Review Article

Sports Medicine 10 (6): 390-404. 1990

0112-1642/90/00 12-0390/$07.50/0
© Adis International Limited
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SPORT2340

Exercise and Mild Essential Hypertension

Recommendations for Adults

Neil F. Gordon, Christopher B. Scott, W. Jody Wilkinson,

John J. Duncan and Steven N. Blair
Institute for Aerobics Research, Dallas, Texas, and University of California,
Los Angeles, Preventive Medicine Residency, School of Public Health,
Los Angeles, California, USA

Contents Summary ......... .................. ................................. .................... ........... ..... ................................... 390
I. Antihypertensive Efficacy and Benefits of Exercise .. ............ .. .......... ................................ 392
1. 1 Epidemiological Studies of Physical Activity and Cardiorespiratory Fitness ........... 392
1.2 Longitudinal Studies of Aerobic Exercise Training .............. ........... ............ ........ ....... 393
1.3 Longitudinal Studies of Resistance Training .......... ................ .......... ........................... 394
1.4 Postulated Mechanisms for Antihypertensive Efficacy of Exercise Training ........... 396
1.5 Combination with Nonpharmacological and Pharmacological Interventions .. .. ...... 397
1.6 Effect of Exercise Training on Coronary Artery Disease Mortality .......................... 399
2. Exercise Prescription for Patients with Mild Hypertension .............. ............................... 400
2.1 Aims and Essential Components of the Exercise Prescription ........ .. ............. .. .... .. ... 400
2.2 Safety Aspects .... .................... ..... ................... .... ..... .................... ....................... ............. 400
2.3 Type. Frequency, Intensity and Duration of Exercise ...................... .......................... 401
3. Conclusion .. ....... .. ..... ......... .. ............ .. ............... .............. ....... ... ... .... ................... .. ................ 402

Summary Chronic essential hypertension is a major public health problem affiicting an esti-
mated 15 to 30% of persons from most Western industrialised countries. Persons with
mild hypertension (diastolic blood pressure between 90 and J04mm Hg and/or systolic
blood pressure between 140 and 159mm Hg) represent the overwhelming majority of
hypertensive individuals in the general population. The achievement of long term blood
pressure control in these individuals is of central strategic concern in the prevention of
hypertension-related morbidity and mortality. Epidemiological studies suggest that reg-
ular participation in physical activity may be beneficial in preventing hypertension. The
findings of epidemiological studies are supported by a recent meta-analysis of 25 long-
itudinal aerobic training studies, in which the average sample-size-weighted reductions
in resting systolic and diastolic blood pressures were JO.8mm Hg and 8.2mm Hg, re-
spectively. Moreover, preliminary analyses from our centre suggest that cardiorespiratory
fitness and, by inference, aerobic exercise training may be of benefit in reducing mortality
rates in hypertensive patients. When compiling an exercise prescription with the intention
of reducing an elevated blood pressure and attenuating the risk for coronary artery dis-
ease, several factors must be considered in order to optimise the likelihood of a safe and
effective response. Specifically, the 5 basic components of the exercise prescription for
patients with mild hypertension are safety aspects, the type of exercise to be performed,
Exercise and Mild Essential Hypertension 391

and the frequency, intensity and duration of exercise training. For those patients who
require pharmacotherapy, the interaction between the specific antihypertensive agent and
exercise responses must also be considered. We recommend that aerobic exercise training
be performed at an intensity corresponding to 60 to 85% of the maximal heart rate and
that the duration and frequency be modulated to achieve a weekly energy expenditure
of between 14 and 20 kca\fkg of bodyweight.

Chronic essential hypertension is a major public
health problem, affiicting an estimated 15 to 30%
of persons from most Western industrialised coun-
tries (Hanson 1988). In the United States alone, as
many as 58 million people are currently believed
to have an elevated blood pressure or to be taking
antihypertensive medication (Joint National Com-
mittee on Detection, Evaluation, and Treatment of
High Blood Pressure 1988). Hypertension not only
has the distinction of being one of the most com-
mon medical problems encountered by physicians
of adult patients in the United States (Collings 1983;
Houston 1989), but also constitutes a leading risk
factor for some of this country's other most prev-
alent and serious diseases (Roberts 1987; Stokes et
al. 1989). In view of this, successful efforts to lower
elevated blood pressures could be expected to have
a profound impact on population morbidity and
mortality statistics (Report of the US Preventive
Services Task Force 1989).
Persons with mild hypertension (diastolic blood
pressure between 90 and 104mm Hg and/or sys-
tolic blood pressure between 140 and 159mm Hg;
table I) represent the overwhelming majority ofhy-
pertensive individuals in the general population
(Kaplan 1984). Although the actual risk for car-
diovascular complications increases continuously
with increasing levels of systolic and diastolic blood
pressure, mild hypertension accounts for most of
the excess cardiovascular disease morbidity and
mortality that can be attributed to high blood pres-
sure (Stamler et al. 1989; Stokes et al. 1989). It is
for this reason that the achievement of long term
blood pressure control in persons with mild hyper-
tension is of central strategic concern in the pre-
vention of hypertension-related morbidity and
mortality.
Quantitatively (that is, in terms of mortality
rates), atherosclerotic coronary artery disease is the
major vascular sequel of mild hypertension (Ka-
plan 1989; National Center for Health Statistics
1986). However, in contrast to vascular sequelae
such as stroke, cardiac failure and renal failure,
there is to date no convincing evidence that cor-
onary artery disease morbidity and mortality are
significantly reduced by the pharmacological treat-
ment of mild hypertension (Helgeland 1980; Hous-
ton 1989; Medical Research Council Working Party
1985; Multiple Risk Factor Intervention Trial Re-
search Group 1982). Although it is still unclear
whether the failure to achieve such benefits is re-
lated to the nature of the hypertensive disease pro-
cess, the design of the clinical trials in question, or
adverse consequences of the drugs tested, this sur-
prising finding has led to a re-examination of pre-
viously held beliefs about the management of
patients with mild hypertension. In particular,
greater emphasis has now been placed on ways of
Table I. Classification of blood pressure in adults: recommen-
dations of the 1988 Joint National Committee on Detection,
Evaluation, and Treatment of High Blood Pressure. This clas-
sification scheme is based on the average of at least 2 readings
on at least 2 separate occasions
Blood pressure Category
range (mm Hg)
Diastolic
< 85 Normal blood pressure
85-89 High normal blood pressure
90-104 Mild hypertension
105-114 Moderate hypertension
~ 115 Severe hypertension
SystoliC (when diastolic blood pressure is < 90)
< 140 Normal blood pressure
140-159 Borderline isolated systolic hypertension
~ 160 Isolated systolic hypertension
392
preventing a shift towards a more atherogenic lipid
profile during antihypertensive pharmacotherapy
and the use of non pharmacological approaches for
the treatment of mild hypertension (Joint National
Committee on Detection, Evaluation, and Treat-
ment of High Blood Pressure 1988; Kaplan 1989;
Wilhelmson 1989).
Exercise training has emerged as one of the few
potentially effective and physiologically desirable
non pharmacological approaches that can be used
both as definitive intervention and as an adjunct
to pharmacological therapy for patients with mild
hypertension. In this article, we review some of the
major contemporary issues and concerns regarding
the efficacy of exercise training in controlling mild
essential hypertension and offsetting adverse drug
consequences. We also provide exercise prescrip-
tion recommendations for patients with mild es-
sential hypertension.
1. Antihypertensive Efficacy and Benefits
of Exercise
1.1 Epidemiological Studies of Physical
Activity and Cardiorespiratory Fitness
Over the years, several major studies have
closely examined the epidemiological relationship
between participation in physical activity, cardio-
respiratory fitness and the risk of developing an
elevated blood pressure. Of these, 2 studies pub-
lished in the early 1980s (Blair et al. 1984; Paffen-
barger et al. 1983) and one more recent study
(Darga et al. 1989) are of particular interest.
In the first study, Paffenbarger et al. (1983) re-
ported on 14998 Harvard male alumni who had
entered college between 1916 and 1950, and were
followed from 1962 or 1966 to 1972. During the
course of the study, which comprised 105662 man-
years of observation, 681 alumni developed hyper-
tension. Alumni who did not engage in vigorous
sports play were found to be at 35% greater risk of
hypertension than those who did. The inverse re-
lationship between hypertension risk and partici-
pation in strenuous exercise held at all ages (35 to
74 years), but was greatest among alumni who were
overweight for their height. The researchers con-
Sports Medicine 10 (6) 1990
cluded that vigorous physical activity is associated
with a reduced risk of hypertension and appropri-
ately may be employed as an intervention regimen.
They further speculated that vigorous exercise may
serve to favourably counteract or redirect bio-
chemical mechanisms by which fatness promotes
hypertension.
In the second study, we (Blair et al. 1984) in-
vestigated the association between baseline cardio-
respiratory fitness and the subsequent develop-
ment of hypertension in a group of 4820 men and
1219 women, aged 20 to 65 years. Study partici-
pants received a preventive medical examination
at the Cooper Clinic in Dallas, Texas, from 1970
to 1981 and were included in the study if they had
no history of hypertension or other cardiovascular
disease, had resting systolic blood pressures under
141 mm Hg and diastolic blood pressures under
91 mm Hg, had normal resting and exercise ECGs,
and had achieved at least 85% of their age-pre-
dicted maximum heart rate during maximal graded
treadmill testing performed using the Balke pro-
tocol. During the 1- to 12-year follow-up interval
(median = 4 years), there were 240 cases of new
hypertension. After adjustment for potential con-
founders, including age, sex, baseline blood pres-
sure, follow-up interval and body mass index, the
relative risk of hypertension in study participants
with low levels of cardiorespiratory fitness (as as-
sessed by the maximal exercise test duration) was
1.52 times that of persons with high levels of car-
diorespiratory fitness. In this study, we also ana-
lysed data from a subsample of participants with
low baseline levels of cardiorespiratory fitness who
had a second clinic examination during the follow-
up period. For this subsample, the incidence of
hypertension was 18 per 1000 in those individuals
(n = 271) who moved into the high fitness category
at their second examination and 32 per 1000 in
those (n = 1032) who were in the low fitness cat-
egory at both examinations. These data collectively
demonstrate that cardiorespiratory fitness, as well
as changes in cardiorespiratory fitness, may be im-
portant contributors to the risk of developing
hypertension.
Most recently, Darga et al. (1989) surveyed 1269
Exercise and Mild Essential Hypertension
members of the American Medical Joggers Asso-
ciation who had been running at least to miles
( 16km) per week on a regular basis and 683 non-
runner members of the American Medical Asso-
ciation. The major strength of this study is the fact
that the 2 survey groups were similar in age, sex,
life-style, profession, socioeconomic position and
knowledge about health. Data analysis revealed that
93% of the runners versus 81 % of the nonrunners
reported having normal blood pressure. Moreover,
almost 5 times as many nonrunners as runners were
currently taking medication for high blood pres-
sure or had taken it in the past. These data add
further credence to the belief that regular exercise
is beneficial in preventing hypertension.
1.2 Longitudinal Studies of Aerobic
Exercise Training
Although epidemiological studies undoubtedly
serve to provide much useful information, clinical
decision-making should ultimately be based pri-
marily on the findings ofrandomised clinical trials.
Until recently, reviews of the findings of longitud-
inal training studies involving hypertensive patients
have used the traditional approach of arranging the
relevant studies chronologically and then describ-
ing each on an individual basis. Such an approach,
of course, permits only subjective conclusions to
be made and does not allow the relationship among
variables to be evaluated. In order to overcome
such limitations, contemporary research reviewing
should ideally be undertaken using meta-analysis,
which enables the research findings of available
studies to be integrated in a quantitative manner.
To this end, Hagberg (1990) recently performed
a meta-analysis of 25 longitudinal studies exam-
ining the antihypertensive effects of aerobic exer-
cise conditioning on patients with high blood pres-
sure (Adragna et al. 1985; Barry et al. 1966;
Bonnano et al. 1974; Boyer & Kasch 1970; Cade
et al. 1984; Choquette & Ferguson 1973; De Plaen
& Detry 1980; DeVries 1970; Duncan et al. 1985;
Hagberg 1983; Hagberg et al. 1989; Hanson &
Nedde 1970; Harris & Holly 1987; Johnson &
Grover 1967; Kiyonaga et al. 1985; Krotkiewski et
393
200
-10.8mm Hg
0; ~
J: 150
E - 8.2mm Hg
.§.
~
Systolic Diastolic
Fig. 1. Results of meta-analysis of 25 longitudinal studies ex-
amining the antihypertensive effects of aerobic exercise con-
ditioning in patients with high blood pressure (Hagberg 1990):
o = before exercise training; • = on completion of exercise
training.
al. 1979; Kukkonen et al. 1982; Nelson et al. 1986;
Ressl et al. 1977; Roman et al. 1981; Rudd & Day
1967; Sannerstedt et al. 1973; Urata et al. 1987;
Weber et al. 1986; Wilmore et al. 1970). In the
studies included in the meta-analysis, the ages of
the participants ranged from 15 to 70 years, the
sample size from 4 to 66 participants, and the dur-
ation of exercise training from 4 to 52 weeks. More
than 50% of the studies involved male participants
alone, only 3 studies reported separate data for fe-
male participants, and the remaining studies pre-
sented combined data for men and women. This
extensive variability in study design should be kept
in mind when interpreting the results of the meta-
analysis.
The major findings regarding the efficacy of ex-
ercise training in controlling hypertension were as
follows. The average baseline resting systolic and
diastolic blood pressures, weighted for sample size
in each study, were 150mm Hg and 92mm Hg, re-
spectively. The average sample-size-weighted re-
ductions in resting systolic and diastolic blood
pressures with exercise training were 10.8mm Hg
and 8.2mm Hg, respectively (fig. I). Statistically
significant decreases in systolic blood pressure with
exercise training were noted in 67% of the experi-
mental groups. Similarly, 70% of the experimental
groups experienced statistically significant reduc-
394
tions in diastolic blood pressure with exercise
training.
Thus, it is evident from this meta-analysis that
exercise training can indeed be expected to lower
both systolic and diastolic blood pressures in
patients with essential hypertension. However, it
is important to point out 2 issues of concern. First,
the decrement in blood pressure evoked by exer-
cise training was not of sufficient magnitude to
normalise the patients' blood pressures in many of
the studies. In addition, not all clinical trials sup-
port the conclusion that exercise training is an ef-
fective non pharmacological intervention against
hypertension. For example, in one study per-
formed subsequent to Hagberg's meta-analysis, re-
searchers failed to document a clinically meaning-
ful reduction in resting and 24-hour ambulatory
blood pressure measurements with 16 weeks of ex-
ercise training in 8 subjects with baseline resting
diastolic blood pressures between 85 and
104mm Hg (Gliders et al. 1989). Such observations
raise the possibility that there may in fact be cer-
tain subsets of patients with hypertension who are
more responsive to the blood-pressure-Iowering ef-
fects of exercise training than others.
To address this issue, in his meta-analysis of 25
exercise training and hypertension studies, Hag-
berg (1990) examined the relationship between the
effectiveness of exercise in reducing blood pressure
and several potentially important variables, in-
cluding age, sex, bodyweight, baseline systolic and
diastolic blood pressure, exercise intensity and
length of the exercise training programme. The
magnitude of the reduction in neither systolic nor
diastolic blood pressure was significantly corre-
lated to the age of the study participants. Women
(average reduction in blood pressure = -19/
-14mm Hg) appeared to derive more benefit from
exercise training than men (average reduction in
blood pressure = -7/-5mm Hg). In contrast to the
magnitude of the reduction in diastolic blood pres-
sure with exercise training, which was not corre-
lated to the baseline bodyweight of the study par-
ticipants, the reduction in systolic blood pressure
tended to be less in the heavier participants (r =
-0.43, p = 0.06). Interestingly, no significant cor-
Sports Medicine 10 (6) 1990
relations were noted between the change in body-
weight with exercise training and the changes in
systolic (r = 0.13) or diastolic (r = -0.02) blood
pressures. Although neither the magnitude of the
reduction in systolic or diastolic blood pressure was
correlated to the baseline systolic blood pressure,
both were significantly correlated to the baseline
diastolic blood pressure (r = 0.34, p = 0.05 for re-
duction in systolic blood pressure; r = 0.46, p =
0.01 for reduction in diastolic blood pressure). Sur-
prisingly, the magnitude of the reduction in both
systolic (r = -0.40, p = 0.08) and diastolic (r =
-0.37, p = 0.l1) blood pressures tended to be
somewhat negatively correlated to the intensity at
which exercise training was performed. Finally,
whereas the magnitude of the reduction in systolic
blood pressure was not significantly correlated to
the length of the exercise training programme (r =
0.18), the reduction in diastolic blood pressure was
(r = 0.38, p = 0.05).
Thus, it appears that the precise blood pressure-
lowering benefits that a given hypertensive patient
can expect to derive from participation in exercise
training may be at least partly dependent on their
sex, bodyweight, diastolic blood pressure, the in-
tensity at which they exercise, and the length of
their training programme. Women, patients with
higher diastolic blood pressures, patients with lower
bodyweights (with respect to systolic blood pres-
sure benefits), patients who exercise at relatively
low intensities and those who make a long term
commitment to participation in exercise training
(with respect to diastolic blood pressure benefits)
could theoretically be expected to benefit the most.
1.3 Longitudinal Studies of
Resistance Training
Traditionally, hypertensive patients have been
discouraged from performing any form of resist-
ance training for fear of precipitating a cerebro-
vascular event or placing an excessive demand on
a myocardium that may already display a compro-
mised left ventricular function. Such fears have a-
risen primarily as a result of the marked pressor
response that is known to be elicited during an acute
bout of heavy resistance exercise. For example, in
Exercise and Mild Essential Hypertension
a study by MacDougall et al. (1985) in which blood
pressures were directly recorded by means of a ca-
pacitance transducer connected to a catheter in the
brachial artery, the mean value during a double-
leg press performed by 5 experienced body builders
was 302/250mm Hg, with pressures in one subject
exceeding 480/350mm Hg.
Contrary to what might be expected, studies in-
vestigating the impact of long term participation
in resistance training on resting blood pressure have
generally failed to document a deleterious effect
(Baechle 1978; Colliander & Tesch 1988; Hagberg
et al. 1983; Harris & Holly 1987; Hurley et al. 1988;
Kiveloff & Huber 1971; Stone et al. 1983). Indeed,
the findings of at least 3 appropriately designed
longitudinal training studies have now shown that
chronic resistance training may modify resting
blood pressures in a favourable fashion (Hagberg
et al. 1983; Harris & Holly 1987; Hurley et al. 1988).
In a study of the effects of 16 weeks of high
intensity resistance training in II normotensive
males, supine diastolic blood pressure decreased
from 84 ± 7mm Hg before training to 79 ±
6mm Hg after training (p < 0.05), while supine sys-
tolic blood pressure remained essentially unaltered
(Hurley et al. 1988). Similarly, whereas seated sys-
tolic blood pressures were not significantly modi-
fied in 10 men with mild hypertension who par-
ticipated in 9 weeks of circuit weight-training, seated
diastolic blood pressures fell from 96 ± 20 to 91
± 25mm Hg (p < 0.05) [Harris & Holly 1987]. In
both of these studies (Harris & Holly 1987; Hurley
et al. 1988), no significant blood pressure changes
were noted in the sedentary control groups. Fur-
thermore, in the study by Hurley et al. (1988) re-
sistance training resulted in a 13% increase in high
density lipoprotein cholesterol (p < 0.05), and an
8% decrease in the total cholesterol to high density
lipoprotein cholesterol ratio (p < 0.01), despite an
unchanged maximal oxygen uptake. These plasma
lipoprotein changes are similar to those seen with
aerobic exercise training (Gordon & Cooper 1988)
and are obviously highly desirable.
Hagberg et al. (1983) have further demonstrated
that adolescents with mild systolic hypertension
who lower their systolic blood pressures with aero-
395
bic exercise training are able to maintain the re-
ductions or even reduce their blood pressures fur-
ther by subsequently replacing aerobic training with
weight-training. Thus, while considerable further
research is needed to fully clarify the situation, pre-
liminary evidence suggests that resistance training
performed on a long term basis does not result in
elevated resting blood pressures and might in fact
elicit changes that are in a favourable direction.
The abovementioned studies, however, do not serve
to allay fears that chronic resistance exercise could
adversely affect the structural integrity of the cere-
bral blood vessels and left ventricle, which may al-
ready have been impaired by a lifetime of hyper-
tension.
Experimental evidence on the chronic effects of
resistance training on the risk for cerebrovascular
complications in humans with hypertension is un-
available at present. To determine whether chronic
resistance training would result in a higher inci-
dence of cerebrovascular lesions in animals, Tip-
ton et al. (1988) investigated 40 stroke-prone hy-
pertensive rats using an elegant study design. The
rats were trained to perform resistance exercise by
forelimb hanging over an electrical grid. During the
21-week study, resistance training was performed
4 to 5 times per week and each session involved I
to 3 sets of 6 to 10 repetitions performed with a
hang time of 7 to 10 seconds per hang, while grad-
ually increasing the amount of weight supported
from 0 to 12% of bodyweights for males and 30%
for females. The procedure for chronic forelimb
hanging enabled the rats to increase their strength
by 115%, but did not result in an elevation in rest-
ing blood pressure. Moreover, when the brains of
the rats were histologically examined by a veter-
inary pathologist on completion of the study, 4 of
the animals in the non hanging control group had
evidence for previous strokes whereas only one of
the resistance-trained animals exhibited similar le-
sions. Although considerable further research is
needed before the findings of this study can be ex-
trapolated to humans with hypertension, they do
indicate that resistance training may not necessar-
ily accentuate the risk of the hypertensive patient
for cerebrovascular complications. In contrast, a
396
more recent study by Tipton et al. (1990) has ac-
tually documented an increased vulnerability of
endurance-trained stroke-prone hypertensive rats
to cerebrovascular lesions.
Myocardial hypertrophy is an adaptive mech-
anism that develops in response to increased
haemodynamic loading of the heart. Depending on
the specific cause, the increase in cardiac mass that
occurs in myocardial hypertrophy is associated with
characteristic alterations in the volume of the card-
iac cavities and in the thickness of their walls. On
the basis of these changes, myocardial hypertrophy
can be classified anatomically as being either con-
centric (that is, hearts with thick walls and small
cavities) or eccentric (that is, hearts with walls that
are thicker than normal, but relatively thin due to
cavities that are larger than normal). In contrast to
volume overloading, which is associated with ec-
centric hypertrophy, the pressure overloading which
results from chronic hypertension is associated with
concentric hypertrophy (Weber 1988). In hyperten-
sive patients, concentric hypertrophy of the left
ventricle is associated with an increased risk of ma-
jor cardiovascular events even in the absence of
any of the conventional cardiovascular risk factors
(DiPette & Frohlich 1988). Theoretically, chronic
resistance training, which also results in pressure
overloading of the left ventricle, could be expected
to contribute further to concentric hypertrophy in
hypertensive patients and thereby accentuate their
risk for cardiovascular morbidity and mortality.
However, although additional studies are needed
to refute this possibility, 2 recent reviews of the
cardiovascular adaptations to resistance training
concluded that while resistance training may in-
crease left ventricular wall thickness, there is little
or no change in left ventricular internal dimen-
sions and either no effect or a slight enhancement
of systolic function at rest (Effron 1989; Fleck 1988).
Moreover, whereas the pathological hypertrophy
due to hypertension produces abnormalities in left
ventricular diastolic function, resistance training is
characterised by normal diastolic function (Effron
1989; Fleck 1988). It should also be noted that in
the earlier mentioned study of stroke-prone hyper-
tensive rats, resistance training in fact was not suf-
Sports Medicine 10 (6) 1990
ficient to stimulate further myocardial hypertrophy
(Tipton et al. 1988).
Thus, although the eccentric hypertrophy that
often results from the volume overloading induced
by aerobic exercise training is physiologically more
desirable than the concentric hypertrophy that may
result from resistance training, neither form of ex-
ercise-induced hypertrophy appears to produce any
untoward changes in left ventricular function. In-
deed, it is now postulated that both types of ex-
ercise-induced hypertrophy may be associated with
an increase in myocyte vascularity that is com-
mensurate with the degree of hypertrophy of the
myocytes themselves and may thereby improve
myocardial function and assure myocyte health
(Weber 1988). It is also of some interest that circuit
resistance training can even be performed with a
high level of safety by select patients with coronary
artery disease (Kelemen 1989; Sparling & Cantwell
1989).
1.4 Postulated Mechanisms for
Antihypertensive Efficacy of
Exercise Training
Blood pressure is the product of cardiac output
and total peripheral resistance. In order for blood
pressure to be lowered by exercise training, either
or both of these haemodynamic variables must ul-
timately be reduced. Studies that have sought to
determine the mechanisms underlying the anti-
hypertensive effect of exercise training have yielded
somewhat conflicting findings (De Plaen & Detry
1980; Hagberg et al. 1983, 1989; Hanson & Nedde
1970; Johnson & Grover 1967; Nelson et al. 1986;
Ressl et al. 1977; Sannerstedt et al. 1973; Urata et
al. 1987). Whereas some of these studies have iden-
tified a reduction in cardiac output as being the
primary mechanism, others have attributed the
antihypertensive efficacy of exercise training to a
reduction in total peripheral resistance. Further
studies are needed to clarify the issue.
Postulated mechanisms for exercise training-in-
duced reductions in cardiac output and/or total
peripheral resistance include resetting of barore-
ceptors, altered distribution of blood volume,
changes in the renin-angiotensin axis and a reduc-
Exercise and Mild Essential Hypertension
tion in sympathetic activity (Duncan et al. 1985;
Kiyonaga et al. 1985; Tipton 1984; Urata et al.
1987). Although the findings of the available stud-
ies are not very consistent, the postulate of a re-
duction in sympathetic activity has gained the most
support (Duncan et al. 1985; Kiyonaga et al. 1985;
Urata et al. 1987). Regarding this possibility, we
(Duncan et al. 1985) have demonstrated that hy-
pertensive patients with elevated total resting
plasma catecholamine levels derive greater reduc-
tions in blood pressure with aerobic training than
those whose levels are normal, and that exercise
training lowers plasma noradrenaline (norepineph-
rine) levels and blood pressure without altering {3-
adrenoceptor responsiveness. In our study, de-
creases of plasma noradrenaline values with exer-
cise training were correlated with lower systolic (r
= 0.40, p = 0.05) and diastolic (r = 0.46, p = 0.03)
blood pressures. It is also of interest that in another
recent study (Van Hoof et al. 1989), 4 months of
aerobic exerc~se training significantly lowered the
diastolic blood pressure during the day, whereas no
significant changes were observed during the night.
Because plasma noradrenaline levels are lower at
night than during the day, the researchers inter-
preted their findings as suggesting that exercise
training may be most beneficial in reducing the
blood pressure response at times of heightened
sympathetic activity. Regarding the effect of exer-
cise conditioning on plasma catecholamines, Jost
et al. (1990) have now shown that, when compared
to moderate intensity training, high intensity train-
ing increases the ratio of noradrenaline (norepi-
nephrine) to adrenaline (epinephrine). Their ob-
servation may explain the divergently described
impacts of high and moderate intensity exercise on
the blood pressure response to training.
It has recently become apparent that a single
bout of aerobic exercise may exert a favourable ef-
fect on coronary artery disease risk factors such as
serum high density lipoprotein cholesterol levels,
serum triglycerides, and glucose tolerance (Gordon
& Cooper 1988; Vranic & Wasserman 1990). Sev-
eral studies have now also demonstrated that the
blood pressures of hypertensive patients are re-
duced for 1 to 3 hours following an acute bout of
397
aerobic exercise (Bennett et al. 1984; Hagberg et al.
1987; Hannum & Kasch 1981; Kaufman et al.
1987). In these studies, a single bout of 30 to 45
minutes of aerobic exercise resulted in systolic and
diastolic blood pressure reductions of similar mag-
nitude to those elicited by chronic exercise train-
ing. Therefore, the possibility that a reduction in
blood pressure with regular participation in aerobic
exercise could be due to the accumulative effects
of single exercise bouts rather than actual long term
adaptations to exercise training should be enter-
tained. Clearly, though, additional research is
needed to examine this hypothesis and to identify
the precise mechanisms underlying the antihyper-
tensive efficacy of exercise training.
1.5 Combination with Nonpharmacological
and Pharmacological Interventions
It is evident from figure 2, in which exercise
training is compared with weight reduction, salt re-
striction, potassium consumption, relaxation
therapy and biofeedback techniques, that the anti-
hypertensive efficacy of exercise training compares
favourably with that of other non pharmacological
interventions (Hagberg 1990; Health and Public
Policy Committee 1985; Kaplan 1986). However,
it must be emphasised that exercise training is not
a panacea and does not result in a complete nor-
malisation of blood pressure in many patients with
mild hypertension. For example, in a study of ours
(Duncan et al. 1985), involving 56 patients with
baseline diastolic blood pressures of 90 to
104mm Hg, 16 weeks of aerobic exercise training
failed to normalise blood pressure (that is, a dia-
stolic blood pressure < 90mm Hg) in 43% of
patients.
In such instances, it is necessary to combine ex-
ercise with other non pharmacological interven-
tions and, when indicated, drug therapy (1988 Re-
port ofthe Joint National Committee on Detection,
Evaluation, and Treatment of High Blood Pres-
sure). However, it should be noted that it is cur-
rently not known whether other nonpharmacol-
ogical interventions combine with exercise training
to produce an additive blood pressure-lowering ef-
398 Sports Medicine 10 (6) 1990

Ci
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S 12
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iii
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0
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Aerobic Weight Sodium Potassium Bio- Relaxation
exercise loss restriction consumption feedback therapy

Fig. 2. Effect of non pharmacological interventions on systolic and diastolic blood pressures (BP) in hypertensive patients.
Data are adapted from reviews by Hagberg (1990). Health and Public Policy Committee (1985). and Kaplan (1986).

fect, or vice versa. In addition, not all antihyper-
tensive medications interact with exercise training
in a favourable fashion.
Fortmann et al. (1988) compared the effects of
weight loss by moderate caloric restriction (dieting)
and weight loss by increased caloric expenditure
(exercise) on resting and ambulatory blood pres-
sures in liS overweight, sedentary, normotensive
men. They postulated that the effects of exercise
training on catecholamines would lead to a greater
decrease in ambulatory blood pressure in the ex-
ercise group than in the diet group. However, al-
though blood pressures were reduced to a greater
degree in both weight-loss groups as compared to
a sedentary control group whose weights remained
essentially unaltered during the I-year study pe-
riod, no significant differences were noted between
the 2 intervention groups. This study therefore can
be viewed as providing indirect evidence that ex-
ercise training and weight reduction might not
combine in an additive fashion to lower blood
pressure and highlights the need for further re-
search in this area.
Studies conducted at our and other centres have
clearly demonstrated that some antihypertensive
agents may not be appropriate for patients with un-
complicated essential hypertension who participate
in exercise training (Gordon & Duncan 1990). Spe-
cifically, nonselective i3-blockers and, to a lesser
degree, i31-selective blockers are known to decrease
exercise tolerance in hypertensive patients who are
not limited by myocardial ischaemia (Gordon &
Exercise and Mild Essential Hypertension
Duncan 1990). In contrast to these drugs, angio-
tensin-converting enzyme inhibitors and calcium
antagonists do not appear to exert a negative im-
pact on exercise tolerance in hypertensive patients
(Gordon et al. 1988; Myburgh & Gordon 1987).
Therefore, unless (j-blocker therapy is specifically
indicated, physicians should consider alternative
antihypertensive therapy with an angiotensin-con-
verting enzyme inhibitor or calcium antagonist for
their patients with uncomplicated essential hyper-
tension who lead a physically active lifestyle and
require pharmacotherapy. However, it is import-
ant to point out that should (j-blocker therapy in
fact be prescribed for hypertensive patients, they
should still be encouraged to participate in exercise
training. Such patients are capable of enhancing
their level of cardiorespiratory fitness with exercise
training (Gordon & Duncan 1990). Moreover, re-
cent research conducted at our centre suggests that
long term aerobic exercise training may help offset
some of the detrimental effects of (j-blocker therapy
on lipoprotein metabolism (Gordon et al. 1989).
For patients with mild hypertension who are
treated with both pharmacological and nonphar-
macological approaches, it may be appropriate to
consider discontinuing drug therapy once the non-
pharmacological interventions have been optim-
ised. In a study by Stamler et al. (1987) 39% of
patients who reduced their weight, salt intake and
alcohol consumption remained normotensive 4
years after discontinuing their antihypertensive drug
therapy. Although no such data are available cur-
rently for exercise training, there is no reason why
similar results could not be expected.
1.6 Effect of Exercise Training on Coronary
Artery Disease Mortality
The precise role of habitual physical activity in
the prevention of coronary artery disease has still
to be determined conclusively. However, the find-
ings of more than 40 studies evaluating the benefit
of exercise in the primary prevention of coronary
artery disease strongly support the inference that
physical activity is inversely and causally related
399
to the incidence of coronary artery disease (Powell
et al. 1987).
Currently, no studies have specifically exam-
ined the effect of exercise training on coronary ar-
tery disease mortality in hypertensive patients. We
have recently begun to address this important topic
by investigating the relationship between baseline
cardiorespiratory fitness and all-cause mortality
during subsequent follow-up in hypertensive men
evaluated at the Cooper Clinic, Dallas, Texas (Blair
et al. 1990). Subjects for our preliminary analyses
were 10 224 healthy normotensive men and 1832
men who reported a history of hypertension, but
were otherwise healthy. Study participants under-
went a preventive medical examination at the
Cooper Clinic from 1970 to 1981. Mortality sur-
veillance was maintained on the cohort through
1985, during which time there were 240 deaths in
the normotensive men and 78 deaths in the hy-
pertensive men. Total treadmill time during max-
imal graded exercise testing performed during the
baseline visit was used to assign subjects to car-
diorespiratory fitness quintiles and all-cause death
rates per 10 000 person-years offollow-up were cal-
culated for each fitness quintile for both normo-
tensive and hypertensive men. Age-adjusted all-
cause mortality rates per 10 000 person-years of
follow-up in hypertensive men ranged from 110.5
in the least fit quintile to 24.8 in the most fit quin-
tile; corresponding rates for normotensive men were
64.0 and 18.6. Interestingly, more-fit hypertensive
men had lower death rates than less-fit normoten-
sive men (fig. 3). Furthermore, the relation be-
tween cardiorespiratory fitness and all-cause mor-
tality held in multiple logistic analyses after
adjustment for potential confounders, including
serum cholesterol, body mass index, current smok-
ing habit and length of follow-up. Thus, these anal-
yses suggest that cardiorespiratory fitness and, by
inference, aerobic exercise training may be of bene-
fit in reducing mortality rates in hypertensive
patients. In the future, we plan on extending our
analyses to include cardiovascular disease-specific
mortality rates and persons treated with specific
antihypertensive medications.
400 Sports Medicine 10 (6) 1990

a:::> require pharmacotherapy, the interaction between

.,
_0
~
120
the specific antihypertensive agent and exercise re-
"'=
~ 0
.r:- sponses must also be considered .
",'0
., .,
., ..
-o~

.,., 2.2 Safety Aspects

::> ~
.. c:
.Yg
- ...
'" .,
-on As is the case for the general population, the
;!!o
.,0
::>0
major health hazards of exercise training for adult
'00 patients with mild hypertension are likely to be or-
., ...
'l'~

01" thopaedic injury and sudden cardiac death. To re-

<.9:
1 2 3 4
(low)
Fitness quintile
Fig. 3. Age-adjusted all-cause death rates per 10000 person-
years of follow-up (1970-1985) by cardiorespiratory fitness
groups in hypertensive (_) and normotensive (EI) male Cooper
Clinic patients.
2. Exercise Prescription for Patients with
Mild Hypertension
2. 1 Aims and Essential Components of the
Exercise Prescription
According to the Joint National Committee on
Detection, Evaluation, and Treatment of High
Blood Pressure (1988), the primary aims of treating
patients with high blood pressure are to achieve
and maintain an arterial blood pressure below 140/
90mm Hg, and to prevent morbidity and mortality
associated with high blood pressure. Because, as
earlier mentioned, coronary artery disease is quan-
titatively by far the most important complication
of mild hypertension, we believe that exercise
training programmes for patients with mild hyper-
tension should focus largely on this aspect of
hypertension-related morbidity and mortality.
When compiling an exercise prescription with
the intention of reducing an elevated blood pres-
sure and attenuating the risk for coronary artery
disease, several factors must be considered in order
to optimise the likelihood of a safe and effective
response. Specifically, the 5 basic components of
the exercise prescription for patients with mild
hypertension are safety aspects, the type of exercise
to be performed, and the frequency, intensity, and
duration of exercise training. For those patients who
5 duce their risk for orthopaedic injury, patients
(high)
should be cautioned against attempting to perform
too much exercise too soon, and should adhere to
other standard injury prevention guidelines that are
applicable to all individuals who participate in ex-
ercise programmes (Jones et al. 1988).
Although habitual physical activity is associated
with an overall reduced risk of primary cardiac ar-
rest in the general adult population (Powell et al.
1987), and the chances of sustaining a fatal cardiac
event during exercise training are extremely small
(Thompson et al. 1982), it should be realised that
vigorous exercise can precipitate sudden death. In
adults, the transiently increased risk of cardiac ar-
rest that occurs during vigorous exercise results
largely from the presence of underlying coronary
artery disease (Siscovick et al. 1984; Thompson et
al. 1982). Because of this, and in view of the ac-
centuated risk for coronary artery disease in patients
with mild hypertension, there are at least 3 major
steps that should be taken to minimise the risk of
exercise-related sudden death.
First, we recommend that the following subsets
of patients with mild hypertension undergo a
medical evaluation, including maximal graded ex-
ercise testing with electrocardiographic monitor-
ing, before beginning a programme of vigorous ex-
ercise: males who are 40 or older; females who are
50 or older; and, irrespective of age and sex, all
individuals with an additional major coronary ar-
tery disease risk factor, symptoms suggestive of
cardiopulmonary or metabolic disease, or known
disease. For patients who participate in moderate
(40 to 60% of maximal oxygen uptake) rather than
vigorous (more than 60% of maximal oxygen up-
take) exercise and do not have known disease or
Exercise and Mild Essential Hypertension
symptoms of disease, exercise testing is probably
not necessary provided that training is undertaken
gradually with appropriate guidance. Second, all
patients with mild hypertension who participate in
exercise training should be educated about the
many factors that are necessary for safe exercise,
in particular the premonitory symptoms and signs
of an impending cardiac complication (Gordon &
Blair 1988). Third, all patients with known cor-
onary artery disease should exercise under medical
direction, receive detailed counselling and never
exceed more than 85% of their symptom-limited
heart rate (Gordon & Gibbons 1990).
2.3 Type, Frequency, Intensity and Duration
of Exercise
Much is now known about the physiological ad-
aptations that are evoked by long term participa-
tion in exercise training. The exercise stimuli that
are needed to induce increases in maximal oxygen
uptake, the universally accepted index of cardio-
respiratory fitness, have been intensively investi-
gated. On the basis of the findings of available
studies, the American College of Sports Medicine
(1986) has formulated guidelines for the quality and
quantity of exercise required to enhance and main-
tain cardiorespiratory fitness. Briefly, these guide-
lines recommend that aerobic exercise be per-
formed for 15 to 60 minutes at an intensity
corresponding to 50 to 85% of the maximal oxygen
uptake or 65 to 90% of the maximal heart rate on
3 to 5 days each week. Because maximal oxygen
uptake and cardiovascular health are frequently
considered synonymous, these guidelines are often
extrapolated to the prescription of exercise training
for hypertensive patients. In reality, changes in
blood pressure and the risk for coronary artery dis-
ease do not necessarily parallel increases in max-
imal oxygen uptake, and the precise exercise stim-
uli needed to elicit these 2 important benefits in
hypertensive patients currently are not well de-
fined. It is also likely that the intensity of exercise
which is optimal for enhancing maximal oxygen
uptake may be suboptimal for promoting adher-
ence to exercise training (Wankel 1985).
401
Several studies have now indicated that the
magnitude of reduction in blood pressure elicited
by exercise training is not closely related to the
magnitude of increase in maximal oxygen uptake
(Hagberg 1990; Hagberg et al. 1983, 1989; Roman
et al. 1981). Indeed, it appears from these studies
that moderate intensity exercise may be just as ef-
fective in controlling hypertension, if not more so,
than high intensity exercise. Similarly, recent epi-
demiological studies strongly suggest that moder-
ate levels of leisure time physical activity may be
sufficient for reducing coronary artery disease mor-
tality rates (Leon et al. 1987; Magnus et al. 1979).
These studies show that regular participation in
light to moderate intensity activities, which are un-
likely to have a major impact on maximal oxygen
uptake, is beneficial for preventing coronary artery
disease and that more vigorous exercise in fact may
not offer substantially greater protection. Unlike
improvements in maximal oxygen uptake, which
are closely coupled to both the intensity and vol-
ume of exercise training, it now appears that the
effectiveness of exercise in preventing coronary ar-
tery disease may be primarily dependent on total
energy expenditure.
Although much research is still needed to clarify
the situation, it appears from the abovementioned
epidemiological studies that a threshold level of
energy expenditure during exercise training must
be exceeded to attenuate the risk for coronary ar-
tery disease. After carefully reviewing the available
literature, we recently concluded that exercise
training resulting in a weekly energy expenditure
of between 14 and 20 kcal/kg bodyweight may be
optimal for preventing coronary artery disease
(Gordon & Gibbons 1990).
Weekly energy expenditure during exercise
training, of course, is dependent on the type of ex-
ercise performed and the frequency, intensity and
duration of exercise training. Although we and
others (Frohlich et al. 1985; Kelemen 1989) do not
consider resistance training to be necessarily con-
traindicated in patients with uncomplicated mild
essential hypertension (on the contrary, it may be
important for promoting optimal musculoskeletal
health), activities that can be performed for pro-
402
longed periods, use large muscle groups, and are
rhythmical and aerobic in nature should be em-
phasised because they constitute the most effective
means of attaining the desired level of energy ex-
penditure. Moderate intensity exercise, which elic-
its a heart rate above 60% of the maximal heart
rate but does not exceed 85% of the maximal heart
rate, should be encouraged. Finally, the frequency
and duration of the activity should be modulated
to yield the desired weekly energy expenditure.
Generally, exercise will need to be performed on
at least 3 to 4 days each week for a minimum of
about 30 minutes.
Activities performed for an appropriate dura-
tion and on a regular basis, but at an intensity below
the threshold needed to elicit a significant cardio-
respiratory training effect, may be of particular rel-
evance for patients who currently lead a totally se-
dentary lifestyle. Such patients may not be ready
to make the major transition needed to comply with
a formal exercise programme. Rather than per-
suading them to participate in aggressive exercise
training, these patients should simply be coun-
selled about activities, such as brisk walking, gar-
dening and yard work, which can be engineered
with relative ease into their weekly routine. Once
the sedentary patient with mild hypertension has
become accustomed to an active lifestyle, a more
formal approach to exercise prescription can be
adopted.
For patients who are treated with antihyperten-
sive medications, the above basic principles are still
applicable. Minor modifications of the precise
manner in which exercise is prescribed may be
needed with some drugs. This is particularly ap-
plicable in the case of J3-blocker therapy, which has
a greater impact on haemodynamic and metabolic
responses to exercise than other interventions. Pre-
viously, we (Duncan & Gordon 1990) have rec-
ommended that exercise intensity prescription for
patients treated with a J3-blocker should be based
on the results of an individualised graded exercise
test performed with the patient on medications.
Ideally, testing and training should take place at a
similar time interval after ingestion of the last drug
dose, and exercise testing should be repeated if there
Sports Medicine IO (6) 1990
is a change in dosage or the type of J3-blocker used.
The precise exercise intensity, however, should still
be prescribed in accordance with our abovemen-
tioned recommendations (that is, 60 to 85% of the
maximal heart rate).
3. Conclusion
The achievement of long term blood pressure
control in patients with mild essential hyperten-
sion is of central strategic concern in the preven-
tion of hypertension-related morbidity and mor-
tality. Epidemiological and longitudinal training
studies have identified aerobic exercise training as
an effective and physiologically desirable non-
pharmacological approach that can be used both
as definitive intervention and as an adjunct to
pharmacological therapy for patients with mild
hypertension. Moreover, preliminary analyses from
our centre suggest that cardiorespiratory fitness and,
by inference, aerobic exercise training may be of
benefit in reducing mortality rates in hypertensive
patients. Contrary to what might be expected, the
findings of the few adequately designed resistance
training studies that have been performed to date
suggest that this exercise modality may also modify
resting blood pressures in a favourable fashion.
However, additional studies are needed to confirm
this interesting possibility and to allay fears that
chronic resistance exercise could adversely affect
the structural integrity of the cerebral blood vessels
and left ventricle in hypertensive patients. After re-
ceiving appropriate counselling regarding safety as-
pects of exercise training and, where applicable,
undergoing symptom-limited graded exercise test-
ing, we recommend that aerobic exercise training
ultimately be performed at an intensity corre-
sponding to 60 to 85% of the maximal heart rate
and that the duration and frequency be modulated
to achieve a weekly energy expenditure of between
14 and 20 kcal/kg bodyweight.
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