therapeutic role of exercise in treating hypertension
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Therapeutic role of exercise in treating hypertension. Educational Objectives. To explain the acute blood pressure response to exercise To list the mechanisms by which exercise may improve hypertension To apply exercise guidelines in treating hypertension - PowerPoint PPT PresentationTRANSCRIPT
Therapeutic role of exercise in treating hypertension
Educational ObjectivesTo explain the acute blood pressure
response to exerciseTo list the mechanisms by which exercise
may improve hypertensionTo apply exercise guidelines in treating
hypertensionTo prescribe appropriate drug therapy for
active hypertensive patients
Overview of HypertensionHigh BP is a risk factor for stroke, CHF,
angina, renal failure, …Hypertension clusters with hyperlipidemia,
diabetes and obesityDrugs have been effective in treating high
BP but because of their side effects and cost, non-pharmacologic alternatives are attractive
Classification of Blood Pressure
Blood Pressure Category Systolic DiastolicOptimal <120 <80Normal <130 <85High Normal 130-139 85-89Hypertension Stage 1 (Mild) 140-159 90-99 Stage 2 (Moderate) 160-179 100-109 Stage 3 (Severe) > 180 > 110
Pathophysiology of Hypertension
High blood pressure is also associated with obesity, salt intake, low potassium intake, physical inactivity, heavy alcohol use and psychological stress
Intra-abdominal fat and hyperinsulinemia may play a role in the pathogenesis of hypertension
Prevalence of Other Risk Factors With Hypertension
Risk Factor PercentSmoking 35LDL Cholesterol >140 mg/dl 40HDL Cholesterol < 40 mg/dl 25Obesity 40Diabetes 15Hyperinsulinemia 50Sedentary lifestyle >50
Cardiovascular Consequences of Hypertension
Individuals with BP > 160/95 have CAD, PVD & stroke that is 3X higher than normal
HTN may lead to retinopathy and nephropathy
HTN is also associated with subclinical changes in the brain and thickening and stiffening of small blood vessels
Cardiovascular Consequences of Hypertension
Increased cardiac afterload leads to left ventricular hypertrophy and reduced early diastolic filling
Increased LV mass is positively associated with CV morbidity and mortality independent of other risk factors
High BP also promotes coronary artery calcification, a predictor of sudden death
Hypertension & CVD Outcomes
Increased BP has a positive and continuous association with CV events
Within DBP range of 70-110 mm Hg, there is no threshold below which lower BP does not reduce stroke and CVD risk
A 15/6 mm Hg BP reduction reduced stroke by 34% and CHD by 19% over 5 years
Lifestyle Changes for Hypertension
Reduce excess body weight Reduce dietary sodium to < 2.4 gms/dayMaintain adequate dietary intake of potassium,
calcium and magnesiumExercise moderately each dayEngage in meditation or relaxation dailyCessation of smoking
Blood Pressure classificationBlood Pressure Stage (mm Hg)
Risk Group A No major risk factors No TOD/CCD
Risk Group B At least one major risk factor, not including DM No TOD/CCD
Risk Group C TOD/CCD and/or DM, with or without other risk factors
High-Normal BP 130-139/85-89
Lifestyle Modification
Lifestyle Modification
Medication Lifestyle Modification
Stage 1 HTN 140-159/90-99
Lifestyle Modification (up to 12 mo)
Lifestyle Modification (up to 6 mo)
Medication Lifestyle Modification
Stage 2,3 HTN 160/100
Medication Lifestyle Modification
Medication Lifestyle Modification
Medication Lifestyle Modification
Medical Therapy and Implications for Exercise Training
Pharmacologic and nonpharmocologic treatment can reduce morbidity
Some antihypertensive agents have side-effects and some worsen other risk factors
Exercise and diet improve multiple risk factors with virtually no side-effects
Exercise may reduce or eliminate the need for antihypertensive medications
Acute BP Response to Exercise
Exaggerated BP Response to Exercise
Among normotensive men who had an exercise test between 1971-1982, those who developed HTN in 1986 were 2.4 times more likely to have had an exaggerated BP response to exercise
Exaggerated BP response increased future hypertension risk by 300% after adjusting for all other risk factors
Exaggerated BP Response to Exercise
Exaggerated BP was change from rest in SBP >60 mm Hg at 6 METs; SBP > 70 mm Hg at 8 METs; DBP > 10 mm Hg at any workload.
Subjects in CARDIA study with exaggerated exercise BP were 1.7 times more likely to develop HTN 5 years later
J Clin Epidemiol 51 (1): 1998
NIH Consensus Conference on Physical Activity and CV Health (1995)
Review of 47 studies of exercise and HTN70% of exercise groups decreased SBP by an
avg. of 10.5 mm Hg from 15478% of subjects decreased DBP by an avg. of
8.6 mm Hg from 98Only 1 study showed increased BP w/ EXBeneficial responses are 80 times more
frequent than negative responsesHagberg, J., et.al., NIH, 1995: 69-71
The Pedometera small device worn
at the waist that counts steps
used successfully in obesity studies
PA - A Fountain of YouthPhysical inactivity is a primary risk
factorHarvard Study:
Patient Education Tool
Possible Mechanisms of BP Reduction with Exercise
Reduced visceral fat independent of changes in body weight or BMI
Altered renal function to increase elimination of sodium leading to reduce fluid volume
Anthropomorphic parameters may not be primary mechansims in causing HTN
Possible Mechanisms of BP Reduction with Exercise
Lower cardiac output and peripheral vascular resistance at rest and submaximal exercise Decreased HR Decreased sympathetic and increased
parasympathetic tone Lower blood catecholamines and plasma
renin activity
Antihypertensive & Volume Depleting Effects of Mild Exercise on Essential HTN
Exercise Prescriptions for Patients With Borderline-to-Moderate Hypertension
Patient evaluation
Look for lipid disorders, DM, retinopathy, neuropathy, PVD, renal insufficiency, LV dysfunction, silent MI/ischemia osteoarthritis, osteoporosis
Exercise testing GXT with modified Naughton protocol, R/O asymptomatic ischemic CAD, radionuclide
Exercise type Aerobic, low-impact activities: walking, biking, swimming, tai chi, stepper, treadmill walking
Exercise Prescriptions for Patients With Borderline-to-Moderate Hypertension
Frequency 5 days/week as a minimum
Intensity Start at 50-60% maximum HRR & slowly increase to 70%; within 6 weeks work at 85% HRR or from 50-90% of maximal heart rate
Duration Start with 20-30 min/day of continuous activity for first 3 wk, then 30-45 min/day for next 4-6 wk, and 60 min/day as maintenance
Exercise Prescriptions for Patients With Borderline-to-Moderate Hypertension
Excessive rises in blood pressure should be avoided during exercise (SBP > 230 mm Hg; DBP > 110 mm Hg). Restrictions on participation in vigorous exercise should be placed on patients with left ventricular hypertrophy.
Weight TrainingResistive exercise produces the most striking
increases in BPResistive exercise results in less of a HR
increase compared with aerobic exercise and as a result the “rate pressure product” may be less than aerobic exercise
Assessment of BP response by handgrip should be considered in patients w/ HTN
Growing evidence that resistive training may be of value for controlling BP
Beta-blocker therapy and exercise
Non-selective Beta-blockers may increase a patient’s disposition to exertional hyperthermia. So patients should adhere strictly to guidelines for fluid replacement
Patients should use fluid replacement drinks with low concentrations of K+ to avoid the risk of hypokalemia
Gordon, N.F., Am J Cardiol 55: 74-78,1985
SUMMARYPhysical activity has a therapeutic role in
the treatment of hypertensionNo consistent relationship between
reduced weight and lower BPExercise at lower intensities is effective in
treating mild to moderate hypertensionExercise testing may help identify
exaggerated BP responses to exercise
SUMMARYExercise prescription for HTN should be
based on medical hx and risk factor statusExercise prescription should be adapted
to antihypertensive medications that may affect exercise HR, BP & performance
Incorporating resistive training into the exercise prescription may be of value for controlling blood pressure
ReferencesChintanadilok, J., Exercise in Treating Hypertension, PhysSports Med
30: 11-23, 2002Urata, H., Antihypertensive and Volume-Depleting Effects of Mild
Exercise on Essential Hypertension, Hypertension 9: 245-52, 1987.Tanabe, Y., Changes in Serum Concentration of Taurine and Other
Amino Acids in Clinical Antihypertensive Exercise Therapy, Clin and Exper Hyper A11: 149-165, 1989.
American College of Sports Medicine, Physical Activity, Physical Fitness and Hypertension, Med Sci Sports Exerc 25: i - x , 1993.
ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, Baltimore, Williams & Wilkins, p. 275-280, 1998.