Query: hypertension exercise

title: American College of Sports Medicine position stand. Exercise and hypertension.
abstract: Hypertension (HTN) one of the most common medical disorders, is associated with an increased incidence of all cause and cardiovascular disease (CVD) mortality. Lifestyle modifications are advocated for the prevention, treatment, and control of HTN, with exercise being an integral component. Exercise programs that primarily involve endurance activities prevent the development of HTN and lower blood pressure (BP) in adults with normal BP and those with HTN. The BP lowering effects of exercise are most pronounced in people with HTN who engage in endurance exercise with BP decreasing approximately 5 7 mm HG after an isolated exercise session (acute) or following exercise training (chronic) Moreover, BP is reduced for up to 22 h after an endurance exercise bout (e.g.postexercise hypotension) with greatest decreases among those with highest baseline BP. The proposed mechanisms for the BP lowering effects of exercise include neurohumoral, vascular, and structural adaptations. Decreases in catecholamines and total peripheral resistance, improved insulin sensitivity, and alterations in vasodilators and vasoconstrictors are some of the postulated explanations for the antihypertensive effects of exercise. Emerging data suggest genetic links to the BP reductions associated with acute and chronic exercise. Nonetheless, definitive conclusions regarding the mechanisms for the BP reductions following endurance exercise cannot be made at this time. Individuals with controlled HTN and no CVD or renal complications may participated in an exercise program or competitive athletics, but should be evaluated, treated and monitored closely. Preliminary peak or symptom limited exercise testing may be warranted, especially for men over 45 and women over 55 yr planning a vigorous exercise program (i.e. or 60% VO2R, oxygen uptake reserve) In the interim, while formal evaluation and management are taking place, it is reasonable for the majority of patients to begin moderate intensity exercise (40 <60% VO2R) such as walking. When pharmacological therapy is indicated in physically active people it should be, ideally: a) lower BP at rest and during exertion; b) decrease total peripheral resistance; and, c) not adversely affect exercise capacity. For these reasons, angiotensin converting enzyme (ACE) inhibitors (or angiotensin II receptor blockers in case of ACE inhibitor intolerance) and calcium channel blockers are currently the drugs of choice for recreational exercisers and athletes who have HTN. Exercise remains a cornerstone therapy for the primary prevention, treatment, and control of HTN. The optimal training frequency, intensity, time, and type (FITT) need to be better defined to optimize the BP lowering capacities of exercise, particularly in children, women, older adults, and certain ethnic groups. based upon the current evidence, the following exercise prescription is recommended for those with high BP: Frequency: on most, preferably all, days of the week. Intensity: moderate intensity (40 <60% VO2R) Time: or 30 min of continuous or accumulated physical activity per day. Type: primarily endurance physical activity supplemented by resistance exercise.

title: The Role of Exercise Training in the Treatment of Hypertension
abstract: Hypertension is a very prevalent cardiovascular (CV) disease risk factor in developed countries. All current treatment guidelines emphasise the role of nonpharmacological interventions, including physical activity, in the treatment of hypertension. Since our most recent review of the effects of exercise training on patients with hypertension, 15 studies have been published in the English literature. These results continue to indicate that exercise training decreases blood pressure (BP) in approximately 75% of individuals with hypertension, with systolic and diastolic BP reductions averaging approximately 11 and 8mm Hg, respectively. Women may reduce BP more with exercise training than men, and middle aged people with hypertension may obtain greater benefits than young or older people. Low to moderate intensity training appears to be as, if not more, beneficial as higher intensity training for reducing BP in individuals with hypertension. BP reductions are rapidly evident although, at least for systolic BP, there is a tendency for greater reductions with more prolonged training. However, sustained BP reductions are evident during the 24 hours following a single bout of exercise in patients with hypertension.

title: Exercise and hypertension
abstract: There is good evidence that habitual physical activity and measured physical fitness are inversely related to the incidence of coronary heart disease and mortality. Such relationships have, for example, been observed in studies in the population, in hypertensives and in patients with ischaemic heart disease. The mechanisms of the favourable effects of physical activity and fitness on survival are not yet clearly understood but blood pressure may be involved. Epidemiological evidence indicates that the incidence of hypertension is lower in physically fit or active subjects, independent of confounders such as baseline blood pressure, age and body mass index or body fat. The adjusted relative risk for the development of hypertension ranges from 1.3 to 1.9 in unfit or inactive subjects compared to the fitter or more active. Several large crosssectional studies which allowed for age, anthropometric characteristics and occasionally for other confounders, have reported an inverse relationship between blood pressure and either habitual physical activity or fitness, the difference in blood pressure between the most and least fit or active amounting to 5 mm Hg at the most. Finally, controlled intervention studies have shown that adequate dynamic aerobic training lowers blood pressure by about 5 mm Hg, the effect being more pronounced in hypertensive than in normotensive. The favourable longer term effects of physical activity on blood pressure have attracted a lot of attention. However, it is worthwhile to also consider the short term influences of exercise. Dynamic exercise profoundly affects the cardiovascular system. Systemic vascular resistance is reduced due to predominant vasodilation in the working muscles. Cardiac output increases and the resulting influence on blood pressure consists of a slight rise in diastolic and a more pronounced increase in systolic blood pressure. When exercise is stopped cardiac output decreases rapidly whereas systemic vascular resistance recovers only slowly, resulting in a lower blood pressure than prior to exercise. In addition to the vascular phenomena, a decreased sympathetic ner

title: Exercise Induced Pulmonary Arterial Hypertension
abstract: The clinical relevance of exercise induced pulmonary arterial hypertension (PAH) is uncertain, and its existence has never been well studied by direct measurements of central hemodynamics. Using invasive cardiopulmonary exercise testing, we hypothesized that exercise induced PAH represents a symptomatic stage of PAH, physiologically intermediate between resting pulmonary arterial hypertension and normal.  A total of 406 consecutive clinically indicated cardiopulmonary exercise tests with radial and pulmonary arterial catheters and radionuclide ventriculographic scanning were analyzed. The invasive hemodynamic phenotype of exercise induced PAH (n=78) was compared with resting PAH (n=15) and normals (n=16) Log log plots of mean pulmonary artery pressure versus oxygen uptake &OV0312;o2) were obtained, and a "join point" for a least residual sum of squares for 2 straight line segments (slopes m1, m2) was determined; m2m1="takeoff" pattern. At maximum exercise, &OV0312;o2 (55.8+ 20.3% versus 66.5+ 16.3% versus 91.7+ 13.7% predicted) was lowest in resting PAH, intermediate in exercise induced PAH, and highest in normals, whereas mean pulmonary artery pressure (48.4+ 11.1 versus 36.6+ 5.7 versus 27.4+3.7 mm Hg) and pulmonary vascular resistance (294+ 158 versus 161+ 60 versus 62+ 20 dyne s cm 5, respectively; P<0.05) followed an opposite pattern. An exercise induced PAH plateau (n=32) was associated with lower &OV0312;o2max (60.6+ 15.1% versus 72.0+ 16.1% predicted) and maximum cardiac output (78.2+ 17.1% versus 87.8+ 18.3% predicted) and a higher resting pulmonary vascular resistance (247+ 101 versus 199+ 56 dyne s cm 5; P<0.05) than takeoff (n=40) The plateau pattern was most common in resting PAH, and the takeoff pattern was present in nearly all normals.  Exercise induced PAH is an early, mild, and clinically relevant phase of the PAH spectrum.

title: Exercise Pathophysiology in Patients With Primary Pulmonary Hypertension
abstract: Patients with primary pulmonary hypertension (PPH) have a pulmonary vasculopathy that leads to exercise intolerance due to dyspnea and fatigue. To better understand the basis of the exercise limitation in patients with PPH, cardiopulmonary exercise testing (CPET) with gas exchange measurements, New York Heart Association (NYHA) symptom class, and resting pulmonary hemodynamics were studied.  We retrospectively evaluated 53 PPH patients who had right heart catheterization and cycle ergometer CPET studies to maximum tolerance as part of their clinical workups. No adverse events occurred during CPET. Reductions in peak O2 uptake &OV0312;o2) anaerobic threshold, peak O2 pulse, rate of increase in &OV0312;o2, and ventilatory efficiency were consistently found. NYHA class correlated well with the above parameters of aerobic function and ventilatory efficiency but less well with resting pulmonary hemodynamics.  Patients with PPH can safely undergo noninvasive cycle ergometer CPET to their maximal tolerance. The CPET abnormalities were consistent and characteristic and correlated well with NYHA class.

title: Exercise capacity and mortality among men referred for exercise testing.
abstract: Exercise capacity is known to be an important prognostic factor in patients with cardiovascular disease, but it is uncertain whether it predicts mortality equally well among healthy persons. There is also uncertainty regarding the predictive power of exercise capacity relative to other clinical and exercise test variables.  We studied a total of 6213 consecutive men referred for treadmill exercise testing for clinical reasons during a mean SD) of 6.2+ 3.7 years of follow up. Subjects were classified into two groups: 3679 had an abnormal exercise test result or a history of cardiovascular disease, or both, and 2534 had a normal exercise test result and no history of cardiovascular disease. Overall mortality was the end point.  There were a total of 1256 deaths during the follow up period, resulting in an average annual mortality of 2.6 percent. Men who died were older than those who survived and had a lower maximal heart rate, lower maximal systolic and diastolic blood pressure, and lower exercise capacity. After adjustment for age, the peak exercise capacity measured in metabolic equivalents (MET) was the strongest predictor of the risk of death among both normal subjects and those with cardiovascular disease. Absolute peak exercise capacity was a stronger predictor of the risk of death than the percentage of the age predicted value achieved, and there was no interaction between the use or nonuse of beta blockade and the predictive power of exercise capacity. Each 1 MET increase in exercise capacity conferred a 12 percent improvement in survival.  Exercise capacity is a more powerful predictor of mortality among men than other established risk factors for cardiovascular disease.

title: Assessment of Survival in Patients With Primary Pulmonary Hypertension: Importance of Cardiopulmonary Exercise Testing
abstract: Primary pulmonary hypertension (PPH) is a life threatening disease. Prognostic assessment is an important factor in determining medical treatment and lung transplantation. Whether cardiopulmonary exercise testing data predict survival has not been reported previously.  We studied 86 patients with PPH (58 female, age 46+ 2 years, median NYHA class III) between 1996 and 2001 who were followed up in a tertiary referral center. Right heart catheterization was performed and serum uric acid levels were measured in all patients. Seventy patients were able to undergo exercise testing. At the start of the study, the average pulmonary artery pressure was 60+ 2 mm Hg, average pulmonary vascular resistance was 1664+ 81 dyne s cm 5, average serum uric acid level was 7.5+ 0.35 mg/dL, and average peak oxygen uptake during exercise (peak &OV0312;o2) was 11.2+ 0.5 mL kg 1 min 1. During follow up (mean: 567+ 48 days) 28 patients died and 16 underwent lung transplantation (1 year cumulative event free survival: 68% 95% CI 58 to 78) The strongest predictors of impaired survival were low peak &OV0312;o2 (P <0.0001) and low systolic blood pressure at peak exercise (peak SBP;P <0.0001) In a multivariable analysis, serum uric acid levels (all P <0.005) and diastolic blood pressure at peak exercise independently predicted survival (P <0.05) Patients with peak &OV0312;o2 =10.4 mL kg 1 min 1 and peak SBP =120 mm Hg (ie, 2 risk factors) had poor survival rates at 12 months (23% whereas patients with 1 or none of these risk factors had better survival rates (79% and 97% respectively) Conclusions Peak &OV0312;o2 and peak SBP are independent and strong predictors of survival in PPH patients. Hemodynamic parameters, although also accurate predictors, provide no independent prognostic information.

title: Exercise and Respiratory Training Improve Exercise Capacity and Quality of Life in Patients With Severe Chronic Pulmonary Hypertension
abstract: Pulmonary hypertension (PH) is associated with restricted physical capacity, limited quality of life, and a poor prognosis because of right heart failure. The present study is the first prospective randomized study to evaluate the effects of exercise and respiratory training in patients with severe symptomatic PH.  Thirty patients with PH (21 women; mean age, 50+ 13 years; mean pulmonary artery pressure, 50+ 15 mm Hg; mean World Health Organization [WHO] class, 2.9+ 0.5; pulmonary arterial hypertension, n=23; chronic thromboembolic PH, n=7) on stable disease targeted medication were randomly assigned to a control (n=15) and a primary training (n=15) group. Medication remained unchanged during the study period. Primary end points were the changes from baseline to week 15 in the distance walked in 6 minutes and in scores of the Short Form Health Survey quality of life questionnaire. Changes in WHO functional class, Borg scale, and parameters of echocardiography and gas exchange also were assessed. At week 15, patients in the primary and secondary training groups had an improved 6 minute walking distance; the mean difference between the control and the primary training group was 111 m (95% confidence interval, 65 to 139 m; P<0.001) Exercise training was well tolerated and improved scores of quality of life, WHO functional class, peak oxygen consumption, oxygen consumption at the anaerobic threshold, and achieved workload. Systolic pulmonary artery pressure values at rest did not change significantly after 15 weeks of exercise and respiratory training (from 61+ 18 to 54+ 18 mm Hg) within the training group.  This study indicates that respiratory and physical training could be a promising adjunct to medical treatment in severe PH. The effects add to the beneficial results of modern medical treatment.

title: Blood Pressure Response to Heart Rate During Exercise Test and Risk of Future Hypertension
abstract: Previous works have shown that exaggerated blood pressure response to exercise is a valid risk marker for future hypertension, yet the use of an exercise test as a means of early prediction of hypertension still requires methodological development and confirmation. The purpose of this study was to determine abnormal ranges of blood pressure responses in relation to heart rate increase during exercise and to examine the clinical utility of exercise blood pressure measurement in evaluating individual risk for developing hypertension. We examined exercise test data from a population based sample of 1033 nonmedicated normotensive men (mean age, 42.9+ 8.5 years; range, 20 to 59 years) Percentile curves of systolic and diastolic blood pressure responses to relative heart rate increments during submaximal exercise were constructed using a third order polynomial model with multiple regression analysis. Of the original study sample, a cohort of 726 subjects was followed for hypertensive outcome for an average period of 4.7 years. Progression to hypertension, defined as a blood pressure of =140/90 mm Hg or the initiation of antihypertensive therapy, was found in 114 subjects (15.4% Kaplan Meier survival estimates showed that the cumulative incidence of hypertension increased progressively with higher percentiles of systolic and diastolic blood pressure response (both, P <0.01) A Cox proportional survival analysis revealed a significantly increased risk for developing hypertension associated with exaggerated blood pressure response to exercise after multivariable adjustments for traditional risk factors (relative risk, 3.8; 95% confidence interval, 2.3 to 6.1) These results suggest that an exaggerated blood pressure response to heart rate during exercise is predictive of future hypertension independent of other important risk factors and lend further support to the concept that blood pressure measurement during exercise test is a valuable means of identifying normotensive individuals at high risk for developing hypertension.

title: Clinical correlates and prognostic significance of six minute walk test in patients with primary pulmonary hypertension. Comparison with cardiopulmonary exercise testing.
abstract: The six minute walk test is a submaximal exercise test that can be performed even by a patient with heart failure not tolerating maximal exercise testing. To elucidate the clinical significance and prognostic value of the six minute walk test in patients with primary pulmonary hypertension (PPH) we sought (1) to assess the relation between distance walked during the six minute walk test and exercise capacity determined by maximal cardiopulmonary exercise testing, and (2) to investigate the prognostic value of the six minute walk test in comparison with other noninvasive parameters. The six minute walk test was performed in 43 patients with PPH, together with echocardiography, right heart catheterization, and measurement of plasma epinephrine and norepinephrine. Symptom limited cardiopulmonary exercise testing was performed in a subsample of patients (n 27) Distance walked in 6 min was significantly shorter in patients with PPH than in age and sex matched healthy subjects (297 188 versus 655 91 m, p 0. 001) The distance significantly decreased in proportion to the severity of New York Heart Association functional class. The distance walked correlated modestly with baseline cardiac output (r 0.48, p 0.05) and total pulmonary resistance (r 0.49, p 0. 05) but not significantly with mean pulmonary arterial pressure. In contrast, the distance walked correlated strongly with peak V O(2) (r 0.70, p 0.001) oxygen pulse (r 0.57, p 0.01) and V E VCO(2) slope (r 0.66, p 0.001) determined by cardiopulmonary exercise testing. During a mean follow up period of 21 16 mo, 12 patients died of cardiopulmonary causes. Among noninvasive parameters including clinical, echocardiographic, and neurohumoral parameters, only the distance walked in 6 min was independently related to mortality in PPH by multivariate analysis. Patients walking 332 m had a significantly lower survival rate than those walking farther, assessed by Kaplan Meier survival curves (log rank test, p 0.01) These results suggest that the six minute walk test, a submaximal exercise test, reflects exercise capacity determined by maximal cardiopulmonary exercise testing in patients with PPH, and it is the distance walked in 6 min that has a strong, independent association with mortality.