Multi-modal intervention to reduce cardiovascular risk among hypertensive older adults: Design of a randomized clinical trial

Comparative effects of water- and land-based combined exercise training in hypertensive older adults

OBJECTIVES

A randomized controlled trial was designed to compare water- and land-based combined (aerobic and resistance) exercise training programs on cardiometabolic parameters, functional fitness, and quality-of-life (QoL) in hypertensive older adults.

METHODS

Fifty-three participants were divided into three groups: 1) land-based exercise group (LET, n=17), 2) water-based exercise group (WET, n=16), and 3) control group (CON, n=20). All programs comprised of a 12-week supervised training program (three 1-hr sessions per week), followed by a 12-week self-supervised training program. Blood pressure (BP), glutathione peroxidase (GPx), total nitrite/nitrate (NOx-), malondialdehyde (MDA), high-sensitive C-reactive protein (hs-CRP), blood lipids, functional fitness, and QoL were assessed before and after each period.

RESULTS

Following the supervised period, systolic BP, rate-pressure product, GPx, NOx-, MDA, hs-CRP concentrations, physical and psychological domains, and overall QoL significantly improved in both training groups. Only the WET improved LDL-C and lipoprotein combine index. Meanwhile, the 30s chair-stand test and 2-min step test improved only in the LET. Succeeding the self-supervised period, systolic BP and NOx- concentration significantly improved in both training groups. Notwithstanding, the 30s chair-standing and arm curl tests improved only in the LET.

CONCLUSIONS

Both training programs rendered ameliorated systolic BP, antioxidant capacity and inflammation, muscular strength, aerobic endurance and QoL with a higher progression in the LET. Nevertheless, metabolic variables were greater improved in the WET. Additionally, due to greater exercise participation, the WET program may be a useful tool in motivating hypertensive older adults to continuously exercise on their own.

Angiotensin Converting Enzyme Inhibitors Combined with Exercise for Hypertensive Seniors (The ACES Trial): Study Protocol of a Randomized Controlled Trial

Prior evidence suggests that the choice of antihypertensive medication may influence functional status among older adults with hypertension, particularly in conjunction with exercise. In particular, angiotensin converting enzyme (ACE) inhibitors have shown potential to positively influence function. However, randomized, controlled trials are needed to confirm this hypothesis. This paper outlines an RCT designed to determine if choice of first-line antihypertensive medication influences functional and cardiovascular risk factor responses to exercise among older adults with hypertension. Two hundred and thirteen inactive, community-dwelling adults ≥60 years of age with hypertension and functional limitations will be recruited to engage in a 32-week intervention study. Participants will be randomized to one of three first-line antihypertensive agents: (1) the ACE inhibitor perindopril, (2) the AT1 receptor antagonist losartan, or (3) the thiazide diuretic hydrochlorothiazide (HCTZ). Six weeks after randomization, participants will begin a 20-week structured aerobic exercise intervention. Participants will perform two 45-min center-based sessions coupled with 60 min of home-based walking per week. The primary aim is to determine if perindopril improves self-paced gait speed when compared with losartan and HCTZ. The secondary aim is to determine the relative effect of perindopril on secondary outcomes such as: (a) exercise capacity, (b) body mass and composition, and (c) circulating indices of cardiovascular risk. This RCT is expected to identify differential effects of first-line antihypertensive medications when combined with physical exercise thus have potential implications for antihypertensive prescription guidelines for older adults. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03295734.

Multimodal Intervention to Improve Functional Status in Hypertensive Older Adults: A Pilot Randomized Controlled Trial

This pilot randomized controlled trial (RCT) was designed to provide the preliminary data necessary to conduct a full-scale trial to compare the efficacy of differing first-line antihypertensive medications in improving functional status in older adults, when combined with exercise. The primary objectives were to assess study feasibility, safety, and protocol integrity. Dependent outcomes included gait speed, exercise capacity, body composition, and systemic cardiometabolic biomarkers. Thirty-one physically inactive older adults (70.6 ± 6.1 years) with hypertension and functional limitations were randomly assigned to (1) Perindopril (8 mg/day n = 10), (2) Losartan (100 mg/day; n = 13), or (3) Hydrochlorothiazide (HCTZ: 25 mg/day; n = 8). Participants were also assigned to a 24-week multimodal exercise intervention, separated into an aerobic and concurrent (aerobic + resistance) phase to evaluate potential mode effects. Retention was 84% (26/31), and compliance was >90% and >79% with medication and exercise, respectively. A total of 29 adverse events (Perindopril = 5; Losartan = 12; HCTZ = 11) and one unrelated serious adverse event were observed throughout the trial. Overall, this pilot RCT provided critical data and identified several challenges to ultimately designing and implementing a fully powered trial.

Development of a multivariate model of the six-minute walked distance to predict functional exercise capacity in hypertension

BACKGROUND

Hypertension is associated with deterioration of musculoskeletal function and functional capacity. Existing prediction models for assessment of the 6-min walk test (6MWT) do not capture the disease-related functional capacity. This study developed a multivariate prediction model of the measured 6-min walked distance (6MWD_M) in hypertension and proposed target-values based on optimal therapeutic aims.

METHODS

Seventy-six patients (38 men, 56.1 ± 14.3 years, systolic pressure 156.7 ± 17.5 mmHg, diastolic pressure 92.9 ± 6.9 mmHg) underwent anamnesis, physical examination, and laboratory analysis. Functional capacity was assessed using the 6MWT, being the 6MWD_M considered as the dependent variable. Independent variables included sex (S, coded 'male' = 1, 'female' = 0), age (A), body height (H), body mass, mean blood pressure (MBP), and physical activity (IPAQ, coded 1-5). Target-values were derived from theoretical scenarios of optimal blood pressure and physical activity, separately and combined.

RESULTS

Patients walked 324.5 ± 10.1 m in the average of two trials 30-min apart. Pearson's correlation coefficient showed moderate-to-weak significant associations between 6MWD_M and all independent variables. The final multivariate model was 6MWD_P = 611.347-4.446 × MBP + 267.630 × H - 1.511 × A + IPAQ_code + S_code (adjusted R² = 0.680, SE of bias = 6.3 m), suggesting that clinical, anthropometric, and hemodynamic information determines functional capacity. Predicted values yielded a group-average of 325 ± 87 m. Target-values under the optimal scenario resulted in 420 ± 60 m.

CONCLUSIONS

Sex (men), higher body height, higher physical activity, lower mean blood pressure, and lower age are independently correlated with higher 6MWD_M in patients with hypertension. Target-values can be estimated for therapeutic aims related to hemodynamics and lifestyle.

Cardioprotective Exercise and Pharmacologic Interventions as Complementary Antidotes to Cardiovascular Disease

Exercise and pharmacologic therapies to prevent and treat cardiovascular disease have advanced largely through independent efforts. Understanding of first-line drug therapies, findings from preclinical animal studies, and the need for research initiatives related to complementary cardioprotective exercise-pharma interventions are reviewed from the premise that contemporary cardioprotective therapies must include adjunctive exercise and lifestyle interventions in addition to pharmacologic agents.

Exercise training improves functional status in hypertensive older adults under angiotensin converting enzymes inhibitors medication

BACKGROUND

The study aims to analyze the effect of three types of treatment on functional status, and cardiovascular risk outcomes in hypertensive older adults with comorbidities.

METHODS

Participants (n=418) underwent one of the following 3 conditions: i) multicomponent exercise training 3 times/week (MEX; n=116); ii) angiotensin converting enzyme inhibitors used mono-dose daily (ACEi; n=70); iii) combined exercise and ACEi drugs (ACEiMEX; n=232). The trial was completed by 82% of the participants (n=342): MEX (n=90); ACEi (n=66); ACEiMEX (n=186). Baseline and 2-year follow-up evaluations included the Senior Fitness Test battery, Short Form Health Survey 36 (SF-36), the health history questionnaires, anthropometric and hemodynamic profile.

RESULTS

MEX and ACEiMEX groups improved all physical functional status outcomes, decreased systolic (SBP) and diastolic blood pressure (p<0.001) and augmented the physical functioning, role physical and physical component score (PCS) (p<0.05), but also bodily pain (p<0.05). The ACEi group reduced the upper body strength, upper and lower body flexibility and aerobic endurance (p<0.05); worsened the anthropometric profile, and SBP (p<0.001); and decreased general health and PCS (p<0.05).

CONCLUSIONS

The improvement of the physical functioning and HRQoL in older hypertensive adults using ACEi medications only occur if they adopt an exercise training regimen, increasing also the management of the blood pressure and other cardiovascular risk factors.