Reprinted from Australian Family Physician Vol. 34, No.

6, June 2005 4 419

Approxinalely 29' of Auslralians have blood
pressure (BP above lhe reconnended level of <120
syslolic and <30 diaslolic. These individuals accounl for
3.6' of palienl encounlers and 7.9' of prescriplions
in general praclice.
1
As lhe populalion ages, lhese
slalislics will increase. Over 50' of adulls aged 55-74
years already have BP oulside lhe desirable range
(Tab|e !. An individual wilh nornal BP al 55 years
of age has a 90' lifeline risk of developing high
BP.
2
Cosls associaled wilh drugs, palhology, radiology
and conplicalions due lo slroke, coronary hearl
disease, kidney disease, hearl failure, and end slage
renal disease
3
nakes hyperlension lhe lhird grealesl
nodifiable nedical risk faclor burden in Auslralia,
second only lo lobacco snoking and physical inaclivily.
4

For lhis reason, lifeslyle nodifying lrealnenls, including
diel and physical aclivily, are firsl line inlervenlions for
high BP nanagenenl, even when drug lherapy is
inplenenled.
5,6

There is lillle debale lhal exercise is as inporlanl
as pharnacologic inler venlion for nany nedical
condilions.
7
Yel, while nedical sludenls spend years
learning aboul how lo prescribe drugs, lhey are rarely
inslrucled on lhe value of lhe exercise prescriplion
for various nedical condilions, or how lo prescribe il.
3

The hypertension-exercise relationship
Epideniologic sludies suggesl lhal lhe relalionship
belween sedenlar y behavi our and hyperlensi on
is so slrong lhal lhe alional Hearl Foundalion,
5

lhe vorld Heallh Organisalion and nlernalional
Sociely of Hyperlension,
9
lhe Uniled Slales Joinl
ali onal Conni llee on Delecli on, Eval uali on
and Trealnenl of High Blood Pressure,
6
and lhe
Exercise and
hypertension
BACKGROUND Exercise is advocated for the
prevention, treatment and control of hypertension.
However, the treatment effect of exercise on
hypertension is difficult to determine as many
studies are poorly controlled and involve small
sample sizes.
OBJECTIVE This article reviews current
knowledge about exercise and blood pressure
(BP), and provides a guideline for exercise
prescription that considers the health status and
age of the patient.
DISCUSSION An evidence based literature
analysis by the American College of Sports
Medicine indicates that an isolated exercise
session (acute effect) lowers BP an average of
57 mmHg. Depending upon the degree the
patients BP has been normalised by drug therapy,
regular aerobic exercise significantly reduces
BP the equivalent of 1 class of antihypertensive
medication (chronic effect). For most hypertensive
patients exercise is quite safe. Caution is required
for those over 50 years of age, and those with
established cardiovascular disease (CVD) (or
at high CVD risk) and in these patients, the
advice of a clinical exercise physiologist is
recommended.
Healthy heart

THEME
Tom Baster
BChB, BSc, DipS,
is a general praclilioner,
Brisbane, Oueensland.
lbasler@bigpond.nel.au
Christine Baster-Brooks,
PhD, CSCS, is a
kinesiologisl specialising
in exercise prescriplion
for aging populalions,
Brevard Connunily
College, USA.
420 3Reprinted from Australian Family Physician Vol. 34, No. 6, June 2005
Theme: Exercise and hypertension
Anerican College of Sporls edicine (ACS
10
have
all reconnended increased physical aclivily as a
firsl line inlervenlion for prevenling and lrealing
palienls wilh prehyperlension (syslolic BP 120-
139 nnHg and/or diaslolic BP 30-39 nnHg. The
guidelines also reconnend exercise as a lrealnenl
slralegy for palienls wilh grade 1 (140-159/30-
90 nnHg, or grade 2 (160-179/100-109 nnHg
hyperlension (Tab|e 2. Physical aclivily is parlicularly
appealing because il has favourable effecls on olher
cardiovascular disease (CVD risk faclors. l is a low
cosl inlervenlion wilh few adverse side effecls if
underlaken according lo reconnended guidelines.
11
How much can exercise lower BP?
The 2004 ACS revi ew of evi denced based
lileralure on lhe BPexercise relalionship
11
suggesls
lhe fol l owi ng i nporlanl concl usi ons for lhe CP
lo consider:
A lifeslyle of physical aclivily can reduce lhe risk of
developing hyperlension. naclive individuals have
a 30-50' grealer risk lhan lheir nore physically
aclive counlerparls for developing high BP as lhey
age. Therefore, an aclive lifeslyle has an inporlanl
prevenlive effecl
Two lypes of endurance exerci se effecls are
significanl - acule effecls and chronic effecls
- acule effecls: lhere is an average reduclion in
BP of 5-7 nnHg innedialely afler an exercise
sessi on. Thi s i s referred lo as poslexerci se
hypolensi on (PEH. vhi l e PEH occurs i n bolh
nornolensive and hyperlensive palienls, a grealer
PEH is seen in hyperlensives. The PEH effecls can
occur for up lo 22 hours regardless of lhe exercise
inlensily
- chronic effecls: lhe average BP reduclion wilh
regul ar endurance exerci se for hyperlensi ves
nol nornalised by drug lherapy in lhe lileralure
revi ew i s 7. 4/ 5. 3 nnHg. f basel i ne BP i s
nornal because of drug lherapy, lhe average
decr ease was an addi l i onal 2. 6/ 1. 3 nnHg
irrespeclive of drug lherapy lype. The sludies
used a vari ely of endurance based prograns
involving walking, jogging or cycling of noderale
inlensily (30-90' of VO2 reserve ranging fron
4-52 weeks in lenglh. Sessions lypically lasled
30-60 ninules
Overall, resislance lraining has a favourable chronic
effecl on resling BP, bul lhe nagnilude of lhe BP
reduclions are less lhan lhose reporled for an
aerobic based exercise progran.
12
As well, liniled
evidence suggesls lhal resislance exercise lraining
has lillle PEH effecl.
These decreases in BP do nol seen lo be large,
bul as lhe ACS poinl oul, a 2 nnHg reduclion in
syslolic and diaslolic BP reduces lhe risk of slroke
Table 1. Australian population statistics for hypertension, cholesterol and overweight
20
Hypertensive (%) TotaI choIesteroI of 5.5 mmoI/L or more (%) Overweight (%)
Age group in years Men Women Men Women Men Women
25-34 7.1 3.4 32.2 31.2 61.1 35
35-54 21.6 14.9 58 46.5 68.1 51.5
55-74 58.5 55.8 58.3 72.5 74.1 67.8
75+ 78.8 74.6 49.3 65.4 63.6 52
Table 2. Definition and classification of BP levels (mmHg)
5
Category SystoIic DiastoIic Action
Normal <120 <80 Ehcourage liIesIyle modiIicaIioh iI sedehIary
High hormal 120-139 80-89 LiIesIyle modiIicaIioh
Grade 1 (mild) 140-159 90-99 LiIesIyle modiIicaIioh
Grade 2 (moderaIe) 160-179 100-109 LiIesIyle modiIicaIioh
Grade 3 (severe) z180 z110 LiIesIyle modiIicaIioh
solaIed sysIolic hyperIehsioh z140 <90 LiIesIyle modiIicaIioh
High-hormal has beeh labelled as prehyperIehsioh
6
Reprinted from Australian Family Physician Vol. 34, No. 6, June 2005 4 421
Theme: Exercise and hypertension
by 14' and 17', and lhe risk of coronary arlery
di sease by 9' and 6' respecli vel y. The Hearl
Foundalions H,per!ension nanagenen! guide !or
doc!ors slales lhal fewer lhan 50' of pali enls
lrealed for hyperlension will achieve an oplinal
response wilh a single anlihyperlensive nedicalion,
and lhal in lhe najorily of cases 2 or 3 agenls
fron differenl lherapeulic classes will be required.
5

As an exanple of lhe effecls of drug lherapy on
hyperlension, lhe producl infornalion for irbesarlan
quoles nean decreases in BP (based on 7 najor
placebo conlrolled 3-12 week sludies in palienls wilh
Table 3. How to prescribe exercise to hypertensive patients based on health status and age
21
PaIiehI caIegory
Eercise IesIihg
ahd mohiIorihg
Eercise Iype
Frequehcy
hIehsiIy
DuraIioh
WeighI problems
CoIumn A
PrehyperIehsives wiIh ho
suspecIed CVD <50 years
Grade 1 hyperIehsives <50
years
NoI hecessary
Aerobic acIiviIies: walkihg,
|oggihg, cyclihg, swimmihg
PesisIahce Iraihihg Ior reIaihihg
muscle mass
MohiIorihg hoI hecessary, buI
suggesI Ihey seek advice Irom a
clihical eercise physiologisI Ior
a cohdiIiohihg ahd aerobic based
Iraihihg program
6-7 days/week
SIarI wiIh 20-30 mihuIes
cohIihuous aerobic acIiviIy aI
comIorIable pace (50-65%) oI
maimum hearI raIe Ior 3-4
weeks Ior geheral cohdiIiohihg
Theh eercise aI up Io 85% oI
maimum hearI raIe
MaihIaih ah ehdurahce based
resisIahce Iraihihg Ior muscle
maihIehahce
Aim Ior 30-60 mihs/day
(mihimum 150 mihs/week oI
aerobic acIiviIy)
CoIumn B
PrehyperIehsives wiIh
suspecIed CVD
PrehyperIehsives >50 years
wiIh ho suspecIed CVD
Grade 2 hyperIehsives wiIh ho
suspecIed CVD <50 years
Pecommehded
Walkihg, cyclihg uhIil medically
evaluaIed
Sehd Io clihical eercise
physiologisI Ior cohdiIiohihg ahd
aerobic Iraihihg advice
MohiIorihg probably hoI
hecessary uhless paIiehI has
beeh sedehIary Ior a humber oI
years ahd Ieels uhcomIorIable
abouI eercise
PesisIahce Iraihihg Ior muscle
maihIehahce
5-7 days/week
Work aI lighI-moderaIe ihIehsiIy
uhIil evaluaIed ahd cohdiIiohed
Theh uhderIake a maihIehahce
aerobic program aI up Io 85% oI
maimum hearI raIe
MaihIaih ah ehdurahce based
resisIahce Iraihihg Ior muscle
maihIehahce
SIarI wiIh 20-30 mihs/day oI
cohIihuous acIiviIy. Build Io
30-60 mihs/day
CoIumn C
HyperIehsives wiIh ho
suspecIed CVD >50 years
HyperIehsives wiIh suspecIed
CVD
Pecommehded
Low impacI acIiviIies such as
walkihg, cyclihg, swimmihg
PesisIahce Iraihihg Ior muscle
maihIehahce
Sehd Io clihical eercise
physiologisI Ior mohiIored
cohdiIiohihg program
Follow aerobic Iraihihg program
desighed by a clihical eercise
physiologisI. Periodic mohiIorihg
may be hecessary
5-7 days/week
LighI-moderaIe. Lower ihIehsiIy
cah sIarI wiIh 20-30 mihs/day oI
cohIihuous acIiviIy Iheh build Io
45-60 mihs/day
MaihIaih ah ehdurahce based
resisIahce Iraihihg Ior muscle
maihIehahce
SIarI wiIh 20-30 mihs/day oI
cohIihuous acIiviIy. Build Io
30-60 mihs/day (mihimum 150
mihs/week)
For paIiehIs who are overweighI, emphasise weighI reducIioh Ihrough dieI modiIicaIioh. Goal is 60 mihs/
day oI aerobic eercise. SuggesI alIerhaIihg aerobic acIiviIy Iype Io avoid ih|uries. Emphasise ehdurahce
resisIahce Iraihihg oI 3 seIs oI 12-15 repeIiIiohs. Do hoI make resisIahce Iraihihg maih eercise. I is
imporIahI hoI Io hold breaIh while liIIihg weighIs
422 3Reprinted from Australian Family Physician Vol. 34, No. 6, June 2005
Theme: Exercise and hypertension
a baseline diaslolic BP of 95-110 nnHg conpared
lo placebo afler 6-12 weeks as:
7.5-9.9/4.6-6.2 nnHg for lhe 150 ng dose, and
7.9-12.6/5.2-7.0 nnHg for lhe 300 ng dose.
13
Why exercise has a reducing effect on BP
How physical aclivily posilively affecls BP is nol known.
One lheory is lhal physical aclivily inproves endolhelial
funclion. The endolheliun lining of blood vessel walls
nainlains nornal vasonolor lone, enhances fluidily of
blood, and regulales vascular growlh.
14
Abnornalilies in
lhese funclions conlribule lo nany disease processes
including angina, nyocardial infarclion, coronary
vasospasn, and hyperlension.
Anolher lheory proposes lhal exercise enhances
shear slress (a force acling parallel lo blood vessels
14
slinulaling lhe produclion of nilric oxide (O by lhe
endolheliun. n heallhy blood vessels O enhances
snoolh nuscle relaxalion and nainlains lhe blood
vessel in lhe nornal resling slale.
15
Snall changes in
vessel dianeler profoundly inpacls vascular resislance.
There are also vascular slruclural changes such as
increased lenglh, cross seclional area, and/or dianeler
of exisling arleries and veins in addilion lo new vessel
growlh.
11
Endurance lrained subjecls, for exanple,
have larger arlerial lunen dianeler in conduil arleries
lhan unlrained conlrols.
16
Aerobic based lraining also
appears lo increase large arlery conpliance.
Table 4. Classification of physical activity
intensity based on physical activity lasting
up to 60 minutes
21

hIehsiIy % maimum hearI raIe
Very lighI <35
LighI 35-54
ModeraIe 55-69
Hard 70-89
Very hard >90
Maimal 100
Maimum hearI raIe cah be esIimaIed by 220-age
Figure 1. Flow chart for selecting a suitable exercise prescription for hypertensive patients
Is patient prehypertensive or hypertensive?
PrehyperIehsive
SuspecIed CVD
No Yes
<50 years
Yes No
Follow eercise
prescripIioh
columh A ( )
Follow eercise
prescripIioh
columh B ( )
Follow eercise
prescripIioh
columh C ( )
Grade 1 ahd 2 hyperIehsive
SuspecIed CVD
No Yes
<50 years
Yes No
Follow eercise
prescripIioh
columh A
( )
Follow eercise
prescripIioh
columh C ( )
Follow eercise
prescripIioh
columh C ( )
Follow eercise
prescripIioh
columh B ( )
Grade 2 Grade 1
Reprinted from Australian Family Physician Vol. 34, No. 6, June 2005 4 423
Theme: Exercise and hypertension
According lo ACS,
11
physical aclivily nay also
reduce lhe elevaled synpalhelic nerve aclivily lhal
is connon in essenlial hyperlension. The exacl
nechanisn for PEH renains unclear, bul appears lo
involve lhe arlerial and cardiopulnonary baroreflexes.
Sludies suggesl lhal lhe operaling poinl of lhe
arlerial baroreflex is sel lo a lower BP afler an acule
boul of exercise.
17

How to prescribe exercise
To delerni ne lhe lype of exerci se you shoul d
prescribe for hyperlensive palienls, use lhe flow
charl in Figure ! and lhen consull lhe appropriale
col unn i n Tab| e 3. Your advi ce depends on lhe
palienls age, BP and overall CVD risk. Based on
lhe l i leralure revi ew, ACS reconnends lhe
following guidelines.
Type of exercise
Fhylhni cal and aerobi c exerci se i nvol vi ng l arge
nuscle groups is lhe preferred lrealnenl slralegy
( wal ki ng, runni ng, cycl i ng, swi nni ng for al l
hyperlensive palienls. oderale inlensily exercise
(50-65' of naxinun hearl rale on nosl days
of lhe week for al leasl 30-60 ninules appears
oplinal. A brisk walking pace is noderale, jogging or
runni ng i s vi gorous. Fesi slance lrai ni ng can be
prescribed as an adjuncl lo aerobic aclivily as lhis
lype of exercise helps nainlain and build nuscle
nass, especi al l y i n an agi ng body. However,
resislance exercise should nol serve as lhe prinary
exercise progran as il does nol have lhe sane
anlihyperlensive effecls as aerobic exercise.
11
Assessment before commencing exercise
osl prehyperlensive and grade 1 hyperlensive
pali enls can safel y begi n a noderale i nlensi ly
exer ci se pr ogr an wi l houl exl ensi ve nedi cal
screening.
13
Palienls wilh grade 2 hyperlension
and no si gns of CVD nusl have l hei r BP
conlrolled before lhey begin an exercise progran.
Palienls wilh risk faclors for CVD and palienls over
50 years of age will benefil fron a slress lesl lo
delernine how lheir hearl responds lo exercise.
An exercise syslolic BP higher lhan 220 nnHg, or
diaslolic BP higher lhan 100 nnHg is considered
abnornal . Sone wi lh lrealed hyperlensi on nay
al so have an exagger al ed BP r esponse l o
exer ci se l hal i s associ al ed wi l h i ncr eased
CVD ri sk. Such i ndi vi dual s requi re a cardi ac
eval ual i on f ol l owed by a l r ai ni ng pr ogr an
desi gned and noni lored by a cerli fi ed cl i ni cal
exercise physiologisl.
Pali enls over 50 years of age wi l l requi re
addi li onal eval uali on, as al l easl hal f wi l l be
over wei ghl, and/ or wi l l have hi gh chol eslerol
(Tab|e !, 40-50' will have hearl, slroke and/or
vascul ar condi li ons, and around 50' wi l l have
led a sedenlar y lifeslyle and be al high risk for
CVD.
19
Theoreli cal l y lhese i ndi vi dual s shoul d be
pl aced under nedi cal super vi si on i n dedi caled
rehabi l i l ali on cenlres where lhey can recei ve
educalion aboul exercise, and lheir physiological
r eacl i ons l o exer ci se noni l or ed unl i l l hey
have sone ni ni nun l evel of condi l i oni ng.
However, dedi caled rehabi l i l ali on cenlres are
generally only available in najor cilies. They are
also usually used for poslcardiac evenl palienls and
nol readily accessible lo olher palienl populalions.
An al lernali ve i s lo arrange for lhe pali enl lo
have a slress lesl, or slress echo, and consul l
wilh a cardiologisl. Afler you have lhis infornalion
send lhe pali enl lo a gyn where lhere i s a
residenl clinical exercise physiologisl on slaff for
educali on aboul lhei r heal lh condi li on and how
an exercise progran can inprove il. The clinical
exercise physiologisl should also design an ongoing
aerobi c based lrai ni ng progran for lhe pali enl
lo pursue afler achi evi ng a ni ni nal l evel of
condi li oni ng. vhi l e fornal educali on and base
condi li oni ng i s laki ng pl ace, nosl pali enls can
begin lighlnoderale exercise such as walking. ole
lhal bela blockers dininish lhe hearl rale response
lo exercise, lherefore palienls laking lhese agenls
should use lhe perceived level of exerlion (Tab|e 4
ralher lhan largel hearl rale.
Conclusion
Allhough il can be difficull lo nolivale palienls
lo exerci se regul arl y, lhe benefi ls of exerci se
equale lo lhe effecls of drug lrealnenl and
should be vigorously encouraged. f lhe exercise
progran is designed correclly, il is quile safe for
nosl hyperlensi ve pali enls and al so has olher
i nporlanl heal lh benefi ls rel evanl lo lhei r CVD
risk faclors. l is lherefore inporlanl lo prescribe
exercise for palienls who have hyperlension, or
are al ri sk of gelli ng hyperlensi on, wi lh lhe
sane consi derali on as prescri bi ng any olher
effeclive lrealnenl.
424 3Reprinted from Australian Family Physician Vol. 34, No. 6, June 2005
Theme: Exercise and hypertension
Summary of important points
Aerobi c exerci se pl ays an i nporl anl rol e i n
BP conlrol, and palienls should be vigorously
encouraged lo exercise.
Blood pressure drops of aboul 5-7 nnHg can be
oblained wilh exercise which nay reduce lhe need
for nedicalion.
Exercise is a low cosl oplion and also has olher
significanl heallh benefils.
For nosl hyperlensive palienls, exercise is quile safe
bul caulion is required for lhose wilh idenlified cardiac
risk faclors. A clinical exercise physiologisl can help
educale lhese palienls aboul lheir heallh condilion
and prescribe a progran of suilable exercise.
Resource
For help in finding a cerlified exercise clinical physiologisl
visil lhe Auslralian Associalion for Exercise and Sporl
Science websile al: www.aaess.con.au
Conflicl of inleresl: none declared.
References
1. Australian Heart Foundation. Blood pressure facts. Heartsite,
2003. Available at: www.heartfoundation.com.au.
2. Vasan RS, Beiser A, Seshadri S, et al. Residual lifetime risk for
developing hypertension in middle aged women and men: the
Framingham Heart Study. JAMA 2002;287:1003-10.
3. He J, Wheldon PK. Elevated systolic blood pressure and risk
of cardiovascular and renal disease: overview of evidence from
observational epidemiologic studies and randomised controlled
trials. Am Heart J 1999;138:211-9.
4. Mathers C, Vos T, Stevenson C. The burden of disease and
injury in Australia. Canberra: Australian Institute of Health
and Welfare, 1999.
5. Heart Foundation. Hypertension management guide for
doctors. 2004, Heart Foundation. Available at: www.heartfoun-
dation.com.au.
6. Joint National Committee on Detection and Treatment of
High Blood Pressure. The Sixth Report of the Joint National
Committee on Detection, Evaluation, and Treatment of High
Blood Pressure. Report V. Arch Intern Med 1997;157:2413-45.
7. Chintanadilok J, Lowenthal DT. Exercise in treating hyperten-
sion. The Physician and Sportsmedicine 2002;30:11-23, 50.
8. Elrick HE. Commentary: exercise is medicine. The Physician
and Sportsmedicine 1996;24:2.
9. Worl d Heal t h Organi s at i on/Int ernat i onal Soci et y of
Hypertension. Prevention of hypertension and associated car-
diovascular disease: a 1991 statement. In: Clin Exp Hypertens
1992;333-41.
10. American College of Sports Medicine. Position stand: physi-
cal activity, physical fitness, and hypertension. Med Sci Sports
Exerc 1993;25:1-5.
11. American College of Sports Medicine. Exercise and hyperten-
sion. Med Sci Sports Exerc 2004;34:533-53.
12. Kelley GA, Kelley KS. Progressive resistance exercise and resting
blood pressure: a meta-analysis of randomised controlled trials.
Hypertens 2000;35:838-43.
13. Bristol-Myers Squibb Australia Pty Ltd. Product Information.
Irbesartan. Available at: www.bristol-myers.com/products/data.
14. Sherman DL. Exercise and endothelial function. Coron Artery
Dis 2000;11:117-22.
15. Kelm M. Control of coronary vascular tone by nitric oxide.
Circ Res 1990;l66:1561-75.
16. Huonker M, Halle M, Keul J. Structural and functional adapta-
tions of the cardiovascular system by training. Int J Sports Med
1996;17(Suppl 3):S164-72.
17. Halliwill JR, Taylor JA, Eckberg DL. Impaired sympathetic
vascular regulation in humans after acute dynamic exercise. J
Physiol 1996;195(Pt 1):279-88.
18. American College of Sports Medicine. Guidelines for exercise
testing and prescription. Philadelphia: Lippincott Williams &
Wilkins, 2000.
19. Australian Institute of Health Welfare. Heart, stroke and vascu-
lar diseases. Canberra: AIHW, 2004.
20. Australian Institute of Health Welfare. Risk factors for diabetes
and its complications. Canberra: AIHW, 2002.
21. American College of Sports Medicine. Guidelines for exercise
testing and prescription. Philadelphia: Lippincott Williams &
Wilkins, 2000.
EmaiI: afp@racgp.org.au AFP