Benefits of exercise training on blood pressure and beyond in cardiovascular diseases

Abstract

Considerable evidence has emphasized that despite the substantial recommendations for major societies, sedentary behavior and physical inactivity remain high and physical activity (PA) and exercise training (ET) remains low in the US and much of the world. Therefore, greater efforts are needed to improve PA/ET in the primary and secondary prevention of cardiovascular disease (CVD) risk factors, including hypertension (HTN), and CVD. Although the European Society of Cardiology did not adopt the lower blood pressure (BP) guidelines that are now present in the US guidelines, still in Europe, the US and most of the world HTN is extremely prevalent and it contributes to markedly increased the risk of CVD and CVD-related morbidity and mortality. Studies have emphasized the potential for ET to reduce BP and HTN and to improve overall CVD prognosis. In the current issue of the European Journal of Preventive Cardiology, Noone et al. performed perhaps the largest and most thorough meta-analysis to date on the impact of ET on BP in people with HTN, while also comparing the anti-HTN effects of ET versus modern-day pharmacological intervention for HTN. In an analysis of 93 randomized controlled trials (RCTs), in 32 of those trials (404 patients with HTN), both ET and medications, together, effectively lowered BP compared to controlled conditions. Although the point estimate suggested that the anti-HTN medications were more effective than ET, there was insufficient evidence to suggest that first-line anti-HTN medications (including angiotensin-converting-enzyme inhibitors (ACEIs), angiotensin-receptor blockers (ARBs), calcium-channel blockers (CCBs) and thiazide-like diuretics) significantly reduced BP to a greater extent than ET intervention did, supporting the idea that vigorous non-pharmacologic therapy, including ET, should be considered as first-line therapy for at least mild HTN. Other studies and meta-analyses have also evaluated the impact of ET on BP, including one with water ET. In comparison to the prior meta-analysis by Naci et al., the same issue plagues both reviews/analyses, specifically a dearth of RCTs of ET in the population with HTN (N1⁄4 1057 exercise HTN patients in the current study and N1⁄4 3508 in the study by Naci et al.). While ET is proven equal to medications, as suggested by Naci et al., or slightly inferior to medications as firstline therapy, as the current study suggests, this does not impact a recommendation for ET for all individuals as either first-line or as an adjunct to initial therapy in uncomplicated HTN. Given its low cost, lack of side effects and no medication interactions, especially considering the known benefits of ET well beyond just BP lowering and especially on its impact to improve levels of cardiorespiratory fitness (CRF), perhaps the strongest CVD risk marker, ET should be part of every antiHTN regimen. In the present study, the authors correctly alluded to the need for future studies to examine the effects of varying ET intensities on resting systolic BP (SBP) and diastolic BP (DBP), against pharmacologic intervention, as this was not factored into their analyses. A strong body of literature has revealed dose–response relations between ET intensity and CRF, and inverse relations with risk of developing metabolic disorders, CVD and mortality. While high-intensity ET may contribute to many physiologic adaptations that protect against CVD, comparatively greater benefits associated with performing moderate-intensity ET have also been identified. For instance, the Studies of a Targeted Risk Reduction Intervention Through Defined Exercise (STRITDE) found greater improvements in triglycerides and insulin sensitivity in the moderate-intensity group compared to the high-intensity group. As a result of the differential changes in