Effects of aerobic exercise intensity on ambulatory blood pressure and vascular responses in resistant hypertension: a crossover trial

The efficacy of Pilates method in patients with hypertension: systematic review and meta-analysis

This study aimed to systematically review the available evidence on the effects of Pilates training programs on blood pressure in hypertensive patients. Randomized clinical trials and comparative studies were searched in four electronic databases until September 2023 (updated December 2023). The methodological quality of included studies was assessed using the Physiotherapy Evidence Database and Methodological Index for Non-Randomized Studies scales. A total of 4 randomized clinical trials and 7 comparative studies were included, showing a low (n = 1), hight (n = 6), and good (n = 4) methodological quality. Data synthesis indicated that participants who performed Pilates program obtained significantly reduces on systolic blood pressure and diastolic blood pressure, of -4.76 mmHg (95% CI: -6.55 to -2.97, p < 0.001) and -3.43 mmHg (95% CI: -4.37 to -2.49, p < 0.001), respectively, in comparison with those included in the comparison groups. When the analysis was performed by comparing hypertensive, and normotensive patients, the results remained non-significant for blood pressure (systolic blood pressure: 0.96 mmHg (95% CI: -2.85 to 4.77, P = 0.49); diastolic blood pressure: 1.18 mmHg (95% CI: -1.23 to 3.58, P = 0.34); mean blood pressure: 1.73 mmHg (95% CI: -1.96 to 5.42, P = 0.36). Evidence suggests Pilates is safe for hypertensive patients and can be part of their rehabilitation, but it may not necessarily offer superior results or improve exercise adherence compared to other modalities.

Can postexercise hypotension also be observed in African and Asian populations: a systematic review and meta-analysis of randomized controlled trials

Worldwide, raised blood pressure (BP) or hypertension is the global leading risk factor for the development of cardiovascular diseases and all-cause mortality, with the highest prevalence found in Asian and African origin populations. Post-exercise hypotension (PEH), defined as a sustained reduction in BP after a single bout of exercise is an important physiological phenomenon in BP management. However, little is known about the hypotensive effect of a single bout of exercise in non-Caucasian populations. We systematically summarized the acute effects of a single bout of aerobic exercise on BP in a population of African or Asian origin. We searched the MEDLINE database identifying randomized controlled trials investigating the effect of a single bout of aerobic exercise on BP in African or Asian populations with optimal BP, high normal BP or hypertension published in a peer reviewed journal up to August 2021. A subsequent meta-analysis was performed using random-effect models fitted to estimate effect sizes. We identified 10 aerobic exercise trials performed in individuals of Asian origin (n = 136; mean age: 29.51 (21.2-69) years: 78% male; baseline systolic BP/diastolic BP: 118.9 ± 9.64/68.9 ± 2.69 mmHg) and 11 aerobic exercise trials involving individuals of African origin (n = 157; mean age: 41.05 (29.9-49) years; 59% male; baseline systolic BP/diastolic BP: 134.5 ± 8.65 mmHg/82.2 ± 3.24 mmHg). Non-significant reductions in office systolic BP and diastolic BP at 30 min post exercise (-2.25 [-6.38, 1.88] mmHg, p = 0.28/-1.02 [-2.51, 0.47] mmHg, p = 0.18) and 60 min post exercise (-2.80 [-7.90, 2.28], p = 0.27/-1.95, [-5.66, 1.75], p = 0.3) were observed compared to the control intervention. No statistically significant differences were found between both ethnic groups (p > 0.05). Ambulatory BP was reported only in a few African groups. No effect was found on 24h-systolic BP post exercise, but 24h-diastolic BP was statistically significantly reduced (-1.89 [-3.47, -0.31] mmHg, p < 0.01) after a bout of aerobic exercise compared to the control intervention. The available evidence is insufficient to recommend a single session of aerobic exercise as an efficient tool to lower BP in African and Asian populations. Though, the paucity of data in non-Caucasian populations underscores the need for additional efforts to establish the efficacy of single bouts of exercise, including isometric and dynamic resistance exercise, as a potential non-pharmacological adjunct to help lowering BP in the daily life of descendants of Asian or African origin.

Exercise to Treat Hypertension: Late Breaking News on Exercise Prescriptions That FITT

ABSTRACT

Hypertension is the leading risk factor for cardiovascular disease and an independent predictor of mortality. The prevalence of hypertension has doubled in the last two decades and evidence suggests that almost half the individuals are unaware of their condition. The antihypertensive effects of exercise are now undisputable, and exercise training is recommended by the major professional and scientific societies, including the American College of Sports Medicine (ACSM), as first-line treatment to prevent, treat, and control hypertension. This review aims to overview the evidence supporting the current ACSM Frequency, Intensity, Time, and Type exercise recommendations for hypertension, discuss new and emerging evidence on exercise in the treatment of hypertension from our laboratories; and propose future directions of research integrating this new and emerging evidence.

The blood pressure response to acute exercise predicts the ambulatory blood pressure response to exercise training in patients with resistant hypertension: results from the EnRicH trial

Reports suggest that the blood pressure (BP) response to an acute bout of exercise is associated with the BP response to aerobic training in participants with elevated BP. These associations have not been tested among patients with resistant hypertension. This study aimed to determine whether the BP response to acute exercise predicts the 24-h ambulatory BP response to a 12-week exercise training program in patients with resistant hypertension (n = 26, aged 59.3 ± 8.2 years, 24-h ambulatory BP 127.4 ± 12.2/75.6 ± 7.8 mm Hg) who completed the exercise arm of the EnRicH trial. Ambulatory BP measurements were obtained before and after the exercise program to assess the chronic BP response. To assess acute BP changes, resting BP was measured before and 10 min after three exercise sessions in the third week of training and averaged. The resting systolic (9.4 ± 6.7, p < 0.001) and diastolic BP (1.9 ± 3.2, p = 0.005) were reduced after acute exercise. The 24-h systolic (6.2 ± 12.2, p = 0.015) and diastolic BP (4.4 ± 6.1, p = 0.001) were decreased after exercise training. The reductions in systolic BP after acute exercise were associated with the reductions in 24-h systolic BP after exercise training (ß = 0.538, adjusted r² = 0.260, P = 0.005). The reductions in diastolic BP after acute exercise (ß = 0.453, adjusted r² = 0.187) and baseline 24-h diastolic BP (ß = -0.459, adjusted r² = 0. 199) accounted for 38.6% (p = 0.008) of the 24-h diastolic BP response to exercise training. In conclusion, the magnitude of the BP response to acute exercise appears to predict the ambulatory BP response to exercise training among patients with resistant hypertension.

Exercise Enhances Branched-Chain Amino Acid Catabolism and Decreases Cardiac Vulnerability to Myocardial Ischemic Injury

Long-term exercise-induced metabolic adaptations occupy a central position in exercise-afforded cardiac benefits. Emerging evidence suggests that branched-chain amino acid (BCAA) catabolic defect contributes to cardiac dysfunction in multiple cardiometabolic diseases. However, the role of BCAA catabolism in exercise-afforded cardiac benefits remains unknown. Here, we show that exercise improves BCAA catabolism and thus reduce cardiac vulnerability to myocardial ischemic injury. Exercise increased circulating BCAA levels in both humans (male adolescent athletes) and mice (following an 8-week swimming intervention). It increased the expression of mitochondrial localized 2C-type serine-threonine protein phosphatase (PP2Cm), a key enzyme in regulating BCAA catabolism, and decreased BCAA accumulation in mouse hearts, indicating an increase in BCAA catabolism. Pharmacological promotion of BCAA catabolism protected the mouse heart against myocardial infarction (MI) induced by permanent ligation of the left descending coronary artery. Although cardiac-specific PP2Cm knockout showed no significant effects on cardiac structural and functional adaptations to exercise, it blunted the cardioprotective effects of exercise against MI. Mechanistically, exercise alleviated BCAA accumulation and subsequently inactivated the mammalian target of rapamycin in MI hearts. These results showed that exercise elevated BCAA catabolism and protected the heart against myocardial ischemic injury, reinforcing the role of exercise in the promotion of cardiac health.

Physical Exercise in Resistant Hypertension: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Physical exercise reduces blood pressure (BP) in patients with hypertension in general but more evidence is needed specifically for a high-risk phenotype associated with intensive medication, resistant hypertension (RH). In this systematic review and meta-analysis, we aimed to summarize current evidence of the exercise effects on BP in patients with RH. A systematic search was conducted in PubMed, Web of Science and Cochrane Library (from inception to 3rd November, 2021). A random effects meta-analysis was performed when at least two trials assessed the effect of either acute or regular exercise (vs. a control condition) on the same outcome. Ten studies (N = 380 participants; 51% female; mean age 52 to 67 years) were included in the review, of which four (N = 58) and six (N = 322) assessed the effects of acute and regular exercise, respectively. Evidence overall suggests that a single bout of acute exercise results in a short-term (≤ 24 h) reduction of BP, although no meta-analysis could be performed. As for regular exercise, three randomized controlled trials (N = 144, 50% female) could be meta-analyzed, which showed that exercise training intervention (8-12 weeks, 3 sessions/week) significantly reduces 24-h (-9.9 mmHg, 95% confidence interval -15.4-4.4 for systolic BP; and -5 mmHg, -7.0-3.0 for diastolic BP) and daytime ambulatory BP (-11.7 mmHg, -17.8-5.7; and -7.4 mmHg, -11.9-2.9). In summary, physical exercise appears as an effective option to reduce BP in patients with RH, although more research is needed to confirm these findings as well as to determine the most effective exercise characteristics.

Effectiveness of Physical Activity and Exercise on Ambulatory Blood Pressure in Adults with Resistant Hypertension: A Systematic Review and Meta-Analysis

INTRODUCTION

Resistant hypertension (RHT) is a phenotype of hypertension that is challenging to manage by medications alone. While high grade evidence supports physical activity (PA) and exercise to reduce blood pressure (BP) in hypertension, it is unclear whether these are also effective for RHT.

AIMS

To determine the quality of evidence for the effectiveness of PA and exercise and the change of magnitude of 24-hour ambulatory BP (24hABP) in adults with RHT.

METHODS

Scopus, MEDLINE, CINHAL, Web of Science, Embase and SPORTDiscus databases were searched. Cochrane risk of bias tools, Review Manager and Grading of the Recommendation Assessment, Development and Evaluation were used to assess the methodological quality, the clinical heterogeneity and quality of the evidence.

RESULTS

Four studies comprising 178 individuals in total were included. A meta-analysis with random effects showed decreased 24hABP. The experimental group demonstrated grater mean differences for 24hABP following the PA and exercise programmes (systolic - 9.88 mmHg, 95% CI: - 17.62, - 2.14, I2 = 72%, p = 0.01; diastolic - 6.24 mmHg, 95% CI: - 12.65, 0.17, I2 = 93%,p = 0.06); and aerobic exercise (systolic - 12.06 mmHg, 95% CI: - 21.14, - 2.96, I2 = 77%, p = 0.009, diastolic - 8.19 mmHg, 95% CI: - 14.83, - 1.55, I2 = 92% ,p = 0.02). In the included studies, indirectness and publication bias were 'moderate' while inconsistency and imprecision were rated as 'low'. Thus, the overall quality of the evidence was considered to be 'low'.

CONCLUSIONS

Low certainty evidence suggests that PA and aerobic exercise added to usual care may be more effective in 24hABP reduction in RHT than usual care alone.

REGISTRATION

PROSPERO-2019 CRD42019147284 (21.11.2019).

Cardiovascular Autonomic Responses to Aerobic, Resistance and Combined Exercises in Resistance Hypertensive Patients

Here, we report the acute effects of aerobic (AER), resistance (RES), and combined (COM) exercises on blood pressure, central blood pressure and augmentation index, hemodynamic parameters, and autonomic modulation of resistant (RH) and nonresistant hypertensive (NON-RH) subjects. Twenty participants (10 RH and 10 NON-RH) performed three exercise sessions (i.e., AER, RES, and COM) and a control session. Hemodynamic (Finometer®, Beatscope), office blood pressure (BP), and autonomic variables (accessed through spectral analysis of the pulse-to-pulse BP signal, in the time and frequency domain-Fast Fourrier Transform) were assessed before (T0), one-hour (T1), and twenty-four (T2) hours after each experimental session. There were no changes in office BP, pulse wave behavior, and hemodynamic parameters after (T0 and T1) exercise sessions. However, AER and COM exercises significantly reduced sympathetic modulation in RH patients. It is worth mentioning that more significant changes in sympathetic modulation were observed after AER as compared to COM exercise. These findings suggest that office blood pressure, arterial stiffness, and hemodynamic parameters returned to baseline levels in the first hour and remained stable in the 24 hours after the all-exercise sessions. Notably, our findings bring new light to the effects of exercise on RH, indicating that RH patients show different autonomic responses to exercise compared to NON-RH patients. This trial is registered with trial registration number NCT02987452.

Acute Aerobic Exercise Induces Short-Term Reductions in Ambulatory Blood Pressure in Patients With Hypertension: A Systematic Review and Meta-Analysis

[Figure: see text].

Post-exercise hypotension effects in response to plyometric training of 7- to 9-year-old boys with overweight/obesity: a randomized controlled study

BACKGROUND

Physical activity plays an important role on children with obesity. This study evaluated the effects of plyometric training on the anthropometry, body composition, and the blood pressure (BP) and heart rate (HR) of boys with obesity.

METHODS

Boys aged 7 to 9 years old were divided in: non-trained (N.=12) and trained (N.=29). The plyometric training program consisted of jumps on nonconsecutive days for twelve weeks. Anthropometry and body composition, BP and HR were evaluated. BP, HR and rate-pressure product were recorded at rest and 2 minutes after the section. Two-way repeated factors ANOVA was used.

RESULTS

Trained group had a reduction in skinfolds and an increase in free fat mass (within and between-groups) and a large effect size for most anthropometric and body composition variables. Late systolic response was reduced from 122±1.1 (immediately post-exercise at the first week) to 112±1.0 at the end of plyometric training period. Diastolic reduction was seen two minutes after each session of exercise (from 68±1.1 to 62±1.2). HR was reduced in response to plyometric training (108 bpm to 97 bpm).

CONCLUSIONS

Our findings strengthen previous studies that suggest that intense exercise has significant adaptive effects on BP and HR.

Nonpharmacological Management of Resistant Hypertension

PURPOSE OF REVIEW

In the United States (US), 46% of adults have hypertension (systolic blood pressure ≥ 130 mmHg, diastolic blood pressure ≥ 80 mmHg). Approximately, 16% of patients with hypertension have apparent treatment-resistant hypertension (aTRH) and the incidence of true resistant hypertension (RHT) is thought to be much lower (~ 2%). These patients with RHT are at a higher risk for adverse events and worse clinical outcomes.

RECENT FINDINGS

Although lifestyle interventions have proven to be effective as the first line of defense in treating hypertension, their role in the management of patients with RHT is not well established. Despite fewer in number, available studies examining lifestyle interventions in patients with RHT do indeed show promising results. In this review, we aim to discuss the role of common lifestyle interventions such as physical activity, exercise, weight loss, and dietary modifications on blood pressure control in patients with RHT.

Apparent treatment-resistant hypertension among ambulatory hypertensive patients: a cross-sectional study from 13 general hospitals

BACKGROUND/AIMS

To examine the prevalence and clinical characteristics of apparent treatment-resistant hypertension among ambulatory hypertensive patients.

METHODS

We enrolled adult ambulatory hypertensive patients at 13 well-qualified general hospitals in Korea from January to June 2012. Apparent resistant hypertension was defined as an elevated blood pressure > 140/90 mmHg with the use of three antihypertensive agents, including diuretics, or ≥ 4 antihypertensives, regardless of the blood pressure. Controlled hypertension was defined as a blood pressure within the target using three antihypertensives, including diuretics.

RESULTS

Among 16,915 hypertensive patients, 1,172 (6.9%) had controlled hypertension, and 1,514 (8.9%) had apparent treatment-resistant hypertension. Patients with apparent treatment-resistant hypertension had an earlier onset of hypertension (56.8 years vs. 58.8 years, p = 0.007) and higher body mass index (26.3 kg/m2 vs. 24.9 kg/m2, p < 0.001) than those with controlled hypertension. Drug compliance did not differ between groups. In the multivariable analysis, earlier onset of hypertension (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.97 to 0.99; p < 0.001) and the presence of comorbidities (OR, 2.06; 95% CI, 1.27 to 3.35; p < 0.001), such as diabetes mellitus, ischemic heart disease, heart failure, and chronic kidney disease, were independent predictors. Among the patients with apparent treatment-resistant hypertension, only 5.2% were receiving ≥ 2 antihypertensives at maximally tolerated doses.

CONCLUSION

Apparent treatment-resistant hypertension prevalence is 8.9% among ambulatory hypertensive patients in Korea. An earlier onset of hypertension and the presence of comorbidities are independent predictors. Optimization of medical treatment may reduce the rate of apparent treatment-resistant hypertension.

Transcranial direct current stimulation modulates autonomic nervous system and reduces ambulatory blood pressure in hypertensives

Purpose: Transcranial direct current stimulation (tDCS) seems to positively modulate the autonomic nervous system in different clinical conditions and healthy subjects; however, its effects on hypertensive (HTN) patients are not completely known. This study aimed to evaluate the effects of a tDCS or SHAM session (20 min) on blood pressure (BP) and autonomic variables of HTN patients.Materials and Methods: Subjects (n = 13) were randomly submitted to SHAM and tDCS sessions (1 week of washout). Hemodynamic and autonomic variables were measured at baseline, during, and immediately after tDCS or SHAM stimulation (Finometer®, Beatscope). Ambulatory BP measurement (ABPM) was evaluated after the experimental period.Results: Hemodynamic variables were not changed by tDCS, except for the fall in peripheral vascular resistance (Δ = -1696.51 ± 204.65 dyn.s/cm5). After the tDCS, sympathetic modulation was decreased (-61.47%), and vagal modulation was increased (+38.09%). Such acute autonomic changes may have evoked positive results observed in 24 hs-systolic blood pressure (Δ = -8.4 ± 6.2; P = .0022) and 24hs-diastolic blood pressure (Δ = -5.4 ± 4.2; P = .0010) in tDCS subjects compared with that in SHAM.Conclusion: These findings suggest that the tDCS could promote positive acute adjustments on cardiac autonomic control and reduced values on 24-hs BP of HTN patients. More than a proof-of-concept, these results may point out to the future, where brain stimulation (tDCS) can be used to HTN syndromes, such as refractory HTN.

Cardiovascular and Autonomic Responses after a Single Bout of Resistance Exercise in Men with Untreated Stage 2 Hypertension

The aim of this paper is to assess the integrated responses of ambulatory blood pressure (BP), cardiac autonomic modulation, spontaneous baroreflex sensitivity (BRS), and vascular reactivity after a single bout of resistance exercise (RE) in men with stage 2 hypertension who have never been treated before. Ten hypertensive men were subjected to a RE session of three sets of 20 repetitions and an intensity of 40% of the 1-repetition maximum (RM) test in seven different exercises. For the control (CTR) session, the volunteers were positioned on the exercise machines but did not perform any exercise. Forearm blood flow was measured by venous occlusion plethysmography. We also analyzed the heart rate variability (HRV), ambulatory BP, blood pressure variability (BPV), and BRS. All measurements were performed at different timepoints: baseline, 20 min, 80 min, and 24 h after both RE and CTR sessions. There were no differences in ambulatory BP over the 24 h between the RE and CTR sessions. However, the area under the curve of diastolic BP decreased after the RE session. Heart rate (HR) and cardiac output increased for up to 80 and 20 min after RE, respectively. Similarly, forearm blood flow, conductance, and vascular reactivity increased 20 min after RE (p < 0.05). In contrast, HRV and BRS decreased immediately after exercise and remained lower for 20 min after RE. We conclude that a single bout of RE induced an increase in vascular reactivity and reduced the pressure load by attenuating AUC of DBP in hypertensive individuals who had never been treated with antihypertensive medications.

Can respiratory muscle training change the blood pressure levels in hypertension? A systematic review with meta-analysis

The aim was to systematically review randomized controlled trials investigating the effects of respiratory training on blood pressure control in hypertensive individuals. Systematic review with meta-analysis was coducted following the guidelines from PRISMA statement. Searches for randomized controlled trials were performed in four electronic databases (PubMed, Cochrane Library, SCOPUS, and PEDro). Studies were included if they were randomized controlled trials that examined the impact of respiratory training on blood pressure of individuals with systemic arterial hypertension and the patients had no other associated disease. Eight studies were included for final analysis (total of 270 participants; 18-85 years) and presented an average score of 6.25 in the PEDro scale, being considered of high methodological quality. The meta-analysis showed a reduction in systolic and diastolic blood pressure for respiratory training when the load was applied [-15.72 (-18.63; -12.81) and -7.08 (-9.03; -5.13) mmHg, respectively]. There was also a reduction in systolic, but not in diastolic blood pressure when the training was performed without load [-5.08 (-7.49; -2.66) and -1.04 (-2.55; +0.46) mmHg, respectively]. The respiratory training has a positive effect in BP in hypertensive patients, however, only when performed with load seems to be able to promote some beneficial effect on diastolic blood pressure reduction.

Effects of 12 weeks of aerobic versus combined aerobic plus resistance exercise training on short-term blood pressure variability in patients with hypertension

Short-term blood pressure (BP) variability (BPV), measured by 24-h ambulatory BP monitoring (ABPM), has been independently related to a higher risk of cardiovascular events and target organ in hypertensive patients. The aim of this study was to compare the effects of two different exercise modalities on BPV in hypertensive patients enrolled in a cardiac rehabilitation program. This study is a randomized trial, with two intervention arms: 1) aerobic training (AT) and 2) combined aerobic and resistance training (CT). We studied 55 male patients with hypertension. They were randomly assigned either to AT or CT group. The training program lasted 12 wk for each group. Short-term BP variability was evaluated by means of average real variability (ARV), at baseline and after 12 wk, by ABPM. Systolic and diastolic 24-h BP values decreased significantly (P < 0.01) in both groups, without between-groups differences (P = 0.11). The 24-h systolic BP variability decreased in both groups (AT: from 8.4 ± 1.2 to 7.6 ± 0.8; CT: from 8.8 ± 1.5 to 7.1 ± 1.1), with a greater decrease in CT (P = 0.02). Night-time systolic BPV decreased in CT (from 9.4 ± 1.3 to 8.3 ± 1.2, P = 0.03) and remained unchanged in AT (from 9.5 ± 1.2 to 9.4 ± 1.4). Day-time BPV decreased in both groups without between-groups differences (P = 0.07). CT was more effective than AT in reducing short-term BPV in hypertensive patients, and both exercise modalities reduced BP to a same extent. CT appears to be a more appropriate exercise modality if the objective is to reduce BPV in addition to BP levels.NEW & NOTEWORTHY Combined exercise training (CT) including aerobic plus resistance exercises could be more effective in comparison with aerobic exercise (AT) alone in reducing blood pressure variability (BPV) in hypertensive patients. We report that CT was indeed more effective than AT in reducing short-term BPV, and both exercise modalities reduced BP levels to the same extent. CT appears to be a more appropriate exercise modality if the objective is to reduce BPV in addition to BP levels.

Resistant hypertension: new insights and therapeutic perspectives

Resistant hypertension (RH) is a concept that currently goes beyond the classical definition of blood pressure ≥140/90 mmHg in subjects receiving three or more drugs of different classes at maximally tolerated doses. Here, we review the clinical relevance of RH and the different types of RH-associated phenotypes, namely refractory hypertension, controlled resistant hypertension, and masked uncontrolled hypertension. We also discuss current drug strategies and future treatments for these high-risk phenotypes.

Combined Aerobic and Resistance Exercises Evokes Longer Reductions on Ambulatory Blood Pressure in Resistant Hypertension: A Randomized Crossover Trial

Aim

The present study compared the acute effects of aerobic (AER), resistance (RES), and combined (COM) exercises on blood pressure (BP) levels in people with resistant hypertension (RH) and nonresistant hypertension (NON-RH).

Methods

Twenty patients (10 RH and 10 NON-RH) were recruited and randomly performed three exercise sessions and a control session. Ambulatory BP was monitored over 24 hours after each experimental session.

Results

Significant reductions on ambulatory BP were found in people with RH after AER, RES, and COM sessions. Notably, ambulatory BP was reduced during awake-time and night-time periods after COM. On the other hand, the effects of AER were more prominent during awake periods, while RES caused greater reductions during the night-time period. In NON-RH, only RES acutely reduced systolic BP, while diastolic BP was reduced after all exercise sessions. However, the longest postexercise ambulatory hypotension was observed after AER (~11 h) in comparison to RES (~8 h) and COM (~4 h) exercises.

Conclusion

Findings of the present study indicate that AER, RES, and COM exercises elicit systolic and diastolic postexercise ambulatory hypotension in RH patients. Notably, longer hypotension periods were observed after COM exercise. In addition, NON-RH and RH people showed different changes on BP after exercise sessions, suggesting that postexercise hypotension is influenced by the pathophysiological bases of hypertension.

Effect of High-velocity Resistance Exercise on 24-h Blood Pressure in Hypertensive Older Women

This study investigated the acute post-exercise effect of high-velocity resistance exercise on ambulatory blood pressure in hypertensive older women. Fourteen volunteers (67.9±5.1 years) performed a high-velocity resistance exercise session (8 exercises using Thera-Band, 3 sets of 6 repetitions as fast as possible in the concentric phase with moderate intensity) and a control session, separated by a 7-10-day period. Ambulatory blood pressure was monitored following 12-h post-sessions and compared between conditions at 1 to 4-h, 5 to 8-h, and 9 to 12-h. Average 24-h ambulatory blood pressure, awake, asleep periods, and blood pressure load were also analyzed. There was a condition by time interaction for systolic ambulatory blood pressure over 12-h post-sessions (P=0.043). It was observed a lower systolic ambulatory blood pressure in the first 4-h period following the high-velocity resistance exercise session compared to the control session (-6.7 mmHg, 95% CI  - 11.6 to -1.8 mmHg; P=0.011). No changes were observed for diastolic ambulatory blood pressure over 12-h post-sessions as well as for the other variables analyzed (P>0.05). In summary, a single high-velocity resistance exercise session elicits a post-exercise antihypertensive effect and may be considered as a strategy to acutely improve blood pressure control in hypertensive older women.

Exercise, Cardiovascular Health, and Risk Factors for Atherosclerosis: A Narrative Review on These Complex Relationships and Caveats of Literature

The following narrative review addresses the relationship between physical activity and exercise with cardiovascular health, focusing primarily on the following risk factors for atherosclerosis: hypertension, dyslipidemia, and vascular function. Cardiovascular diseases are intimately associated with mortality and morbidity, and current societal organization contributes to the incidence of cardiovascular events. A worldwide epidemiological transition to cardiovascular deaths was observed in the last century, with important decrements in physical activity and diet quality. An atherogenic environment started to be the new normal, with risk factors such as dyslipidemia, hypertension, and endothelial dysfunction observed in great portions of the population. Exercise is an important tool to improve overall health. For hypertension, a great amount of evidence now puts exercise as an effective therapeutic tool in the treatment of this condition. The effects of exercise in modifying blood lipid-lipoprotein are less clear. Despite the rationale remaining solid, methodological difficulties impair the interpretation of possible effects in these variables. Vascular function, as assessed by flow-mediated dilatation, is a good measure of overall vascular health and is consistently improved by exercise in many populations. However, in individuals with hypertension, the exercise literature still needs a further description of possible effects on vascular function variables. Physical activity and exercise are associated with improved cardiovascular health, especially with reduced blood pressure, and should be encouraged on the individual and population level. Evidence regarding its effects on blood lipids and flow-mediated dilatation still need solid landmark studies to guide clinical practice.

The effect of community pharmacist-led health coaching on clinical outcomes

OBJECTIVE

To evaluate the impact of a community pharmacist-driven health coaching program on clinical outcomes from baseline to 1 year.

SETTING

Independent community pharmacy in western North Carolina.

PRACTICE DESCRIPTION

Sona Pharmacy + Clinic is an independent community pharmacy offering enhanced clinical services such as medication synchronization, adherence packaging, and free delivery. Sona Benefits offers pharmacy benefit manager (PBM) services to self-funded plans in western North Carolina.

PRACTICE INNOVATION

Sona Health Management Program is a disease management program offered to Sona Benefits PBM clients; the services began in October 2016.

EVALUATION

Change in clinical outcome measures (total number of medications, blood pressure, hemoglobin A1c, weight, low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C], triglycerides [TG], patient health questionnaire [PHQ-9] scores, and asthma control test [ACT] scores) were assessed for members who participated in the program for a minimum of 12 months for at least 2 of the following conditions: hypertension, hyperlipidemia, diabetes, depression, and asthma.

RESULTS

Health coaching was provided to 42 members (mean age of 55.9 years and 2.7 qualifying disease states). The mean number of medications per patient significantly decreased from 7.2 to 6.2 (P = 0.02). Systolic and diastolic blood pressures were significantly reduced from 130.8 mm Hg to 125.7 mm Hg (P = 0.04) and 76.9 mm Hg to 73.7 mm Hg (P = 0.04), respectively. Other clinical outcome measures evaluated, such as hemoglobin A1c, weight, LDL-C, HDL-C, TG, and PHQ-9 and ACT scores, were improved but did not reach significance.

CONCLUSION

These results suggest that community pharmacists can have a positive impact on patients with multiple chronic conditions through health coaching services. This project suggests a potential model of pharmacist health coaching through pharmacist-run PBM services.

Post-exercise hypotension in concurrent training: a systematic review

Abstract Physical exercise is capable to reduce blood pressure (BP) acutely in a phenomenon described as post-exercise hypotension (PEH). However, the acute effect of concurrent training on PEH needs clarification. The present review aimed to verify and summarize the acute effect of concurrent training on PEH in normotensive and hypertensive subjects. The search was carried out in the databases PubMed, Scielo, and Lilacs, and resulted in 3806 articles. Only 14 studies met the eligibility criteria and were selected. According to included studies, concurrent training can promote PEH regardless of the order, volume, and intensity prescribed, being an effective strategy in the control of arterial hypertension. There is no consensus in the literature regarding the best prescription strategy, as well as the order of execution of the types of exercise.

Impact of therapeutic lifestyle changes in resistant hypertension

Hypertensive individuals are at an increased risk of developing heart disease and stroke. Adopting healthy lifestyles, such as being active on ≥4 days per week, weight-loss in the presence of obesity, consuming a diet rich in fruits and vegetables, and sodium below the recommended threshold, avoiding high alcohol consumption and refraining from smoking have been effective lifestyle therapies to prevent or control stage 1 hypertension (HTN). Among the 1 in 3 Americans who have HTN (systolic blood pressure ≥ 130 mmHg or diastolic blood pressure ≥ 80 mmHg), 16% are diagnosed with resistant HTN (RHT). Although there are comparatively fewer studies examining the blood pressure lowering effects of therapeutic lifestyle interventions in patients with resistant HTN, the available literature appears promising. This paper reviews key studies that quantify the blood pressure lowering effects of certain therapeutic lifestyles in patients with RHT and highlights areas needing more attention.

Role of the Balance of Akt and MAPK Pathways in the Exercise-Regulated Phenotype Switching in Spontaneously Hypertensive Rats

The mechanisms regulating vascular smooth muscle cell (VSMC) phenotype switching and the critical signal modulation affecting the VSMCs remain controversial. Physical exercise acts as an effective drug in preventing elevated blood pressure and improving vascular function. This study was designed to explore the influence of aerobic exercise on the suppression of VSMC phenotype switching by balancing of the Akt, also known as PKB (protein kinase B) and mitogen-activated protein kinase (MAPK) signaling pathways. Spontaneously hypertensive rats (SHRs) and normotensive rats were subjected to exercise treatment before measuring the vascular morphological and structural performances. Exercise induced reverse expression of VSMC protein markers (α-SM-actin, calponin, and osteopontin (OPN)) in spontaneously hypertensive rats. It is noteworthy that the low expression of phosphorylated Akt significantly decreased the expression of VSMC contractile phenotype markers (α-SM-actin and calponin) and increased the expression of the VSMC synthetic phenotype marker (OPN). However, the MAPK signal pathway exerts an opposite effect. VSMCs and whole vessels were treated by inhibitors, namely the p-Akt inhibitor, p-ERK inhibitor, and p-p38 MAPK inhibitors. VSMC phenotype markers were reversed. It is important to note that a significant reverse regulatory relationship was observed between the expression levels of MAPK and the contractile markers in both normotensive and spontaneously hypertensive rats. We demonstrate that aerobic exercise regulates the VSMC phenotype switching by balancing the Akt and MAPK signaling pathways in SHRs.

Resistant Hypertension Updated Guidelines

PURPOSE OF REVIEW

To discuss the current definition as well as recommendations for diagnosis and treatment of resistant hypertension (RH) based on the 2018 American Heart Association (AHA) guidelines and recent literature.

RECENT FINDINGS

RH is defined as uncontrolled blood pressure (BP) on ≥ 3 anti-hypertensives, one of which should be a diuretic, prescribed at maximally tolerated doses and appropriate dosing frequency. The diagnosis of RH requires exclusion of white coat effect and medication non-adherence, underscoring the importance of out-of-office BP measurements. Secondary causes of hypertension must be excluded in all patients with RH. A step-wise approach to treatment focusing on lifestyle modifications and medication optimization can be effective in > 50% of the patients with RH. Device-based interventional therapies for RH are currently investigational. Out-of-office BP measurements are central to the diagnosis of RH. Medication optimization is successful in most patients. Further studies are needed to define the role of device-based interventions.

Acute antihypertensive effect of self-selected exercise intensity in older women with hypertension: a crossover trial

PURPOSE

Acute reduction in blood pressure (BP) following an exercise session is evidenced in controlled settings with formal supervision in hypertensive older populations. This study investigated the effect of a self-selected exercise (SSE)-intensity session on ambulatory BP in hypertensive older women in a "real-world" setting.

METHODS

Twenty inactive older women with hypertension (64.9±4.5 years) were included in this randomized, controlled, crossover trial. After baseline assessments, participants performed 30 minutes of an SSE-intensity session on an outdoor track and a control session, separated by 7-10 days. Heart rate (HR), rating of perceived exertion (RPE), and affective response were assessed. Ambulatory BP was monitored for 20 hours following both sessions. Paired t-tests and generalized estimation were used for data analysis.

RESULTS

Participants exercised at 5.1±1.1 km/h, spent ~90% of the exercise time at moderate-vigorous intensity (≥40% of heart rate reserve). SSE-intensity session was reported as light (RPE 11.0±1.5) and pleasant (affect 3.4±1.2). SSE-intensity session elicited reductions in systolic BP in the first 6 hours postexercise (6.0 mmHg, CI 2.7-9.3 mmHg; P<0.001). Average systolic BP in the 20-hour (-3.4 mmHg, CI -5.9 to -0.9 mmHg; P=0.010) and awake (-4.0 mmHg, CI -6.4 to -1.6 mmHg; P=0.003) periods were lower following SSE-intensity session compared to control session. No differences were observed in average systolic BP during asleep period and diastolic BP during the 20-hour awake and asleep periods between the SSE-intensity session and control session (P>0.05).

CONCLUSION

An SSE-intensity session elicited a reduction in ambulatory systolic BP in inactive older women with hypertension during awake and 20-hour periods. Also, the SSE-intensity session was reported as light and pleasant.

Cardiac remodeling after six weeks of high-intensity interval training to exhaustion in endurance-trained men

High-intensity interval training (HIIT) improves physical performance of endurance athletes, although studies examining its cardiovascular effects are sparse. We evaluated the impact of HIIT on blood pressure, heart rate, and cardiac cavities' size and function in endurance-trained adults. Seventeen endurance-trained men underwent 24-h ambulatory blood pressure monitoring and Doppler echocardiography at baseline and after 6 wk of HIIT. Participants were divided into 2 groups [85% maximal aerobic power (HIIT₈₅), n = 8 and 115% maximal aerobic power (HIIT₁₁₅), n = 9] to compare the impact of different HIIT intensities. Ambulatory blood pressure monitoring and cardiac chambers' size and function were similar between groups at baseline. HIIT reduced heart rate (55 ± 8 vs. 51 ± 7 beats/min; P = 0.003), systolic blood pressure (121 ± 11 vs. 118 ± 9 mmHg; P = 0.01), mean arterial pressure (90 ± 8 vs. 89 ± 6 mmHg; P = 0.03), and pulse pressure (52 ± 6 vs. 49 ± 5 mmHg; P = 0.01) irrespective of training intensity. Left atrium volumes increased after HIIT (maximal: 50 ± 14 vs. 54 ± 14 mL; P = 0.02; minimal: 15 ± 5 vs. 20 ± 8 mL; P = 0.01) in both groups. Right ventricle global longitudinal strain lowered after training in the HIIT₈₅ group only (20 ± 4 vs. 17 ± 3%, P = 0.04). In endurance-trained men, 6 wk of HIIT reduced systolic blood pressure and mean arterial pressure and increased left atrium volumes irrespective of training intensity, whereas submaximal HIIT deteriorated right ventricle systolic function.NEW & NOTEWORTHY The novel findings of this study are that 6 wk of high-intensity interval training increases left atrial volumes irrespective of training intensity (85 or 115% maximal aerobic power), whereas the submaximal training decreases right ventricular systolic function in endurance-trained men. These results may help identify the exercise threshold for potential toxicity of intense exercise training for at-risk individuals and ideal exercise training regimens conferring optimal cardiovascular protection and adapted endurance training for athletes.

Exercise as a tool for hypertension and resistant hypertension management: current insights

Although there has been an observed progress in the treatment of hypertension, its prevalence remains elevated and constitutes a leading cause of cardiovascular disease development. Resistant hypertension is a challenge for clinicians, as the available treatment options have reduced success. Physical activity and exercise training play an important role in the management of blood pressure. The importance of physical activity and exercise training as part of a comprehensive lifestyle intervention is acknowledged by several professional organizations in their recommendations/guidelines for the management of arterial hypertension. Aerobic exercise, dynamic resistance exercise, and concurrent training - the combination of dynamic resistance and aerobic exercise training in the same exercise session or on separate days - has been demonstrated to reduce blood pressure and help in the management of hypertension. The present review draws attention to the importance of exercise training in the management of blood pressure in both hypertension and resistant hypertension individuals.

Effects of ninety minutes per week of continuous aerobic exercise on blood pressure in hypertensive obese humans

The main objective of this study was to examine the effect of continuous aerobic training (CAT) in hypertensive, obese people. Seven patients of average age (45.3±3.9 years), height (1.63±0.1 m), body weight (89.09±22.0 kg), and body mass index (33.44±8.6 kg/m2) were subjected to the training. CAT was performed in thrice-weekly nonconsecutive sessions (90 min per week) with intervals of 48 hr between each session. The training sessions entailed 30 min of walking at an intensity of 70%–80% of the maximum heart rate (MHR) on a treadmill over a period of eight weeks, giving a total of 24 sessions. Through correlation analyses, we found significant improvement in the systolic pressure (R=0.5675, P=0.0253) and diastolic pressure (R=0.7083, P=0.0088) when the last session was compared to the first session of training. We found no differences in the diastolic pressure and systolic pressure before, during and after 15 min of the protocol exercise. The program showed a large effect size (ES) for systolic pressure (ES=0.85) and a small ES for diastolic pressure (ES=0.33). We found no differences in the blood pressure (BP) and heart rate (HR) during and after the training of obese hypertensive humans, but we found a positively significant correlation between HR and BP in the last session and a large ES, suggesting that this protocol exercise might have significance effect in the long term.

Cross-Sectional and longitudinal associations of objectively-measured physical activity on blood pressure: evaluation in 37 countries

Background: We examined the cross-sectional and longitudinal associations of objectively-measured physical activity (step counts) and blood pressure (BP) among adults spanning 37 countries.

Methods: Across 37 countries, we used data from a pool of 9238 adult owners of Withings’ Pulse activity trackers, which measures steps taken each day, and Wireless Blood Pressure Monitor, which measures BP. Analyses were adjusted on age, sex, number of days where the tracker was worn, and number of BP measurements. Data was collected from 2009 to 2013.

Results: Subjects had a mean ± standard deviation (SD) age of 51.6 ± 11.3 years and a body mass index (BMI) of 28.7±5.5 kg/m². A 1-month increase of more than 3000 steps per day was associated with a decrease of systolic BP (SBP) and diastolic BP (DBP) among the obese (1.57mm Hg and 1.29 mm Hg respectively, both P<0.001) and the overweight population (0.79 mm Hg and 0.84 mm Hg respectively, both P≤0.001), but not in the normal weight population (P=0.60 and P=0.36 respectively).

Conclusion: One-month increases in daily step counts was associated with a decrease of SBP and DBP in a large obese and overweight free living population.

Postexercise hypotension during different water-based concurrent training intrasession sequences in young women

The purpose of the study was to compare the acute effects of water-based resistance-aerobic (RA) and aerobic-resistance (AR) sequences on systolic blood pressure, diastolic blood pressure (DBP), and mean blood pressure (MBP) in young women. Thirteen active women participated in four sessions: (1) exercises familiarization, (2) aquatic maximal test to determine the heart rate (HR) corresponding to the anaerobic threshold (HR_AT), (3) concurrent protocol RA, and (4) concurrent protocol AR. Both protocols were initiated with the blood pressure measurements at rest in supine position. After that, either RA or AR concurrent protocol was performed. At the end of both protocols, blood pressure was measured throughout 60 minutes (every 10 minutes). The water-based resistance protocol was made up by exercises at maximal velocity, and the water-based aerobic protocol was performed at ±5 bpm of HR_AT continuously. Two-way analysis of variance with repeated measures was used to analyze the data (α = 0.05). There was no hypotensive effect on systolic blood pressure among the time points (P = .235) in both water-based intrasession exercise sequences (P = .423). Regarding the DBP and MBP, both intrasession exercise sequences presented similar (DBP: P = .980; MBP: P = .796) hypotensive effects in the first 10 minutes (DBP: P = .003; MBP: P = .008) at the end of RA and AR sessions (DBP: -4 vs. -13 mm Hg; MBP: -3 vs. -10 mm Hg). It was concluded that both RA and AR water-based concurrent training sessions resulted in postexercise hypotension (DBP and MBP) in normotensive young women.

Acute and chronic effects of aerobic exercise on blood pressure in resistant hypertension: study protocol for a randomized controlled trial

BACKGROUND

Resistant hypertension is a specific condition that affects approximately 10% of subjects with hypertension, and is characterized by persistently high blood pressure levels even using therapy of three or more antihypertensive agents or with blood pressure control using therapy with four or more antihypertensive agents. Changes in lifestyle, such as physical exercise, are indicated for controlling blood pressure. However, investigating studies about this therapy in individuals with resistant hypertension are few.

METHODS/DESIGN

This is a randomized controlled clinical trial. Forty-eight patients with resistant hypertension will be submitted to perform four short-term interventions: aerobic exercise sessions (mild-, moderate- and high-intensity) and control session, in random order and on separate days. After the short-term sessions, the patients will be randomly allocated into four groups for 8 weeks of follow-up: mild-, moderate- and high-intensity aerobic exercise, and a control group. The primary outcome is the occurrence of blood pressure reduction (office and ambulatory analysis, and acute and chronic effects). Secondary outcomes are autonomic and hemodynamic mechanisms: cardiac and vasomotor autonomic modulation, spontaneous baroreflex sensitivity, forearm blood flow and vascular resistance.

DISCUSSION

The importance of exercise for hypertension has been known for decades, but little is known about the effects on patients with resistant hypertension. This study will help to understand whether different aerobic exercise intensities can induce different responses, as well as by what mechanisms adjustments in blood pressure levels may occur.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02670681 . Registered on 28 January 2016 (first version); Brazilian Registry Platform Clinical Trials: protocol RBR-5q24zh . Registered on 24 June 2015.

Neurohumoral and Endothelial Responses to Heated Water-Based Exercise in Resistant Hypertensive Patients

BACKGROUND

The neurohumoral and endothelial responses to the blood pressure (BP) lowering effects of heated water-based exercise (HEx) in resistant hypertension (HT) patients remain undefined.Methods and Results:We investigated these in 44 true resistant HT patients (age 53.3±0.9 years, mean±SEM). They were randomized and allocated to 2 groups, 28 to a HEx training protocol, which consisted of callisthenic exercises and walking in a heated pool for 1 h, three times weekly for 12 weeks and 16 patients to a control group maintaining their habitual activities. Measurements made before and after 12 weeks of HEx included clinic and 24-h BP, plasma levels of nitric oxide, endothelin-1, aldosterone, renin, norepinephrine and epinephrine, as well as peak V̇O₂, and endothelial function (reactive hyperemia). After 12 weeks of HEx patients showed a significant decrease in clinic and 24-h systolic and diastolic BPs. Concomitantly, nitric oxide increased significantly (from 25±8 to 75±24 μmol/L, P<0.01), while endothelin-1 (from 41±5 to 26±3 pg/mL), renin (from 35±4 to 3.4±1 ng/mL/h), and norepinephrine (from 720±54 to 306±35 pg/mL) decreased significantly (P<0.01). Plasma aldosterone also tended to decrease, although not significantly (from 101±9 to 76±4 pg/mL, P=NS). Peak V̇O₂increased significantly after HEx (P<0.01), while endothelial function was unchanged. No significant change was detected in the control group.

CONCLUSIONS

The BP-lowering effects of HEx in resistant HT patients were accompanied by a significant reduction in the marked neurohumoral activation characterizing this clinical condition.