Therapeutic role of exercise

in treating hypertension
Dalynn T. Badenhop, Ph.D., FACSM
Professor of Medicine
Director , Cardiac Rehabilitation
Medical College of Ohio
Educational Objectives
To explain the acute blood pressure
response to exercise
To list the mechanisms by which exercise
may improve hypertension
To apply exercise guidelines in treating
hypertension
To prescribe appropriate drug therapy for
active hypertensive patients
Overview of Hypertension
High BP is a risk factor for stroke, CHF,
angina, renal failure, LVH and MI
Hypertension clusters with hyperlipidemia,
diabetes and obesity
Drugs have been effective in treating high
BP but because of their side effects and
cost, non-pharmacologic alternatives are
attractive
1997 JNC VI Classification of
Blood Pressure
Blood Pressure Category Systolic Diastolic
Optimal <120 <80
Normal <130 <85
High Normal 130-139 85-89
Hypertension
Stage 1 (Mild) 140-159 90-99
Stage 2 (Moderate) 160-179 100-109
Stage 3 (Severe) > 180 > 110
Overview of Hypertension
Joint National Committee VI (JNC VI) on
Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (1997)
50 million hypertensive patients in the U.S.
National Health and Nutrition Examination
Survey III (NHANES III) (1995)
only 21% of treated hypertensive patients have BP
controlled to <140/90 mm Hg
35% of hypertensive patients are unaware of their
condition
High-normal BP is associated with an incresed
risk of cardiovascular disease
N Eng J Med 2001; 345; 1291-7
Pathophysiology of Hypertension
Essential hypertension is characterized by
increased DBP and related arteriolar
vasoconstriction leading to increased SBP
BP is mainly determined by cardiac output
and total peripheral resistance
High blood pressure may be linked to age-
related vascular stiffening
Pathophysiology of Hypertension
High blood pressure is also associated
with obesity, salt intake, low potassium
intake, physical inactivity, heavy alcohol
use and psychological stress
Intra-abdominal fat and hyperinsulinemia
may play a role in the pathogenesis of
hypertension
Prevalence of Other Risk
Factors With Hypertension
Risk Factor Percent
Smoking 35
LDL Cholesterol >140 mg/dl 40
HDL Cholesterol < 40 mg/dl 25
Obesity 40
Diabetes 15
Hyperinsulinemia 50
Sedentary lifestyle >50
Kaplan NM. Dis Mon 1992; 38:769-838
Cardiovascular Consequences
of Hypertension
Individuals with BP > 160/95 have CAD,
PVD & stroke that is 3X higher than
normal
HTN may lead to retinopathy and
nephropathy
HTN is also associated with subclinical
changes in the brain and thickening and
stiffening of small blood vessels
Cardiovascular Consequences
of Hypertension
Increased cardiac afterload leads to left
ventricular hypertrophy and reduced early
diastolic filling
Increased LV mass is positively
associated with CV morbidity and mortality
independent of other risk factors
High BP also promotes coronary artery
calcification, a predictor of sudden death
Hypertension & CVD Outcomes
Increased BP has a positive and
continuous association with CV events
Within DBP range of 70-110 mm Hg, there
is no threshold below which lower BP
does not reduce stroke and CVD risk
A 15/6 mm Hg BP reduction reduced
stroke by 34% and CHD by 19% over 5
years
Lifestyle Changes
for Hypertension
Reduce excess body weight
Reduce dietary sodium to < 2.4 gms/day
Maintain adequate dietary intake of potassium,
calcium and magnesium
Limit daily alcohol consumption to < 2 oz. of
whiskey, 10 oz. of wine, 24 oz. of beer
Exercise moderately each day
Engage in meditation or relaxation daily
Cessation of smoking
JNC VI Blood Pressure
Classification
Blood Pressure
Stage (mm Hg)
Risk Group A
No major risk factors
No TOD/CCD
Risk Group B
At least one major risk factor,
not including DM
No TOD/CCD
Risk Group C
TOD/CCD and/or DM, with or
without other risk factors
High-Normal BP
130-139/85-89
Lifestyle
Modification
Lifestyle
Modification
Medication

Lifestyle
Modification

Stage 1 HTN
140-159/90-99
Lifestyle
Modification
(up to 12 mo)

Lifestyle
Modification
(up to 6 mo)
Medication

Lifestyle
Modification

Stage 2,3 HTN
160/100
Medication

Lifestyle
Modification
Medication

Lifestyle
Modification
Medication

Lifestyle
Modification

Medical Therapy and
Implications for Exercise Training
Pharmacologic and nonpharmocologic
treatment can reduce morbidity
Some antihypertensive agents have side-
effects and some worsen other risk factors
Exercise and diet improve multiple risk
factors with virtually no side-effects
Exercise may reduce or eliminate the
need for antihypertensive medications
Acute BP Response to Exercise
Exaggerated BP Response
to Exercise
Among normotensive men who had an
exercise test between 1971-1982, those
who developed HTN in 1986 were 2.4
times more likely to have had an
exaggerated BP response to exercise
Exaggerated BP response increased
future hypertension risk by 300% after
adjusting for all other risk factors
Exaggerated BP Response
to Exercise
Exaggerated BP was change from rest in
SBP >60 mm Hg at 6 METs; SBP > 70
mm Hg at 8 METs; DBP > 10 mm Hg at
any workload.
Subjects in CARDIA study with
exaggerated exercise BP were 1.7 times
more likely to develop HTN 5 years later
J Clin Epidemiol 51 (1): 1998
NIH Consensus Conference on
Physical Activity and CV Health (1995)
Review of 47 studies of exercise and HTN
70% of exercise groups decreased SBP by an
avg. of 10.5 mm Hg from 154
78% of subjects decreased DBP by an avg. of
8.6 mm Hg from 98
Only 1 study showed increased BP w/ EX
Beneficial responses are 80 times more
frequent than negative responses
Hagberg, J., et.al., NIH, 1995: 69-71
Increasing Lifestyle Activity for Patients with High-
Normal Blood Pressure and Stage I Hypertension
Medical College of Ohio Study Group
Kevin A. Phelps, D.O.
Larry Johnson, M.D.
Sandra Puczynski, Ph.D.
Dalynn Badenhop, Ph.D.
Michael McCrea
Wendy Boone, RN, M.P.H
Lifestyle Activity vs.
Structured Exercise
JAMA 1999; 281(4): 327-334
moderate-intensity lifestyle activity showed similar or
better results versus structured exercise for
improved cardiovascular fitness
reduced body fat
decreased total cholesterol
reduced blood pressure
patient compliance
In the past five years the Surgeon General, CDC, NIH,
and ACSM have published position statements on the
potential health benefits of lifestyle activity
Twenty-four week, physician-directed
intervention program to lower BP by
increasing physical activity

Patients randomized into two groups:
Group 1 - educational intervention
monitored via activity logs
Group 2 - educational intervention
monitored via activity logs and pedometer
Study Design
The Pedometer
a small device worn
at the waist that
counts steps
used successfully in
obesity studies
Study Hypotheses
Adding a pedometer
to goal setting will increase the level and
frequency of physical activity

will improve BP control of adult patients with
high-normal BP or Stage 1 HTN
Main Outcome Measures
Blood Pressure and BMI
Physical Activity assessed by:
two questionnaires
Physical Activity Recall Scale (PASE):
assessed activity in past seven days
Physician-based Assessment and Counseling
for Exercise (PACE) :
assessed readiness for change in level of
physical activity
Patient Education Tool
Methods: Patient
Identification
Potential subjects identified by chart
audit
average BP of past three visits in High
Normal BP or Stage 1 HTN category
Exclusion Criteria:
Antihypertensive med use
confirmed BP 160/100
Dx DM, CHF, CAD, CVD, CA, MR
pregnant
child (< 18 yrs)
Methods: Patient
Recruitment
Identified subjects contacted during
regularly scheduled physician visit

Physician introduced study to patient

Interested patients met with research
assistant for more information about study
Methods: Patient Eligibility
Interested patients had two eligibility
visits two weeks apart to confirm
elevated BP

If average BP at two visits confirmed
High-Normal BP or Stage 1 HTN from
chart audit, then patient was scheduled
for first study visit (t
0
)
Sample Characteristics
Category Group 1(n=7)
(no pedometer)
Group 2 (n=13)
(pedometer)
Age (M/SD) 61 (14.5) 54 (10)
Race
Caucasian
Non-Caucasian
6
1
8
5
Marital Status
married
not married
4
3
8
5
Income
$40,000
<$40,000
1
5
8
5
Education
high or tech school
college graduate
4
3
7
6
BMI (M/SD) 31.3 (6) 31.2 (6)
Methods: Study Visits
Research Assistant
measured BP and weight, reviewed activity log at
all visits
administered PASE and PACE at baseline and
completion
Physician
discussed barriers to increasing activity
new activity goal setting
assisted with problem solving
Preliminary Results

Outcome measures analyzed at
beginning of study, week 0 (t
0
)

end of intervention period, week 12 (t
1
)
end of maintenance period, week 24 (t
2
)
Change in Systolic BP from Time 0 to
Time 1 (12 weeks) for both groups
122
124
126
128
130
132
134
136
138
140
0 1 2
Time
S
y
s
t
o
l
i
c

B
P



.


Group 1, No Pedometer (n = 7)
Group 2, Pedometer (n = 13)
P = .005
Change in Systolic BP across time
for both groups (24 weeks)
122
124
126
128
130
132
134
136
138
140
0 1 2
Time
S
y
s
t
o
l
i
c

B
P

Group 1, No Pedometer (n = 7)
Group 2, Pedometer (n = 13)
P = .005
Change in Diastolic BP from Time 0 to
Time 1 for both groups (12 weeks)
74
76
78
80
82
84
86
88
90
0 1 2
Time
D
i
a
s
t
o
l
i
c

B
P

(
m
m

H
g
)
Group 1, No Pedometer (n = 7)
Group 2, Pedometer (n = 13)
P = .022
Change in Diastolic BP across time
for both groups (24 weeks)
74
76
78
80
82
84
86
88
90
0 1 2
Time
D
i
a
s
t
o
l
i
c

B
P

(
m
m

H
g
)







.
Group 1, No Pedometer (n = 7)
Group 2, Pedometer (n = 13)
Change in BMI across time for
both groups (24 weeks)
30.4
30.5
30.6
30.7
30.8
30.9
31
31.1
31.2
31.3
31.4
0 1 2
Time
B
M
I
Group 1, No Pedometer (n = 6)
Group 2, Pedometer (n = 9)
Change in PASE across time for
both groups (24 weeks)
150
160
170
180
190
200
210
220
230
240
0 2
Time
P
A
S
E

S
c
o
r
e
Group 1, No Pedometer (n = 6)
Group 2, Pedometer (n = 12)
Preliminary Conclusions
Intervention alone (Group 1) did not
significantly improve BP

Intervention plus a pedometer (Group 2)
significantly improved BP, but only with
regular physician visits
Possible Mechanisms of BP
Reduction with Exercise
Reduced visceral fat independent of
changes in body weight or BMI
Altered renal function to increase
elimination of sodium leading to reduce
fluid volume
Anthropomorphic parameters may not be
primary mechansims in causing HTN
Possible Mechanisms of BP
Reduction with Exercise
Lower cardiac output and peripheral
vascular resistance at rest and
submaximal exercise
Decreased HR
Decreased sympathetic and increased
parasympathetic tone
Lower blood catecholamines and plasma
renin activity
Antihypertensive & Volume Depleting
Effects of Mild Exercise on Essential HTN
20 subjects with HTN (155/100) randomized to
Exercise or Control group
Cycle Ergometer Exercise at Blood Lactic Acid
Threshold for 60 min. 3X/wk for 10 weeks
Changes in BP, hemodynamics and humoral
factors of EX group compared with control group
Urata, H., et. al. Hypertension 9:245-252,1987
Antihypertensive & Volume Depleting
Effects of Mild Exercise on Essential HTN
Antihypertensive & Volume Depleting
Effects of Mild Exercise on Essential HTN
Whole blood and plasma volume indices were
significantly reduced (p < 0.05)
Change in serum Na+:serum K+ positively
correlated with change in SBP
Plasma NE concentrations at rest & Workload
@ BLAT during GXTs were reduced
Change in resting NE correlated with change in
mean BP
Urata, H., et. al. Hypertension 9:245-252, 1987
Changes in Taurine & other Amino Acids in
Response to Mild Exercise
Blood pressures were significantly decreased by
14.8/6.6 mmHg in the EX group but not the
Control group
Serum concentration increases of taurine (26%),
cystine (287%), asparagine (11%), histidine
(6%) and lysine (7%) in the EX
Serum taurine was negatively correlated with
the change in plasma NE
Tanabe, Y, et. al., Clin & Exper Hyper 11:149-165, 1989
Changes in Taurine & other Amino Acids in
Response to Mild Exercise
Exercise Prescriptions for Patients With
Borderline-to-Moderate Hypertension
Patient
evaluation
Look for lipid disorders, DM,
retinopathy, neuropathy, PVD,
renal insufficiency, LV
dysfunction, silent MI/ischemia
osteoarthritis, osteoporosis
Exercise testing GXT with modified Naughton
protocol, R/O asymptomatic
ischemic CAD, radionuclide
Exercise type Aerobic, low-impact activities:
walking, biking, swimming, tai
chi, stepper, treadmill walking
Modified Naughton
Treadmill Protocol
Exercise Prescriptions for Patients With
Borderline-to-Moderate Hypertension
Frequency 5 days/week as a minimum
Intensity Start at 50-60% maximum HRR &
slowly increase to 70%; within 6
weeks work at 85% HRR or from
50-90% of maximal heart rate
Duration Start with 20-30 min/day of
continuous activity for first 3 wk,
then 30-45 min/day for next 4-6
wk, and 60 min/day as
maintenance
Exercise Prescriptions for Patients With
Borderline-to-Moderate Hypertension
Excessive rises in blood pressure
should be avoided during exercise
(SBP > 230 mm Hg; DBP > 110 mm
Hg). Restrictions on participation in
vigorous exercise should be placed
on patients with left ventricular
hypertrophy.
Weight Training
Resistive exercise produces the most striking
increases in BP
Resistive exercise results in less of a HR
increase compared with aerobic exercise and as
a result the rate pressure product may be less
than aerobic exercise
Assessment of BP response by handgrip should
be considered in patients w/ HTN
Growing evidence that resistive training may be
of value for controlling BP Kelemen, et.al., JAMA 263:2766-
71,1990

Drug Therapy for Active
Hypertensive Patients
Hypertension only
Thiazide diuretics in combination with a
potassium supplement are effective and
inexpensive
Diuretics limit plasma volume expansion
and decrease peripheral resistance
Other antihypertensive drugs can be used
as monotherapy for this type of patient
Drug Therapy for Active
Hypertensive Patients
Hypertension with other diseases
CAD - calcium-channel blocker or a beta-
blocker
Diabetes - ACE inhibitor
LVH but coughs with ACE inhibitor -
angiotensin-2-receptor blocker
Elderly men with prostatism - peripheral
alpha-blocker (terazosin, doxazosin)
Drug Therapy for Active
Hypertensive Patients
Beta
1
-selective blockers such as
atenolol or metoprolol are preferable
to non-selective agents such as
propranolol, nadolol or pindolol for
hypertensive patients engaged in
regular exercise
Kaplan, N.M., Am J Hypertens 2:75-77,1989
Beta-blocker therapy
and exercise
Non-selective Beta-blockers may increase
a patients disposition to exertional
hyperthermia. So patients should adhere
strictly to guidelines for fluid replacement
Patients should use fluid replacement
drinks with low concentrations of K
+
to
avoid the risk of hypokalemia
Gordon, N.F., Am J Cardiol 55: 74-78,1985
Beta-blocker therapy
and exercise
Exercise therapy is desirable during
Beta-blocker therapy to offset the
adverse alterations in lipoprotein
metabolism contributed by some
Beta-blocker medications

Gordon, N.F., Compr Ther 14: 52-57, 1988
Beta-blocker therapy
and exercise
Exercise intensity for patients on Beta-
blocker medications should be in
accordance with traditional guidelines
based on the results of individualized
exercise testing performed on the
medication.

American College of Sports Medicine
Guidelines for Exercise Testing and Prescription, 2000
Beta-blocker therapy
and exercise
Non-selective Beta-blockers
dramatically reduce peak aerobic
capacity and at the same time
increase a patients rating of
perceived exertion for a given amount
of work.

Kaplan, N.M., Am J Hypertens 2:75-77,1989


Beta-blocker therapy
and exercise
Patients treated with Beta-blockers
are capable of deriving the expected
enhancement of cardiorespiratory
fitness during training, irrespective of
the type of drug used

Blood, S.M., J Cardiopulmonary Rehabil 8: 141-144, 1988
SUMMARY
Physical activity has a therapeutic role in
the treatment of hypertension
No consistent relationship between
reduced weight and lower BP
Exercise at lower intensities is effective in
treating mild to moderate hypertension
Exercise testing may help identify
exaggerated BP responses to exercise
SUMMARY
Exercise prescription for HTN should be
based on medical hx and risk factor status
Exercise prescription should be adapted
to antihypertensive medications that may
affect exercise HR, BP & performance
Incorporating resistive training into the
exercise prescription may be of value for
controlling blood pressure
References
Chintanadilok, J., Exercise in Treating Hypertension, PhysSports Med
30: 11-23, 2002
Urata, H., Antihypertensive and Volume-Depleting Effects of Mild
Exercise on Essential Hypertension, Hypertension 9: 245-52, 1987.
Tanabe, Y., Changes in Serum Concentration of Taurine and Other
Amino Acids in Clinical Antihypertensive Exercise Therapy, Clin and
Exper Hyper A11: 149-165, 1989.
American College of Sports Medicine, Physical Activity, Physical
Fitness and Hypertension, Med Sci Sports Exerc 25: i - x , 1993.
ACSMs Resource Manual for Guidelines for Exercise Testing and
Prescription, Baltimore, Williams & Wilkins, p. 275-280, 1998.