What Kind of Exercise Is Good -- or Bad -- for Patients With Hypertension?

Q:Should hypertensive patients be discouraged from participating in moderate to vigorous exercise?A:On the contrary, most patients with sustained hypertension should bestrongly encouraged to exercise regularly at moderate to vigorous levels.Randomized controlled clinical trials have demonstrated that increasedphysical activity can lower blood pressure (BP) and delay or prevent the developmentof hypertension and thus the need for antihypertensive medication.¹In addition, physical activity can help reduce cardiovascular risk factors by improvinglipid profiles and reducing weight and blood glucose levels. In elderlypersons, exercise is associated with improvements in osteoporosis, depression,and physical functioning, as well as an enhanced sense of well-being.A few words of caution. Before you encourage patients with stage 2 hypertensionto exercise, be sure their BP is controlled. A thorough cardiac evaluationis required for patients with suspected ischemic heart disease, a historyof aortic stenosis or hypertrophic obstructive cardiomyopathy, cardiac arrhythmia,or second- or third-degree heart block without a pacemaker who wish tostart an exercise program.I recommend exercise stress testing before the initiation of an exerciseprogram for patients who have previously been inactive or who have a strongfamily history of coronary disease. The heart rate response to exercise providesa practical index to the level of stress placed on the heart. The maximumheart rate in beats per minute is a function of age (maximum heart rate equals220 minus age in years). Myocardial work, oxygen consumption, coronaryblood flow, cardiac output, and heart rate all increase proportionately.Exercise stress testing helps determine a patient's functional capacity sothat the most appropriate exercise program can be prescribed. It is also usefulfor determining the exercise capacity of a hypertensive patient with heartdisease.Exercise stress testing can help identify patients with an exaggerated BPresponse to exercise. In normotensive persons, an exercise systolic BP higherthan 220 mm Hg or diastolic BP higher than 100 mm Hg is considered abnormal.Some normotensive persons with a strong family history of hypertensionare at increased risk for hypertension and often display an exaggerated BP pattern.Those with higher prehypertensive BPs and some with treated hypertensionmay also have an exaggerated BP response to exercise (or to mentalstress). Some evidence suggests that this pattern is associated with increasedcardiovascular disease risk.Physical activity level and hypertension. Observational studies have reportedan inverse relationship between physical activity level and BP. The incidenceof hypertension was higher in those who had lower activity levels orlower levels of cardiorespiratory fitness.A recent meta-analysis of 54 controlled trials examined the effects of aerobicexercise on systolic and diastolic BP.² These data and the results of other meta-analyses have suggested that physical activity significantly decreases systolicand diastolic BP in all population groups, and with all types of exerciseexamined. The one exception was that the effect of exercise on diastolic BP inelderly persons was not significant. Benefits are generally greatest in hypertensivepatients who spend the most time exercising.Exercise recommendations. Rhythmic and aerobic exercises that involvelarge muscle groups are encouraged; these include walking, running, cycling,and swimming. Optimally, patients should exercise at least 3 to 5 times perweek for 20 to 60 minutes per session. The recommended intensity goal is 50%to 70% of maximum heart rate, which is considered moderate. A rate above 70%of maximum heart rate is considered vigorous. A brisk walking pace of 3 to 4miles per hour is moderate; jogging or running is vigorous to intense.Many persons are interested in weight training (often called isometric exercise).Although it can be considered part of an overall exercise program,isometric exercise--particularly with heavy weights--is not recommended asan exclusive form of exercise.The Seventh Report of the Joint National Committee on Prevention, Detection,Evaluation, and Treatment of High Blood Pressure (JNC 7) strongly encouragesphysical activity as a first-line intervention for patients with prehypertension(systolic BP, 120 to 139 mm Hg and/or diastolic BP, 80 to 89 mm Hg).³The guidelines also recommend exercise as an important adjunct to treatmentfor patients with stage 1 or 2 hypertension. For these patients, a minimum of30 minutes of moderate intensity physical activity on most days can enhancethe effects of pharmacotherapy and allow for reduced dosages.¹ Note that-blockers diminish the heart rate response to exercise; thus, for patients takingthese agents, it is better to use the perceived level of exertion (moderateto vigorous) than the target heart rate range.