Exercise and Blood Pressure Reactivity
Condition: Hypertension
MeSH terms: Hypertension
Study type: Observational

Summary: 
      Introduction: Daily stress levels of population are increasing over the last decades.
      Frequent spouse to stress is considered an important risk factor for development of
      cardiovascular diseases. Other well documented risk factor for cardiovascular diseases is
      systemic hypertension which, in turn, has been related to elevated blood pressure reactivity
      (BPR) to stress. The exacerbated BPR may suggest a poor autonomic modulation due to an
      elevated sympathetic tone, condition that has been associated with medium to long-term
      cardiovascular complications. Also, some reports have demonstrated that individuals
      hyper-reactive to stress chronically increase their risk for psychological disorders such as
      anxiety, irritability and frustration. These feelings are associated to increased sympathetic
      tone induced chronic elevation in BP. Although the hemodynamic benefits of aerobic and
      resistance exercises had been documented in a variety of reports5, the acute effects of the
      aforementioned exercise modes combined in a circuit method on post-exercise BP, including the
      responses to cardiovascular stressor test need further investigations. Objective: To
      investigate the blood pressure (BP) responses to cardiovascular stressor test after a
      combined exercise circuit session at moderate intensity. Methods: Twenty individuals
      (10male/10fem; 33.4±6.9years; 70.2±15.8kg; 170.4±11.5cm; 22.3±6.8 %body fat) volunteered to
      randomly perform on different days: 1) Exercise session consisting of 3-laps in a circuit
      model in the following sequence: knee extension, bench press, knee flexion, rowing in the
      prone, squat, shoulder press and 5-min of aerobic exercise at 75-85% of age-predicted maximum
      heart rate and/or 13 in the Borg-Scale [6-20]. The sets of resistance exercise were composed
      by 15 repetitions with ~50% of one repetition maximum test and; 2) a control session without
      exercise. The systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured
      at resting and during 1h of recovery in both experimental sessions. After that, blood
      pressure reactivity (BPR) was evaluated using the Cold Pressor Test (a test with hand in the
      cold water during one minute). The hypotheses are that after doing the exercise session occur
      attenuation of blood pressure increase during the Cold Pressor Test compared to sitting
      without exercise (control session).
    

Detailed description: 
      * Subjects:

      - Twenty apparently healthy individuals of both genders (10 men and 10 women) with a mean age
      of 33.4±6.9 years (24 - 50 years), weight of 70.2±15.8 kg (45 - 96 kg), height of 170.4±11.5
      cm (149 - 192 cm), body mass index (BMI) of 23.9±3.5 kg/m2(-1) (19.2 - 23.7 kg/m2(-1)) and
      percent body fat of 22.3±6.8% (8.5 - 35.0 %) volunteered for participation. The
      classification of the subjects in "apparently healthy" was performed by the risk
      stratification criteria of the American College of Sports Medicine in 1995 (interview with
      signs, symptoms and/or cardiopulmonary risk factors). No subject was using any medication and
      had no history of diagnosed cardiovascular or metabolic disease.

      The study was conducted in accordance to the Declaration of Helsinki and was approved by the
      Institutional Committe (CEDEP - COMITÊ DE ÉTICA E DEONTOLOGIA EM ESTUDOS E PESQUISAS),
      Petrolina-PE (protocol 0047.0.441.000-10). All participants were informed on the experimental
      methods before giving written consent.

        -  Anthropometric Assessment:

           - Standard procedures were used to measure weight, height and body mass index (BMI).
           Body density was determined with specifications by Jackson & Pollock16 for men
           ([1,1093800 - 0,0008267 * (sum of skinfolds of the chest, abdomen and thigh) + 0,0000016
           * (sum of skinfolds of the chest, abdomen and thigh)2 - 0,0002574 * age]) and Jackson et
           al.17 for women ([1,0994921 - 0,0009929 * (sum of skinfolds of the triceps, suprailiac
           and thigh) + 0,0000023 * (sum of skinfolds of the triceps, suprailiac and thigh)2 -
           0,0001392 * age]). Body fat percentage was derived from Siri equation ([4.91 / density -
           4.5] * 100).

        -  Blood Pressure Measurement:

           - All BP measurements were performed by the same trained technician through the
           auscultatory method following previously described recommendations18, using a
           stethoscope (Duo Sonic, Brazil) and a calibrated sphygmomanometer (Missouri, São Paulo,
           SP, Brazil) certified by Inmetro (National Institute of Metrology, Quality and
           Technology). Measurements were taken at the left arm with the individual comfortably
           seated in a calm and controlled room temperature at 25o C. The auscultatory procedures
           were ensured against an automated and previously validated19 oscillometric method
           (Microlife, BP 3AC1-1, USA). Briefly, 30 independent individuals (another sample of
           individuals) of both genders rested for ten minutes and had BP randomly measured through
           both auscultatory and oscilometric methods, being the last blinded conducted by another
           evaluator. Correlations between methods were r=0.90 (p<0.001) for systolic blood
           pressure (SBP) and r=0.80 (p<0.001) for diastolic blood pressure (DBP). Also, agreement
           between methods was examined using the Bland & Altman20 procedure. Mean differences were
           3.9 mmHg [20.2/-12.4 mmHg] and -3.4 mmHg [10.5/-17.3 mmHg] for SBP and DBP,
           respectively.

        -  Blood Pressure Reactivity (BPR) Assessment:

           - BPR measurements were performed using the Cold Pressor Test (CPT) according to
           specifications previously described by Hines & Brow3. These authors had demonstrated the
           high reproducibility of the procedure for both normotensive and hypertensive
           individuals. The protocol consisted of one minute immersion of the right hand in water
           carefully kept at 4º C (Incoterm®, Porto Alegre, RS). BP measurements were respectively
           taken 30 and 60 seconds of immersion through the auscultatory method. The two BP values
           were respectively named Peak30" and Peak60" and the procedure is considered as an index
           of BPR. BP was also measured two minutes after the immersion cessation (After2'). Of
           note, the adoption of the auscultatory method for BP evaluation was due to the
           requirement of measurements at 30 and 60 seconds, what would not be possible using the
           automated oscillometric device.

        -  Experimental Sessions:

           - Volunteers randomly underwent two experimental sessions on different days and
           separated by 48 to 72 hours. The combined exercise session consisting of 3 laps in a
           circuit model with two minutes recovery among laps, performing each of the following
           resistance and aerobic exercises: knee extension, bench press, knee flexion, rowing in
           the prone, squat, shoulder press and five minutes of up to down in a 15 centimeters high
           step between 75-85% heart rate maximum and/or 13 in the rate of perceived exertion (RPE)
           of Borg Scale score of 6 to 20 points21. Resistance exercise loads were implemented
           using dumbbells to upper body exercises and weights attached on the legs and arms to
           lower body exercises. Each resistance exercise was performed in 15 repetitions with the
           estimative of 50% of one repetition maximum test as suggested by Tiggemann et al.22,23
           with the utilization of RPE21. One second for the concentric phase and one second for
           the eccentric phase to resistance exercise were performed with rhythmic control
           (Metronome Plus®). The control session was conducted under the same conditions of the
           combined exercise session, with the exception that subjects did not perform exercises.

        -  Measurements during the Experimental Sessions:

           - Resting SBP, DBP and mean arterial pressure (MAP) measurements were taken at each five
           minutes interval during 20 minutes and the average was considered for the analyses
           (Missouri, São Paulo, SP, Brazil). Also, BP was measured after each circuit lap and at
           each 15 minutes intervals of post-exercise recovery during one hour. The same timeline
           and measures were followed during the control session. The CPT was conducted before each
           session (after 20 minutes of rest) and one hour after the combined exercise and control
           sessions. Heart Rate (HR) was also measured during each exercise and at the respective
           moment in the control session (Pulse Tronic Club Trainer®/ Direction Technology
           Co/Suiça). The HR measurements were considered for aerobic exercise control and
           identification of the cardiovascular load imposed by the experimental sessions. RPE was
           taken during the combined exercise session for control of exercise intensity and the
           mean value considered for subsequent analyses.

        -  Statistical Analyses:

             -  Data are presented using descriptive statistics with procedures of mean, standard
                deviation as well as lowest and maximum values. The Shapiro-Wilk test was used to
                verify and present normality of data distribution. Pearson correlation was used to
                examine the relationship between resting BP measured through the different methods
                (i.e., auscultatory and oscillometric), as well as BPR in the different moments and
                the BP response during and after exercise and control sessions. The Bland &
                Altman20 technique was conducted to verify agreement between the two BP measurement
                methods. Paired-samples t test was used to compare data for correspondent moments
                of experimental sessions. A two-way repeated measures ANOVA was conducted to
                compare BP and BPR responses within and between experimental sessions [Time (Pre
                vs. Post) * Session (Exercise vs. Control)]. Data were considered significant at P
                < 0.05 and statistical analyses were performed using the SPSS15.0 software (SPSS,
                Chicago, IL).
    

Intervention name(s): Exercise on Blood Pressure Reactivity
Intervention type(s): Behavioral
Intervention description(s): To comparison, volunteers randomly underwent 2 experimental sessions separated by 48-72h. The exercise session consisting of 3-laps in a circuit, performing resistance and aerobic exercises: knee extension, bench press, knee flexion, rowing in the prone, squat, shoulder press and five minutes of up to down in a 15cm high step between 75-85% heart rate maximum. Resistance exercise loads used dumbbells to upper body exercises and weights attached on the legs and arms to lower body exercises. Each resistance exercise was performed in 15reps with 50% of one repetition maximum test. Two secs for repetition were performed with rhythmic control. The control session was conducted under the same conditions of the exercise session, with the exception that subjects did not perform exercises.
Observational model: Case-Control
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        Community sample.
      
Keywords: blood pressure reduction; vascular reactivity; combined exercise session