High Intensity Interval Training For Hypertension .9

High-Intensity Interval Training
for Hypertension
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Program Design and Application

by Brent Uken, M.S.; Matthew Lee, M.S., ACSM-EP; Gage Wright, M.S.;
and Yuri Feito, Ph.D., MPH, FACSM, ACSM-CEP
INTRODUCTION
Apply It!
H
ypertension (HTN) is a significant risk factor for cardiovascular disease
This article explores the frequency, (CVD) and a leading cause of disability and death in the United States
intensity, time, and type frame- and globally (1). The prevalence of HTN among U.S. adults over
work within the context of HIIT, 20 years of age is estimated to be 116 million, divided nearly equally
the unique elements of HIIT (e.g., between men and women (1). The most recent estimates of the total
intensity and work-to-recovery ratio), direct and indirect cost to society associated with HTN in the United States is more
and concludes with examples of HIIT than $55 billion (annual average), and projections show that by 2035, the total costs of
exercise regimens. By reading this HTN could increase to more than $220 billion (1).
article, health and fitness profes-
sionals will be reminded of the fol-
lowing takeaways:
HTN develops gradually and is
generally the product of lifestyle
choices concerning diet and
exercise.
Although HTN is routinely treated
with pharmacological intervention,
lifestyle intervention is a primary
therapeutic option for those newly
diagnosed with hypertension.
Research supports the imple-
mentation of aerobically based
HIIT and MICT for inducing similar
reductions in systolic blood pres-
sure and diastolic blood pressure
in adults with pre-HTN and/or HTN.
HIIT for any client must be
introduced gradually — and
deliberately — over time. The The high prevalence of HTN creates a significant likelihood that health and fitness pro-
introduction of HIIT should start fessionals will regularly encounter individuals who have HTN — diagnosed or not. Table 1
with a single, brief set of HIIT presents blood pressure categories and their corresponding systolic blood pressure (SBP) and
(e.g., a few minutes of HIIT) to diastolic blood pressure (DBP) levels.
evaluate the client’s readiness HTN develops gradually and is generally the product of lifestyle choices concerning
and receptivity to the approach. diet and exercise. These same lifestyle choices also frequently lead to other chronic dis-
Key words: Hypertension, Systolic eases, such as diabetes, dyslipidemia, overweight, and obesity — all common comorbidities
Blood Pressure, High Intensity, with HTN. Although HTN is routinely treated with pharmacological intervention (e.g.,
HIIT, Interval Training beta-blockers, diuretics, angiotensin II receptor blockers, and angiotensin-converting en-
zyme inhibitors), lifestyle intervention is a primary therapeutic option for most who have
been newly diagnosed with hypertension (2,3). Pharmacological interventions and dietary
28 ACSM’s Health & Fitness Journal ® September/October 2021
Copyright © 2021 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
TABLE 1: Blood Pressure Categories 3 days per week (6). The current ACSM frequency, intensity,
SBP (Upper time, tand type (FITT) recommendations for individuals with
Blood Pressure Number), DBP (Lower HTN are summarized in Table 2.
Category mm Hg Number), mm Hg
Normal <120 and <80

Elevated 120–129 and <80

The American College of Sports Medicine
High blood pressure 130–139 or 80–89
(HTN stage 1) (ACSM), along with the American Heart
High blood pressure ≥140 or ≥90
Association, the World Health Organization, and
(HTN stage 2) other prominent groups, universally endorses
Hypertensive crisis >180 and/or >120 aerobic exercise for the treatment of HTN, with
(consult physician specific details outlined in its Exercise and
immediately)
Source: American Heart Association (2020).
Hypertension Position Stand (4) and in ACSM’s
Guidelines for Exercise Testing and Prescription (5).
changes, which are effective for controlling blood pressure, are Although the generally accepted ExRx for HTN does not in-
beyond the scope of this article; therefore, our focus is on the clude HIIT, the effectiveness and benefits of HIIT are worthy of
role of exercise in mitigating or possibly reversing HTN. More consideration as a therapeutic option. Consequently, the pur-
specifically, our focus is on the role of high-intensity interval pose of this article is to explore HIIT as an emerging approach
training (HIIT) as an element of the exercise prescription to ExRx for individuals with hypertension.
(ExRx) in addressing HTN.
HIIT
Over the past few decades, there has been an increased empha-
Current ExRx for HTN sis on HIIT in support of various physiological outcomes, in-
The American College of Sports Medicine (ACSM), along with cluding fat loss and improved athletic performance (7,8).
the American Heart Association, the World Health Organiza- Controlled and observational research and field results have
tion, and other prominent groups, universally endorses aerobic shown that HIIT is efficacious across various populations (9).
exercise for the treatment of HTN, with specific details outlined HIIT is often characterized along two primary axes: (i) intensity
in its Exercise and Hypertension Position Stand (4) and in level (e.g., aerobic capacity and percent of age-predicted heart rate)
ACSM’s Guidelines for Exercise Testing and Prescription (5). The and (ii) the work-to-recovery ratio (WRR), or the duration of work
consensus is that ExRx for adults with HTN should comprise performed to recovery allowed between repetitions and sets.
30 to 60 minutes per day and at least 150 minutes per Intensity levels approach, and may even exceed, V·O2max or
week of moderate-intensity aerobic exercise, supplemented age-predicted maximum heart rate (HR max ), and recovery
with moderate-intensity dynamic resistance training 2 to periods are tightly controlled. The intensity and the WRR
TABLE 2: FITT Recommendations for Individuals with HTN

FITT Element Aerobic Exercise Resistance Exercise
Frequency ≥5–7 days/week ≥2–3 days/week
Intensity Moderate (i.e., 40%–59% O2R or Moderate (i.e., 60%–70% 1-RM; may progress to 80% 1-RM; for
HRR; RPE 12–13 on a 6–20 scale) older individuals and novice exercisers, begin with 40%–50% 1-RM)
Time ≥30 minutes/day of continuous or 2–4 sets of 8–12 repetitions for each of the major muscle groups
accumulated exercise per session to total ≥20 minutes per session with rest days
interspersed depending on the muscle groups being exercised
Type Prolonged, rhythmic activities using large muscle Resistance machines, free weights, resistance bands,
groups (e.g., walking, cycling, swimming) and/or functional bodyweight exercise
Source: ACSM’s Guidelines for Exercise Testing and Prescription, 11th edition (2021).
1-RM, one repetition maximum; HRR, heart rate reserve; O2R, oxygen uptake reserve; RPE, rating of perceived exertion.
Volume 25 | Number 5 www.acsm-healthfitness.org 29
HIIT FOR HYPERTENSION
variables are modified depending on the individual goals, each 10% increase in relative V·O2peak corresponds to a
ability, and motivation. decrease in resting blood pressure of 1.5 mm Hg SBP and
0.6 mm Hg DBP, respectively (13). In comparison, commonly
The Case for HIIT prescribed antihypertensive drugs can produce reductions in
There is an emerging body of evidence showing that exercise- SBP and DBP up to 9.1 and 5.5 mm Hg, respectively.
induced reductions in SBP and DBP are dose dependent and re- Therefore, overall blood pressure reductions resulting from
lated to exercise intensity. As a result, HIIT can be viewed as an HIIT have the potential to reduce SBP and DBP up to 11 and
alternative to moderate-intensity continuous training (MICT) 7 mm Hg, respectively, similar to pharmaceuticals, and thus
for addressing HTN (10). In short, MICT is characterized by HIIT embodies the phrase Exercise is Medicine® (14).
longer-duration, lower-intensity exercise (e.g., rhythmic exer- Currently, MICT is considered the gold standard for
cises, such as jogging), whereas HIIT is characterized by short- exercise-based HTN treatment, given the volume of research
duration, high-intensity movements (e.g., sprinting). over the past few decades supporting its positive effects on car-
Research supports the implementation of aerobically based diovascular fitness. However, MICT has some inherent imprac-
HIIT and MICT for inducing similar reductions in SBP and ticalities because of the duration of both individual and
DBP in adults with pre-HTN and/or HTN (11,12). In fact, collective weekly exercise sessions. This considerable time
TABLE 3: Pros, Cons, and Considerations of HIIT for HTN at a Glance

Pros Cons Considerations
• HIIT has been shown to lower blood • Unsupervised or improperly executed • Clearance: Has the individual
pressure in hypertensive individuals HIIT is a riskier form of exercise for received physician clearance to
• HIIT effectively addresses common HTN hypertensive individuals relative to participate in HIIT?
comorbidities, such as diabetes, current guidelines • Fitness level: Does the individual have
overweight, and obesity • For clinicians and health and fitness sufficient baseline fitness to safely
• HIIT may increase participant motivation professionals, initiating HIIT may be a more perform HIIT?
and facilitate a higher level of exercise time-intensive approach to patient • Motivation level: Is the individual
compliance wellness relative to traditional ExRx due motivated to begin the incorporation of
• HIIT allows for virtually unlimited variability in to additional risk factors and considerations HIIT into his/her exercise regimen?
programming when considering the • Tolerance: Is the individual willing and
combinations of modality, work intensity, able to tolerate the unique and high
WRR, recovery activity, recovery intensity, level of discomfort associated with
total session duration, etc. HIIT?
• Modality: What will be most effective for
an individual given his/her goals,
preferences, abilities, and limitations?
TABLE 4: Measures of Exercise Intensity
· ·
Intensity %HRR or %V O2R %HRmax %V O2max RPE scale (6–20) METs (absolute)
Vigorous 60% to 89% 77% to 95% 64% to 90% 14–17 6.0 to 8.7
Near maximal to maximal ≥90% ≥96% ≥91% ≥18 ≥8.8
Source: ACSM’s Guidelines for Exercise Testing and Prescription, 11th edition (2021).
commitment often leads to reductions in program adherence. with a single, brief set of HIIT (e.g., a few minutes of HIIT) to
Alternatively, and promisingly, the shorter duration sessions, evaluate the client’s readiness and receptivity to the approach.
coupled with the inherent exercise variety found in HIIT proto- A safe and effective progression would build to a single HIIT ses-
cols, may facilitate higher compliance rates and corresponding re- sion per week (e.g., multiple sets of HIIT comprising 20 to
sults (15). Furthermore, HIIT also has been shown to address 40 minutes of activity) and remain at this level of frequency
common comorbidities (e.g., diabetes, dyslipidemia, overweight, while initial neuromuscular and other physiological adaptations
and obesity) seen in hypertensive individuals (8,15,16). occur. Over time, clients may progress to multiple HIIT sessions
per week, allowing for at least one day of rest between sessions.
Safety and Risk Profile
Safety is essential when considering exercise for any population
and even more so when implemented for individuals with
known CVD. Although at first glance HIIT may appear to be
HIIT for any client must be introduced
problematic for those with CVD or other HTN-related condi- gradually — and deliberately — over time. The
tions, mounting evidence indicates that individuals in various introduction of HIIT should start with a single,
states of CVD respond well to HIIT (8,10–17). Furthermore,
research shows that the rate of serious adverse events during
brief set of HIIT (e.g., a few minutes of HIIT) to
HIIT (e.g., cardiac arrest) is not statistically different from evaluate the client’s readiness and receptivity
traditional MICT exercise programs (18). to the approach.
HIIT Programming Variables
The FITT framework, a model with which most health and fit-
ness professionals have experience, can be used to develop Intensity
HIIT-centric ExRx. Intensity within the context of HIIT comprises two elements:
physical exertion (also referred to as “work”) and the WRR.
Frequency Physical exertion can be measured in many ways: heart rate re-
HIIT for any client must be introduced gradually — and serve, HRmax, V·O2max, V·O2 reserve, rate of perceived exertion,
deliberately — over time. The introduction of HIIT should start and metabolic equivalents (METs) (5). It is important to note,
TABLE 5: Recommendations for Hypertensive Individuals

Absolute contraindication • Exercise of any type is an absolute contraindication for an individual experiencing a hypertensive crisis.
Client goals and attributes • Evaluate HIIT in the context of an individual’s goals and desired health outcomes
• Identify and discuss any physical limitations that may interfere with HIIT (including past or
current injuries)
• Discuss the unique elements of HIIT concerning motivation and levels of discomfort/pain;
transparency on these elements of HIIT will position individuals to make informed decisions
and better calibrate training expectations
Modality • Identify and discuss modality options
• Consider alternating modalities day to day and week to week to avoid concurrent high-impact
sessions, especially for older adults
Acclimation and progression • Start an individual on an MICT or modified HIIT protocol to establish baseline fitness
• Modified HIIT could involve a more generous WRR (e.g., 1:5) or a lower-intensity level during
work intervals (e.g., 75% HRmax instead of 90% HRmax)
• Progress gradually to higher intensities (increase work and/or reduce recovery)
• Progress gradually from 1 session per week to a maximum of 3 sessions per week
TABLE 6: HIIT Programming Examples
Programa Common Modalities Sets Protocol Frequency Timeb
Example A • Cycle ergometer 4 sets 4 4 minutes (1:1 WRR)c 1–3 sessions per week 28 minutes
• Treadmill
• Rowing machine
Example B • Cycle ergometer 10 sets 1 1 minute (1:1 WRR)c 1–3 sessions per week 19 minutes
• Treadmill
• Rowing machine
Example C • Cycle ergometer 8 sets 30 60 seconds (1:2 WRR)c 1–3 sessions per week 11 minutes
• Treadmill
• Rowing machine
a
All programs assume that clients are physically able to participate in high-intensity exercise and have developed a base level of fitness to engage in these types
of protocols.
b
Literal time elapsed (sets work duration recovery period); actual session time will be longer than the time shown when including training sessions elements
such as warm-up, transition time between sets, switching modalities (if applicable), and cooldown.
c
Recovery may range from no activity (complete rest) to moderate activity.
however, that HIIT research varies in the definition of “high The key variables, number of sets, minutes of work, and re-
intensity” with respect to both the primary measure (e.g., covery periods, can be modified to create any number of combi-
V·O2max) and range of values (e.g., range of % of maximum). nations of HIIT sessions to meet individual client objectives.
What is used is a blend of the ACSM-defined categories Initially, it is recommended to implement these protocols at
“vigorous” and “near maximal to maximal” (e.g., 70% to 95%
of V·O2max) (5).
WRR consists of several methodologies, usually consisting of
a ratio (e.g., 1 minute of work to 3 minutes of recovery = 1:3
WRR) or a focus on the absolute time between repetitions or
sets without regard to the time spent working (e.g., 30 seconds
of recovery between sprints). Either approach is within the gen-
erally accepted concept of HIIT. The critical element is to vary
the amount of recovery: (i) intensity of the work (i.e., maximal ef-
fort requires more recovery time than vigorous effort), (ii) ability
and training status of the individual, and (iii) limiting the poten-
tial of injury. Recovery during HIIT can be the main modifiable
variable for generating increases in workout intensity, even in
the absence of changes to exercise effort. For example, doing sets
of (1 minute on/1 minute rest) can be modified to (1 minute on/
30 seconds rest), where the “on” remains at the same intensity,
but the shorter recovery makes the effort more challenging. It
is also important to note that recovery in this context does not
necessarily mean an individual is inactive; recovery also may en-
compass light or moderate activity. Consequently, the concept
of recovery is best defined as the period over which an individual
develops readiness to perform the next repetition or set with
maximal effort.
In research and practice, some of the most common WRR
protocols include the following:
• 4 sets 4 minutes of work 3 minutes of recovery (4:3

WRR) (11,18,19,20)
• 4 sets 4 minutes of work 4 minutes of recovery (1:1
WRR) (12,20)
• 10 sets 1 minute of work 1 minute of recovery (1:1
WRR) (11,16,18,19,20)
TABLE 7: Key Considerations for Health and Fitness variety this affords a health and fitness professional in developing
Professionals client workouts, it also yields a level of variety that may supercharge
• Properly address the need for medical clearance (as-if a client’s level of motivation, exercise program compliance, and —
necessary) most importantly — results (e.g., lower SBP and lower DBP).
• Review and understand the implications of all medications

CONCLUSION
• Evaluate suitability (physical and psychological) Although moderate-intensity aerobic exercise is a long-established
• Appreciate that MICT and HIIT are not mutually exclusive therapeutic modality for HTN, a growing body of evidence sug-
• Identify the appropriate modality gests that HIIT is an alternative exercise protocol yielding similar
clinical benefits. For the health and fitness professional, using HIIT
• Start slowly and monitor performance with the hypertensive population is a safe and effective means of
• Make progressions deliberately and slowly exercise that many clients may find as an engaging addition to
their exercise routines.
lower intensities or at a more generous WRR to allow clients ap-

propriate acclimation to HIIT. 1. Virani SS, Alonso A, Benjamin EJ, et al. Heart disease and stroke statistics-2020
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Curr Hypertens Rep. 2015;17(11):1–10.
significant fatigue and delayed onset muscle soreness (DOMS).
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p. 137–68.
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ment, etc. Common modalities for HIIT include the cycle patients: a systematic review and meta-analysis. Curr Hypertens Rep. 2020;22
ergometer and treadmill, but the possibilities are numerous. (3):1–13.
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moderate-intensity continuous training on blood pressure in adults with pre- to established
ilar exercises are used in HIIT programs, and as long as the in- hypertension: a systematic review and meta-analysis of randomized trials. Sports
tensity stays high, physiological adaptations will occur. Med. 2018;48(9):2127–42.
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irrespective of its intensity improves markers of blood fluidity in hypertensive patients.
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Examples of HIIT Session Programs
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Table 6 provides three examples of HIIT sessions. Each of these high-intensity interval training on cardiometabolic health: a systematic
examples highlight the WRR and combined work and recovery review and meta-analysis of intervention studies. Br J Sports Med. 2017;51(6):
494–503.
periods relative to total sets performed. Although we have pre-
16. Jelleyman C, Yates T, O’Donovan G, et al. The effects of high-intensity interval
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combinations possible across these elements. In addition to the 2015;16(11):942–61.
17. Wewege M, Van Den Berg R, Ward R, Keech A. The effects of high-intensity
interval training vs. moderate-intensity continuous training on body composition in
Gage Wright, M.S., is a graduate of the
overweight and obese adults: a systematic review and meta-analysis. Obes Rev. Master of Science in Applied Exercise
2017;18(6):635–46. and Health Science program at Kennesaw
18. Wewege MA, Ahn D, Yu J, Liou K, Keech A. High-intensity interval training for patients State University. He currently serves as a
with cardiovascular disease—is it safe? A systematic review. J Am Heart Assoc.
Commissioned Officer in the United States
2018;7(21):e009305.
Navy. Beyond his military service, his pro-
19. Boutcher Y, Boutcher S. Exercise intensity and hypertension: what’s new? J Hum
Hypertens. 2017;31(3):157–64. fessional interests include tactical strength
20. Ito S. High-intensity interval training for health benefits and care of cardiac and conditioning for active-duty military
diseases—the key to an efficient exercise protocol. World J Cardiol. 2019;11(7):
171–88.
personnel and health and wellness for
adolescents.
Disclosure: The authors declare no conflict of interest and do Yuri Feito, Ph.D., MPH, FACSM, ACSM-
not have any financial disclosures. CEP, is the education and professional devel-
opment strategist for the American College of
Brent Uken, M.S., earned his Master of Sports Medicine where he is responsible for
Science degree with honors in Applied Ex- the educational portfolio of the College. Be-
ercise and Health Science from Kennesaw fore this role, he spent 11 years as a faculty
State University. Mr. Uken’s research in- member and researcher at Kennesaw State
terests include special populations, nutri- University (Kennesaw, GA) and Barry
tional strategies, high-intensity exercise, University (Miami, FL), achieving the rank of full professor.
and heart rate variability. Mr. Uken is He has been involved in the medical fitness industry for more than
the founder and CEO of two health and 20 years working with a variety athletes and clinical populations.
fitness entities, Vitalyon LLC and its not-for-profit counterpart, He is a fellow of the American College of Sports Medicine and is
The Vitalyon Foundation. certified as a clinical exercise physiologist.
Matthew Lee, M.S., ACSM-EP, is an

aspiring medical student with a Master BRIDGING THE GAP
of Science degree in Applied Exercise Phys- HTN is a significant risk factor for CVD and is a leading
iology and two Bachelor of Science degrees cause of disability and death globally. In the United States
in Biochemistry and Exercise Science. alone, the prevalence of HTN among adults is estimated to
Currently, he is involved in biochemical re- be 116 million, divided nearly equally between men and
search concerning supplementation and women. HTN develops gradually over several years and is
cartilage regeneration while managing his generally the product of lifestyle choices concerning diet
personal training company, Lifestyle Health and exercise. Fortunately, improvements in these same
and Wellness, LLC. two areas can be used to mitigate, and potentially reverse,
HTN. The current ExRx for HTN is continuous, aerobic,
moderate-intensity exercise. However, a growing body of
evidence highlights the effectiveness of HIIT for this
population. In addition to its blood pressure-lowering
effect, HIIT offers individuals unique programming
flexibility and variety that many find invigorating and
challenging, therefore leading to increased exercise
compliance, usually resulting in improved blood pressure.

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High-Intensity Interval Training

Program Design and Application

28 ACSM’s Health & Fitness Journal ® September/October 2021

Normal <120 and <80

Elevated 120–129 and <80

TABLE 2: FITT Recommendations for Individuals with HTN

Volume 25 | Number 5 www.acsm-healthfitness.org 29

TABLE 3: Pros, Cons, and Considerations of HIIT for HTN at a Glance

30 ACSM’s Health & Fitness Journal ® September/October 2021

TABLE 5: Recommendations for Hypertensive Individuals

• 4 sets 4 minutes of work 3 minutes of recovery (4:3

• Review and understand the implications of all medications

lower intensities or at a more generous WRR to allow clients ap-

Volume 25 | Number 5 www.acsm-healthfitness.org 33

Matthew Lee, M.S., ACSM-EP, is an

34 ACSM’s Health & Fitness Journal ® September/October 2021

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