|Year : 2020 | Volume
| Issue : 1 | Page : 1-7
Effectiveness of physical activity in the prevention and treatment of hypertension: A mini review
Chidiebere Emmanuel Okechukwu
Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
|Date of Submission||29-Sep-2019|
|Date of Decision||23-Nov-2019|
|Date of Acceptance||26-Dec-2019|
|Date of Web Publication||19-Jun-2020|
Chidiebere Emmanuel Okechukwu
Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome
Source of Support: None, Conflict of Interest: None
Physical activity (PA) is associated with a clear decrease in blood pressure (BP) and cardiovascular mortality in both men and women. The aim of this review was to evaluate the effectiveness of PA as an adjunct therapy in support of the prevention and pharmacological treatment of hypertension. Studies that reported on the correlation of PA and exercise on BP control among hypertensive patients from 1994 to 2019 were evaluated. PubMed electronic database was utilized. The MeSH system was used to extract relevant research studies from PubMed using the following keywords: “Exercise,” “training,” “hypertension,” “blood pressure,” “systematic review,” and “meta-analysis,” All selected articles were published in English. Sedentariness negatively affects cardiometabolic health, body composition, and BP among hypertensive patients, whereas PA significantly improves cardiometabolic parameters and body composition and leads to an overall improvement in cardiac parasympathetic system by increasing vagal tone, causing a reduction in resting heart rate, and systolic BP in hypertensive adults. Exercise should be tailored according to patient's clinical and functional status to avoid imposing variable internal training load on the patients. Moderate intensity aerobic, isometric and dynamic resistance exercise training alone, or a combination was equally effective in lowering BP among hypertensive adults.
Keywords: Cardiometabolic diseases, exercise training, hypertension, physical activity
|How to cite this article:|
Okechukwu CE. Effectiveness of physical activity in the prevention and treatment of hypertension: A mini review. CHRISMED J Health Res 2020;7:1-7
|How to cite this URL:|
Okechukwu CE. Effectiveness of physical activity in the prevention and treatment of hypertension: A mini review. CHRISMED J Health Res [serial online] 2020 [cited 2020 Oct 26];7:1-7. Available from: https://www.cjhr.org/text.asp?2020/7/1/1/286893
| Introduction|| |
Physical activity (PA) is associated with a clear decrease in cardiovascular and all-cause mortality in both men and women. Being physically active reduces the risk of all-cause mortality, and the major advantage in chronic disease prevention was found in progressing from sedentary to low-intensity levels of PA. A dose of moderate-to-vigorous-intensity PA below recent recommendations reduced mortality in older adults, an additional upsurge in PA dose enhanced these benefits, and older adults should be encouraged to include even low doses of moderate-to-vigorous-intensity PA in their day-to-day activities in order to prevent cardiovascular diseases.
The American College of Sports Medicine recommends that an adult should accumulate at least 30–60 min/day (≥150 min/week) of moderate-intensity aerobic exercise, 20–60 min/day (≥75 min/week) of vigorous-intensity aerobic exercise, or a combination of moderate- and vigorous-intensity aerobic exercise per day. With respect to resistance training, an adult should train each muscle group for a total of 2–4 sets with 8–12 repetitions per se t, with a rest interval of 2–3 min between the sets to improve muscular fitness. For older adults and deconditioned individuals, ≥1 set of 10–15 repetitions of moderate-intensity (60%–70% one repetition maximum) resistance exercise is recommended.
Hypertension is one of the major risk factors for the development of cardiovascular disease and a significant public health issue globally; research studies have proven that hypertension remains ineffectively managed all over the world, with a fair adherence to blood pressure (BP)-lowering drugs. Hypertension is a key health concern worldwide owing to its detrimental effect on population health; there are limited studies to quantitatively evaluate effective interventions for hypertensive patients.
It was found that endurance, dynamic resistance, and isometric resistance training lowered systolic BP (SBP) and diastolic BP (DBP), whereas combined exercise training was found to lower only DBP; less studies advocate that isometric resistance training reduces SBP. It was also found that resistance training leads to a significant BP reduction; isometric handgrip training leads to a larger reduction in BP than dynamic resistance training, however there was an increase in peak after dynamic resistance training.
Patients with high BP who participated in PA had a decreased risk of cardiovascular mortality, whereas higher risk of mortality was found among physically inactive individuals. Nevertheless, the type of PA, frequency, duration, intensity, and volume, as well as BP stages, were not reliable across numerous investigations; additional investigations are needed to establish the effects of all types of PA on cardiovascular health and whether any differences exist between sexes. Supervised exercise training is effective in improving BP control, lowering low-density lipoprotein-cholesterol, and elevating high-density lipoprotein-cholesterol (HDL-C) levels in persons with Type 2 diabetes mellitus. Aerobic exercise was related to a significant reduction in mean SBP (−3.84 mmHg [95% confidence interval (CI), −4.97 to − 2.72 mmHg]) and DBP (−2.58 mmHg [95% CI, −3.35 to − 1.81 mmHg]).
In general, endurance training leads to a significant decrease in daytime SBP. Isometric resistance training lowers SBP, DBP, and mean arterial pressure, the extent of its outcome is greater than those described on dynamic aerobic or resistance training. Hypertensive patients who participated in isometric resistance training showed a greater decrease in mean arterial pressure than normotensive controls. Isometric resistance training decreases SBP, DBP, and mean arterial pressure.
Exercise training improves cardiorespiratory fitness and cardiometabolic health, which is important in minimizing the risk of cardiovascular disease. Exercise can produce health benefits among hypertensive patient groups and reduce the adverse effects of cardiovascular disease. Walking at a moderate pace is effective in improving BP control in adults; it is necessary for hypertensive patients to walk regularly, which is a simple form of PA that can be accumulated.
All the categories of exercise training including the combination of endurance and resistance exercises and all classes of antihypertensive medications were effective in dropping baseline SBP. Among hypertensive populations, there were no noticeable changes in the SBP-lowering effects of angiotensin-converting enzyme inhibitor, angiotensin II receptor blockers, β-blockers, and diuretic medicines when compared with endurance or dynamic resistance exercise. Physicians should emphasize on preventative and lifestyle facets of cardiovascular health in order to encourage individual and general public well-being. A devoted method to recommend the quantity of weekly PA at moderate intensity could help in controlling BP values, circumventing the supposition of antihypertensive drugs. Aerobic and resistance exercises should be individually tailored based on the precise features of the people involved.
There were significant reductions in SBP among hypertensive patients when compared to those in control group, after participating in supervised resistance training. Aerobic exercise is usually recommended as the first-line antihypertensive lifestyle treatment grounded on solid indications, showing that it lowers BP 5–7 mmHg among hypertensive adults. Moderate-intensity resistance training is not contraindicated and could become part of the nonpharmacological interventional plan to prevent and battle high BP. Dynamic resistance exercise reduces resting SBP and DBP in adults. Progressive resistance exercise is efficacious for reducing resting SBP and DBP in adults.
Continuing isometric handgrip training decreases BP. Other benefits accrued from hypertension prevention arise as the volume of PA increases; however, the systematic review conducted by Pescatello et al. provided a strong and convincing evidence on the importance of PA in preventing the development of hypertension among adults with normal BP and prehypertension and its effectiveness in the treatment of hypertension by lowering BP and lessening the progression of cardiovascular disease among hypertensive adults. Their findings occurred in a dose–response manner with no limit to the volume of PA that converses the benefit. Moreover, aerobic and dynamic resistance exercise training alone or combined was equally effective in lowering BP among adults with normal BP, prehypertension, and hypertension; however, aerobic exercise training, dynamic resistance exercise training, combined aerobic and resistance training, and isometric exercise training led to significant drop in SBP, and no additional benefit of combined aerobic and resistance exercise was observed compared to single-type exercise training. Three-month participation in a traditional exercise-based lifestyle intervention program produced a decrease in SBP of approximately 5 mmHg and DBP of 3 mmHg in older individuals, and the same is expected in younger people.
The aim of this review was to evaluate the effectiveness of PA as an adjunct therapy in support of the prevention and pharmacological treatment of hypertension.
| Materials and Methods|| |
Literature search strategy
Relevant systematic reviews and meta-analyses that reported on the correlation of PA and exercise on BP control among hypertensive patients from 1994 to 2019 were evaluated. PubMed electronic database was utilized. Full-text articles were assessed, and relevant information was extracted. The MeSH system was used to extract relevant research studies from PubMed using the following keywords: “Exercise,” “training,” “hypertension,” “blood pressure,” “systematic review,” and “meta-analysis.” All selected articles were published in English.
Types of selected studies
Meta-analysis and systematic review.
Inclusion and exclusion criteria
Relevant articles that reported on PA, exercise training, hypertension, and cardiometabolic diseases were included. Articles that were not published in English were excluded. Fifty-three studies were selected for this review.
Data extraction and management
All selected studies were retrieved from PubMed database. Articles were reviewed for relevance based on the following keywords: physical activity, exercise training, hypertension, lifestyle modifications, and cardiometabolic diseases. Full-text copies of all the articles identified as potentially relevant were retrieved and exclusions were based on background discussion and duplicate publication.
Neural mechanisms that regulate the cardiovascular system during exercise
There are three key mechanisms involved in the neural control of the cardiovascular system during exercise; the first mechanism involves the activation of regions of the brain that play a role in the recruitment of skeletal muscle motor units which concurrently activate neuronal circuits within the medulla, therefore creating changes in parasympathetic and sympathetic efferent activities which determine the cardiovascular responses during skeletal muscle contraction. This mechanism is known as “central command,” in the second mechanism, neural signals generated because of the subsequent stimulation of mechano and/or chemosensitive receptors in the contracting muscles would activate the cardiovascular control areas in the medulla, which is referred to as the “muscle metaboreflex,” and the third mechanism involves the arterial baroreceptor reflex. Under resting conditions, an increase in arterial pressure usually induces a decrease in heart rate (HR) through a baroreceptive reflex mechanism. During muscular exercise, the increase in arterial pressure is accompanied by a simultaneous increase in HR, which significantly contributes to the rise in BP, which is reversed after exercise due to increase in parasympathetic activity and decrease in sympathetic activity. The clinical importance of these mechanisms is that PA can induce cardioprotective effects on cardiac autonomic modulation, hence enhancing cardiovascular function [Figure 1].
|Figure 1: Neural mechanisms that regulate the cardiovascular system during exercise (Copyright Iellamo F, Auton Neurosci; 2001;20:66-75)|
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Physical activity and the risk of hypertension
The risk of hypertension was reduced by 6% at 10 metabolic equivalents (METh/week) of leisure-time light-, moderate-, and vigorous-intensity PA among adults with normal BP. The protective effect increased by 6% for each additional intensification of 10 METh/week; for adults with 20 METh/week of leisure-time light-, moderate-, and/or vigorous-intensity PA, the risk of hypertension decreased by 12% and for those with 60 METh/week of leisure-time light-, moderate-, and/or vigorous-intensity PA, the risk of hypertension lessened by 33%.
Resistance, aerobic exercise, and blood pressure
A single session of resistance exercise produced little-to-moderate decreases in SBP at 60 min and 90 min post exercise, compared to the control session. The decrease in SBP was more distinct in hypertensive compared to normotensive people, when using more muscle groups and when participants were recovering in the supine position.
Dance therapy reduces SBP and DBP in individuals with hypertension. Corso et al. found that concurrent exercise training decreased SBP and DBP. Dickinson et al. reported that lifestyle modification which includes improved diet, aerobic exercise, alcohol restriction, sodium restriction, and fish oil supplements was found to be significantly effective in reducing mean SBP and DBP. Huai et al. found that both vigorous and moderate intensities of leisure-time PA were associated with decreased risk of hypertension.
PA is an effective tool by which a decrease in arterial BP can be achieved among hypertensive patients. PA reduces BP over a short and long period of time by decreasing sympathetic activity, increasing vagal activity, and improving the baroreflex mechanisms by controlling HR. Exercise training is not only effective in improving the neurovegetative control of HR and reducing BP, but also effective in improving endothelial function and functional capacity in adults that commenced training.,
| Discussion|| |
Hypertensive patients should be advised to spend less time in sitting because a light-intensity PA such as washing dishes at home or walking can reduce the risk of further cardiovascular disease. Furthermore, Murtagh et al. observed that walking increases aerobic capacity (3.04 mL/kg/min, 95% CI, 2.48–3.60) and decreases SBP (−3.58 mmHg, 95% CI, −5.19–−1.97), DBP (−1.54 mmHg, 95% CI, −2.83–−0.26), waist circumference (−1.51 cm, 95% CI, −2.34–−0.68), weight (−1.37 kg, 95% CI, −1.75–−1.00), percentage body fat (−1.22%, 95% CI, −1.70–−0.73), and body mass index (−0.53 kg/m2, 95% CI, −0.72–−0.35). This shows that an improvement in the intensity and pace of walking could be important in the primary and secondary prevention of hypertension. Park and Han found that meditation and yoga exercises seemed to decrease both SBP and DBP, and the reduction was statistically significant. BP stages and patient age were shown to be the reasons of variations in the outcome of some investigations, and meditation played a key role in decreasing the BP of patients older than 60 years of age.
Wen and Wang in their meta-analysis assessed a total of 13 articles with 802 samples and found that there were no significant differences in SBP and DBP between aerobic and control groups before exercise (standardized mean difference [SMD] = 0.15, 95% CI, −0.16–0.46 and SMD = 0.16, 95% CI, −0.23–0.55, respectively), but there were significant reductions in SBP and DBP in the aerobic group after aerobic exercise, compared with control (SMD = −0.79, 95% CI, −1.29–−0.28 and SMD = −0.63, 95% CI, −1.14–−0.12, respectively). However, a significant publication bias was detected in SBP (t = −2.2314, P = 0.04549) but not in DBP (t = −1.4962, P = 0.1604); the DBP result was altered after the exclusion of two individual papers. Moreover, yoga was associated with a decrease in BP among patients aged <60 years.
Reichert et al. found a decrease in SBP in patients who underwent aquatic training compared to those in the control group; this effect was sustained with training progression, the effect on SBP was significant only in hypertensive but not in prehypertensive subjects, however aquatic training caused a decrease in DBP after training, in both prehypertensive and hypertensive patients, aquatic training caused a similar decrease in SBP when compared to land training; however, the decrease in DBP in hypertensive patients was much lower when compared to prehypertensive patients. Cao et al. observed significant effects of aerobic exercise on lowering SBP, HR, and ambulatory SBP, hence aerobic exercise training might be an effective tool for BP reductions in hypertensive patients.
Yang et al. observed that meditation exercise significantly decreases SBP and DBP. Qigong, a Chinese exercise regimen that involves coordinated body movement, breathing, and meditation, could be more effective in lowering SBP and DBP among hypertensive patients. Involvement in Baduanjin exercise, a form of traditional Chinese Qigong exercise, characterized by the alignment and interaction between symmetrical physical postures and movements, mind, and breathing in a well-balanced manner, in addition to antihypertensive treatment significantly reduced SBP, blood glucose, and total cholesterol levels compared to the treatment with only antihypertensive drugs; this showed that Baduanjin could be an effective adjunct therapy for the treatment of hypertension. When compared to antihypertensive medication, qigong was an equally effective therapy for the treatment of hypertension. A gradual increase in PA level led to decrease in SBP and DBP (5–10 mmHg and 1–6 mmHg, respectively) among hypertensive adults.
Aerobic exercises resulted in significant drops in SBP of patients after stroke incidence, compared to those in control group. Collective variations in BP showed significant reductions in SBP: −4.7 mmHg and DBP: −3.2 mmHg, among East Asians. High-intensity interval training (HIIT) leads to a greater drop in night-time DBP compared to moderate-intensity continuous training; moreover, an approximate-significant larger drop in daytime BP was found with HIIT compared to moderate-intensity continuous training. Kelley et al. examined 47 clinical trials and observed statistically significant decreases in resting SBP and DBP in both hypertensive and normotensive groups; the differences between the two groups were statistically significant, and comparative decreases were approximately 4% (systolic) and 5% (diastolic) in hypertensives and 2% (systolic) and 1% (diastolic) in normotensives.
PA, if properly planned and supervised by a medical doctor specialized in cardiology, is an effective therapy that is capable of lowering BP in normotensive, prehypertensive, and hypertensive patients because PA improves cardiac autonomic control by reducing sympathetic activity and improving parasympathetic activity of the heart,,, [Table 1] [Figure 2] and [Figure 3]. However, short-term HIIT <12 weeks significantly improves maximal oxygen uptake () and decreases DBP and fasting glucose in overweight and obese individuals, whereas long-term HIIT >12 weeks significantly reduces waist circumference and body fat; improves and reduces resting HR, SBP, and DBP in overweight and obese individuals. HIIT should be supervised in a clinical setting, to prevent adverse cardiac events.
|Table 1: Exercise prescription for hypertensive patients tailored according to frequency, intensity, time, and type principle of exercise training|
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|Figure 3: Role of physical activity in the primary and secondary prevention of hypertension|
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According to a high-impact meta-analysis of randomized controlled trials on the effect of exercise on BP control in hypertensive patients conducted by Fagard et al., the authors found significant effect of exercise on BP. Their meta-analysis on endurance training involved 72 trials and 105 study groups; after considering for the number of trained participants, they found that training induced significant net reductions in resting and daytime ambulatory BP, 3.0/2.4 mmHg (P < 0.001) and 3.3/3.5 mmHg (P < 0.01), respectively. The reduction in resting BP was more pronounced in thirty hypertensive study groups (−6.9/−4.9) than in others (−1.9/−1.6; P < 0.001 for all); systemic vascular resistance decreased by 7.1% (P < 0.05), plasma norepinephrine by 29% (P < 0.001), and plasma renin activity by 20% (P < 0.05). Body weight decreased by 1.2 kg (P < 0.001), waist circumference by 2.8 cm (P < 0.001), percentage of body fat by 1.4% (P < 0.001), the Homeostasis Model Assessment Index of Insulin Resistance by 0.31 units (P < 0.01), and HDL-C increased by 0.032 mmol/l (P < 0.05). However, their meta-analysis of nine randomized controlled trials (12 study groups) on mostly dynamic resistance training revealed a weighted net reduction in SBP and DBP (3.2 mmHg [P = 0.10]/3.5 [P < 0.01] mmHg, respectively), however, endurance training was found to decrease BP through a reduction in systemic vascular resistance, in which the sympathetic nervous system and the renin-angiotensin system appear to be involved, and positively affects concurrent cardiovascular risk factors.
There is a need to research, prove, and stipulate the optimal and exact dose of various exercises that can be prescribed by physicians in support of pharmacological treatment of hypertension, alone or combined in terms of volume and intensity and can be tailored according to patient's clinical and functional status in order to control BP.
| Conclusion|| |
According to the evaluated studies with respect to this review, moderate-intensity aerobic, isometric, and dynamic resistance exercise training administered alone or in combination was found equally effective in lowering both SBP and DBP among adults with normal BP, prehypertension, and hypertension. However, a well-planned, supervised, and individually tailored exercise training program based on patient's functional capacity and health status should be included as an adjunct therapy for BP control in addition to pharmacological treatment among hypertensive patients.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Nocon M, Hiemann T, Müller-Riemenschneider F, Thalau F, Roll S, Willich SN. Association of physical activity with all-cause and cardiovascular mortality: A systematic review and meta-analysis. Eur J Cardiovasc Prev Rehabil 2008;15:239-46.
Woodcock J, Franco OH, Orsini N, Roberts I. Non-vigorous physical activity and all-cause mortality: Systematic review and meta-analysis of cohort studies. Int J Epidemiol 2011;40:121-38.
Hupin D, Roche F, Gremeaux V, Chatard JC, Oriol M, Gaspoz JM, et al
. Even a low-dose of moderate-to-vigorous physical activity reduces mortality by 22% in adults aged ≥60 years: A systematic review and meta-analysis. Br J Sports Med 2015;49:1262-7.
Warburton DE, Bredin SS. Health benefits of physical activity: A systematic review of current systematic reviews. Curr Opin Cardiol 2017;32:541-56.
Machado M, Bajcar J, Guzzo GC, Einarson TR. Sensitivity of patient outcomes to pharmacist interventions. Part II: Systematic review and meta-analysis in hypertension management. Ann Pharmacother 2007;41:1770-81.
Carter BL, Rogers M, Daly J, Zheng S, James PA. The potency of team-based care interventions for hypertension: A meta-analysis. Arch Intern Med 2009;169:1748-55.
Cornelissen VA, Smart NA. Exercise training for blood pressure: A systematic review and meta-analysis. J Am Heart Assoc 2013;2:e004473.
Cornelissen VA, Fagard RH, Coeckelberghs E, Vanhees L. Impact of resistance training on blood pressure and other cardiovascular risk factors: A meta-analysis of randomized, controlled trials. Hypertension 2011;58:950-8.
Rossi A, Dikareva A, Bacon SL, Daskalopoulou SS. The impact of physical activity on mortality in patients with high blood pressure: A systematic review. J Hypertens 2012;30:1277-88.
Hayashino Y, Jackson JL, Fukumori N, Nakamura F, Fukuhara S. Effects of supervised exercise on lipid profiles and blood pressure control in people with type 2 diabetes mellitus: A meta-analysis of randomized controlled trials. Diabetes Res Clin Pract 2012;98:349-60.
Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: A meta-analysis of randomized, controlled trials. Ann Intern Med 2002;136:493-503.
Cornelissen VA, Buys R, Smart NA. Endurance exercise beneficially affects ambulatory blood pressure: A systematic review and meta-analysis. J Hypertens 2013;31:639-48.
Carlson DJ, Dieberg G, Hess NC, Millar PJ, Smart NA. Isometric exercise training for blood pressure management: A systematic review and meta-analysis. Mayo Clin Proc 2014;89:327-34.
Inder JD, Carlson DJ, Dieberg G, McFarlane JR, Hess NC, Smart NA. Isometric exercise training for blood pressure management: A systematic review and meta-analysis to optimize benefit. Hypertens Res 2016;39:88-94.
Lin X, Zhang X, Guo J, Roberts CK, McKenzie S, Wu WC, et al
. Effects of exercise training on cardiorespiratory fitness and biomarkers of cardiometabolic health: A systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc 2015;4. pii: e002014.
Naci H, Ioannidis JP. Comparative effectiveness of exercise and drug interventions on mortality outcomes: Metaepidemiological study. BMJ 2013;347:f5577.
Murtagh EM, Nichols L, Mohammed MA, Holder R, Nevill AM, Murphy MH. The effect of walking on risk factors for cardiovascular disease: An updated systematic review and meta-analysis of randomised control trials. Prev Med 2015;72:34-43.
Naci H, Salcher-Konrad M, Dias S, Blum MR, Sahoo SA, Nunan D, et al
. How does exercise treatment compare with antihypertensive medications? A network meta-analysis of 391 randomised controlled trials assessing exercise and medication effects on systolic blood pressure. Br J Sports Med 2019;53:859-69.
de Sousa EC, Abrahin O, Ferreira AL, Rodrigues RP, Alves EA, Vieira RP. Resistance training alone reduces systolic and diastolic blood pressure in prehypertensive and hypertensive individuals: Meta-analysis. Hypertens Res 2017;40:927-31.
MacDonald HV, Johnson BT, Huedo-Medina TB, Livingston J, Forsyth KC, Kraemer WJ, et al
. Dynamic resistance training as stand-alone antihypertensive lifestyle therapy: A meta-analysis. J Am Heart Assoc 2016;5. pii: e003231.
Cornelissen VA, Fagard RH. Effect of resistance training on resting blood pressure: A meta-analysis of randomized controlled trials. J Hypertens 2005;23:251-9.
Kelley G. Dynamic resistance exercise and resting blood pressure in adults: A meta-analysis. J Appl Physiol (1985) 1997;82:1559-65.
Kelley GA, Kelley KS. Progressive resistance exercise and resting blood pressure: A meta-analysis of randomized controlled trials. Hypertension 2000;35:838-43.
Farah BQ, Germano-Soares AH, Rodrigues SL, Santos CX, Barbosa SS, Vianna LC, et al
. Acute and chronic effects of isometric handgrip exercise on cardiovascular variables in hypertensive patients: A systematic review. Sports (Basel) 2017;5. pii: E55.
Pescatello LS, Buchner DM, Jakicic JM, Powell KE, Kraus WE, Bloodgood B, et al
. Physical activity to prevent and treat hypertension: A systematic review. Med Sci Sports Exerc 2019;51:1314-23.
Herrod PJ, Doleman B, Blackwell JE, O'Boyle F, Williams JP, Lund JN, et al
. Exercise and other nonpharmacological strategies to reduce blood pressure in older adults: A systematic review and meta-analysis. J Am Soc Hypertens 2018;12:248-67.
Iellamo F. Neural mechanisms of cardiovascular regulation during exercise. Auton Neurosci 2001;90:66-75.
Liu X, Zhang D, Liu Y, Sun X, Han C, Wang B, et al
. Dose-response association between physical activity and incident hypertension: A systematic review and meta-analysis of cohort studies. Hypertension 2017;69:813-20.
Casonatto J, Goessler KF, Cornelissen VA, Cardoso JR, Polito MD. The blood pressure-lowering effect of a single bout of resistance exercise: A systematic review and meta-analysis of randomised controlled trials. Eur J Prev Cardiol 2016;23:1700-14.
Conceição LS, Neto MG, do Amaral MA, Martins-Filho PR, Oliveira Carvalho V. Effect of dance therapy on blood pressure and exercise capacity of individuals with hypertension: A systematic review and meta-analysis. Int J Cardiol 2016;220:553-7.
Corso LM, Macdonald HV, Johnson BT, Farinatti P, Livingston J, Zaleski AL, et al
. Is concurrent training efficacious antihypertensive therapy? A meta-analysis. Med Sci Sports Exerc 2016;48:2398-406.
Dickinson HO, Mason JM, Nicolson DJ, Campbell F, Beyer FR, Cook JV, et al
. Lifestyle interventions to reduce raised blood pressure: A systematic review of randomized controlled trials. J Hypertens 2006;24:215-33.
Huai P, Xun H, Reilly KH, Wang Y, Ma W, Xi B. Physical activity and risk of hypertension: A meta-analysis of prospective cohort studies. Hypertension 2013;62:1021-6.
Park SH, Han KS. Blood pressure response to meditation and yoga: A systematic review and meta-analysis. J Altern Complement Med 2017;23:685-95.
Wen H, Wang L. Reducing effect of aerobic exercise on blood pressure of essential hypertensive patients: A meta-analysis. Medicine (Baltimore) 2017;96:e6150.
Reichert T, Costa RR, Barroso BM, da Rocha VM, Delevatti RS, Kruel LF. Aquatic training in upright position as an alternative to improve blood pressure in adults and elderly: A systematic review and meta-analysis. Sports Med 2018;48:1727-37.
Cao L, Li X, Yan P, Wang X, Li M, Li R, et al
. The effectiveness of aerobic exercise for hypertensive population: A systematic review and meta-analysis. J Clin Hypertens (Greenwich) 2019;21:868-76.
Yang H, Wu X, Wang M. The effect of three different meditation exercises on hypertension: A network meta-analysis. Evid Based Complement Alternat Med 2017;2017:9784271.
Xiong X, Wang P, Li S, Zhang Y, Li X. Effect of Baduanjin exercise for hypertension: A systematic review and meta-analysis of randomized controlled trials. Maturitas 2015;80:370-8.
Xiong X, Wang P, Li X, Zhang Y. Qigong for hypertension: A systematic review. Medicine (Baltimore) 2015;94:e352.
Semlitsch T, Jeitler K, Hemkens LG, Horvath K, Nagele E, Schuermann C, et al
. Increasing physical activity for the treatment of hypertension: A systematic review and meta-analysis. Sports Med 2013;43:1009-23.
Wang C, Redgrave J, Shafizadeh M, Majid A, Kilner K, Ali AN. Aerobic exercise interventions reduce blood pressure in patients after stroke or transient ischaemic attack: A systematic review and meta-analysis. Br J Sports Med 2019;53:1515-25.
Igarashi Y, Akazawa N, Maeda S. Regular aerobic exercise and blood pressure in East Asians: A meta-analysis of randomized controlled trials. Clin Exp Hypertens 2018;40:378-89.
Way KL, Sultana RN, Sabag A, Baker MK, Johnson NA. The effect of high Intensity interval training versus moderate intensity continuous training on arterial stiffness and 24h blood pressure responses: A systematic review and meta-analysis. J Sci Med Sport 2019;22:385-91.
Kelley GA, Kelley KA, Tran ZV. Aerobic exercise and resting blood pressure: A meta-analytic review of randomized, controlled trials. Prev Cardiol 2001;4:73-80.
Igarashi Y, Akazawa N, Maeda S. The required step count for a reduction in blood pressure: A systematic review and meta-analysis. J Hum Hypertens 2018;32:814-24.
Kelley G, McClellan P. Antihypertensive effects of aerobic exercise. A brief meta-analytic review of randomized controlled trials. Am J Hypertens 1994;7:115-9.
Kelley GA. Aerobic exercise and resting blood pressure among women: A meta-analysis. Prev Med 1999;28:264-75.
Kelley GA, Kelley KS, Tran ZV. Walking and resting blood pressure in adults: A meta-analysis. Prev Med 2001;33:120-7.
Kelley GA, Kelley KS. Aerobic exercise and resting blood pressure in women: A meta-analytic review of controlled clinical trials. J Womens Health Gend Based Med 1999;8:787-803.
Pescatello LS, MacDonald HV, Lamberti L, Johnson BT. Exercise for hypertension: A prescription update integrating existing recommendations with emerging research. Curr Hypertens Rep 2015;17:87.
Batacan RB Jr., Duncan MJ, Dalbo VJ, Tucker PS, Fenning AS. Effects of high-intensity interval training on cardiometabolic health: A systematic review and meta-analysis of intervention studies. Br J Sports Med 2017;51:494-503.
Fagard RH, Cornelissen VA. Effect of exercise on blood pressure control in hypertensive patients. Eur J Cardiovasc Prev Rehabil 2007;14:12-7.
[Figure 1], [Figure 2], [Figure 3]