# Effect of exercise modalities on postexercise hypotension in pre- and postmenopausal women: a systematic review and meta-analysis

Morgane Le Bourvellec, Nathalie Delpech, Jéromine Hervo, Laurent Bosquet, Carina Enea

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Morgane Le Bourvellec, Nathalie Delpech, Jéromine Hervo, Laurent Bosquet, Carina Enea. Effect of exercise modalities on postexercise hypotension in pre- and postmenopausal women: a systematic review and meta-analysis. Journal of Applied Physiology, 2024, 136 (4), pp.864-876. 10.1152/japplphysiol.00684.2023. hal-04724730

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3 Effect of exercise modalities on post-exercise
4 hypotension in pre- and postmenopausal women: a
5 systematic review and meta-analysis

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Morgane Le Bourvellec,<fnref n="1" /> Nathalie Delpech,<fnref n="1" /> Jéromine Hervo,<fnref n="2" /> Laurent Bosquet,<fnref n="1" /> and Carina
Enea<fnref n="1" />

Correspondence: Morgane Le Bourvellec, (email: morgane.le.bourvellec@univ-poitiers.fr).

13 ABSTRACT

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Hormonal changes associated with menopause increase the risk of hypertension. Post-exercise
hypotension (PEH) is an important tool in the prevention and management of hypertension; however,
menopause may alter this response.

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The aim of this systematic review and meta-analysis (PROSPERO: CRD42023297557) was to evaluate the
effect of exercise modalities (aerobic, AE; resistance, RE; and combined exercise, CE: AE+RE) on PEH in
women, according to their menopausal status (premenopausal or postmenopausal).

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We searched controlled trials in PubMed, Web of Science, EBSCO, and Science Direct published between
1990 and March 2023. Inclusion criteria were normotensive, pre- and hypertensive, pre- and
postmenopausal women who performed an exercise session compared with a control session and
reported systolic (SBP) and diastolic (DBP) blood pressure (BP) for at least 30 minutes after the sessions.
Methodological quality was assessed using the PEDro scale. Standardized mean differences (Hedge's g)
and their 95% confidence intervals (CI) were calculated, and Q-test and Z-test were conducted to assess
differences between moderators.

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41 trials with 718 women (474 menopausal) were included. Overall, we found with moderate evidence
that SBP and DBP decreased significantly after exercise session (SBP: g= -0.69, 95%CI -0.87 to -0.51; DBP:
g= -0.31, 95%CI -0.47 to -0.14), with no difference between premenopausal and postmenopausal
women. Regarding exercise modalities, RE is more effective than AE and CE in lowering BP in women
regardless of menopausal status.

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In conclusion, women's menopausal status does not influence the magnitude of PEH, and the best
modality to reduce BP in women seems to be RE.

34 **Keywords:** Blood pressure; Post-exercise hypotension; Exercise; Menopause; Systematic review

<footnote n="1">¹Laboratory MOVE (UR20296), Faculté des Sciences du Sport, Université de Poitiers, France.</footnote>

<footnote n="2">²Laboratoire de Traitement de l'information Médicale (LaTIM), UMR1101, Université Bretagne Occidentale, France.</footnote>
35 **NEW & NOTEWORTHY**
36 This meta-analysis has demonstrated that a single bout of exercise induces PEH in women, and that the
37 hormonal shift occurring with menopause does not influence the magnitude of PEH. However, we have
38 shown with moderate evidence, that the effectiveness of exercise modalities differs between pre- and
39 postmenopausal women. Resistance and combined exercises are the best modalities to induce PEH in
40 premenopausal women, whereas resistance and aerobic exercises are the more effective in
41 postmenopausal women.

42 **INTRODUCTION**
43 Menopause is a critical stage of female aging characterized by hormonal changes that significantly affect
44 blood pressure (BP) and, more broadly cardiovascular health (1, 2). Indeed, while aging is associated
45 with an increase in BP in both men and women, this age-related increase is more pronounced in
46 postmenopausal women (3, 4), exposing them to a higher cardiovascular risk than age-matched men (5).
47 Although women are relatively protected from hypertension during their reproductive life, about 30 to
48 50% of them become hypertensive in the decade following their menopause (3). This factor is a major
49 contributor to the increased cardiovascular risk in postmenopausal women (6, 7). Most of the protective
50 effects of female sex hormones on BP regulation have been attributed to their action on both vascular
51 and cardiac functions, through a variety of direct and indirect effects (arterial stiffness, endothelial
52 function, autonomic regulation, renin-angiotensin-aldosterone system...) (8, 9). In addition, women are
53 more likely than men to have poorly controlled hypertension, highlighting the need to develop specific
54 strategies to prevent and manage hypertension in this population (10).

55 For several years, regular physical activity has been recognized as a key determinant of successful aging
56 and has been used as a non-pharmacological strategy for hypertension (11). Initially, research on
57 physical activity and BP focused on aerobic exercise, but more recent studies performed in the general
58 population have demonstrated the value of other modalities, such as resistance exercise or combined
59 exercise (12, 13). To predict the BP response to an exercise program, clinicians can examine the
60 decrease in BP after a single session of physical exercise, called "post-exercise hypotension" (PEH) (14,
61 15). PEH is defined as a reduction in BP below the values immediately before the exercise session or
62 compared to a control session without exercise (16) and can be explained by a reduction in cardiac
63 output (CO) and/or systemic vascular resistance (SVR). In addition to the clinical prediction of BP
64 reduction with chronic exercise, a recent study highlighted the usefulness of measuring PEH to improve
65 exercise adherence in hypertensive patients (17). Despite the clinical relevance of PEH (18), the
66 underlying physiological mechanisms are not fully understood (18) and vary with sex, age, and exercise
67 modality (19, 20). Several studies have demonstrated sex- and age-related differences in cardiovascular
68 adaptations during and after exercise (19, 21, 22), highlighting the need for population-specific studies.
69 For example, it has been shown that young women have a lower exercise and post-exercise BP response
70 than age-matched men (23-26) and that hemodynamic determinants (CO and SVR) respond differently
71 after a single bout of exercise (20, 21, 27).

72 Menopause is also known to influence acute cardiovascular adaptations to exercise (28), which may be
73 explained by impaired cardiovascular autonomic modulation and endothelial dysfunction (29, 30) which
74 can influence hemodynamic determinants implicated in PEH (2). Therefore, it is relevant to determine
the efficacy of the most common exercise modalities on PEH in women, according to their menopausal status. Since Fitzgerald's seminal paper describing PEH in 1981 (23), several systematic reviews have demonstrated the benefits of exercise session in lowering BP in the general population (31–39). However, none of them had examined the specific responsiveness of women according to their menopausal status. Therefore, the aim of this study was to perform a meta-analysis to determine the influence of exercise session characteristics on the magnitude of PEH in both pre- and postmenopausal women.

## MATERIALS AND METHODS

The systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statements (40). The protocol was registered in the International Prospective Registered of Systematic Review (PROSPERO) database (registration number CRD42023297557).

### Literature search strategy

The databases PubMed, Web of Science, EBSCO, and Science Direct were searched from 1990 to March 2023 using the keywords and synonyms of "menopause" and "women" and "post-exercise hypotension" and "blood pressure". The full search strategies adapted for each database are available in **Supplemental material file (S1)**. Randomized and non-randomized controlled trials in the female population were eligible; animal studies were excluded. There were no language restrictions.

### Eligibility criteria

#### Population

The study population included normotensive, prehypertensive, and hypertensive adult women who were premenopausal or postmenopausal. When the menopausal status was not clearly reported in the studies, women were categorized as premenopausal if the age mean (95% CI) was 18-49 years, or categorized as postmenopausal if the age mean (95% CI) was > 50 years. Studies were not included if participants had comorbidities (heart failure, stroke, cancer, diabetes, etc.) or were defined as perimenopausal women.

#### Intervention and comparator

The intervention analyzed was a single physical exercise session compared to a control session in a sitting or supine position (no exercise performed).

#### Outcome

The main outcome of the review is systolic and diastolic post-exercise hypotension (PEH) measured for at least 30 minutes after the exercise session and the control session. Blood pressure (BP) had to be measured between 30 minutes and 24 hours after each session, using office BP and/or ambulatory blood pressure monitoring (ABPM).

### Data

Studies were included if all data necessary to calculate effect sizes were available (i.e., the number of participants, mean, and standard deviation for BP values). Trials were excluded if they reported results that had already been reported in a previously included trial.
113 **Study selection**

114 Studies were selected from the different databases before being imported into the Zotero software to
115 remove duplicates. Studies were then imported into the online Rayyan software and screened by two
116 independent authors (MLB and JH). Articles were screened first for titles and abstracts, and then for full
117 text to include only studies that met the inclusion criteria (Figure 1). Any disagreement between the
118 two reviewers was discussed in a consensus meeting, and unresolved issues were referred to a third
119 reviewer (CE) for resolution. In addition, the reference lists of the included full-text articles were
120 manually examined to collect further studies that were not identified electronically.

121 **Risk of bias assessment**

122 Each study was blinded about authors, affiliations, and the publishing journal and was read and coded
123 by two independent reviewers (MLB and JH). Methodological quality was assessed using the PEDro scale
124 (41), with a score of 1 indicating that the study met the item and a score of 0 indicating that the item
125 was not met. Studies with a PEDro score ≥ 6 were considered to be of high quality, 4 or 5 of medium
126 quality, and < 4 of low quality. As with study selection, disagreements were resolved by a third author
127 (CE).

128 **Data collection and extraction**

129 Each study was read and coded using the following moderator variables: exact age, body mass index
130 (BMI), menopausal status (pre- or postmenopausal), BP status (normotensive, prehypertensive or
131 hypertensive), physical activity level (active or inactive), exercise modality (aerobic: AE, resistance: RE, or
132 combined: CE), characteristics of AE (modality: continuous or intermittent; environment: water or dry;
133 material: cycling, walking or stepping) and RE (concentric, isometric, or power training), exact systolic
134 and diastolic BPs, and the exact time of post-exercise BP measurements. Exercise intensity was coded
135 according to the American College of Sports Medicine (ACSM) criteria (light, moderate, vigorous, or
136 maximal) (42). The RE workout volume session was coded using the formula: number of exercises * sets
137 * repetitions. A nominal scale was used for coding menopause status, BP status, physiological
138 dominance, and exercise characteristics, while an interval scale was used for other measures. The timing
139 of post-exercise measures was then divided into 6 categories: 30, 40-50, 60, >90 minutes, ABPM awake
140 and asleep, age was divided into 2 categories: 18 to 49 years old (premenopausal) and 50 years and
141 older (postmenopausal), BMI into 3 categories: 18.5-24.9, 25-29.9, >30 and workout volume into 3
142 categories: <150, 150-250, >250.

143 **Statistical analyses**

144 Standardized mean differences (SMDs) for each study group were calculated using Hedges' g (43).
145 Because the majority of studies used multiple measures of post-exercise BP, a single composite SMD
146 was calculated (44) for each session (combining all BP measurements and awake and asleep ABPM).
147 Considering that the effects of exercise on post-exercise BP may differ according to the exercise
148 characteristics and other moderators relative to the characteristics of the participants, we decided a
149 priori to use a random-effects model with the DerSimonian and Laird method. Standardized mean
150 differences were weighted by the inverse of the variance to calculate an overall effect and its 95%
151 confidence interval (CI), to determine whether the SMD differed from 0. Secondly, to analyze the effect
152 of categories of moderator variables (menopausal status, hypertensive status, exercise modalities...) on
153 SMDs, a Q-test based on the analysis of variance was performed to test the null hypothesis (44). When
154 the null hypothesis was rejected, pairwise comparisons were performed using a Z-test. Cohen's criteria
were used to interpret the magnitude of SMD: < 0.2, trivial; 0.2 to 0.5, small; 0.5 to 0.8, moderate; and >
0.8, large (45). Statistical heterogeneity, which refers to the percentage of the variability between
studies that is due to clinical and methodological heterogeneity rather than the sampling error, was
using the I² statistic (44). According to Higgins (2003), I² values of 25%, 50%, and 75% represent low,
medium, and high heterogeneity, respectively (46). All calculations were performed using
Comprehensive Meta-analysis (www.meta-analysis.com).

Level of evidence

A specific scale was developed by Neal et al. (2016) to categorize the level of evidence, based on
methodological quality and statistical heterogeneity (47). The level of evidence was considered strong if
the pooled results were obtained from three or more studies, including at least two high-quality studies
that were statistically homogeneous (i.e. I² < 50%). The level of evidence was considered moderate if the
pooled results were obtained from several studies that were statistically heterogeneous (i.e. I² > 50%),
including at least one high-quality study, or, from several medium-quality or low-quality studies that
were statistically homogeneous. The level of evidence was considered limited if the results were
obtained from one high-quality study, or, from several medium- or low-quality studies that were
statistically heterogeneous. The level of evidence was considered very limited if the results were
obtained from one medium-quality study or one low-quality study. Finally, it was considered that there
was no evidence if the pooled results were not statistically significant and came from several studies that
were statistically heterogeneous.

RESULTS

Overall results

A total of 41 controlled studies (37 randomized) out of 5266 were included in the meta-analysis, enroll
718 women in 63 exercise sessions (48–88). The PRISMA 2020 flow diagram of the study selection
process is presented in **Figure 1**.

Among 718 women study participants, 244 were premenopausal (age= 32.4 ± 6.9 years old; BMI= 26.46 ± 3.2 kg/m²) and 474 were postmenopausal (age= 63.36 ± 4.9 years old; BMI= 27.88 ±1.75 kg/m²). In the included studies, the exercise sessions consisted of AE in 21 of them, RE in 35, and CE in 7 sessions. To assess PEH, 36 studies used office BP (from 30 to 120 minutes after exercise) in a sitting (30 studies) or supine (6 studies) position, and 9 studies used 20 to 24h ambulatory BP measurement (ABPM).

The description of each study, with methodological quality scores, is presented in a **Supplemental material file (S2)**. The average methodological quality in PEDRo was 5.1 ± 1.1 (range: 3 to 8). According to the PEDRo classification, 14 studies were classified as high quality, 22 as medium quality, and 5 as low quality. We also performed a sensitivity analysis to assess the influence of the quality score on the magnitude of the effect, and we found no difference between groups (studies with PEDRo score <4/10 vs. all studies).

Overall, our meta-analysis showed with moderate evidence a significant reduction in systolic (g=-0.69, 95% CI -0.87 to -0.51, I²=72%) and diastolic BP (g=-0.31, 95% CI -0.47 to -0.14, I²=60%) after exercise session compared to control session (Figure 2). If all exercise modalities are efficient in reducing SBP, RE is the most efficient in comparison to others (g=-0.99, 95% CI -1.3 to -0.68, I²=74%). For DBP, RE is the
194 only exercise modality associated with a significant effect on PEH (g=-0.62, 95% CI -0.93 to -0.32, 195 I²=66%).

196 **Effect of menopausal status on PEH**

197 As shown in **Figure 3**., exercise session is an effective strategy to induce systolic and diastolic PEH in pre- 198 and postmenopausal women. No difference was found in the magnitude of systolic and diastolic PEH 199 between pre- and postmenopausal women.

200 However, when pre- and postmenopausal women were compared depending on their clinical status 201 (hypertensive or normotensive), we found a menopausal status effect only in systolic PEH. In 202 normotensive women, only premenopausal had systolic PEH (g=-0.51, 95% CI -0.87 to -0.16, I²=69% vs. 203 g=0.1, 95% CI -0.43 to 0.63, I²=19%). In hypertensive women, both pre- and postmenopausal decreased 204 in SBP and DBP, with a greater systolic PEH in postmenopausal women. These results are presented in a 205 **Supplemental material file (S3).**

206 **PEH in premenopausal women**

207 Sensitivity analysis showed no influence of methodological quality on the estimate of the magnitude of 208 the effect. Overall, we found with moderate evidence that exercise session is effective in reducing both 209 SBP (g=-0.50, 95% CI -0.76 to -0.24, I²=65%) and DBP (g=-0.39, 95% CI -0.69 to -0.08, I²=54%). The level 210 of heterogeneity (54 < I² < 65%) justifies exploring the potential effect of some moderating variables. The 211 results of this subgroup analysis are presented in **Table 1**.

212 **Moderating variables: population characteristics**

213 Systolic PEH was observed independently of clinical status or physical activity level (PAL) in 214 premenopausal women, but not in normal weight women (p=0.437). However, the magnitude of systolic 215 PEH was more important in prehypertensive (g=-0.84, 95% CI -1.20 to -0.49, I²=0%) vs. hypertensive 216 women (g=-0.35, 95% CI -0.52 to -0.18, I²=0%; z=2.48). A greater magnitude of PEH was found in women 217 using medication for BP control (g=-0.84, 95% CI -1.20 to -0.49, I²=0%) vs. women not using medication 218 (g=-0.35 95% CI -0.52 to -0.18, I²=0%; z=-2.48). Similarly, the magnitude of systolic PEH was more 219 important in obese women (g=-1.67, 95% CI -2.56 to -0.79, I²=65%) compared to overweight (z=2.98). 220 Regarding diastolic PEH, the effect of exercise session was limited to hypertensive (g=-0.53, 95% CI -0.93 221 to -0.14, I²=0%) and prehypertensive women (g=-1.20, CI 95% -1.43 to -0.98, I²=0%). A greater magnitude 222 of PEH was also found in women taking medication for BP control (g=-1.20, 95% CI -1.43 to -0.98, I²=0%) 223 compared to women not taking medication (g=-0.53 95% CI -0.93 to -0.14, I²=0%; z=-6.08). Considering 224 BMI, diastolic PEH was observed in obese (g=-1.11, CI 95% -2.02 to -0.21, I²=58%) and overweight 225 women (g=-0.28, CI 95% -0.50 to -0.06, I²=1%) but not in normal weight women (g=0.24, CI 95% -0.13 to 226 0.60, I²=39%).

227 **Moderating variables: exercise characteristics**

228 RE or CE are both effective to induce systolic PEH (g=-0.80, 95% CI -1.31 to -0.30, I²=59% and g=-0.53, 95 229 % CI -0.84 to -0.21, I²=36%, respectively), while AE is not (g=-0.04, 95% CI -0.41 to 0.32, I²=55%). We 230 found no evidence of diastolic PEH for RE, CE and AE.

231 Considering the content of the RE sessions, it appeared that systolic PEH could be obtained with 232 concentric exercises (g=-0.91, 95% CI -1.45 to -0.37, I²=62%) and moderate intensity (g=-1.18, 95% CI - 233 1.92 to -0.43, I²=65%). We found no evidence of diastolic PEH. Regarding the volume of RE, it appeared
that a workout volume session between 150 and 250 induced systolic (g=-1.41, 95%CI -2.65 to -0.18, I²=55%) and diastolic PEH (g=-0.78, 95% CI -1.37 to -0.19, I²=57%), while the effect was limited to systolic PEH when the workout volume session was less than 150 (g=-0.72, 95% CI -0.91 to -0.53, I²=2%).

Regarding the AE sessions, all studies used a continuous cycling exercise, but with different intensities. The condition to observe systolic and diastolic PEH was the use of vigorous intensity (g=-0.43, 95% CI -1.31 to -0.30, I²=0% and g=-0.87, 95% CI -1.22 to -0.52, I²=0%, respectively).

## 240 PEH in postmenopausal women

Sensitivity analysis showed no influence of methodological quality on the magnitude of the effect. Overall, we found moderate evidence that exercise session is effective in reducing systolic (g=-0.81, 95% CI -1.05 to -0.57, I²=73%) and diastolic (g=-0.27, 95% CI -0.47 to -0.07, I²=63%) BP. As in the studies od premenopausal women, the level of heterogeneity (63 < I² < 73%) justifies exploring the potential effect of some moderating variables. The results of this subgroup analysis are presented in Table 2.

## 246 Moderating variables: population characteristics

Systolic PEH was observed regardless of age (50-60 and > 60) or BMI (overweight and obese). However, an effect of BP status was observed, with a PEH in hypertensive (g=-0.93, 95% CI -1.19 to -0.67, I²=74%) but not in normotensive women (g=0.10, 95% CI -0.43 to 0.63, I²=19%; z=3.42). Medication for BP control was used by all hypertensive postmenopausal women. A greater magnitude of PEH was found in active women (g=-2.10, 95% CI -2.89 to -1.30, I²=63%) than in inactive women (g=-0.23, 95% CI -0.37 to -0.09, I²=0%; z=4.54). For diastolic PEH, the effect of exercise session was restricted to hypertensive women (g=-0.33, 95% CI -0.55 to -0.12, I²=65%), overweight women (g=-0.87, 95% CI -1.45 to -0.30, I²=58%), and women >60 years of age (g=-0.33, 95% CI -0.59 to -0.08, I²=67%).

## 255 Moderating variables: exercise characteristics

RE or AE are both effective to induce systolic PEH, while CE is not (g=-0.79, 95% CI -2.33 to 0.75, I²=0%). However, RE is more efficient than AE to induce systolic PEH (g=-1.10, 95% CI -1.50 to -0.70, and I²=77% and g=-0.47, 95% CI -0.66 to -0.29, I²=26%, respectively; z=2.81). For inducing diastolic PEH, only RE is efficient (g=-0.55, 95% CI -0.84 to -0.26, I²=67%).

Regarding the modality of RE sessions, only concentric contraction was effective to induce systolic (g=-1.37, 95% CI -1.85 to -0.89, I²=76%) and diastolic (g=-0.68, 95% CI -1.03 to -0.34, I²=67%) PEH. Systolic and diastolic PEH was observed at both light (g=-2.69, 95% CI -3.98 to -1.40, I²=65%; g=-1.24, 95% CI -2.06 to -0.42, I²=56%, respectively) and vigorous intensities (g=-0.76, 95% CI -1.29 to -0.23, I²=78%; g=-0.46, 95% CI -0.88 to -0.04, I²=76%, respectively), but light intensity was more effective for systolic PEH (z=3.3). All workout volumes sessions were effective to induce systolic PEH, but only volumes <250 led to diastolic PEH.

In AE sessions, systolic PEH was observed when moderate (g=-0.50, 95% CI -0.69 to -0.30, I²=65%) or vigorous (g=-0.65, 95% CI -1.00 to -0.30, I²=21%) intensity was used. However, only vigorous intensity induced diastolic PEH (g=-0.32, 95% CI -0.59 to -0.05, I²=21%). The environment (dry or water), material (cycling, walking, stepping), and modality (continuous or intermittent) used for AE did not influence the magnitude of systolic or diastolic PEH.
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# DISCUSSION

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The present meta-analysis aimed to determine the influence of exercise session characteristics on the magnitude of PEH in both pre- and postmenopausal women. Given the evidence that female sex hormones play an important role in BP regulation and that the underlying mechanisms may differ between exercise modalities, we hypothesized that menopausal status may modify the magnitude of PEH and that the best modality differs between pre- and postmenopausal women. Our analysis included 718 women ranging in age from 32.4 ± 6.9 to 63.4 ± 4.9 years. When all the women were pooled together, our meta-analysis confirmed that a single bout of exercise significantly reduced SBP and DBP in the female population (moderate effect size), regardless of menopausal status. Our results also showed that the effective exercise modalities in reducing BP differed in the two populations. Indeed, although AE and RE are effective in postmenopausal women, only RE and CE induce PEH in premenopausal women. In both, the magnitude of the effect is better after RE, compared to AE or CE.

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## PEH in the female population

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Throughout their lives, women undergo several sex-specific hormonal changes (pregnancy, menopause...) that may affect their risk of developing hypertension. Indeed, cross-sectional studies suggest that menopause is associated with a twofold increase in the risk of hypertension, with a prevalence of 75% in postmenopausal women (89, 90). As hypertension is one of the major risk factors for the development of CVD in women (5), the prevention and management of elevated BP by prescribing regular physical activity is a major challenge in this population. Consistent with previous studies performed in male or mixed populations, our meta-analysis showed that a single bout of exercise significantly reduced SBP and DBP, regardless of the type of exercise (AE, RE, CE) (91). This information is important because most studies of PEH have not considered the effects of sex, whereas sex hormones appear to play an important role in cardiovascular adaptations to exercise (19, 92-94). Thus, in the few studies that have compared BP responses in men and women, many have observed a greater response in men compared with women, regardless of age (19, 27, 91, 95). For example, a meta-analysis by Cornellissen and Smart reported a twofold greater reduction in BP in middle-aged men compared with women after aerobic exercise (91). Similarly, Mourot et al. showed that premenopausal women, unlike men, did not have PEH after aerobic exercise (competitive half marathon) (27). These findings suggest that PEH differs between the sexes and emphasize highlighting the need to evaluate the effects of exercise in women, considering their menopausal status (pre- vs. postmenopausal).

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## Effect of female population characteristics on PEH

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Our study showed no difference in the magnitude of systolic and diastolic PEH between pre- and postmenopausal women. These results may be partly explained by the fact that both populations differ in parameters other than menopausal status.

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First, in our meta-analysis, 87% of postmenopausal women were hypertensive, compared with 11% in the premenopausal group. Previous studies have reported similar results, with a greater systolic and diastolic PEH in hypertensive subjects than in normotensive subjects (34, 75). In addition, depending on the medications used by women, the BP response to exercise may be potentiated. Indeed, the use of antihypertensive treatments such as angiotensin receptor blockers, angiotensin-converting enzyme
inhibitors, diuretics, or calcium channel blockers could potentiate PEH (96). Interestingly, in our study, hypertensive postmenopausal women had a greater magnitude of PEH compared with hypertensive premenopausal women, which may be explained by a systematic use of antihypertensive treatments in the postmenopausal group. Similarly, the possible use of hormone replacement therapy after menopause may increase the magnitude of PEH in postmenopausal women (97). However, this treatment was not detailed in the included studies, so its effects could not be examined.

Another important characteristic is the physical activity level of the women. In our study, 58% of postmenopausal women were considered active, compared with only 32% of premenopausal women. It is well documented that regular physical activity can induce cardiovascular adaptations to exercise and improve BP response (98, 99). One of the adaptations observed in active women is the exercise activation of the vascular ERRα receptor. This intracellular pathway may induce better vasodilation in active postmenopausal women compared to inactive age-matched women (100). Our meta-analysis showed greater systolic and diastolic PEH in active than inactive postmenopausal women, supporting this hypothesis.

Finally, body composition (BMI, fat mass, fat distribution) may influence the BP response to exercise. Menopause is associated with an increase in fat mass and a shift from a gynoid to an android body fat distribution, leading to an increase in CV risk (80, 81). In our work, we did not find a significant difference in BMI between pre- and postmenopausal women (26.5 ± 3.2 and 27.9 ± 1.7 kg m⁻², respectively). However, % fat mass and fat distribution were lacking in most studies. Nevertheless, as mentioned above, the proportion of hypertensive women was higher in our postmenopausal group, which is consistent with a potentially impaired body fat distribution (103).

## Effect of exercise modality on PEH

Another confounding factor that accounts for the highly variable magnitude and duration of PEH observed in the literature is the variety of exercise modalities (i.e., aerobic, resistance, combined) (37, 104, 105). To date, none has shown evidence of superiority, and all these exercises are recommended by the American College of Sports Medicine (ACSM) (106). However, several data suggest that the mechanisms involved in the PEH may differ depending on the exercise modality (107). Thus, following AE, PEH is typically induced by a reduction in SVR, except in specific circumstances where there is a decrease in CO (elderly, overweight and hypertension) (108). Conversely, RE commonly leads to PEH through a decline in CO or a combination of both (CO and SVR) among individuals.

To our knowledge, our review is the first to focus on the effects of exercise modalities in the female population and to consider these effects separately in pre- and postmenopausal women. In our opinion, this approach is essential to optimize exercise prescriptions, especially in women, whose hormonal specificities are too often neglected. Our results indicate important differences in the PEH effect size between AE, RE, and CE, with RE promoting greater benefits, regardless of menopausal status (pre- or postmenopausal women). These results are interesting because AE is often considered the most efficient type of exercise in mixed populations (95, 109) and has received much attention in recent years to determine the best characteristics of this type of exercise (intensity, duration, continuous, intermittent...) (110, 91, 111). However, some studies have shown that there are sex differences in the
350 BP response to this exercise modality, with significantly higher maximal exercise SBP and PEH in men
351 than in women (26, 112). Since PEH is mainly related to SVR after AE, we can hypothesize that women
352 and especially young women, have a blunted peripheral vascular responsiveness to sympathetic
353 activation/deactivation during and after exercise, as previously observed with another
354 sympathoexcitatory stimulus (ie, the cold pressor test) in a hypoxemic condition (113).
355

355 When pre- and postmenopausal women were separated in a subgroup analysis, we found that only RE
356 and CE induced PEH in premenopausal women, although AE and RE were effective in postmenopausal
357 women. Regarding exercise characteristics, concentric RE induced a greater PEH using moderate
358 intensity in premenopausal women, and light or vigorous intensity in postmenopausal women. AE
359 reduced BP in postmenopausal women using moderate to vigorous intensity, whatever the environment
360 (water or dry), material (cycling, stepping, or walking) and modality (continuous or intermittent). In
361 premenopausal women performing AE, only vigorous intensity reduced BP. We hypothesize that in this
362 population which has a higher vasodilatory state than postmenopausal women (114), the
363 sympathoexcitatory stimulus induced by low- to moderate-intensity aerobic exercise is insufficient to
364 induce PEH. Indeed, in our both populations, the magnitude of the effect was better after RE than after
365 AE or CE. These results are consistent with those of several previous studies showing that resistance
366 may be more effective in women than in men (115).
367

367 Strengths

368 In our opinion, an important strength of this work is that only controlled studies (comparison between
369 control session and exercise session) were included in the meta-analysis. As described by De Brito et al.,
370 three different methods could be used to determine the PEH, which may also explain the high variability
371 of PEH observed in the literature (107). The first is the difference between pre-exercise BP and post-
372 exercise BP; the second is the difference between post-exercise BP and post-control BP, and the third is
373 the difference between (pre-exercise BP to post-exercise BP) and (post-exercise BP to post-control BP).
374 The second and third methods are interesting because they avoid the effects of nychthemeral variations
375 in BP. Another important point is the subgroup analysis performed between women aged 50 to 60
376 years and women older than 60 years. In fact, Gliemann and Hellsten, 2019 provided the exercise timing
377 hypothesis, according to which the initiation of exercise interventions during the menopausal transition
378 may be more effective in reducing vascular resistance than the initiation many years later (116).
379 Therefore, the magnitude of the PEH may vary depending on the time since menopause.
380

380 Limitations

381 This systematic review with meta-analysis also had some limitations that need to be acknowledged.
382 First, the inclusion of women in premenopausal or postmenopausal groups was arbitrary, depending on
383 the mean age, in all the included studies that did not specify the menopausal status of the women.
384 Fortunately, in our work, the mean age was 32.4 ± 6.9 and 63.4 ± 4.9 years in the premenopausal and
385 postmenopausal groups, respectively, which ensured that women were assigned to the appropriate
386 group. In addition, to account for the effect of the timing hypothesis described above, we have also
387 divided postmenopausal women into two categories (50-60 and > 60 years, respectively) because the
388 number of years after menopause was not reported in all studies. Another important point is the small
389 number of studies (and participants) investigating the effect of AE in premenopausal women (5
experimental groups and 31 participants) and CE in postmenopausal women (2 experimental groups and 29 participants). Therefore, it is difficult to conclude that they are not effective in inducing PEH. Finally, this study did not evaluate the effect of mind-body exercises, although there is a growing interest in this type of exercise in the scientific literature, especially in the female population. However, to date, their beneficial effects on BP must be interpreted with caution due to the low quality of the studies (106).

## Perspectives

Further research is warranted to explore the potential effects of endogenous and exogenous female sex hormones on PEH, particularly in middle-aged women. Indeed, we know that sex hormones may influence the responsiveness of endothelial function to exercise training (117). Therefore, it would be interesting to study the effect of menopause, and eventually the effect of the sex hormone patterns observed during the menopausal transition (118) on cardiovascular response to exercise. Second, it would be important to determine if the use of menopausal hormone therapy can influence the PEH by improving vascular function (117). Similarly, several menopausal symptoms which are known to increase the cardiovascular risk, may influence the response to exercise, such as vasomotor symptoms, which appear to be associated with autonomic dysfunction (119).

## Clinical applications

*Why measure the PEH in clinical practice?*

In clinical practice, we know that measuring PEH can be useful to predict the effectiveness of an exercise program for BP reduction and to increase patient adherence to exercise prescriptions (14, 17).

*Who are the responders?*

In female patients, regardless of menopausal status, the magnitude of PEH is more important in hypertensive, medicated, active, and overweight to obese women.

*What type of exercise should be prescribed in women?*

Concentric RE induce a greater PEH, using moderate intensity in premenopausal women, and light or vigorous intensity in postmenopausal women. AE reduces BP in postmenopausal women, using moderate to vigorous intensity whatever the environment, material and modality. In premenopausal women, AE reduces BP only with vigorous intensity.

## CONCLUSION

In conclusion, this is the first meta-analysis to examine the PEH and to compare the effect size of traditional modalities (AE, RE, or CE) in pre- and postmenopausal women. Our meta-analysis showed no difference in systolic and diastolic PEH between pre- and postmenopausal women. Regarding exercise modalities, RE seems to be more effective than AE and CE in reducing BP, regardless of menopausal status. Further studies are needed to evaluate the PEH effect of AE in premenopausal women and CE in postmenopausal women. These data are a first step in the development of evidence-based women-specific physical activity programs for the prevention of hypertension and CVD in this population.

## SUPPLEMENTAL MATERIAL

Supplemental material S1: https://doi.org/10.6084/m9 figshare.24198123

Supplemental material S2: https://doi.org/10.6084/m9 figshare.24716166
428

Supplemental material S3: https://doi.org/10.6084/m9.fishare.24716283

429

GRANTS

430

This work is supported by the Nouvelle Aquitaine Region, the Sport Health University Chaire, and the
University of Poiters' program UP-SQUARED (ANR-21-EXES-0013), financed by France2030 and its
Investment Programme for the Future 4 (PIA4) « ExcellencES in all its forms ».

431

432

433

DISCLOSURES

434

No conflicts of interest, financial or otherwise, are declared by the authors.

435

AUTHOR CONTRIBUTIONS

436

M.L.B, N.D, L.B, and C.E conceived and designed the research; M.L.B and J.H analyzed the data; M.L.B, N.D, L.B, and C.E interpreted the experimental results; M.L.B prepared the figures; M.L.B, N.D, L.B, and C.E drafted the manuscript; M.L.B, N.D, J.H, L.B, and C.E approved the final version of the manuscript.

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# FIGURE LEGENDS

**Figure 1.** PRISMA 2020 flow diagram

**Figure 2.** Global effect of exercise session on systolic (a) and diastolic (b) post-exercise hypotension (PEH) in women.

Values are standard mean difference (SMD) using Hedge's g presented with 95% confidence interval; *: significant difference of exercise session from control session (p<0.05). SBP: systolic blood pressure; DBP: diastolic blood pressure; AE: aerobic exercise; CE: combined exercise; RE: resistance exercise.

**Figure 3.** Effect of menopausal status on systolic (a) and diastolic (b) post-exercise hypotension (PEH) in women.

Values are standard mean difference (SMD) using Hedge's g presented with 95% confidence interval; *: significant difference of exercise session from control session (p<0.05). SBP: systolic blood pressure; DBP: diastolic blood pressure; AE: aerobic exercise; CE: combined exercise; RE: resistance exercise.

# TABLES

**Table 1.** Meta-analysis results of post-exercise hypotension (PEH) in premenopausal women.

Values are standard mean difference (SMD) using Hedge's g presented with 95% confidence interval (95% CI), p-value and heterogeneity (I²). EG: experimental group; P: participants; BMI: body mass index; PAL: physical activity level; BP: blood pressure; ABPM: ambulatory blood pressure monitoring; AE: aerobic exercise; CE: combined exercise; RE: resistance exercise. Comparisons between moderators were performed using Q-test and Z-test. * Difference from the second moderator (p<0.05); # Difference from the third moderator (p<0.05).

**Table 2.** Meta-analysis results of post-exercise hypotension (PEH) in postmenopausal women.

Values are standard mean difference (SMD) using Hedge's g presented with 95% confidence interval (95% CI), p-value and heterogeneity (I²). EG: experimental group; P: participants; BMI: body mass index; PAL: physical activity level; BP: blood pressure; ABPM: ambulatory blood pressure monitoring; AE: aerobic exercise; CE: combined exercise; RE: resistance exercise. Comparisons between moderators were performed using Q-test and Z-test. * Difference from the second moderator (p<0.05); # Difference from the third moderator (p<0.05).
# Effect of exercise modalities on post-exercise hypotension in pre- and postmenopausal women: a systematic review and meta-analysis

Le Bourvellec M., Delpech N., Hervo J., Bosquet L., Enea C.

## METHODS

<figure><img src="image_2.png" /></figure>

### Study aim

Evaluate the effect of exercise modalities (aerobic, AE; resistance, RE; and combined exercise, CE) on post-exercise hypotension (PEH) in pre- and postmenopausal women.

### Study eligibility criteria

**Population:** Normotensive, pre- and hypertensive women before or after menopause (or 18-49 and ≥ 50 years old)

**Intervention:** Acute exercise session

**Comparison:** Control session

**Outcome:** Systolic and diastolic PEH between 30 minutes and 24 hours

**Design:** Controlled trials

## RESULTS

N=41 controlled trials, 63 exercise sessions, 718 women (244 premenopausal)

### 1 Global effect of exercise session on PEH in women

<figure><img src="image_3.png" /></figure>

### 2 Efficacy of exercise modalities on PEH by menopausal status in women

**Premenopausal women:** RE and CE induced PEH, and RE is more efficient.

**Postmenopausal women:** RE and AE induced PEH, and RE is more efficient.

## CONCLUSION

Menopausal status does not influence the magnitude of PEH, and the best modality to reduce blood pressure in women seems to be RE.
<figure><img src="image_4.png" /><figcaption>**Figure 1.** PRISMA 2020 flow diagram</figcaption></figure>
(a) SBP PEH

<figure><img src="image_5.png" /></figure>

(b) DBP PEH

<figure><img src="image_6.png" /><figcaption>**Figure 2.** Global effect of exercise session on systolic (a) and diastolic (b) post-exercise hypotension (PEH) in women</figcaption></figure>
<figure><img src="image_7.png" /></figure>

<figure><img src="image_8.png" /><figcaption>**Figure 3.** Effect of menopausal status on systolic (a) and diastolic (b) post-exercise hypotension (PEH) in women</figcaption></figure>
<table><caption>**Table 1.** Meta-analysis results of post-exercise hypotension (PEH) in premenopausal women</caption><thead><tr><th rowspan="2"></th><th colspan="3">Systolic PEH</th><th colspan="3">Diastolic PEH</th></tr><tr><th>Number of EG</th><th>Number of P</th><th>g (95% CI)</th><th>p-value</th><th>I<sup>2</sup> (%)</th><th>g (95% CI)</th><th>p-value</th><th>I<sup>2</sup> (%)</th></tr></thead><tbody><tr><td><strong>Overall effect</strong></td><td>21</td><td>244</td><td>-0.50 (-0.76 to -0.24)</td><td><strong>&lt;0.001</strong></td><td>66</td><td>-0.39 (-0.69 to -0.08)</td><td><strong>0.014</strong></td><td>54</td></tr><tr><td colspan="9"><strong>Population characteristics</strong></td></tr><tr><td><strong>Clinical status</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- HT</td><td>4</td><td>26</td><td>-0.35 (-0.52 to -0.18)*</td><td><strong>&lt;0.001</strong></td><td>0</td><td>-0.53 (-0.93 to -0.14)*</td><td><strong>0.008</strong></td><td>0</td></tr><tr><td>- PreHT</td><td>2</td><td>10</td><td>-0.84 (-1.20 to -0.49)</td><td><strong>&lt;0.001</strong></td><td>0</td><td>-1.20 (-1.43 to -0.98)#</td><td><strong>&lt;0.001</strong></td><td>0</td></tr><tr><td>- NT</td><td>15</td><td>208</td><td>-0.51 (-0.87 to -0.16)</td><td><strong>0.005</strong></td><td>69</td><td>-0.23 (-0.57 to 0.12)</td><td>0.195</td><td>65</td></tr><tr><td><strong>BP treatment</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Medicated</td><td>2</td><td>28</td><td>-0.84 (-1.20 to -0.49)*</td><td><strong>&lt;0.001</strong></td><td>0</td><td>-1.20 (-1.43 to -0.98)</td><td><strong>&lt;0.001</strong></td><td>0</td></tr><tr><td>- Not medicated</td><td>4</td><td>8</td><td>-0.35 (-0.52 to -0.18)</td><td><strong>&lt;0.001</strong></td><td>0</td><td>-0.53 (-0.93 to -0.14)</td><td><strong>0.008</strong></td><td>0</td></tr><tr><td><strong>BMI</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- 18.5-24.9</td><td>7</td><td>107</td><td>-0.18 (-0.63 to 0.27)#</td><td>0.437</td><td>1</td><td>0.24 (-0.13 to 0.60)*#</td><td>0.199</td><td>39</td></tr><tr><td>- 25-29.9</td><td>4</td><td>65</td><td>-0.28 (-0.52 to -0.03)#</td><td><strong>0.028</strong></td><td>22</td><td>-0.28 (-0.50 to -0.06)</td><td><strong>0.012</strong></td><td>1</td></tr><tr><td>- &gt;30</td><td>5</td><td>49</td><td>-1.67 (-2.56 to -0.79)</td><td><strong>&lt;0.001</strong></td><td>65</td><td>-1.11 (-2.02 to -0.21)</td><td><strong>0.016</strong></td><td>58</td></tr><tr><td><strong>PAL</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Inactive</td><td>10</td><td>138</td><td>-0.77 (-1.27 to -0.26)</td><td><strong>0.003</strong></td><td>69</td><td>-0.49 (-0.99 to 0.01)</td><td>0.052</td><td>62</td></tr><tr><td>- Active</td><td>4</td><td>65</td><td>-0.47 (-0.90 to -0.03)</td><td><strong>0.035</strong></td><td>15</td><td>0.07 (-0.11 to 0.25)</td><td>0.443</td><td>12</td></tr><tr><td colspan="9"><strong>Exercise characteristics</strong></td></tr><tr><td><strong>Exercise type</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Aerobic (AE)</td><td>5</td><td>31</td><td>-0.04 (-0.41 to 0.32)*</td><td>0.811</td><td>55</td><td>-0.22 (-0.93 to 0.49)</td><td>0.539</td><td>22</td></tr><tr><td>- Resistance (RE)</td><td>11</td><td>167</td><td>-0.80 (-1.31 to -0.30)</td><td><strong>0.002</strong></td><td>59</td><td>-0.42 (-0.88 to 0.05)</td><td>0.078</td><td>61</td></tr><tr><td>- Combined (CE)</td><td>5</td><td>36</td><td>-0.53 (-0.84 to -0.21)</td><td><strong>&lt;0.001</strong></td><td>36</td><td>-0.44 (-1.05 to 0.16)</td><td>0.149</td><td>5</td></tr><tr><td><strong>Intensity (AE)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Moderate</td><td>4</td><td>23</td><td>0.07 (-0.37 to 0.51)*</td><td>0.758</td><td>56</td><td>0.11 (-0.73 to 0.94)*</td><td>0.801</td><td>0</td></tr><tr><td>- Vigorous</td><td>1</td><td>8</td><td>-0.43 (-0.73 to -0.14)</td><td><strong>0.004</strong></td><td>0</td><td>-0.87 (-1.22 to -0.52)</td><td><strong>&lt;0.001</strong></td><td>0</td></tr><tr><td><strong>Modality (RE)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Concentric</td><td>10</td><td>147</td><td>-0.91 (-1.45 to -0.37)*</td><td><strong>&lt;0.001</strong></td><td>62</td><td>-0.46 (-0.97 to 0.04)</td><td>0.072</td><td>62</td></tr><tr><td>- Isometric</td><td>1</td><td>20</td><td>0.25 (-0.18 to 0.68)</td><td>0.256</td><td>0</td><td>0.00 (-0.42 to 0.42)</td><td>1.000</td><td>0</td></tr><tr><td><strong>Volume (RE)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- &lt;150</td><td>3</td><td>45</td><td>-0.72 (-0.91 to -0.53)#</td><td><strong>&lt;0.001</strong></td><td>2</td><td>0.13 (-0.05 to 0.31)*#</td><td>0.148</td><td>13</td></tr><tr><td>- 150-250</td><td>5</td><td>69</td><td>-1.41 (-2.65 to -0.18)</td><td><strong>0.025</strong></td><td>55</td><td>-0.78 (-1.37 to -0.19)</td><td><strong>0.009</strong></td><td>57</td></tr><tr><td>- &gt;250</td><td>2</td><td>33</td><td>-0.34 (-0.67 to 0.00)</td><td><strong>0.048</strong></td><td>0</td><td>-0.32 (-0.65 to 0.01)</td><td>0.060</td><td>0</td></tr><tr><td><strong>Intensity (RE)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Light</td><td>4</td><td>66</td><td>-0.21 (-0.54 to 0.12)</td><td>0.203</td><td>0</td><td>-0.03 (-0.42 to 0.35)</td><td>0.862</td><td>1</td></tr><tr><td>- Moderate</td><td>7</td><td>101</td><td>-1.18 (-1.92 to -0.43)</td><td><strong>0.002</strong></td><td>65</td><td>-0.64 (-1.31 to 0.02)</td><td>0.056</td><td>68</td></tr><tr><td colspan="9"><strong>Measure time</strong></td></tr><tr><td><strong>Office BP</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- 30 min</td><td>11</td><td>99</td><td>-0.32 (-0.88 to 0.24)</td><td>0.260</td><td>68</td><td>-0.20 (-0.68 to 0.29)</td><td>0.426</td><td>66</td></tr><tr><td>- 40-50 min</td><td>10</td><td>87</td><td>-0.97 (-1.64 to -0.30)</td><td><strong>0.005</strong></td><td>62</td><td>-0.39 (-0.87 to 0.08)</td><td>0.103</td><td>66</td></tr><tr><td>- 60 min</td><td>18</td><td>150</td><td>-0.54 (-0.87 to -0.21)</td><td><strong>0.001</strong></td><td>43</td><td>-0.40 (-0.83 to 0.04)</td><td>0.075</td><td>52</td></tr><tr><td>- ≥ 70 min</td><td>7</td><td>49</td><td>-0.47 (-0.82 to -0.12)</td><td><strong>0.009</strong></td><td>25</td><td>-0.42 (-1.09 to 0.25)</td><td>0.220</td><td>12</td></tr><tr><td><strong>ABPM (20-24h)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Awake</td><td>4</td><td>41</td><td>-0.20 (-0.48 to 0.08)</td><td>0.163</td><td>0</td><td>-0.25 (-0.53 to 0.04)</td><td>0.087</td><td>0</td></tr><tr><td>- Asleep</td><td>4</td><td>41</td><td>-0.11 (-0.45 to 0.23)</td><td>0.536</td><td>3</td><td>-0.19 (-0.64 to 0.26)</td><td>0.401</td><td>5</td></tr></tbody></table>

Values are standard mean difference (SMD) using Hedge's g presented with 95% confidence interval (95% CI), p-value and heterogeneity (I²). EG: experimental group; P: participants; BMI: body mass index; PAL: physical activity level; BP: blood pressure; ABPM: ambulatory blood pressure monitoring; AE: aerobic exercise; CE: combined exercise; RE: resistance exercise. Comparisons between moderators were performed using Q-test and Z-test. * Difference from the second moderator (p<0.05); # Difference from the third moderator (p<0.05).
<table><caption>Table 2. Meta-analysis results of post-exercise hypotension (PEH) in postmenopausal women</caption><thead><tr><th rowspan="2"></th><th colspan="2">Number of</th><th colspan="3">Systolic PEH</th><th colspan="3">Diastolic PEH</th></tr><tr><th>EG</th><th>P</th><th>g (95% CI)</th><th>p-value</th><th>I² (%)</th><th>g (95% CI)</th><th>p-value</th><th>I² (%)</th></tr></thead><tbody><tr><td>Overall effect</td><td>42</td><td>474</td><td>-0.81 (-1.05 to -0.57)</td><td><strong>&lt;0.001</strong></td><td>73</td><td>-0.27 (-0.47 to -0.07)</td><td><strong>0.008</strong></td><td>63</td></tr><tr><td colspan="9"><strong>Population characteristics</strong></td></tr><tr><td>Clinical status</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- HT</td><td>37</td><td>410</td><td>-0.93 (-1.19 to -0.67)*</td><td><strong>&lt;0.001</strong></td><td>74</td><td>-0.33 (-0.55 to -0.12)*</td><td><strong>0.003</strong></td><td>65</td></tr><tr><td>- NT</td><td>5</td><td>64</td><td>0.10 (-0.43 to 0.63)</td><td>0.721</td><td>18</td><td>0.26 (0.07 to 0.44)</td><td><strong>0.008</strong></td><td>1</td></tr><tr><td>BMI</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- 25-29.9</td><td>38</td><td>431</td><td>-0.77 (-1.03 to -0.51)</td><td><strong>&lt;0.001</strong></td><td>74</td><td>-0.31 (-0.53 to -0.10)*</td><td><strong>0.005</strong></td><td>62</td></tr><tr><td>- &gt;30</td><td>3</td><td>28</td><td>-0.92 (-1.29 to -0.56)</td><td><strong>&lt;0.001</strong></td><td>47</td><td>0.22 (-0.15 to 0.59)</td><td>0.246</td><td>55</td></tr><tr><td>PAL</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Inactive</td><td>14</td><td>142</td><td>-0.23 (-0.37 to -0.09)*</td><td><strong>0.001</strong></td><td>0</td><td>0.03 (-0.07 to 0.12)*</td><td>0.543</td><td>0</td></tr><tr><td>- Active</td><td>15</td><td>166</td><td>-2.10 (-2.89 to -1.30)</td><td><strong>&lt;0.001</strong></td><td>63</td><td>-0.87 (-1.45 to -0.30)</td><td><strong>0.003</strong></td><td>58</td></tr><tr><td>Age</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- 50-60</td><td>12</td><td>114</td><td>-0.71 (-1.09 to -0.33)</td><td><strong>&lt;0.001</strong></td><td>9</td><td>-0.16 (-0.42 to 0.10)</td><td>0.218</td><td>13</td></tr><tr><td>- &gt;60</td><td>30</td><td>360</td><td>-0.86 (-1.16 to -0.56)</td><td><strong>&lt;0.001</strong></td><td>78</td><td>-0.33 (-0.59 to -0.08)</td><td><strong>0.011</strong></td><td>67</td></tr><tr><td colspan="9"><strong>Exercise characteristics</strong></td></tr><tr><td>Exercise type</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Aerobic (AE)</td><td>16</td><td>235</td><td>-0.47 (-0.66 to -0.29)*</td><td><strong>&lt;0.001</strong></td><td>26</td><td>0.11 (-0.16 to 0.38)*</td><td>0.433</td><td>40</td></tr><tr><td>- Resistance (RE)</td><td>24</td><td>226</td><td>-1.10 (-1.50 to -0.70)</td><td><strong>&lt;0.001</strong></td><td>77</td><td>-0.55 (-0.84 to -0.26)</td><td><strong>&lt;0.001</strong></td><td>67</td></tr><tr><td>- Combined (CE)</td><td>2</td><td>29</td><td>-0.79 (-2.33 to 0.75)</td><td>0.316</td><td>0</td><td>-0.24 (-0.93 to 0.44)</td><td>0.487</td><td>0</td></tr><tr><td>Environment (AE)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Dry</td><td>11</td><td>125</td><td>-0.36 (-0.55 to -0.16)</td><td><strong>&lt;0.001</strong></td><td>8</td><td>-0.11 (-0.21 to -0.01)</td><td><strong>0.027</strong></td><td>0</td></tr><tr><td>- Water</td><td>5</td><td>110</td><td>-0.82 (-1.25 to -0.40)</td><td><strong>&lt;0.001</strong></td><td>25</td><td>0.72 (-0.43 to 1.87)</td><td>0.218</td><td>0</td></tr><tr><td>Modality (AE)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Continuous</td><td>10</td><td>197</td><td>-0.50 (-0.69 to -0.30)</td><td><strong>&lt;0.001</strong></td><td>21</td><td>0.35 (-0.09 to 0.78)</td><td>0.124</td><td>27</td></tr><tr><td>- Interval</td><td>6</td><td>99</td><td>-0.39 (-0.77 to -0.02)</td><td><strong>0.040</strong></td><td>27</td><td>-0.21 (-0.46 to 0.05)</td><td>0.114</td><td>10</td></tr><tr><td>Material (AE)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Cycling</td><td>3</td><td>18</td><td>-0.59 (-1.06 to -0.13)</td><td><strong>0.011</strong></td><td>0</td><td>-0.10 (-0.52 to 0.32)</td><td>0.647</td><td>0</td></tr><tr><td>- Walking</td><td>8</td><td>137</td><td>-0.28 (-0.52 to -0.05)</td><td><strong>0.019</strong></td><td>14</td><td>-0.09 (-0.21 to 0.03)</td><td>0.139</td><td>0</td></tr><tr><td>- Step</td><td>1</td><td>12</td><td>-0.64 (-0.98 to -0.29)</td><td><strong>&lt;0.001</strong></td><td>0</td><td>-0.28 (-0.60 to 0.04)</td><td>0.090</td><td>0</td></tr><tr><td>Intensity (AE)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Moderate</td><td>10</td><td>197</td><td>-0.50 (-0.69 to -0.30)#</td><td><strong>&lt;0.001</strong></td><td>65</td><td>0.35 (-0.09 to 0.78)*</td><td>0.124</td><td>65</td></tr><tr><td>- Vigorous</td><td>4</td><td>73</td><td>-0.65 (-1.00 to -0.30)#</td><td><strong>&lt;0.001</strong></td><td>21</td><td>-0.32 (-0.59 to -0.05)</td><td><strong>0.018</strong></td><td>21</td></tr><tr><td>- Maximal</td><td>2</td><td>26</td><td>0.15 (-0.35 to 0.64)</td><td>0.557</td><td>0</td><td>0.03 (-0.44 to 0.50)</td><td>0.890</td><td>0</td></tr><tr><td>Modality (RE)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Concentric</td><td>20</td><td>188</td><td>-1.37 (-1.85 to -0.89)*#</td><td><strong>&lt;0.001</strong></td><td>76</td><td>-0.68 (-1.03 to -0.34)*#</td><td><strong>&lt;0.001</strong></td><td>67</td></tr><tr><td>- Isometric</td><td>2</td><td>12</td><td>0.07 (-0.16 to 0.31)</td><td>0.554</td><td>1</td><td>0.04 (-0.18 to 0.27)</td><td>0.702</td><td>0</td></tr><tr><td>- Power training</td><td>2</td><td>26</td><td>-0.17 (-0.41 to 0.06)</td><td>0.149</td><td>1</td><td>0.01 (-0.23 to 0.24)</td><td>0.948</td><td>0</td></tr><tr><td>Volume (RE)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- &lt;150</td><td>10</td><td>131</td><td>-1.03 (-1.58 to -0.48)</td><td><strong>&lt;0.001</strong></td><td>2</td><td>-0.64 (-1.05 to -0.23)#</td><td><strong>0.002</strong></td><td>71</td></tr><tr><td>- 150-250</td><td>10</td><td>78</td><td>-1.63 (-2.58 to -0.68)</td><td><strong>0.001</strong></td><td>55</td><td>-0.73 (-1.39 to -0.07)#</td><td><strong>0.030</strong></td><td>0</td></tr><tr><td>- &gt;250</td><td>2</td><td>20</td><td>-0.82 (-1.02 to -0.61)</td><td><strong>&lt;0.001</strong></td><td>0</td><td>0.06 (-0.12 to 0.23)</td><td>0.508</td><td>55</td></tr><tr><td>Intensity (RE)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Light</td><td>7</td><td>67</td><td>-2.69 (-3.98 to -1.40)*#</td><td><strong>&lt;0.001</strong></td><td>65</td><td>-1.24 (-2.06 to -0.42)*</td><td><strong>0.003</strong></td><td>56</td></tr><tr><td>- Moderate</td><td>9</td><td>96</td><td>-0.34 (-0.87 to 0.18)</td><td>0.199</td><td>60</td><td>-0.11 (-0.48 to 0.26)</td><td>0.571</td><td>45</td></tr><tr><td>- Vigorous</td><td>8</td><td>136</td><td>-0.76 (-1.29 to -0.23)</td><td><strong>0.005</strong></td><td>78</td><td>-0.46 (-0.88 to -0.04)</td><td><strong>0.031</strong></td><td>76</td></tr><tr><td colspan="9"><strong>Measure time</strong></td></tr><tr><td>Office BP</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- 30 min</td><td>31</td><td>348</td><td>-0.84 (-1.16 to -0.53)#</td><td><strong>&lt;0.001</strong></td><td>64</td><td>-0.29 (-0.55 to -0.02)</td><td><strong>0.034</strong></td><td>45</td></tr><tr><td>- 40-50 min</td><td>26</td><td>267</td><td>-1.06 (-1.46 to -0.67)#</td><td><strong>&lt;0.001</strong></td><td>68</td><td>-0.61 (-0.91 to -0.31)#</td><td><strong>&lt;0.001</strong></td><td>54</td></tr><tr><td>- 60 min</td><td>25</td><td>270</td><td>-0.32 (-0.52 to -0.11)</td><td><strong>0.002</strong></td><td>27</td><td>0.00 (-0.11 to 0.10)</td><td>0.950</td><td>1</td></tr><tr><td>- ≥ 70 min</td><td>7</td><td>45</td><td>-1.81 (-2.67 to -0.94)#</td><td><strong>&lt;0.001</strong></td><td>70</td><td>-1.06 (-1.72 to -0.39)#</td><td><strong>0.002</strong></td><td>67</td></tr><tr><td>ABPM (20-24h)</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>- Awake</td><td>8</td><td>129</td><td>-0.18-0.35 to -0.02)</td><td><strong>0.031</strong></td><td>1</td><td>-0.09 (-0.23 to 0.05)</td><td>0.217</td><td>0</td></tr><tr><td>- Asleep</td><td>8</td><td>129</td><td>-0.15-0.31 to 0.02)</td><td>0.080</td><td>0</td><td>-0.07 (-0.21 to 0.08)</td><td>0.384</td><td>0</td></tr></tbody></table>

Values are standard mean difference (SMD) using Hedge's g presented with 95% confidence interval (95% CI), p-value and heterogeneity (I²). EG: experimental group; P: participants; BMI: body mass index; PAL: physical activity level; BP: blood pressure; ABPM: ambulatory blood pressure monitoring; AE: aerobic exercise; CE: combined exercise; RE: resistance exercise. Comparisons between moderators were performed using Q-test and Z-test. * Difference from the second moderator (p<0.05); # Difference from the third moderator (p<0.05).