The joint association of physical activity, blood-pressure control, and pharmacologic treatment of hypertension for all-cause mortality risk

Commonalities and differences in carotid body dysfunction in hypertension and heart failure

Carotid body pathophysiology is associated with many cardiovascular-respiratory-metabolic diseases. This pathophysiology reflects both hyper-sensitivity and hyper-tonicity. From both animal models and human patients, evidence indicates that amelioration of this pathophysiological signalling improves disease states such as a lowering of blood pressure in hypertension, a reduction of breathing disturbances with improved cardiac function in heart failure (HF) and a re-balancing of autonomic activity with lowered sympathetic discharge. Given this, we have reviewed the mechanisms of carotid body hyper-sensitivity and hyper-tonicity across disease models asking whether there is uniqueness related to specific disease states. Our analysis indicates some commonalities and some potential differences, although not all mechanisms have been fully explored across all disease models. One potential commonality is that of hypoperfusion of the carotid body across hypertension and HF, where the excessive sympathetic drive may reduce blood flow in both models and, in addition, lowered cardiac output in HF may potentiate the hypoperfusion state of the carotid body. Other mechanisms are explored that focus on neurotransmitter and signalling pathways intrinsic to the carotid body (e.g. ATP, carbon monoxide) as well as extrinsic molecules carried in the blood (e.g. leptin); there are also transcription factors found in the carotid body endothelium that modulate its activity (Krüppel-like factor 2). The evidence to date fully supports that a better understanding of the mechanisms of carotid body pathophysiology is a fruitful strategy for informing potential new treatment strategies for many cardiovascular, respiratory and metabolic diseases, and this is highly relevant clinically.

Can the association between hypertension and physical activity be moderated by age?

Objectives

Physical inactivity, hypertension and non-communicable diseases are major public concerns across the globe. To our knowledge, there is a lack of research that has investigated the moderating effect of age on the relationship between hypertension and physical activity in developing countries. This study had two objectives: (1) investigating hypertension and sociodemographic factors associated with physical activity and (2) investigating whether age moderates the relationship between hypertension and physical activity.

Methods

Nationally representative data of Malaysia were used to generate cross-sectional evidence. The sample size was 2156 respondents. An ordered probit regression was utilized to assess factors associated with the practice of physical activity.

Results

Respondents aged 40-49 years with hypertension were 7.3% less likely to participate in high-level physical activity when compared to those without hypertension. The probability of having a low level of physical activity was 12.3% higher among hypertensive patients aged ≥60. Males, married individuals, less-educated adults, low-income earners, and individuals who were aware of their BMI, had a higher tendency to indulge in a highly active lifestyle than others.

Conclusion

The effect of hypertension on physical activity was moderated by age. Factors influencing physical activity levels among adults were income, gender, marital status, education, employment status, and BMI awareness.

Antihypertensive treatment effect on exercise blood pressure and exercise capacity in older adults

BACKGROUND

An exaggerated blood pressure (BP) response to exercise and low exercise capacity are risk factors for cardiovascular disease (CVD). The effect of pharmacological antihypertensive treatment on exercise BP in older adults is largely unknown. This study investigates these effects accounting for differences in exercise capacity.

METHODS

Participants enrolled in the Southall and Brent Revisited (SABRE) study undertook a 6-min stepper test with expired gas analysis and BP measured throughout exercise. Participants were stratified by antihypertensive treatment status and resting BP control. Exercise systolic and diastolic BP (exSBP and exDBP) were compared between groups using potential outcome means [95% confidence intervals (CIs)] adjusted for exercise capacity. Exercise capacity was also compared by group.

RESULTS

In total, 659 participants were included (mean age ± SD: 73 ± 6.6 years, 57% male). 31% of normotensive and 23% of hypertensive older adults with controlled resting BP had an exaggerated exercise BP. ExSBP was similar between normotensive and treated/controlled individuals [mean (95%CI): 180 (176 184) mmHg vs. 177 (173 181) mmHg, respectively] but was higher in treated/uncontrolled and untreated/uncontrolled individuals [mean (95% CI): 194 (190 197) mmHg, P  < 0.001 and 199 (194 204) mmHg, P  < 0.001, respectively]; these differences persisted after adjustment for exercise capacity and other confounders. Exercise capacity was lower in treated vs. normotensive individuals [mean (95% CI) normotensive: 16.7 (16.0,17.4) ml/kg/min]; treated/controlled: 15.5 (14.8,16.1) ml/kg/min, P  = 0.009; treated/uncontrolled: [15.1 (14.5,15.7) ml/kg per min, P  = 0.001] but was not reduced in untreated/uncontrolled individuals [mean (95% CI): 17.0 (16.1,17.8) ml/kg per min, P  = 0.621].

CONCLUSION

Irrespective of resting BP control and despite performing less exercise, antihypertensive treatment does not fully mitigate an exaggerated BP response to exercise suggesting residual CVD risk in older adults.

Impact of the Health Gym Program on mortality from Systemic Arterial Hypertension in Pernambuco state, Brazil

The aim of this paper was to analyze the impact of the Health Gym Program (HGP) on the Systemic Arterial Hypertension mortality rate in Pernambuco state, Brazil. This public policy impact analysis used a quasi-experimental approach which consisted of the application of Propensity Score Matching in the years 2010 and 2017. Socioeconomic, demographic, and epidemiological data of 89 municipalities that implemented HGP (treated) and 54 that did not (controls) were collected from the Brazilian Health Data Department, Brazilian Institute of Geography and Statistics, and other databases. The impact of HGP on hypertension mortality rate was estimated through a logit model using the Kernel algorithm. Treated municipalities presented a decrease of 12.8% in global hypertension mortality rate, 12.5% in brown-skinned people and 13.1% in those over 80 years of age. The balancing test attests to the robustness of the estimated model to explain the impact of the program on mortality due to hypertension. The implementation of the program proved to be effective in decreasing the mortality rate in the treated municipalities, indicating that it seems to contribute to controlling the progress of chronic non-communicable diseases.

Do the combined blood pressure effects of exercise and antihypertensive medications add up to the sum of their parts? A systematic meta-review

Objective

To compare the blood pressure (BP) effects of exercise alone (EXalone), medication alone (MEDSalone) and combined (EX+MEDScombined) among adults with hypertension.

Data sources

PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus and the Cochrane Library.

Eligibility criteria

Randomised controlled trails (RCTs) or meta-analyses (MAs) of controlled trials that: (1) involved healthy adults>18 year with hypertension; (2) investigated exercise and BP; (3) reported preintervention and postintervention BP and (4) were published in English. RCTs had an EX+MEDScombined arm; and an EXalone arm and/or an MEDSalone arm; and MAs performed moderator analyses.

Design

A systematic network MA and meta-review with the evidence graded using the Physical Activity Guidelines for Americans Advisory Committee system.

Outcome

The BP response for EXalone, MEDSalone and EX+MEDScombined and compared with each other.

Results

Twelve RCTs qualified with 342 subjects (60% women) who were mostly physically inactive, middle-aged to older adults. There were 13 qualifying MAs with 28 468 participants (~50% women) who were mostly Caucasian or Asian. Most RCTs were aerobic (83.3%), while the MAs involved traditional (46%) and alternative (54%) exercise types. Strong evidence demonstrates EXalone, MEDSalone and EX+MEDScombined reduce BP and EX+MEDScombined elicit BP reductions less than the sum of their parts. Strong evidence indicates EX+MEDScombined potentiate the BP effects of MEDSalone. Although the evidence is stronger for alternative than traditional types of exercise, EXaloneelicits greater BP reductions than MEDSalone.

Conclusions

The combined BP effects of exercise and medications are not additive or synergistic, but when combined they bolster the antihypertensive effects of MEDSalone.

PROSPERO registration number

The protocol is registered at PROSPERO CRD42020181754.

Short-Term Effect of Self-Selected Training Intensity on Ambulatory Blood Pressure in Hypertensive Older Women: A Randomized Controlled Trial

PURPOSE

To investigate the short-term effect of self-selected training intensity (SSTI) on ambulatory blood pressure (BP) in hypertensive older women.

PARTICIPANTS AND METHODS

This is a randomized, single-blind, two-arm, parallel-group controlled trial that included 40 medicated hypertensive older women (64.4±3.6 years; resting systolic 118±19 and diastolic BP 68±9 mmHg). SSTI intervention was performed three times per week, 30-50 minutes per session (n=20). The control group participated in health education meetings once per week (n=20). Ambulatory BP (primary outcome) and six-minute walking test performance (secondary outcome) were assessed at baseline and following 8 weeks of intervention. Heart rate (HR), rating of perceived exertion (RPE, 6-20), and affective valence (ie, feeling scale, -5/+5) were recorded during all SSTI sessions. Intention-to-treat and per-protocol analyses were used for data analyses.

RESULTS

Fifteen participants from the SSTI group and 17 from the control group completed the study. No differences in ambulatory BP (24-h, awake, and asleep) were observed between SSTI and control groups (intention-to-treat and per-protocol analyses; p>0.05). The SSTI group showed a greater six-minute walking test performance than the control group in the intention-to-treat and per-protocol analyses (p<0.05). The participants exercised at 52±10% of HR reserve reported an RPE of 11±1 and an affective valence of 3.4±1.1 over the 8-week period.

CONCLUSION

SSTI is a feasible approach to induce a more active lifestyle and increase health-related fitness in hypertensive older women, although it does not improve BP control over a short-term period.

Exercise and Hypertension

Hypertension is a fatal yet preventable risk factor for cardiovascular disease and is responsible for majority of cardiovascular mortality. Hypertension is closely associated with inactive lifestyle. Physical activity and/or exercise are shown to delay development of hypertension. Both aerobic and resistance exercise have been proven to reduce blood pressure (BP) effectively. Since brisk walking is an easy, inexpensive, simple, and effective way of exercise, this type of an aerobic workout can be recommended to society. All professional organizations and government bodies recommend moderate-intensity aerobic exercise for at least 30 min on at least 3 days of the week or resistance exercise on 2-3 days of the week. Exercise sessions can either be continuous for 30 min or be composed of at least 10 min of short exercise duration to a daily total of 30 min. After an exercise session, BP decreases, and this decline continues for up to 24 h; which is called post-exercise hypotension. Overall 5 mmHg decrease in BP with regular exercise may be ensured. With a decrease of 5 mmHg in systolic BP, mortality due to coronary heart disease decreases by 9%, mortality due to stroke decreases by 14% and all-cause mortality decreases by 7%. Regular exercise should therefore be recommended for all individuals including normotensives, prehypertensives, and hypertensives.

Acute antihypertensive effect of self-selected exercise intensity in older women with hypertension: a crossover trial

Purpose

Acute reduction in blood pressure (BP) following an exercise session is evidenced in controlled settings with formal supervision in hypertensive older populations. This study investigated the effect of a self-selected exercise (SSE)-intensity session on ambulatory BP in hypertensive older women in a “real-world” setting.

Methods

Twenty inactive older women with hypertension (64.9±4.5 years) were included in this randomized, controlled, crossover trial. After baseline assessments, participants performed 30 minutes of an SSE-intensity session on an outdoor track and a control session, separated by 7-10 days. Heart rate (HR), rating of perceived exertion (RPE), and affective response were assessed. Ambulatory BP was monitored for 20 hours following both sessions. Paired t-tests and generalized estimation were used for data analysis.

Results

Participants exercised at 5.1±1.1 km/h, spent ~90% of the exercise time at moderate–vigorous intensity (≥40% of heart rate reserve). SSE-intensity session was reported as light (RPE 11.0±1.5) and pleasant (affect 3.4±1.2). SSE-intensity session elicited reductions in systolic BP in the first 6 hours postexercise (6.0 mmHg, CI 2.7–9.3 mmHg; P<0.001). Average systolic BP in the 20-hour (−3.4 mmHg, CI −5.9 to −0.9 mmHg; P=0.010) and awake (−4.0 mmHg, CI −6.4 to −1.6 mmHg; P=0.003) periods were lower following SSE-intensity session compared to control session. No differences were observed in average systolic BP during asleep period and diastolic BP during the 20-hour awake and asleep periods between the SSE-intensity session and control session (P>0.05).

Conclusion

An SSE-intensity session elicited a reduction in ambulatory systolic BP in inactive older women with hypertension during awake and 20-hour periods. Also, the SSE-intensity session was reported as light and pleasant.

Long term outcomes of cluster randomized trial to improve cardiovascular health at population level: The Cardiovascular Health Awareness Program (CHAP)

Study question

The Cardiovascular Health Awareness Program (CHAP) cardiovascular risk reduction program consisted of sessions run by local volunteers in local pharmacies during which cardiovascular risk was assessed, healthy lifestyle and preventive care was promoted, and the participants were oriented to local resources to support changes in modifiable risk factors. A clustered randomized trial implemented in September 2006 across 39 communities targeting community-dwelling individuals 65 years and older showed a significant reduction in hospitalization one year after its implementation (rate ratio of 91 [95% confidence interval (CI): 86%-97%]). This study explores the impact of CHAP in the first five years.

Methods

Using health administrative data housed at the Institute for Clinical Evaluative Sciences, we established a closed cohort consisting of all individuals eligible in these communities at the study onset whom we followed over time. We assessed hospitalizations and survival using a negative binomial model for count data and Cox regression to assess time to first event, accounting for the clustered design. The primary outcome was the rate of cardiovascular-related hospitalizations defined as congestive heart failure, stroke or acute myocardial infarction.

Results

Most estimates pointed to an advantage for the intervention arm, but only all-cause mortality reached statistical significance (hazard ratio [95% CI] = 0.955 [0.914–0.999]). The hospitalization cardiovascular-related hospitalization rate ratio was (0.958, 95% CI: 0.898–1.022) in favour of the intervention communities, translating to an estimated 408 averted hospitalizations over the five-year period. There was no evidence of the effect of time from start of intervention.

Conclusions

The consistent direction of the outcomes in favour of the intervention arms suggests that CHAP likely had a meaningful impact on reducing cardiovascular-related morbidity and mortality. Given the low cost of the intervention, further development of CHAP should be pursued.

Association between Physical Exercise and Biomarkers of Oxidative Stress among Middle-Aged and Elderly Community Residents with Essential Hypertension in China

This study aimed to investigate the role of different types and frequencies of physical exercise in biomarkers of oxidative stress among middle-aged and elderly community residents with essential hypertension in China. A community-based cross-sectional survey was undertaken in 7 subdistricts. Individuals, 45-79 years old, with essential hypertension (n = 402) and without cardiovascular disease (n = 1047) were included. Superoxide dismutase (SOD) activities and plasma levels of malondialdehyde (MDA) and 4-hydroxynonenal (4-HNE) were determined. Multilevel linear regression was used to estimate the associations between various types of physical exercise and oxidative stress biomarker levels. Participants engaged in high frequency walking/square dancing or taiji/yoga demonstrated decreased systolic blood pressure in both groups; however, diastolic blood pressure decreased only among individuals with hypertension participating in walking/square dancing. In individuals with hypertension, MDA levels decreased in those participating in walking/square dancing, SOD activity increased in those participating in walking/square dancing, and 4-HNE levels decreased in those involved in taiji/yoga. In individuals without cardiovascular disease, MDA levels decreased in those involved in walking/square dancing or taiji/yoga, SOD activity increased in those performing walking/square dancing, and 4-HNE levels decreased in those involved in taiji/yoga. Oxidative stress marker levels also improved in those involved in walking/square dancing or taiji/yoga groups as the exercise frequency increased. Thus, frequent participation in walking/square dancing or taiji/yoga effectively decreases hypertension-related oxidative stress biomarker levels.

Blood pressure control status and associated factors among adult hypertensive patients on outpatient follow-up at University of Gondar Referral Hospital, northwest Ethiopia: a retrospective follow-up study

Background

Large segments of the hypertensive population in the world are either untreated or inadequately treated. The incidence of heart failure and mortality from cardiovascular complications of hypertension is high among patients with uncontrolled blood pressure (BP). But BP control status of hypertensive patients has not been investigated in the study area. The study aimed to assess BP control status and determinant factors among adult hypertensive patients on antihypertensive medication attending outpatient follow-up at University of Gondar Referral Hospital, northwest Ethiopia.

Methods

An institution-based retrospective follow-up study was conducted from September 2015 to April 2016. Data were collected using a structured and pretested questionnaire adopted from the World Health Organization STEPwise approach. BP records of 6 months were used, and patients were classified as having controlled BP if their BP readings were <140/90 mmHg for all adults ≥18 years of age and <150/90 mmHg for adults aged ≥60 years. A generalized estimating equation was fitted, and the odds ratio with a 95% confidence level was used to determine the effect of covariates on BP control status.

Results

Among 395 participants, 50.4% (95% CI: 45–55) of them controlled their BP in the last 6 months of the survey. Physical activity (adjusted odds ratio [AOR]=1.95, 95% CI: 1.41–2.68), duration on antihypertensive drugs of 2–4 years (AOR=1.70, 95% CI: 1.13–2.56) and 5 years or more (AOR=1.96, 95% CI: 1.32–2.92), and high adherence (AOR=2.18, 95% CI: 1.14–4.15) to antihypertensive drugs were positively associated with BP control, while salt intake (AOR=0.67, 95% CI: 0.49–0.93), overweight (AOR=0.50, 95% CI: 0.36–0.68), and obesity (AOR=0.56, 95% CI: 0.36–0.87) were inversely associated with BP control.

Conclusion

In this study, only half of the hypertensive patients controlled their BP. Thus, health care providers need to be made aware about the importance of counseling hypertensive patients on drug adherence, moderate physical activity, and salt restriction to improve BP control.

Aquatic Training in Upright Position as an Alternative to Improve Blood Pressure in Adults and Elderly: A Systematic Review and Meta-Analysis

BACKGROUND

Meta-analyses have shown that land training (LT) reduces blood pressure; however, it is not known whether aquatic training (AT) promotes this same effect.

OBJECTIVE

The aim was to conduct a meta-analysis on the effects of AT on systolic blood pressure (SBP) and diastolic blood pressure (DBP) in adults and elderly and compare them to those of LT and no training [control group (CG)].

DATA SOURCES

Embase, PubMed, Cochrane and Scopus were searched up to May 2017.

STUDY ELIGIBILITY CRITERIA

Studies that evaluated the effect of upright AT (i.e., AT performed in upright position) on the blood pressure of adult individuals and the elderly who did not present with cardiovascular disease (other than hypertension) were included.

DATA ANALYSIS

Two independent reviewers screened search results, performed data extraction and assessed risk of bias. Random effect was used, and the effect size (ES) was calculated by using the standardized mean difference with a 95% confidence interval.

RESULTS

AT promoted a reduction in SBP (ES - 1.47; 95% CI - 2.23 to - 0.70; p < 0.01) compared to CG. This effect is maintained with training progression (ES - 1.52; 95% CI - 2.70 to - 0.33; p = 0.01) and no progression (ES - 1.43; 95% CI - 2.64 to - 0.23; p = 0.02). These effects were significant only in hypertensive (ES - 2.20; 95% CI - 2.72 to - 1.68; p < 0.01), and not in pre-hypertensive individuals. AT promoted a decrease in DBP (- 0.92; 95% CI - 1.27 to - 0.57; p < 0.01) after training with progression (- 0.81; 95% CI - 1.62 to - 0.001; p = 0.04) and no progression (- 1.01; 95% CI - 1.40 to - 0.62; p < 0.01) in pre-hypertensive (- 1.12; 95% CI - 1.53 to - 0.70; p < 0.01) and hypertensive patients (- 0.69; 95% CI - 1.31 to - 0.06; p = 0.03). AT promoted similar reductions in SBP compared to LT; however, reduction of DBP in hypertensive patients was lower (1.82; 95% CI 0.84 to 2.79; p < 0.01).

CONCLUSION

AT promotes blood pressure reduction in adults and elderly. The reduction in SBP in those performing AT is similar to those performing LT, but reduction of DBP is lower in the AT group compared to that in the LT group.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42016049716.

Objectively Measured Physical Activity and Healthcare Expenditures Related to Arterial Hypertension and Diabetes Mellitus in Older Adults: SABE Study

Research using questionnaires has shown that physical activity level (PAL) is associated with healthcare costs. The purpose of this study was to examine the association between objectively measured PAL and healthcare costs among hypertensive and diabetic noninstitutionalized Brazilian older people. The method consisted of a cross-sectional study forming part of the SABE Study, composed of 377 older people interviewed in 2010. Expenditures were estimated taking into account self-reported medicine prescription, outpatient service, and hospitalizations, with the highest quartile of expenditures considered as a risk category. PAL was estimated using an Actigraph accelerometer. Associations were expressed as odds ratios and 95% confidence intervals, adjusted for covariates. Overall expenditures were higher in the sedentary group. The insufficiently active group presented greater odds for higher total, outpatient, and hospitalization expenditure. It was concluded that healthcare expenditures were lower in more active hypertensive and diabetic older people. The promotion of physical activity could be relevant in the attenuation of the burden of chronic diseases in economic losses.

Correlates of physical activity counseling by health providers to patients with diabetes and hypertension attended by the Family Health Strategy in the state of Pernambuco, Brazil

AIMS

The aim of this study was to determine correlates of physical activity (PA) counseling by health providers of the Brazilian primary care delivery system, for hypertensive and diabetic subjects, as well as correlates of actual leisure-time PA of these subjects.

METHODS

This was a cross-sectional study conducted in random samples of 785 hypertensive and 822 diabetic subjects, in the State of Pernambuco, Brazil. Relationships between PA counseling and leisure-time PA and explanatory variables were sought through multiple logistic regressions.

RESULTS

PA counseling had been received by 59.4% of the diabetic and 53.0% of the hypertensive subjects; around 30% of the diabetic and the hypertensive subjects declared having leisure-time PA. After adjustment, factors associated with PA counseling for diabetic subjects were: female gender, formal schooling, hypertension, obesity; for hypertensive subjects: being on a weight-loss diet, age between 60 and 74 and over 75. For both subject groups, leisure-time PA was more frequent when they lived in a medium-sized municipality, were female, aged between 60 and 75, and on a weight-loss diet.

CONCLUSION

PA counseling appeared restricted to subjects with excess weight and/or cardiovascular risk factors when it should be directed to all subjects with hypertension or diabetes.

Expenditures of medicine use in hypertensive/diabetic elderly and physical activity and engagement in walking: cross secctional analysis of SABE Survey

BACKGROUND

The literature shows the inverse association between physical activity level (PAL) and chronic diseases that have a significant burden over health care costs. However, in upper-middle income countries and in elderly population this information are scarce.

OBJECTIVE

To describe the annual drug expenditures for the hypertensive and diabetic elderly population in Brazil and to analyze the association with PAL and engagement in walking.

METHODS

This cross sectional study is part of SABE Survey and comprised 806 hypertensive and/or diabetic elderly (≥60 years old). The annual expenditures of medicine use was estimated for all medications for hypertension and/or diabetes they were taking. The PAL was considered insufficient when moderate physical activity was <150 min/week or vigorous physical activity was < 75 min/week. Engagement in walking was considered by at least 1 day a week. All expenditures were presented through the descriptive values (in American Dollars US$) according PAL and engagement in walking. The association analysis between annual expenditures, PAL and engagement in walking were performed by multiple logistic regression models adjusted for gender, age and body mass index.

RESULTS

The average annual cost was higher in diabetic and insufficient physically activity elderly. The 1-year estimated.cost was US$ 73386,09 and 295% higher in insufficiently physically active. Older people who reported not walking had a higher risk to higher annual expenditures of medicine use (OR = 1.57, 95% CI 1.03-2.40).

CONCLUSIONS

The annual expenditures of medicine use for controlling hypertension and diabetes of Brazilian elderly were higher and inversely associated with physical activity level and engagement in walking.

Deep-targeted exon sequencing reveals renal polymorphisms associate with postexercise hypotension among African Americans

We found variants from the Angiotensinogen-Converting Enzyme (ACE), Angiotensin Type 1 Receptor (AGTR1), Aldosterone Synthase (CYP11B2), and Adducin (ADD1) genes exhibited intensity-dependent associations with the ambulatory blood pressure (BP) response following acute exercise, or postexercise hypotension (PEH). In a validation cohort, we sequenced exons from these genes for their associations with PEH Obese (30.9 ± 3.6 kg m-2) adults (n = 23; 61% African Americans [AF], 39% Caucasian) 42.0 ± 9.8 years with hypertension (139.8 ± 10.4/84.6 ± 6.2 mmHg) completed three random experiments: bouts of vigorous and moderate intensity cycling and control. Subjects wore an ambulatory BP monitor for 19 h. We performed deep-targeted exon sequencing using the Illumina TruSeq Custom Amplicon kit. Variant genotypes were coded as number of minor alleles (#MA) and selected for further statistical analysis based upon Bonferonni or Benjamini-Yekutieli multiple testing corrected p-values under time adjusted linear models for 19 hourly BP measurements per subject. After vigorous intensity over 19 h among ACE, AGTR1, CYP11B2, and ADD1 variants passing multiple testing thresholds, as the #MA increased, systolic (SBP) and/or diastolic BP decreased 12 mmHg (P = 4.5E-05) to 30 mmHg (P = 6.4E-04) among AF only. In contrast, after moderate intensity over 19 h among ACE and CYP11B2 variants passing multiple testing thresholds, as the #MA increased, SBP increased 21 mmHg (P = 8.0E-04) to 22 mmHg (P = 8.2E-04) among AF only. In this replication study, ACE, AGTR1, CYP11B2, and ADD1 variants exhibited associations with PEH after vigorous, but not moderate intensity exercise among AF only. Renal variants should be explored further with a multi-level "omics" approach for associations with PEH among a large, ethnically diverse sample of adults with hypertension.

Exercise for Hypertension: A Prescription Update Integrating Existing Recommendations with Emerging Research

Hypertension is the most common, costly, and preventable cardiovascular disease risk factor. Numerous professional organizations and committees recommend exercise as initial lifestyle therapy to prevent, treat, and control hypertension. Yet, these recommendations differ in the components of the Frequency, Intensity, Time, and Type (FITT) principle of exercise prescription (Ex Rx); the evidence upon which they are based is only of fair methodological quality; and the individual studies upon which they are based generally do not include people with hypertension, which are some of the limitations in this literature. The purposes of this review are to (1) overview the professional exercise recommendations for hypertension in terms of the FITT principle of Ex Rx; (2) discuss new and emerging research related to Ex Rx for hypertension; and (3) present an updated FITT Ex Rx for adults with hypertension that integrates the existing recommendations with this new and emerging research.

Efficacy of a Community-Based Physical Activity Program KM2H2 for Stroke and Heart Attack Prevention among Senior Hypertensive Patients: A Cluster Randomized Controlled Phase-II Trial

Objective

To evaluate the efficacy of the program Keep Moving toward Healthy Heart and Healthy Brain (KM2H²) in encouraging physical activities for the prevention of heart attack and stroke among hypertensive patients enrolled in the Community-Based Hypertension Control Program (CBHCP).

Design

Cluster randomized controlled trial with three waves of longitudinal assessments at baseline, 3 and 6 months post intervention.

Setting

Community-based and patient-centered self-care for behavioral intervention in urban settings of China.

Participants

A total of 450 participants diagnosed with hypertension from 12 community health centers in Wuhan, China were recruited, and were randomly assigned by center to receive either KM2H² plus standard CBHCP care (6 centers and 232 patients) or the standard care only (6 centers and 218 patients).

Intervention

KM2H² is a behavioral intervention guided by the Transtheoretical Model, the Model of Personalized Medicine and Social Capital Theory. It consists of six intervention sessions and two booster sessions engineered in a progressive manner. The purpose is to motivate and maintain physical activities for the prevention of heart attack and stroke.

Outcome Measures

Heart attack and stroke (clinically diagnosed, primary outcome), blood pressure (measured, secondary outcome), and physical activity (self-report, tertiary outcome) were assessed at the individual level during the baseline, 3- and 6-month post-intervention.

Results

Relative to the standard care, receiving KM2H² was associated with significant reductions in the incidence of heart attack (3.60% vs. 7.03%, p < .05) and stroke (5.11% vs. 9.90%, p<0.05), and moderate reduction in blood pressure (-3.72mmHg in DBP and -2.92 mmHg in DBP) at 6-month post-intervention; and significant increases in physical activity at 3- (d = 0.53, 95% CI: 0.21, 0.85) and 6-month (d = 0.45, 95% CI: 0.04, 0.85) post-intervention, respectively.

Conclusion

The program KM2H² is efficacious to reduce the risk of heart attack and stroke among senior patients who are on anti-hypertensive medication. Findings of this study provide solid data supporting a formal phase-III trial to establish the effectiveness of KM2H² for use in community settings for prevention.

Trial Registration

ISRCTN Register ISRCTN12608966

Exercise Hypertension

Irrespective of apparent 'normal' resting blood pressure (BP), some individuals may experience an excessive elevation in BP with exercise (i.e. systolic BP ≥210 mm Hg in men or ≥190 mm Hg in women or diastolic BP ≥110 mm Hg in men or women), a condition termed exercise hypertension or a 'hypertensive response to exercise' (HRE). An HRE is a relatively common condition that is identified during standard exercise stress testing; however, due to a lack of information with respect to the clinical ramifications of an HRE, little value is usually placed on such a finding. In this review, we discuss both the clinical importance and underlying physiological contributors of exercise hypertension. Indeed, an HRE is associated with an increased propensity for target organ damage and also predicts the future development of hypertension, cardiovascular events and mortality, independent of resting BP. Moreover, recent work has highlighted that some of the elevated cardiovascular risks associated with an HRE may be related to high-normal resting BP (pre-hypertension) or ambulatory 'masked' hypertension and that an HRE may be an early warning signal of abnormal BP control that is otherwise undetected with clinic BP. Whilst an HRE may be amenable to treatment via pharmacological and lifestyle interventions, the exact physiological mechanism of an HRE remains elusive, but it is likely a manifestation of multiple factors including large artery stiffness, increased peripheral resistance, neural circulatory control and metabolic irregularity. Future research focus may be directed towards determining threshold values to denote the increased risk associated with an HRE and further resolution of the underlying physiological factors involved in the pathogenesis of an HRE.