Dr. Neilson is Assistant Professor, Department of Clinical Foundations, Ross University School of Medicine, Barbados, West Indies. Dr. Selfridge is Professor and Chair, Department of Clinical Foundations, Ross University School of Medicine, Barbados, West Indies.

Dr. Neilson and Dr. Selfridge report no financial relationships relevant to this field of study.

SYNOPSIS: A random-effects network meta-analysis demonstrated comparable reductions in systolic blood pressure among normotensive and hypertensive participants using either antihypertensive medication or exercise interventions.

SOURCE: Naci H, Salcher-Konrad M, Dias S, et al. How does exercise treatment compare with antihypertensive medications? A network meta-analysis of 391 randomized controlled trials assessing exercise and medication effects on systolic blood pressure. Br J Sports Med 2019;53:859-869.

Hypertension is one of the most common causes of morbidity and mortality in the world. It is also modifiable. The 2017 American College of Cardiology and the American Heart Association guidelines have expanded the categories of hypertension to now include people at risk of developing the disease and its associated complications, and recommend lifestyle modification, including exercise programs, as a key component in the treatment of each of these categories.¹

In this network meta-analysis, Naci et al showed that the large amount of data available regarding systolic blood pressure (SBP)-lowering effects of antihypertensive medications are quite consistent. Although research evidence on the effect of exercise is more limited and variable, it too can be as effective at reducing SBP, especially in patients with hypertension.

Naci et al analyzed pooled data from recently published meta-analyses and randomized, controlled trials (RCTs) of exercise or antihypertensive medication effects on SBP. Exercise intervention trials included endurance, dynamic resistance, isometric resistance, or combinations of endurance and dynamic resistance lasting at least four weeks. Medication intervention eligibility was based on the British National Formulary dosing criteria and included studies of angiotensin-converting enzyme inhibitors (ACE-I), angiotensin-2 receptor blockers (ARB), β-blockers, calcium channel blockers (CCB), or diuretics. Mean SBP changes with a 95% confidence interval were calculated for each treatment modality, and comparison data were compiled.

Results are summarized in Table 1. (Note: Values were omitted in the publication for β-blockers, although the mean and 95% confidence interval were shown in a comparison graph.) Overall, both exercise and medication interventions lowered SBP. When comparing different types of exercises, endurance, isometric resistance, and a combination showed the greatest improvements in SBP. Variations in intensity did not demonstrate statistically significant differences. The largest medication decreases in SBP were from CCB classes. Among patients with hypertension, reductions were greatest in the combination exercises group and outperformed the largest medication reductions by an average of
1-3 mmHg.

Limitations of the review, affecting its internal validity, primarily reflected limitations in the original studies. These included significant heterogeneity within the exercise studies, limitations in reporting, and methodological flaws (e.g., small sample sizes, lack of blinding of investigators and participants in exercise trials, blood pressure change as a secondary or tertiary outcome for many of the exercise studies).

Upon conclusion of the analysis, the authors noted the need for more robust research consisting of larger-scaled, well-designed studies comparing the effectiveness of antihypertensive medication directly to various types and intensities of exercise in reducing blood pressure in hypertensive patients. Additional investigations into types and timing of monitoring methodologies for more rigorously structured exercise programs and for measured outcomes are critical to the study of exercise and its influence on disease prevention and treatment.

COMMENTARY

Additional evidence supports the contribution that exercise makes to living a healthy life, in this study, by decreasing SBP.^2-4 A blood pressure of 120-129/> 80 mmHg now is considered elevated, and clinical guidelines recommend nonpharmacological lifestyle interventions, including exercise.¹ A sedentary lifestyle, in and of itself, is a risk for cardiovascular disease, and exercise has demonstrated broad benefits for cardiovascular health.⁵ However, the benefits of exercise do not just stop at the heart. Exercise is important for the growth and development of children, reducing the incidence and impact of diseases such as diabetes and cancer, improving mental health, and lowering the risk of falls and their related injuries in older populations.⁴

The challenge is how to help and influence people to initiate and maintain a regular beneficial exercise regimen. Fewer than 30% of people adhere to current exercise recommendations, and the numbers are even worse for women and adolescents (19% and 20%, respectively). This fact is costing people their lives, an estimated 10% early mortality, and more than an estimated $110 billion in healthcare expenditures.⁴ Adhering to recommendations of moderate-intensity exercise for 150 minutes per week with additional muscle-strengthening exercises two days a week is critical to reversing these trends.⁴

Physicians are encouraged to play a role in counseling patients to exercise more often. There is some evidence that this support translates into a more active lifestyle for many.^4,6 Training medical students and encouraging practicing physicians to promote exercise consistently as an evidence-based intervention may help move us closer to a tipping point in terms of patient adherence to exercise recommendations.⁶ When exercise interventions are added to other nonpharmacological interventions, such as weight loss, an evidence-based heart-healthy DASH diet, and reductions in sodium intake, even larger reductions in SBP are observed.¹ Naci et al are to be applauded for their contribution to this end.

REFERENCES

1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: Executive Summary: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018;71:1269-1324.
2. Appel LJ, Champagne CM, Harsha DW, et al. Effects of comprehensive lifestyle modification on blood pressure control: Main results of the PREMIER clinical trial. JAMA 2003;289:2083-2093.
3. Paffenbarger RS, Hyde RT, Wing AL, Hsieh CC. Physical activity, all-cause mortality, and longevity of college alumni. N Engl J Med 1986;314:605-613.
4. U.S. Department of Health and Human Services. Physical Activity Guidelines, 2nd edition. 2018.
5. Myers J. Exercise and cardiovascular health. Circulation 2003;107:e2-e5.
6. Seth A. Exercise prescription: What does it mean for primary care? Br J Gen Pract 2014;64:12-13.