1
|
Le Bourvellec M, Delpech N, Hervo J, Bosquet L, Enea C. Effect of exercise modalities on postexercise hypotension in pre- and postmenopausal women: a systematic review and meta-analysis. J Appl Physiol (1985) 2024; 136:864-876. [PMID: 38328822 DOI: 10.1152/japplphysiol.00684.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/16/2024] [Accepted: 01/31/2024] [Indexed: 02/09/2024] Open
Abstract
Hormonal changes associated with menopause increase the risk of hypertension. Postexercise hypotension (PEH) is an important tool in the prevention and management of hypertension; however, menopause may alter this response. The aim of this systematic review and meta-analysis [International Prospective Registered of Systematic Review (PROSPERO): CRD42023297557] was to evaluate the effect of exercise modalities (aerobic, AE; resistance, RE; and combined exercise, CE: AE + RE) on PEH in women, according to their menopausal status (premenopausal or postmenopausal). We searched controlled trials in PubMed, Web of Science, EBSCO, and Science Direct published between 1990 and March 2023. Inclusion criteria were normotensive, pre- and hypertensive, pre- and postmenopausal women who performed an exercise session compared with a control session and reported systolic blood pressure (SBP) and diastolic blood pressure (DBP) for at least 30 min after the sessions. Methodological quality was assessed using the PEDro scale. Standardized mean differences (Hedge's g) and their 95% confidence intervals (CIs) were calculated, and Q-test and Z-test were conducted to assess differences between moderators. Forty-one trials with 718 women (474 menopausal) were included. Overall, we found with moderate evidence that SBP and DBP decreased significantly after exercise session (SBP: g = -0.69, 95% CI -0.87 to -0.51; DBP: g = -0.31, 95% CI -0.47 to -0.14), with no difference between premenopausal and postmenopausal women. Regarding exercise modalities, RE is more effective than AE and CE in lowering blood pressure (BP) in women regardless of menopausal status. In conclusion, women's menopausal status does not influence the magnitude of PEH, and the best modality to reduce BP in women seems to be RE.NEW & NOTEWORTHY This meta-analysis has demonstrated that a single bout of exercise induces postexercise hypotension (PEH) in women and that the hormonal shift occurring with menopause does not influence the magnitude of PEH. However, we have shown with moderate evidence that the effectiveness of exercise modalities differs between pre- and postmenopausal women. Resistance and combined exercises are the best modalities to induce PEH in premenopausal women, whereas resistance and aerobic exercises are more effective in postmenopausal women.
Collapse
Affiliation(s)
- Morgane Le Bourvellec
- Laboratory MOVE (UR20296), Faculté des Sciences du Sport, Université de Poitiers, Poitiers, France
| | - Nathalie Delpech
- Laboratory MOVE (UR20296), Faculté des Sciences du Sport, Université de Poitiers, Poitiers, France
| | - Jéromine Hervo
- Laboratoire de Traitement de l'information Médicale (LaTIM), UMR1101, Université Bretagne Occidentale, Brest, France
| | - Laurent Bosquet
- Laboratory MOVE (UR20296), Faculté des Sciences du Sport, Université de Poitiers, Poitiers, France
| | - Carina Enea
- Laboratory MOVE (UR20296), Faculté des Sciences du Sport, Université de Poitiers, Poitiers, France
| |
Collapse
|
2
|
David GB, Schaun GZ, Mendes AR, Nunes GN, Bocalini DS, Pinto SS, Alberton CL. Short-Term Effects of Land-Based Versus Water-Based Resistance Training Protocols on Post-Exercise Hypotension in Normotensive Men: A Crossover Study. Sports (Basel) 2022; 10:sports10110181. [PMID: 36422950 PMCID: PMC9698456 DOI: 10.3390/sports10110181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/11/2022] [Accepted: 11/15/2022] [Indexed: 11/18/2022] Open
Abstract
Considering that water immersion may acutely reduce blood pressure (BP) and that exercise may elicit positive post-exercise hypotension (PEH) responses, we aimed to analyze the presence of PEH in normotensive individuals and compare its magnitude between two resistance training sessions performed in aquatic or land environments. Ten physically active men (23.2 ± 3.1 years) performed the two training protocols in a randomized, counterbalanced fashion. BP measurements were performed for 30 min (at 5 min intervals) both prior to (resting) and after each of the protocols. No differences were observed between protocols at baseline (p > 0.05). Only the water-based resistance training protocol resulted in a systolic BP reduction from 10 to 20 min post-exercise (all p < 0.05) compared to baseline. Compared to the land-based session, systolic BP was lower in the water-based protocol from 10 to 25 min post-exercise (all p < 0.05). On the other hand, diastolic BP showed a similar PEH effect between water and land-based protocols for the entire 30 min post-session period (all p < 0.001). Our results suggest that water-based resistance training holds the potential as a nonpharmacological strategy to lower BP levels following exercise.
Collapse
Affiliation(s)
- Gabriela Barreto David
- Department of Sports, Physical Education School, Federal University of Pelotas, Pelotas 96055-630, Brazil
| | - Gustavo Zaccaria Schaun
- Department of Sports, Physical Education School, Federal University of Pelotas, Pelotas 96055-630, Brazil
- Centre for Sport Science and University Sports, University of Vienna, 1150 Vienna, Austria
| | - Amanda Ricardo Mendes
- Department of Sports, Physical Education School, Federal University of Pelotas, Pelotas 96055-630, Brazil
| | - Gabriela Neves Nunes
- Department of Sports, Physical Education School, Federal University of Pelotas, Pelotas 96055-630, Brazil
| | - Danilo Sales Bocalini
- Physiology and Biochemistry Laboratory, Physical Education and Sport Center, Federal University of Espírito Santo, Vitoria 29075-810, Brazil
| | - Stephanie Santana Pinto
- Department of Sports, Physical Education School, Federal University of Pelotas, Pelotas 96055-630, Brazil
| | - Cristine Lima Alberton
- Department of Sports, Physical Education School, Federal University of Pelotas, Pelotas 96055-630, Brazil
- Correspondence:
| |
Collapse
|
3
|
Álvarez C, Guede-Rojas F, Ramírez-Campillo R, Andrade DC, Vásquez-Gómez J, Rodríguez-Rodríguez F, Ciolac EG, Caamaño-Navarrete F, Delgado-Floody P. Characterizing the interindividual postexercise hypotension response for two order groups of concurrent training in patients with morbid obesity. Front Physiol 2022; 13:913645. [PMID: 36299263 PMCID: PMC9589449 DOI: 10.3389/fphys.2022.913645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 09/07/2022] [Indexed: 12/05/2022] Open
Abstract
Background: Postexercise hypotension (PEH) is a common physiological phenomenon occurring immediately after endurance training (ET), resistance training (RT), and ET plus RT, also termed concurrent training (CT); however, there is little knowledge about the interindividual and magnitude response of PEH in morbidly obese patients. Aim: The aims of this study were (1) to investigate the effect of CT order (ET + RT vs. RT + ET) on the blood pressure responses; 2) characterize these responses in responders and nonresponders, and 3) identify potential baseline outcomes for predicting blood pressure decreases as responders. Methods: A quasi-experimental study developed in sedentary morbidly obese men and women (age 43.6 ± 11.3 years; body mass index [BMI] ≥40 kg/m2) was assigned to a CT group of ET plus RT (ET + RT; n = 19; BMI 47.8 ± 16.7) or RT plus ET order group (RT + ET; n = 17; BMI 43.0 ± 8.0). Subjects of both groups received eight exercise sessions over four weeks. Primary outcomes include systolic (SBP), diastolic (DBP), mean arterial pressure [MAP], heart rate at rest [HR], and pulse pressure [PP] measurements before and after 10 min post-exercise. Secondary outcomes were other anthropometric, body composition, metabolic, and physical fitness parameters. Using the delta ∆SBP reduction, quartile categorization (Q) in “high” (Rs: quartile 4), “moderate” (MRs: quartile 3), “low” (LRs: quartile 2), and “nonresponders” (NRs: quartile 1) was reported. Results: Significant pre–post changes were observed in ET + RT in session 2 for SBP (131.6 vs. 123.4 mmHg, p = 0.050) and session 4 (131.1 vs. 125.2 mmHg, p = 0.0002), while the RT + ET group showed significant reductions in session 4 (134.2 vs. 125.3 mmHg, p < 0.001). No significant differences were detected in the sum of the eight sessions for SBP (∑∆SBP) between ET + RT vs. RT + ET (−5.7 vs. −4.3 mmHg, p = 0.552). Interindividual analyses revealed significant differences among frequencies comparing Q1 “NRs” (n = 8; 22.2%), Q2 “LRs” (n = 8; 22.2%), Q3 “MRs” (n = 9; 25.0%), and Q4 “HRs” (n = 11; 30.5%), p < 0.0001. Quartile comparisons showed significant differences in SBP changes (p = 0.035). Linear regression analyses revealed significant association between ∑∆SBP with body fat % (β –3.826, R2 0.211 [21.1%], p = 0.031), skeletal muscle mass [β –2.150, R2 0.125 (12.5%), p = 0.023], fasting glucose [β 1.273, R2 0.078 (7.8%), p = 0.003], triglycerides [β 0.210, R2 0.014 (1.4%), p = 0.008], and the 6-min walking test [β 0.183, R2 0.038 (3.8%), p = 0.044]. Conclusion: The CT order of ET + RT and RT + ET promote a similar ‘magnitude’ in the postexercise hypotensive effects during the eight sessions of both CT orders in 4 weeks of training duration, revealing “nonresponders” and ‘high’ responders that can be predicted from body composition, metabolic, and physical fitness outcomes.
Collapse
Affiliation(s)
- Cristian Álvarez
- Exercise and Rehabilitation Sciences Institute, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago, Chile
| | - Francisco Guede-Rojas
- Exercise and Rehabilitation Sciences Institute, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago, Chile
| | - Rodrigo Ramírez-Campillo
- Exercise and Rehabilitation Sciences Institute, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago, Chile
| | - David C. Andrade
- Exercise Applied Physiology Laboratory, Centro de Investigación en Fisiología y Medicina de Altura, Departamento Biomedico, Facultad de Ciencias de la Salud, Universidad de Antofagasta, Antofagasta, Chile
| | - Jaime Vásquez-Gómez
- Centro de Investigación de Estudios Avanzados del Maule (CIEAM), Laboratorio de Rendimiento Humano, Universidad Católica del Maule, Talca, Chile
| | | | - Emmanuel Gomes Ciolac
- Exercise and Chronic Disease Research Laboratory, Department of Physical Education, School of Sciences, Sáo Paulo State University (UNESP), Bauru, Buazil
| | | | - Pedro Delgado-Floody
- Department of Physical Education, Sport and Recreation, Universidad de La Frontera, Temuco, Chile
- Department Physical Education and Sports, Faculty of Sport Sciences, University of Granada, Granada, Spain
- Strength & Conditioning Laboratory, CTS-642 Research Group, Department Physical Education and Sports, Faculty of Sport Sciences, University of Granada, Granada, Spain
- *Correspondence: Pedro Delgado-Floody,
| |
Collapse
|
4
|
Liu J, Li Y, Li J, Zheng D, Liu C. Sources of automatic office blood pressure measurement error: a systematic review. Physiol Meas 2022; 43. [PMID: 35952651 DOI: 10.1088/1361-6579/ac890e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 08/11/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Accurate and reliable blood pressure (BP) measurement is important for the prevention and treatment of hypertension. The oscillometric-based automatic office blood pressure measurement (AOBPM) is widely used in hospitals and clinics, but measurement errors are common in BP measurements. There is a lack of systematic review of the sources of measurement errors. APPROACH A systematic review of all existing research on sources of AOBPM errors. A search strategy was designed in six online databases, and all the literature published before October 2021 was selected. Those studies that used the AOBPM device to measure BP from the upper arm of subjects were included. MAIN RESULTS A total of 1365 studies were screened, and 224 studies were included in this final review. They investigated 22 common error sources with clinical AOBPM. Regarding the causes of BP errors, this review divided them into the following categories: the activities before measurement, patient's factors, measurement environment, measurement procedure, and device settings. 13 sources caused increased systolic and diastolic BP (SBP and DBP), 2 sources caused the decrease in SBP and DBP, only 1 source had no significant effect on BPs, and the other errors had a non-uniform effect (either increase or decrease in BPs). The error ranges for SBP and DBP were -14 to 33 mmHg and -6 to 19 mmHg, respectively. SIGNIFICANCE The measurement accuracy of AOBPM is susceptible to the influence of measurement factors. Interpreting BP readings need to be treated with caution in clinical measurements. This review made comprehensive evidence for the need for standardized BP measurements and provided guidance for clinical practitioners when measuring BP with AOBPM devices.
Collapse
Affiliation(s)
- Jian Liu
- School of Instrument Science and Engineering, Southeast University, Sipailou 2, Nanjing, Jiangsu, 210096, CHINA
| | - Yumin Li
- School of Instrument Science and Engineering, Southeast University, Sipailou 2, Nanjing, Jiangsu, 210096, CHINA
| | - Jianqing Li
- School of Instrument Science and Engineering, Southeast University, Sipailou road2, Nanjing, Jiangsu, 210096, CHINA
| | - Dingchang Zheng
- Research Centre of Intelligent Healthcare, Coventry University, West Midlands, Coventry, CV1 5FB, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Chengyu Liu
- School of Instrument Science and Engineering, Southeast University, Sipailou 2, Nanjing, Jiangsu, 210096, CHINA
| |
Collapse
|
5
|
Jarrett CL, Tucker WJ, Angadi SS, Gaesser GA. Postexercise Hypotension Is Delayed in Men With Obesity and Hypertension. Front Physiol 2022; 13:819616. [PMID: 35350685 PMCID: PMC8958023 DOI: 10.3389/fphys.2022.819616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 02/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Postexercise hypotension (PEH) can play a major role in the daily blood pressure management among individuals with hypertension. However, there are limited data on PEH in persons with obesity and hypertension, and no PEH data in this population beyond 90 min postexercise. Purpose The purpose of this study was to determine if PEH could be elicited in men with obesity and hypertension during a 4-h postexercise measurement period. Methods Seven men [age = 28 ± 4 years; body mass index = 34.6 ± 4.8 kg/m2; brachial systolic blood pressure (SBP): 138 ± 4 mmHg; brachial diastolic BP (DBP): 80 ± 5 mmHg; central SBP: 125 ± 4 mmHg; central DBP: 81 ± 8 mmHg] performed two exercise sessions on a cycle ergometer, each on a separate day, for 45 min at ∼65% VO2max. One exercise session was performed at a cadence of 45 RPM and one at 90 RPM. Blood pressure was monitored with a SunTech Oscar2 ambulatory blood pressure monitor for 4 h after both exercise sessions, and during a time-matched control condition. Results Both brachial and central SBP were not changed during the first h postexercise but were reduced by ∼5-11 mmHg between 2 and 4 h postexercise (p < 0.05) after both exercise sessions. Brachial and central DBP were elevated by ∼5 mmHg at 1 h postexercise (p < 0.05) but were ∼2-3 mmHg lower compared to control at 4 h postexercise, and ∼2-4 mmHg lower at 3 h postexercise compared to baseline. Mean arterial pressure (MAP) was elevated compared to control at 1 h postexercise after both exercise sessions, but was ∼2-3 mmHg lower compared to control at 2, 3, and 4 h postexercise, and ∼4-7 mmHg lower at 3 h postexercise compared to baseline. Conclusion Despite the small sample size and preliminary nature of our results, we conclude that PEH is delayed in men with obesity and hypertension, but the magnitude and duration of PEH up to 4 h postexercise is similar to that reported in the literature for men without obesity and hypertension. The PEH is most pronounced for brachial and central SBP and MAP. The virtually identical pattern of PEH after both exercise trials indicates that the delayed PEH is a reproducible finding in men with obesity and hypertension.
Collapse
Affiliation(s)
- Catherine L Jarrett
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center (VAMC), Salt Lake City, UT, United States.,Utah Vascular Research Laboratory, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Wesley J Tucker
- Department of Nutrition and Food Sciences, Texas Woman's University, Houston, TX, United States
| | - Siddhartha S Angadi
- Department of Kinesiology, School of Education and Human Development, University of Virginia, Charlottesville, VA, United States
| | - Glenn A Gaesser
- College of Health Solutions, Arizona State University, Phoenix, AZ, United States
| |
Collapse
|
6
|
Bommasamudram T, Gandhi P, Iype RO, Raj B, Chandrasekaran B. Circadian influence on post-exercise hypotension: a review. COMPARATIVE EXERCISE PHYSIOLOGY 2021. [DOI: 10.3920/cep200051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Circadian rhythm (CR) can influence the physiological and psychological parameters in every individual. There is a sinusoidal response to blood pressure brought about by the CR. A drop in blood pressure response immediately after an exercise is termed as post-exercise hypotension (PEH). The objective of the present paper is to review the influence of CR on PEH. Comparing the types of exercises, aerobic training showed a higher magnitude of the drop in PEH than resistance training. However, the majority of the studies have not considered the CR influence on PEH. With the evidence available, we can conclude that morning exercise shows the higher magnitude of the drop in PEH and could be sustained for a longer duration.
Collapse
Affiliation(s)
- T. Bommasamudram
- Department of Exercise and Sports Sciences, Manipal College of Health Professions, Manipal Academy of Higher Education, Marena, Manipal, Udupi 576104, Karnataka, India
| | - P. Gandhi
- Department of Exercise and Sports Sciences, Manipal College of Health Professions, Manipal Academy of Higher Education, Marena, Manipal, Udupi 576104, Karnataka, India
| | - R. Oommen Iype
- Department of Exercise and Sports Sciences, Manipal College of Health Professions, Manipal Academy of Higher Education, Marena, Manipal, Udupi 576104, Karnataka, India
| | - B. Raj
- Department of Exercise and Sports Sciences, Manipal College of Health Professions, Manipal Academy of Higher Education, Marena, Manipal, Udupi 576104, Karnataka, India
| | - B. Chandrasekaran
- Department of Exercise and Sports Sciences, Manipal College of Health Professions, Manipal Academy of Higher Education, Marena, Manipal, Udupi 576104, Karnataka, India
| |
Collapse
|
7
|
Cunha RM, Costa AM, Silva CNF, Póvoa TIR, Pescatello LS, Lehnen AM. Postexercise Hypotension After Aquatic Exercise in Older Women With Hypertension: A Randomized Crossover Clinical Trial. Am J Hypertens 2018; 31:247-252. [PMID: 28985278 DOI: 10.1093/ajh/hpx165] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/01/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Hypertension can be prevented and modified with lifestyle interventions that include regular exercise. Aquatic exercise is widely recommended for older adults for a variety of health benefits, but few studies have assessed the immediate ambulatory blood pressure (BP) response to aquatic exercise, a response termed postexercise hypotension (PEH). Thus, we assessed PEH after a session of aquatic exercise in physically active, older women with hypertension. METHODS Twenty-four women 70.0 ± 3.9 years with a resting systolic (SBP)/diastolic (DBP) BP of 124.0/72.3 mm Hg and body mass index of 29.8 ± 4.1 kg/m2 were randomly assigned to participate in a 45-minute session of moderate intensity, water-based exercise (WATER) and a 45-minute land control session (CONTROL). All experimental sessions started at 9 am sharply with 7 days between them. Subjects left the experiments wearing an ambulatory BP monitor for the next 21 hours. RESULTS SBP was lower by 5.1 ± 1.0 mm Hg after WATER than CONTROL over 21 hours (P < 0.001), over awake hours by 5.7 ± 1.1 mm Hg (P < 0.001), and sleep hours by 4.5 ± 0.4 mm Hg (P = 0.004). DBP was lower following WATER compared to CONTROL: 1.2 ± 0.3 mm Hg over 21 hours (P = 0.043); 0.9 ± 0.6 mm Hg over awake hours (P = 0.101); and 1.4 ± 0.9 mm Hg over sleep hours (P = 0.039). CONCLUSIONS Aquatic exercise elicited PEH (~5 mm Hg) over 21 hours, BP reductions that are comparable in magnitude to land aerobic exercise. The immediate antihypertensive benefits of acute aquatic exercise should continue to be explored in future studies.
Collapse
Affiliation(s)
- Raphael M Cunha
- Departament of Experimental Medicine and Clinical Research Laboratory, Institute of Cardiology of Rio Grande do Sul/University Foundation of Cardiology, Porto Alegre, Rio Grande do Sul, Brazil
- Departament of Physical Education and Exercise Physiology Laboratory of States University of Goiás, Goiás, Brazil
| | - Andressa Moura Costa
- Departament of Physical Education and Exercise Physiology Laboratory of States University of Goiás, Goiás, Brazil
| | - Christoffer Novais F Silva
- Departament of Physical Education and Exercise Physiology Laboratory of States University of Goiás, Goiás, Brazil
| | - Thais Inácio R Póvoa
- Departament of Physical Education and Exercise Physiology Laboratory of States University of Goiás, Goiás, Brazil
| | - Linda S Pescatello
- Department of Kinesiology and Human Performance Laboratory, University of Connecticut, Connecticut, USA
| | - Alexandre Machado Lehnen
- Departament of Experimental Medicine and Clinical Research Laboratory, Institute of Cardiology of Rio Grande do Sul/University Foundation of Cardiology, Porto Alegre, Rio Grande do Sul, Brazil
| |
Collapse
|
8
|
Comparison Among Recommendations for the Management of Arterial Hypertension Issued by Last US, Canadian, British and European Guidelines. High Blood Press Cardiovasc Prev 2017; 25:9-16. [PMID: 29094260 DOI: 10.1007/s40292-017-0236-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 10/17/2017] [Indexed: 12/23/2022] Open
Abstract
Guidelines for the management of hypertension have been issued by different hypertension societies or organizations. Despite many similarities one can identify major differences in the diagnosis, management and treatment of the hypertensive patients among ESH/ESC, NICE, Canadian and NJC8 guidelines. Differences that can be identified are in the definition of hypertension in the elderly population, the optimal blood pressure targets in different hypertensive populations such as patients with diabetes and chronic kidney disease patients and the choose of the initial and appropriate antihypertensive agent depending on comorbidities of the treated population. Everyday clinical praxis physicians are confused by these differences and these incongruities contribute to doctor and patient inertia to reduce blood pressure levels at an optimal level. Community physicians cannot easily distinguish what recommendations are the best to be used for their patients. The critical view of these differences can also help the guidelines committees to make appropriate changes and finally to agree to a global view of recommendations for the management and treatment of hypertension.
Collapse
|