Exercise Prescription for High Blood Pressure

Did you know?

The concept most people are familiar with today, that the heart pumps out arterial blood and venous blood returns to the heart, was confirmed in the 17th century.

More than a hundred years later, the machine for measuring blood pressure was only invented in 1881.

Before the 17th century, people believed in the two blood systems proposed by Galen in Roman times: one being arterial blood sent out by the heart to provide heat, the other being venous blood made by the liver. Some people had proposed different views using animal dissection experiments, but these came to nothing. In the early 17th century, the English physician Harvey put forward his theory of the circulation of the blood, backed by clear anatomical illustrations of the heart and a scientific method of calculating cardiac output, which gradually led the world to accept the idea of blood circulation.

Only afterward did people try to measure a horse’s blood pressure with a glass tube, which led in the 19th century to the invention of the sphygmomanometer, followed by a series of studies and developments focused on high blood pressure. Hypertension is one of the most common diseases in the world, and everything from its symptoms and diagnosis to its treatment and complications has been the subject of dedicated research in countries around the world.

Even now, with COVID-19 widespread, hypertension is also strongly related to mortality after COVID-19 infection. At first some people even thought that the angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) among hypertension medications increased infection risk and were the cause of the high mortality, but fortunately subsequent research overturned this hypothesis.

What is hypertension

Hypertension was previously defined as 140/90 mmHg. In recent years several overseas societies (for example the American College of Cardiology and the American Heart Association, ACC/AHA) proposed a definition of 130/80 mmHg in 2017, recommending that people with a systolic blood pressure of 130-140 mmHg improve their lifestyle earlier. The 2018 European guidelines still use 140/90 mmHg as the standard, recommending that the general population lower systolic blood pressure to 120-129 mmHg and that older people aim for 130-139 mmHg.

Hypertension can be divided into primary and secondary. Primary hypertension is related to genetics and lifestyle and accounts for about 95%; the high blood pressure caused by many people’s current habits of eating fried foods, heavily salted foods, and getting little exercise is primary hypertension. Secondary hypertension is related to conditions such as chronic kidney disease, renal artery stenosis, obstructive sleep apnea, and excessive aldosterone secretion, and accounts for about 5%. Blood pressure that stays elevated for too long continues to damage tissues such as the blood vessels, heart, and kidneys, and can lead to problems such as atherosclerosis, coronary heart disease, stroke, worsening kidney function, and chronic heart failure.

Treatment of hypertension

Because hypertension and dyslipidemia are strongly related to cardiovascular disease, the Framingham cardiovascular disease risk prediction can be used to assess ten-year cardiovascular disease risk. Under 10% is low risk, 10-20% is moderate risk, and over 20% is high risk. You can refer to National Taiwan University Hospital and the US Mayo Clinic web page; for patients in the moderate-to-high risk category the target values will be lower. I calculated my own to be about 1-2%.

The main treatments for hypertension currently include lifestyle change, medication, and appropriate exercise. Of these, lifestyle change is usually the first-line and most fundamental step; without changing lifestyle, even large amounts of medication and exercise do not work well. Hypertension is not an inevitable result of aging, and some people never develop high blood pressure throughout their lives.

Changing lifestyle

Particularly for diet, the recommendations are a low-salt diet, weight loss, limiting alcohol, quitting smoking, and dietary control.

Each 1 gram reduction in sodium intake can lower systolic blood pressure by 2-3 mmHg; limiting daily sodium intake to within 2-4 grams and limiting daily alcohol intake to less than 28 grams for men and less than 14 grams for women can lower systolic pressure by 2-4 mmHg. For people with a BMI greater than 25, each 1 kilogram of weight loss lowers systolic blood pressure by 1 mmHg, and diet likewise can reduce systolic blood pressure by 2-3 mmHg. Quitting smoking helps reduce hypertension complications (for example coronary artery disease and retinopathy).

Medication options

There are many medication options, mainly divided into four classes, ABCD.

Class A refers to the angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB).

Class B refers to beta-blockers.

Class C refers to calcium channel blockers (CCB).

Class D refers to diuretics.

There are also a small number of other types of medication.

Most people with hypertension who need medication control use one or two medications to lower blood pressure, while a small number need to use more types of medication. Referring to the hypertension treatment guidelines of various countries, physicians prescribe suitable medications for different populations, such as those with chronic kidney disease, diabetes, stroke, or cardiovascular disease. Different medications each have their suitable populations and side effects to watch for; for example, beta-blockers reduce the heart rate response, medications that affect vascular tone may cause orthostatic hypotension, and diuretics may cause problems such as electrolyte imbalance. It is advisable to discuss with a professional physician.

Exercise prescription

Patients with hypertension do not necessarily need exercise testing before receiving formal exercise training; this depends mainly on past exercise habits, blood pressure, related vascular or metabolic diseases, and related symptoms, while exercise testing can help understand how blood pressure changes during exercise. Based on the ACSM pre-participation screening process, we can classify people by whether they exercise regularly and, following the steps below, give exercise prescription recommendations.

Typically during exercise, systolic blood pressure increases while diastolic blood pressure stays the same or decreases. The change in blood pressure during exercise is related to the baseline value before exercise and to the medications being taken. Patients who require more attention during exercise include those whose blood pressure is not controlled (resting blood pressure greater than 140/90 mmHg) and those with hypertension-related complications (left ventricular hypertrophy, retinopathy); it is advisable for them to seek a physician’s advice and clearance before starting exercise.

According to studies, if patients with hypertension do at least 30-40 minutes of aerobic exercise a day, 3-4 days a week, and train for more than 8 weeks, there is a chance of reducing systolic blood pressure by 3-7 mmHg. This helps not only blood pressure but also mortality from cardiovascular disease. These are study results and do not predict any individual’s outcome.

Both aerobic exercise and resistance training have benefits for people with hypertension, but this population needs to monitor blood pressure before, during, and after exercise, and if blood pressure exceeds 220/105 mmHg they need to consider stopping exercise. In addition, if sudden dizziness occurs during exercise or systolic blood pressure drops by more than 20 mmHg, it is advisable to stop exercising and discuss it with a physician. Some hypertension medications lower heart rate, so if exercise intensity is targeted and monitored by heart rate, long-term follow-up and adjustment of the heart-rate-based exercise prescription are needed.

Different types of exercise each have things to watch for. Vigorous aerobic exercise is not absolutely prohibited, but it may carry risk, so moderate-intensity aerobic exercise is recommended, which benefits hypertension control while keeping the risk not too high. During resistance exercise, the breathing pattern should avoid the Valsalva effect (Valsalva maneuver), which may increase the chance of a rise in blood pressure and fainting.

Summary

For patients with well-controlled hypertension, the exercise prescription is similar to that of the general population, but attention should be paid to the effects of medication. For patients with poorly controlled or more severe hypertension, it is advisable to first receive a medical evaluation and advice before starting exercise training, and to watch for possible situations during exercise.

Further reading

Exercise prescription for dyslipidemia

An athlete’s heart really is bigger

References

• Hypertension, a Moving Target in COVID-19: Current Views and Perspectives. Circ Res. 2021 Apr 2;128(7):1062-1079.
• Renin-Angiotensin-Aldosterone System Inhibitors and Risk of Covid-19. N Engl J Med. 2020 Jun 18;382(25):2441-2448.
• 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018 Jun;71(6):1269-1324.
• 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018 Sep 1;39(33):3021-3104.

Further reading

• Rehabilitation exercise
• PRP prolotherapy
• Rehabilitation exercise prescription
• Pain management