve activity in humans.
Hypertension 1994; 23:294301.
34. Nami R, Mondillo S, Agricola E, Lenti S, Ferro G, Nami N, Tarantino
M, Glauco G, Span E, Gennari C. Aerobic exercise training fails to
reduce blood pressure in nondipper-type hypertension. Am J Hypertens
2000; 13:593600.
35. King AC, Oman RF, Brassington GS, Bliwise DL, Haskell WL.
Moderate-intensity exercise and self-rated quality of sleep in older
adults. Arandomized controlled trial. JAMA 1997; 277:3237.
36. Gangwisch JE. A review of evidence for the link between sleep duration
and hypertension. Am J Hypertens 2014; 27:12351242.
37. Pescatello LS, Franklin BA, Fagard R, Farquhar WB, Kelley GA, Ray
CA. American College of Sports Medicine position stand. Exercise and
hypertension. Med Sci Sports Exerc 2004; 36:533553.
38. Pollock ML, Franklin BA, Balady GJ, Chaitman BL, Fleg JL, Fletcher B,
Limacher M, Pina IL, Stein RA, Williams M, Bazzarre T. AHA Science
Advisory. Resistance exercise in individuals with and without cardiovascular disease: benefits, rationale, safety, and prescription: an advisory from the Committee on Exercise, Rehabilitation, and Prevention,
Council on Clinical Cardiology, American Heart Association;
Position paper endorsed by the American College of Sports Medicine.
Circulation 2000; 101:828833.
39. Benton MJ. Safety and efficacy of resistance training in patients with
chronic heart failure: research-based evidence. Prog Cardiovasc Nurs
2005; 20:1723.
40. Bertovic DA, Waddell TK, Gatzka CD, Cameron JD, Dart AM, Kingwell
BA. Muscular strength training is associated with low arterial compliance and high pulse pressure. Hypertension 1999; 33:13851391.
41. Carlson DJ, Dieberg G, Hess NC, Millar PJ, Smart NA. Isometric exercise training for blood pressure management: a systematic review and
meta-analysis. Mayo Clin Proc 2014; 89:327334.
42. Sumimoto T, Hamada M, Muneta S, Shigematsu Y, Fujiwara Y, Sekiya
M, Kazatani Y, Hiwada K. Influence of age and severity of hypertension on blood pressure response to isometric handgrip exercise. J Hum
Hypertens 1991; 5:399403.
43. Araujo CG, Duarte CV, Goncalves Fde A, Medeiros HB, Lemos FA,
Gouvea AL. Hemodynamic responses to an isometric handgrip training protocol. Arq Bras Cardiol 2011; 97:413419.
44. McGowan CL, Levy AS, Millar PJ, Guzman JC, Morillo CA, McCartney
N, Macdonald MJ. Acute vascular responses to isometric handgrip
exercise and effects of training in persons medicated for hypertension.
Am J Physiol Heart Circ Physiol 2006; 291:28.
45. Taylor AC, McCartney N, Kamath MV, Wiley RL. Isometric training
lowers resting blood pressure and modulates autonomic control. Med
Sci Sports Exerc 2003; 35:251256.
46. Pattyn N, Cornelissen VA, Eshghi SR, Vanhees L. The effect of exercise
on the cardiovascular risk factors constituting the metabolic syndrome:
a meta-analysis of controlled trials. Sports Med 2013; 43:121133.
47. Hagberg JM, Park JJ, Brown MD. The role of exercise training in the
treatment of hypertension: an update. Sports Med 2000; 30:193206.
48. Cornelissen VA, Fagard RH. Effect of resistance training on rest
ing blood pressure: a meta-analysis of randomized controlled trials. J
Hypertens 2005; 23:251259.
49. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin
JM, Walker EA, Nathan DM. Reduction in the incidence of type 2
ventricular dysfunction and structural remodelling in endurance athletes. Eur Heart J 2012; 33:9981006.
72. La Gerche A, Schmied CM. Atrial fibrillation in athletes and
the interplay between exercise and health. Eur Heart J 2013;
34:35993602.
73. Andersen K, Farahmand B, Ahlbom A, Held C, Ljunghall S, Michalsson
K, Sundstrm J. Risk of arrhythmias in 52 755 long-distance crosscountry skiers: a cohort study. Eur Heart J 2013; 34:36243631.
74. Biffi A, Pelliccia A, Verdile L, Fernando F, Spataro A, Caselli S, Santini
M, Maron BJ. Long-term clinical significance of frequent and complex
ventricular tachyarrhythmias in trained athletes. J Am Coll Cardiol
2002; 40:446452.
75. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo
JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT, Roccella EJ. Seventh
Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;
42:12061252.
76. Pescatello LS (ed). American College of Sports Medicine's Guidelines for
Exercise Testing and Prescription, 9th edn. Wolters Kluwer: Philadelphia,
PA, 2014.
77. Jette M, Sidney K, Blumchen G. Metabolic equivalents (METS) in exercise testing, exercise prescription, and evaluation of functional capacity.
Clin Cardiol 1990; 13:555565.
78. Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, Macera
CA, Heath GW, Thompson PD, Bauman A. Physical activity and public
health: updated recommendation for adults from the American College
of Sports Medicine and the American Heart Association. Circulation
2007; 116:10811093.
79. Head GA, McGrath BP, Mihailidou AS, Nelson MR, Schlaich MP,
Stowasser M, Mangoni AA, Cowley D, Brown MA, Ruta LA, Wilson A.
Ambulatory blood pressure monitoring in Australia: 2011 consensus
position statement. J Hypertens 2012; 30:253266.
80. Parati G, Stergiou GS, Asmar R, Bilo G, de Leeuw P, Imai Y, Kario K,
Lurbe E, Manolis A, Mengden T, O'Brien E, Ohkubo T, Padfield P,
Palatini P, Pickering T, Redon J, Revera M, Ruilope LM, Shennan A,
Staessen JA, Tisler A, Waeber B, Zanchetti A, Mancia G. European
Society of Hypertension guidelines for blood pressure monitoring
at home: a summary report of the Second International Consensus
Conference on Home Blood Pressure Monitoring. J Hypertens 2008;
26:15051526.
81. Niiranen TJ, Leino K, Puukka P, Kantola I, Karanko H, Jula AM. Lack
of Impact of a Comprehensive Intervention on Hypertension in the
Primary Care Setting. Am J Hypertens 2014; 27:489496.
82. Trost SG, Owen N, Bauman AE, Sallis JF, Brown W. Correlates of adults'
participation in physical activity: review and update. Med Sci Sports
Exerc 2002; 34:19962001.
83. Weston KS, Wisloff U, Coombes JS. High-intensity interval training in
patients with lifestyle-induced cardiometabolic disease: a systematic
review and meta-analysis. Br J Sports Med 2014; 48:12271234.
84. Thompson PD, Franklin BA, Balady GJ, Blair SN, Corrado D, Estes NA
III, Fulton JE, Gordon NF, Haskell WL, Link MS, Maron BJ, Mittleman
MA, Pelliccia A, Wenger NK, Willich SN, Costa F. 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. Circulation 2007; 115:23582368.
85. Molmen-Hansen HE, Stolen T, Tjonna AE, Aamot IL, Ekeberg IS,
Tyldum GA, Wisloff U, Ingul CB, Stoylen A. Aerobic interval training
reduces blood pressure and improves myocardial function in hypertensive patients. Eur J Prev Cardiol 2012; 19:151160.
86. Ciolac EG, Bocchi EA, Bortolotto LA, Carvalho VO, Greve JM,
Guimaraes GV. Effects of high-intensity aerobic interval training vs.
moderate exercise on hemodynamic, metabolic and neuro-humoral
abnormalities of young normotensive women at high familial risk for
hypertension. Hypertens Res 2010; 33:836843.
87. Francois ME, Baldi JC, Manning PJ, Lucas SJE, Hawley JA, Williams
MJA, Cotter JD. Exercise snacks before meals: a novel strategy to
improve glycaemic control in individuals with insulin resistance.
Diabetologia 2014; 57:14371445.
88. Rognmo O, Moholdt T, Bakken H, Hole T, Molstad P, Myhr NE,
Grimsmo J, Wisloff U. Cardiovascular risk of high- versus moderateintensity aerobic exercise in coronary heart disease patients. Circulation
2012; 126:14361440.
Sharman etal.
108. Pescatello LS, Mack GW, Leach CN Jr, Nadel ER. Thermoregulation
in mildly hypertensive men during beta-adrenergic blockade. Med Sci
Sports Exerc 1990; 22:222228.
109. Brook RD, Rajagopalan S, Pope CA III, Brook JR, Bhatnagar A, DiezRoux AV, Holguin F, Hong Y, Luepker RV, Mittleman MA, Peters A,
Siscovick D, Smith SC Jr, Whitsel L, Kaufman JD. Particulate matter
air pollution and cardiovascular disease: an update to the scientific
statement from the American Heart Association. Circulation 2010;
121:23312378.
110. Sharman JE. Clinicians prescribing exercise: is air pollution a hazard?
Med J Aust 2005; 182:606607.
111.
Albert CM, Mittleman MA, Chae CU, Lee I-M, Hennekens CH,
Manson JE. Triggering of sudden death from cardiac causes by vigorous exertion. N Eng J Med 2000; 343:13551361.
112. Goodman JM, Thomas SG, Burr J. Evidence-based risk assessment
and recommendations for exercise testing and physical activity clearance in apparently healthy individuals. Appl Physiol Nutr Metab 2011;
36:S14S32.
113. Goodman J, Thomas S, Burr JF. Physical activity series: cardiovascular
risks of physical activity in apparently healthy individuals: risk evaluation for exercise clearance and prescription. Can Fam Physician 2013;
59:4649.