The aftereffects of dynamic exercise on

ambulatory blood pressure

LINDA S. PESCATELLO and JONNA M. KULIKOWICH
School of Allied Health, University of Connecticut, Storrs, CT; and Neag School of Education, University of Connecticut,
Storrs, CT

ABSTRACT
PESCATELLO, L. S., and J. M. KULIKOWICH. The aftereffects of dynamic exercise on ambulatory blood pressure. Med. Sci. Sports
Exerc., Vol. 33, No. 11, 2001, pp. 1855–1861. Purpose: Despite the widespread belief that endurance exercise lowers blood pressure
(BP), reports of the lack of such an effect are common when using ambulatory blood pressure (ABP) monitoring. This review examined
the influence of dynamic exercise on ABP to elucidate possible reasons for conflicting reports. Methods: Criteria for inclusion were
dynamic exercise studies that involved ABP determinations after exercise. A total of 23 studies containing 34 groups of which 12 were
normotensive and 22 hypertensive met these criteria. The groups primarily consisted of unmedicated, sedentary, overweight,
non-Hispanic white men and women with a mean ⫾ SEM age of 43.9 ⫾ 1.5 yr Results: Baseline mean day systolic BP (SBP) was
137.3 ⫾ 2.1 mm Hg (95% confidence limits) (133.0, 141.5) and diastolic BP (DBP) was 86.7 ⫾ 1.5 mm Hg (83.7, 89.7). After exercise,
day SBP (N ⫽ 34) was reduced an average of 3.2 ⫾ 1.0 (⫺5.2, ⫺1.2) (P ⫽ 0.003) and DBP by 1.6 ⫾ 0.6 mm Hg (⫺2.9, ⫺0.4) (P
⫽ 0.013); night SBP (N ⫽ 20) by 3.4 ⫾ 1.0 (⫺5.6, ⫺1.2) (P ⫽ 0.005) and DBP by 3.0 ⫾ 1.4 mm Hg (⫺5.6, ⫺0.4) (P ⫽ 0.025); and
24-h SBP (N ⫽ 17) by 3.2 ⫾ 0.8 (⫺4.9, ⫺1.6) (P ⫽ 0.001) and DBP by 1.8 ⫾ 0.5 mm Hg (⫺2.9, ⫺0.7) (P ⫽ 0.003). After detection
of outlying cases using regression diagnostics, initial SBP accounted for 30% (P ⫽ 0.001) and 26% (P ⫽ 0.018) of the variance in
the change in day and night SBP after exercise, respectively. Similarly, initial DBP explained 37% (P ⫽ 0.000) and 33% (P ⫽ 0.005)
of the difference in day and night DBP after exercise. Conclusion: The ABP difference after exercise is a function of initial values
such that groups with the highest baseline BP experience the greatest postexercise ABP reductions. The ABP dynamic exercise studies
raise important methodological considerations that should be attended to in future work. Key Words: BLOOD PRESSURE,
EXERCISE, HYPERTENSION

A
purported health benefit of regular participation in
endurance exercise is lower resting blood pressure
(BP), with the greatest effects seen in those with
hypertension (1,2,8,9,12,16,17,25,33). Fagard (9) noted that
aerobic exercise training decreased BP along a continuum
with systolic (SBP) and diastolic (DBP) BP lowered an
average of 3 mm Hg in individuals with normal BP, 6 and
7 mm Hg in those with high normal BP, and 10 and 8 mm
Hg in people with hypertension, respectively. Because of its
hypotensive influence, endurance exercise training con-
ducted at moderate exercise intensities (ⱕ40 to 70% of
maximal oxygen consumption (V̇O2max)) is advocated as
initial nonpharmacologic antihypertensive therapy for indi-
viduals with high normal to stage I hypertension (1,2,25,33).
Despite the widespread belief that dynamic exercise low-
ers BP, reports of the lack of such a phenomenon are
somewhat common (2,8,9,12,16). Hagberg and Brown (12)
reviewed 47 studies using primarily causal BP determina-
tions and found SBP and DBP to be reduced an average of
10 mm Hg in those with essential hypertension. Nonethe-
less, in their review, 25% of the people with essential
hypertension did not sustain BP reductions after endurance
0195-9131/01/3311-1855/$3.00/0
MEDICINE & SCIENCE IN SPORTS & EXERCISE®
Copyright © 2001 by the American College of Sports Medicine
Submitted for publication November 2000.
Accepted for publication February 2001.
1855
exercise training. Fagard (9) noted that investigators who
adhered to rigorous study design criteria found small reduc-
tions in BP that achieved statistical significance only for
people with hypertension.
More recent investigations involving ambulatory blood pres-
sure monitoring (ABP) are also mixed on the hypotensive
merits of endurance exercise (3,4,11,13,16,17,26,30,36). When
ABP depressor effects are reported, they are of lesser magni-
tude than those seen in studies using causal BP assessments.
Gilders and colleagues (11) found that a 16-wk endurance
exercise program did not alter ABP in normotensive and hy-
pertensive middle aged men and women. In contrast to earlier
work (3), Blumenthal and colleagues (4) recently reported that
a 6-month endurance training program lowered ABP an aver-
age of 4 mm Hg for SBP and DBP among overweight men and
women with hypertension. Nonetheless, the BP reductions in
the exercise group were less than those seen for the diet and
exercise group; however, because of the greater weight loss in
the diet and exercise than in the exercise only group, contra-
dictory findings on the effectiveness of endurance exercise as
a therapeutic antihypertensive agent have led some to question
its utility in this regard (3,8,11,13).
Because ABP is less subject to observer bias and altering
responses than causal determinations, ABP more accurately
reflects the BP a person maintains during activities of daily
living (20,21,24,27,35). ABP readings are 10 to 50% less
than clinic assessments, yet their prognostic significance
seems to be more meaningful (35). The purpose of this
TABLE 1. The mean unadjusted (mean ⫾ SEM) (95% confidence limits) and percent change in ambulatory blood pressure after dynamic exercise.
Ambulatory Blood Pressure Initial Blood Pressure Value Unadjusted Change
Parameter (mm Hg) (mm Hg) % Change*
Day systolic blood pressure 137.3 ⫾ 2.1 –3.2 ⫾ 1.0‡ –2.1 ⫾ 0.7‡
(133.0, 141.5) (–5.2, –1.2) (–3.5, –0.7)
(N ⫽ 34)
Night systolic blood pressure 124.0 ⫾ 2.7 –3.4 ⫾ 1.0‡ –2.6 ⫾ 0.8‡
(118.5, 129.6) (–5.6, –1.2) (–4.3, –0.9)
(N ⫽ 20)
24-h systolic blood pressure 135.7 ⫾ 2.4 –3.2 ⫾ 0.8‡ –2.4 ⫾ 0.6‡
(130.7, 140.8) (–4.9, –1.6) (–3.6, –1.1)
(N ⫽ 17)
Day diastolic blood pressure 86.7 ⫾ 1.5 –1.6 ⫾ 0.6† –1.6 ⫾ 0.7†
(83.7, 89.7) (–2.9, –0.4) (–3.1, –0.1)
(N ⫽ 34)
Night diastolic blood pressure 77.4 ⫾ 2.1 –3.0 ⫾ 1.2† –3.5 ⫾ 1.4†
(73.1, 81.8) (–5.6, –0.4) (–6.4, –0.6)
(N ⫽ 20)
24-h diastolic blood pressure 85.6 ⫾ 1.8 –1.8 ⫾ 0.5‡ –2.1 ⫾ 0.6‡
(81.9, 89.3) (–2.9, –0.7) (–3.3, –0.8)
(N ⫽ 17)
* % Change ⫽ (unadjusted change/initial value) * 100.
† P ⬍ 0.05 mean difference from zero.
‡ P ⬍ 0.01 mean difference from zero.

review was to examine the aftereffects of dynamic exercise
on ABP while attempting to elucidate possible reasons for
conflicting reports.
METHODS
Systematic review. Criteria for inclusion were dy-
namic exercise studies in which postexercise BP was mea-
sured by ABP monitoring. The systematic review strategies
included search of MEDLINE from 1985 until the present,
full text searches of current tables of contents from relevant
journals, scrutiny of reference lists from pertinent reviews
and articles, and personal communications. All data were
extracted, classified, and coded by relevant study, subject,
and exercise intervention characteristics that potentially
could influence the day, night, and 24-h ABP postexercise
response. A total of 23 studies containing 34 groups of
subjects of which 12 were normotensive and 22 were hy-
pertensive met the criteria for inclusion. Of the 23 qualify-
ing studies, 8 examined the immediate aftereffects of en-
durance exercise on ABP (acute) (5,13,22,23,26,32,36,37),
whereas 15 investigated the long-term influence of endur-
ance exercise training on ABP (chronic)
(3,4,6,7,10,11,14,15,18,19,28 –30,34,38).
Statistical analysis. A series of one-sample t-tests
were run to determine if mean differences in day, night, or
24-h ABP after exercise differed from null. ANCOVA was
used to determine if BP changed following exercise after
adjustment for BP classification (normotensive and hyper-
tensive), exercise intervention length (acute and chronic),
exercise intensity, and initial BP with BP classification
removed from the model. Multiple regression analyses were
run to determine whether initial BP value, BP classification,
exercise intervention length, and exercise intensity were
related to changes in day, night, and 24-h BP after exercise.
In these analyses, the degree of collinearity among predictors

TABLE 2. The mean unadjusted and % change in ambulatory blood pressure after dynamic exercise among normotensive and hypertensive study groups (mean ⫾ SEM) (95%
confidence limits).
Normotensive Hypertensive
Ambulatory Blood Pressure Initial Blood Pressure Unadjusted Initial Blood Pressure Unadjusted
Parameter Value (mm Hg) Change (mm Hg) % Change* Value (mm Hg) Change (mm Hg) % Change*
Day systolic blood pressure 124.0 ⫾ 1.8 –0.5 ⫾ 1.6 –0.3 ⫾ 1.1 144.5 ⫾ 1.6 –4.7 ⫾ 1.4† –3.1 ⫾ 0.8
(120.1, 127.9) (–3.8, 2.8) (–2.5, 1.9) (141.2, 147.8) (–7.1, –2.2) (–4.7, –1.5)
(N ⫽ 12) (N ⫽ 22)
Night systolic blood pressure 113.3 ⫾ 2.9 –3.0 ⫾ 1.7 –2.5 ⫾ 1.3 131.2 ⫾ 2.3 –3.6 ⫾ 1.4 –2.6 ⫾ 1.1
(106.4, 120.3) (–6.5, 0.6) (–5.2, 0.3) (126.2, 136.2) (–6.5, –0.7) (–4.9, –0.4)
(N ⫽ 8) (N ⫽ 12)
24-h systolic blood pressure 124.4 ⫾ 1.9 –4.2 ⫾ 1.5 –3.4 ⫾ 1.1 140.5 ⫾ 2.0 –2.8 ⫾ 1.0 –2.0 ⫾ 0.7
(119.2, 129.7) (–7.4, –1.1) (–5.7, –1.0) (136.0, 145.0) (–4.9, –0.8) (–3.5, –0.5)
(N ⫽ 5) (N ⫽ 12)
Day diastolic blood pressure 77.7 ⫾ 2.0 –0.2 ⫾ 1.0 –0.1 ⫾ 1.2 91.5 ⫾ 0.9 –2.4 ⫾ 0.7 –2.5 ⫾ 0.9
(73.3, 82.1) (–2.2, 1.9) (–2.4, 2.5) (89.6, 93.5) (–3.9, –0.9) (–4.3, –0.7)
(N ⫽ 12) P ⫽ 0.886 (N ⫽ 22) P ⫽ 0.079
Night diastolic blood pressure 70.8 ⫾ 2.7 –2.4 ⫾ 2.0 –3.1 ⫾ 2.3 81.9 ⫾ 2.2 –3.3 ⫾ 1.6 –3.7 ⫾ 1.8
(64.6, 77.1) (–6.5, 1.7) (–7.8, 1.6) (77.0, 86.7) (–6.8, 0.0) (–7.6, 0.2)
(N ⫽ 8) (N ⫽ 12)
24-h diastolic blood pressure 77.8 ⫾ 3.2 –1.9 ⫾ 1.0 –2.5 ⫾ 1.1 88.9 ⫾ 1.2 –1.7 ⫾ 0.6 –1.9 ⫾ 0.7
(67.0, 86.6) (–4.0, 0.1) (–4.9, –0.2) (86.1, 91.6) (–3.1, –0.4) (–3.4, –0.4)
(N ⫽ 5) (N ⫽ 12)
* % Change ⫽ (unadjusted change/initial value) * 100.
† P ⬍ 0.05 normotensive vs hypertensive group.

1856 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org

 was examined to ensure that the covariances between the

Change‡ (mm

(–7.1, –1.8)

(–5.4, –1.9)

(–4.0, –0.8)

(–3.0, –0.6)
–4.5 ⫾ 1.3§

–1.7 ⫾ 1.1§
independent variables were low. Because postexercise alter-

–0.7 ⫾ 1.1㛳
(–4.1, 0.7)

(–3.1, 1.9)
P ⫽ 0.052
⫺3.6 ⫾ 0.8

–2.4 ⫾ 0.8

–1.8 ⫾ 0.6
Adjusted

Hg)
ations in ABP may have been related temporally with respect
to the years authors conducted investigations, we used the
Durbin-Watson statistic in each regression analysis to deter-
mine the degree to which residuals were stationary and thus
Adjusted Change†

–1.6 ⫾ 1.0㛳

–0.8 ⫾ 0.9㛳
(–6.2, –1.9)

(–4.9, –1.0)

(–3.2, –0.5)

(–2.8, –0.3)
–4.1 ⫾ 1.0

–1.9 ⫾ 0.7

–1.5 ⫾ 0.6
(–3.7, 0.5)

(–2.8, 1.2)
independent. All statistical analyses were performed with the
(mm Hg)

–2.9 ⫾ 0.9
Statistical Package for Social Sciences Base 10.0.7 for Win-
dows (SPSS, Inc., Chicago, IL) and Advanced Statistics Re-
lease with P ⬍ 0.05 set as the level of statistical significance
(31). Data are presented as mean ⫾ SEM (95% confidence
–2.2 ⫾ 0.7
–3.4 ⫾ 0.8§

–1.2 ⫾ 0.9§
(–5.1, –1.7)

(–3.6, –0.8)

(–4.6, –0.8)

(–3.2, –0.5)
% Change*

–0.7 ⫾ 1.4㛳
–2.7 ⫾ 0.9

–1.9 ⫾ 0.7
(–3.1, 0.6)

(–3.6, 2.2)
P ⫽ 0.063
limits).
Chronic

RESULTS
Change (mm Hg)

(–7.5, –2.4)

(–4.8, –1.0)

(–4.0, –0.9)

(–2.7, –0.4)
Unadjusted

Subject characteristics. Subjects were predomi-

(–3.9, 0.8)

(–3.0, 2.0)
–5.0 ⫾ 1.2§

–1.5 ⫾ 1.1§

–0.5 ⫾ 1.2㛳
P ⫽ 0.086
–2.9 ⫾ 0.9

–2.5 ⫾ 0.8

–1.5 ⫾ 0.6

nately sedentary, overweight to obese, non-Hispanic white

men and women with an average age of 43.9 ⫾ 1.5 yr. If
TABLE 3. The mean unadjusted, %, and adjusted change in ambulatory blood pressure after acute versus chronic dynamic exercise (mean ⫾ SEM) (95% confidence limits).

they were hypertensive, they were not taking medication.

The mean number of subjects in each group was 17.8 ⫾ 1.7
Initial Blood Pressure

individuals. If measured, body weight and diet generally

Value (mm Hg)

(135.6, 145.4)

(118.3, 129.0)

(130.6, 140.1)

(86.3, 92.2)

(72.5, 80.4)

(81.9, 89.4)

remained stable during the study period. The mean intensity

140.5 ⫾ 2.4

123.7 ⫾ 2.5

135.3 ⫾ 2.2

89.3 ⫾ 1.4

76.4 ⫾ 1.8

85.7 ⫾ 1.7
(N ⫽ 20)

(N ⫽ 13)

(N ⫽ 14)

(N ⫽ 20)

(N ⫽ 13)

(N ⫽ 14)

of the exercise sessions was 63.0 ⫾ 2.6% of maximal

oxygen consumption (V̇O2max), and the average duration
was 39.3 ⫾ 2.0 min per session. The dynamic exercise
training programs averaged 3.2 ⫾ 0.2 d·wk⫺1 for a total of
18.4 ⫾ 3.4 wk. V̇O2max increased a mean of 10.3 ⫾ 1.6%
(–10.6, –3.8)
(–9.5, –3.2)
–0.3 ⫾ 1.4

–6.4 ⫾ 1.5

–3.5 ⫾ 1.7

–0.2 ⫾ 0.9

–7.2 ⫾ 1.6

–2.2 ⫾ 1.2
(–3.3, 2.6)

(–7.1, 0.2)

(–2.1, 1.8)

(–4.8, 0.3)

among the groups who were exercise trained.

(mm Hg)
Adjusted
Change‡

Unadjusted postexercise ABP changes. Mean

baseline day systolic BP (SBP) was 137.3 ⫾ 2.1 mm Hg
(133.0, 141.5) and diastolic BP (DBP) was 86.7 ⫾ 1.5 mm
Hg (83.7, 89.7) among the study groups (Table 1). After
(–9.4, –3.8)

(–8.8, –0.4)

(–9.7, –4.4)

(–5.7, –0.4)
–2.0 ⫾ 1.3

–6.6 ⫾ 1.3

–4.6 ⫾ 2.0

–1.2 ⫾ 0.8

–7.0 ⫾ 1.3

–3.0 ⫾ 1.2
(–4.6, 0.6)

(–2.8, 0.5)

exercise, day SBP (N ⫽ 34) was reduced an average of 3.2

(mm Hg)
Adjusted
Change‡

⫾ 1.0 mm Hg (⫺5.2, ⫺1.2) (P ⫽ 0.003) and DBP by 1.6 ⫾

0.6 mm Hg (⫺2.9, ⫺0.4) (P ⫽ 0.013). Night SBP (N ⫽ 20)
was lowered a mean of 3.4 ⫾ 1.0 mm Hg (⫺5.6, ⫺1.2) (P
(–12.6, –4.7)
(–7.6, –2.5)

(–6.3, –0.1)

(–6.2, –0.2)
% Change*

⫽ 0.005) and DBP 3.0 ⫾ 1.2 mm Hg (⫺5.6, ⫺0.4) (P ⫽

–0.3 ⫾ 1.1

–5.1 ⫾ 1.2

–3.2 ⫾ 1.4

–0.1 ⫾ 1.1

–8.6 ⫾ 1.9

–3.2 ⫾ 1.4
(–2.3, 1.7)

(–2.2, 2.3)

0.025) from initial values of 124.0 ⫾ 2.7 mm Hg (118.5,

Acute

129.6) and 77.4 ⫾ 2.1 mm Hg (73.1, 81.8), respectively.

From a baseline average of 135.7 ⫾ 2.4 mm Hg (130.7,
Change (mm Hg)

140.8), 24-h SBP (N ⫽ 17) decreased 3.2 ⫾ 0.8 mm Hg

(–11.0, –4.2)
(–9.9, –3.5)

(–8.7, –0.6)

(–5.6, –0.4)
Unadjusted

–0.7 ⫾ 1.5

–6.7 ⫾ 1.5

–4.7 ⫾ 1.9

–0.3 ⫾ 0.9

–7.6 ⫾ 1.6

–3.0 ⫾ 1.2
(–3.7, 2.3)

(–2.2, 1.5)

(⫺4.9, ⫺1.6) (P ⫽ 0.001) and 24-h DBP was lowered 1.8

⫾ 0.5 mm Hg (⫺2.9, ⫺0.7) (P ⫽ 0.003) from 85.6 ⫾ 1.8
mm Hg (81.9, 89.3). Similarly, the mean relative change in
ABP was significantly decreased for day, night, and 24-h
Initial Blood Pressure

* % Change ⫽ (unadjusted change/initial value) * 100.

SBP and DBP after exercise (P ⬍ 0.05) (Table 1).

Value (mm Hg)

(125.1, 140.2)

(109.0, 140.1)

(93.2, 182.1)

(55.0, 115.7)
137.7 ⫾ 10.3

(77.2, 88.8)

(66.9, 91.6)
132.6 ⫾ 3.5

124.7 ⫾ 6.4

83.3 ⫾ 2.7

79.3 ⫾ 5.0

85.3 ⫾ 7.1

BP classification. The average change in day SBP

(N ⫽ 14)

(N ⫽ 14)
(N ⫽ 7)

(N ⫽ 3)

(N ⫽ 7)

(N ⫽ 3)

† Adjusted for initial blood pressure value.

differed between those with normal BP and hypertension

§ P ⬍ 0.05 mean difference from zero.
㛳 P ⬍ 0.01 mean difference from zero.

(Table 2), with greater postexercise decreases noted for the

‡ Adjusted for blood pressure status.

hypertensive than normotensive groups, ⫺4.7 ⫾ 1.4 (⫺7.1,

⫺2.2) versus ⫺0.5 ⫾ 1.6 (⫺3.8, 2.8) mm Hg, respectively
Night diastolic blood pressure
Night systolic blood pressure

24-h diastolic blood pressure

Ambulatory Blood Pressure

24-h systolic blood pressure

Day diastolic blood pressure

(P ⫽ 0.045). Similar trends were noted for day DBP after

Day systolic blood pressure

exercise between the normotensive and hypertensive groups

Parameter

(P ⫽ 0.079). In contrast, the alterations in night and 24-h

SBP and DBP were similar between those with normal BP
and hypertension (P ⬎ 0.05).
Exercise intervention length. Table 3 contains the
mean unadjusted and adjusted change in day, night, and
AMBULATORY BLOOD PRESSURE AFTER EXERCISE Medicine & Science in Sports & Exercise姞 1857
FIGURE 1—Mean change in day systolic
blood pressure (SBP) as a function of ini-
tial values (N ⴝ 34).
24-h ABP by exercise intervention length. The average
unadjusted change in day SBP after exercise differed be-
tween the acute and chronic dynamic exercise groups, with
the reduction in day SBP greater for the groups who were
trained compared with those who completed an acute exer-
cise bout, ⫺5.0 ⫾ 1.2 (⫺7.5, ⫺2.4) versus ⫺0.7 ⫾ 1.5
(⫺3.7, 2.3) mm Hg, respectively (P ⫽ 0.035). These dif-
ferences between groups persisted when BP status was
entered into the statistical model (P ⫽ 0.043). In contrast,
the change in postexercise day SBP was similar between the
exercise intervention groups (P ⫽ 0.227) with initial day
SBP as a covariate because of a larger proportion of vari-
ability in day SBP response after exercise attributed to initial
SBP (␩2 ⫽ 0.335, large effect) than BP classification (␩2 ⫽
0.112, small to moderate effect) (31). Similar findings were
found for mean day DBP postexercise alterations among
exercise intervention groups, with a greater amount of the
difference in DBP after exercise accounted for by baseline
values (␩2 ⫽ 0.292, large effect) than BP status (␩2 ⫽ 0.120,
small to moderate effect).
In contrast to day ABP, alterations in night SBP and DBP
after exercise were greater for the groups who engaged in an
FIGURE 2—Mean change in night sys-
tolic blood pressure (SBP) as a function of
initial values (N ⴝ 20).
1858 Official Journal of the American College of Sports Medicine
acute dynamic exercise session than those who were trained
(Table 3). These differences remained whether adjustment
was made for BP classification or initial values. The 24-h
BP change after exercise was similar for the acute and
chronic exercise groups.
Regression analyses. Multiple regression analyses
revealed that initial BP and BP classification but not exer-
cise intensity significantly contributed to changes in day and
night ABP after exercise. Variance inflation indices showed
considerable collinearity between initial BP values and BP
classification, of which initial BP was the more powerful
predictor of postexercise BP response. For this reason, mul-
tiple regression models were reduced to simple linear mod-
els that examined the relationship between change in pos-
texercise BP and initial values. After removal of residual
cases (standardized residuals ⬎ ⱍ2.00ⱍ) initial day SBP ex-
plained 30% (P ⫽ 0.001) (Fig. 1) and night SBP 26% (P ⫽
0.018) (Fig. 2) of the variance in the SBP alterations that
resulted from endurance exercise. Similarly, day DBP (P ⫽
0.000) accounted for 37% (Fig. 3) and night 33% (P ⫽
0.005) (Fig. 4) of the difference in the postexercise DBP
response. Neither baseline 24-h SBP (P ⫽ 0.213) nor DBP
http://www.acsm-msse.org
(P ⫽ 0.579) were related to the difference in 24-h BP after
exercise.
DISCUSSION
Dynamic exercise significantly decreased day, night, and
24-h ABP among middle-aged men and women who were
predominately sedentary, overweight, non-Hispanic white
and not taking antihypertensive medications if they were
hypertensive. The day and night ABP alterations after dy-
namic exercise were largely dependent on the mean baseline
values for SBP and DBP, with the greatest ABP reductions
seen in those with the highest initial levels. Wilder termed
this phenomenon the “law of initial values” many years ago
(39). Consistent with these findings, the average day ABP
reductions after exercise were greater for persons with hy-
pertension than those with normal BP. After adjustment for
initial values, an acute exercise session appeared as effective
in lowering ABP as an endurance training program. In
contrast, acute exercise lowered night ABP to a greater
extent than did endurance training even after adjustment for
baseline values. Finally, exercise intensity was found not to
influence the change in ABP after exercise.
The average day ABP reductions of 5 mm Hg for SBP
and 2 mm Hg for DBP among groups with hypertension in
this review range from 20 to 75% lower than those for
reports that assessed postexercise BP by auscultation in
persons of similar BP status (1,2,8,9,12,16,17,25,33). Al-
though the ABP reductions after dynamic exercise are
smaller in magnitude than causal BP determinations, they
are of more clinical importance. ABP is more representative
of the “true” BP that occurs as a consequence of activities of
daily living than are clinic and causal BP measurements
(20,21,24,27,35), and it is superior to these methods in the
prognostic evaluation of hypertension (35).
Methodological implications. In the dynamic exer-
cise ABP studies, mean BP was significantly lowered from
high normal into normotensive ranges. Nonetheless, 35% of
the groups exhibited no change or an increase in day SBP
(N ⫽ 12) (Fig. 1), and 38% showed no change or an
AMBULATORY BLOOD PRESSURE AFTER EXERCISE
elevation in day DBP after exercise (N ⫽ 13) (Fig. 3). These
results concur with others who found a considerable pro-
portion of people not reducing their BP as a result of either
acute or chronic endurance exercise (8,9,12,16).
From the studies contained within this review emerge
important methodological considerations that account for
many of the discrepancies in the literature surrounding the
aftereffects of dynamic exercise on ABP. Approximately
67% of the groups not exhibiting day SBP reductions and
77% of the groups not manifesting a postexercise decrease
in day DBP after exercise were persons with normal to high
normal BP. These observations are consistent with our find-
ing that the variable that makes the greatest contribution to
the decrease in day and night ABP after exercise was base-
line BP or the “law of initial values” (9,39). Given a power
assumption of 0.80 and an alpha level of 0.05, the estimated
sample size that was required to detect a significant decrease
in SBP of 5 mm Hg and DBP of 2 mm Hg among persons
with hypertension was 30 study groups, whereas in actuality
there were 22 groups with hypertension (Table 2). An in-
adequate sample size is a likely explanation for the lack of
detection of a reduction in ABP after dynamic exercise,
especially among persons with low initial values—those
with normal to high normal BP.
The timing of the BP assessments regarding proximity to
the last exercise bout and time of day often were not dis-
closed by study investigators. The possibility remains that
the confounding influences of acute exercise and the diurnal
variation in BP were not accounted for in these studies and
contributed to mixed results. For instance, we found that
night ABP was more extensively reduced immediately after
a session of exercise. If ABP measurements were taken
within 24 h of the last exercise bout, then the hypotensive
influence of endurance training would be overestimated.
Another important methodological issue that emerged
from the ABP dynamic exercise studies was the inclusion of
perturbations other than exercise that influenced BP, per-
haps more so than exercise per se. Nearly 50.0% of the
groups whose ABP values were found not to change or in-
crease after exercise incurred position changes periodically
FIGURE 3—Mean change in day diastolic
blood pressure (DBP) as a function of ini-
tial values (N ⴝ 34).
Medicine & Science in Sports & Exercise姞 1859
FIGURE 4 —Mean change in night dia-
stolic blood pressure (DBP) as a function
of initial values (N ⴝ 20).
during the experiments to assess cardiac output (3,13,23,26).
The position changes from upright to supine posture and back
altered central circulating hemodynamics that possibly attenu-
ated the depressant effects of dynamic exercise on ABP in
these studies (23).
This review was subject to several delimitations. The
authors intentionally chose not to weight the data according
to the size of the sample. Studies with larger samples often
did not adhere to as rigorous study design criteria as the
studies with fewer participants. For this reason, each study
group was deemed to have an equal unit of weight for
purposes of the statistical analysis. A large portion of the
investigators in this review did not obtain night or 24-h ABP
so that inferences from these data should be made with
caution. Since dipper status was frequently not reported, it is
not addressed in this review.
In conclusion, the dynamic exercise studies indicate that
day, night, and 24-h ABP is reduced after exercise among
sedentary, white, middle-aged men and women who are
overweight and not taking medications. The alterations in
day and night ABP after exercise are primarily a function of
initial values. Accordingly, the day ABP reductions were
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