Therapeutic role of exercise in treating hypertension

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, 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

Classification of Blood Pressure

Blood Pressure Category Optimal Normal High Normal Hypertension Stage 1 (Mild) Stage 2 (Moderate) Stage 3 (Severe) Systolic <120 <130 130-139 140-159 160-179 > 180 Diastolic <80 <85 85-89 90-99 100-109 > 110

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 Smoking LDL Cholesterol >140 mg/dl HDL Cholesterol < 40 mg/dl Obesity Diabetes Hyperinsulinemia Sedentary lifestyle Percent 35 40 25 40 15 50 >50

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 Exercise moderately each day Engage in meditation or relaxation daily Cessation of smoking

Blood Pressure classification

Blood Pressure Risk Group A No major risk factors Stage (mm Hg) No TOD/CCD
High-Normal BP Lifestyle Modification 130-139/85-89

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

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 Medication Lifestyle Modification

Stage 2,3 HTN 160/100

Medication Lifestyle Modification

Medication Lifestyle Modification

Medical Therapy and Implications for Exercise Training

Pharmacologic and nonpharmocologic treatment can reduce morbidity Some antihypertensive agents have sideeffects 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

The Pedometer
a small device worn at the waist that counts steps used successfully in obesity studies

PA - A Fountain of Youth
Physical inactivity is a primary risk factor Harvard Study:

Patient Education Tool

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

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 GXT with modified Naughton protocol, R/O asymptomatic ischemic CAD, radionuclide Aerobic, low-impact activities: walking, biking, swimming, tai chi, stepper, treadmill walking

Exercise testing

Exercise type

Exercise Prescriptions for Patients With Borderline-to-Moderate Hypertension

Frequency Intensity 5 days/week as a minimum 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 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

Duration

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

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

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.