Exercise as a tool for hypertension and resistant hypertension management: current insights

[Association between transtheoretical model and physical activity in patients with hypertension]

OBJECTIVE

To identify the association between the transtheoretical model (TTM) and physical activity (PA) carried out in free time in patients with arterial hypertension in the central region of Mexico.

DESIGN

Comparative cross-sectional study. SITE: The study was carried out in the Family Medicine Unit No.1 (UFM1) of the Mexican Social Security Institute in Aguascalientes, Mexico.

PARTICIPANTS

Four hundred thirty-five adults aged 40 to 70 with arterial hypertension who attended the outpatient clinic at UFM1 were included.

INTERVENTIONS

The Global Physical Activity Questionnaire and the Stages of Change algorithm from the TTM were applied.

MAIN MEASUREMENTS

A descriptive, bivariate analysis and ordinal logistic regression were performed to evaluate the association between TTM stages and PA.

RESULTS

As patients progress through the stages of change, their weekly PA increased. Individuals in the action, maintenance and consolidation stages were significantly more likely to perform higher levels of exercise: 20 times more likely in the action stage with an ordinal odds ratio (OR) of 20.07 (CI95%: 10,52-38,25), 24 times more in the maintenance stage with OR 24 (CI95%: 12,79-47,63) and 40 times more in the consolidation stage with OR 40,35 (IC95%: 19,25-84,59).

CONCLUSIONS

The strong association between the stages of change and PA reveals the importance of applying the TTM to achieve success in programs to promote healthy habits by designing strategies that suit each subject.

The effectiveness of functional inspiratory muscle training on exercise capacity and peripheral muscle strength in patients with essential hypertension: a three-arm randomized controlled trial

BACKGROUND

The effect of inspiratory muscle training (IMT) applied along with function in Hypertension (HT) patients is uncertain. In this study, it was to determine the effectiveness of functional IMT (F-IMT) on functional lower and upper exercise capacity, mobility, peripheral and respiratory muscle strength, blood pressure, fatigue, physical activity, and quality of life (HRQoL) in HT patients.

METHODS

Prospective, randomized controlled, assessor-blinded, parallel three-armed trial. Forty-five patients with HT were divided into F-IMT group (IMT with 50% maximal inspiratory pressure (MIP)/4 weeks + exercise and IMT with 50% MIP/4 weeks, n = 15), IMT group (MIP 50%, n = 15) and control group (CG, breathing exercises, n = 15). 6-min walking test (6-MWT), 6-min pegboard ring test (6PBRT), 1-min sit to stand test (1STS), mobility, peripheral muscle strength, MIP, maximal expiratory pressure (MEP), systolic& diastolic blood pressure (SBP, DBP), fatigue, physical activity, and HRQoL were evaluated before and after 8 weeks of training.

RESULTS

Increases in 6-MWT were higher in F-IMT (p < 0.001). 6PBRT, 1STS, quadriceps femoris strength were improved and SBP reduced in F-IMT and IMT than CG (p < 0.001). Mobility, handgrip, HRQoL, and physical activity level increased within groups (p < 0.05). MIP increased within F-IMT and IMT; MEP, fatigue, DBP improved only within F-IMT (p < 0.05).

CONCLUSIONS

F-IMT is more effective in enhancing exercise capacity, reducing fatigue and DBP, and improving MEP. Both IMT and F-IMT show similar benefits for upper extremity exercise capacity, quadriceps femoris strength, SBP, and MIP. Mobility, HRQoL, and physical activity levels are increased with F-IMT, IMT, and breathing exercises.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT06343246 (03/29/2024).

A 3-Month Modified Basketball Exercise Program as a Health-Enhancing Sport Activity for Middle-Aged Individuals

Recreational team sports have received great acceptance lately, in different populations, indicating encouraging results in health-related quality of life. This study examined the efficacy of a 3-month basketball exercise program on selected indices of health (body mass-BM, body fat-BF, blood pressure-BP), functional capacity (flexibility of lower and upper limbs, balance), and physical fitness (maximum strength of lower limbs, trunk and handgrip, aerobic capacity) in middle-aged individuals. Forty middle-aged individuals (males and females; 40-55 years old) were randomly divided into (a) exercise (EG; n = 20) and (b) control groups (CG; n = 20). The EG followed a 3-month modified basketball exercise program (2 times/week; 24 training units), including different basketball drills with and without the ball (dribbling, passing, pivot, stops, etc.), to improve participants' health and physical fitness. Repeated measures ANOVA showed that the EG significantly increased their flexibility (17.23-74.88%; p < 0.001), static balance (44.76-54.69%; p < 0.001), and strength of lower limbs and trunk (11.67-13.13%; p < 0.001), while reducing BP (7.31-12%; p < 0.001), heart rate and RPE (5.30-34.37%; p < 0.001), and time during time-up-and-go test (-10.91%; p < 0.001). Handgrip strength, BM, and BF did not change following the program in the EG (p > 0.05). In the CG, the above variables remained stable. In conclusion, this program may be used to eliminate the detrimental effects of aging on health, functional capacity, and physical fitness parameters.

Lifestyle Medicine: An Antidote to Cardiovascular Diseases

Despite numerous advances in basic understanding of cardiovascular disease pathophysiology, pharmacology, therapeutic procedures, and systems improvement, there hasn't been much decline in heart disease related mortality in the US since 2010. Hypertension and diet induced risk continue to be the leading causes of cardiovascular morbidity. Even with the excessive mortality associated with the COVID-19 pandemic, in 2020, heart disease remained the leading cause of death. Given the degree of disease burden, morbidity, and mortality, there is an urgent need to redirect medical professionals' focus towards prevention through simple and cost effective lifestyle strategies. However, current practice paradigm and financial compensation systems are mainly centered disease management and not health promotion. For example, the financial value placed on 3-10 min smoking cessation counseling (.24RVUs) is 47-fold lower than an elective PCI (11.21 RVUs). The medical community seems to be enamored with the latest and greatest technology, new devices, and surgical procedures. What if the greatest technology of all was simply the way we live every day? Perhaps when this notion is known by enough, we will switch to this lifestyle medicine technology to prevent disease in the first place.

Physical activity in metabolic syndrome

Obesity has become one of the global epidemics, contributing to the burden of disease in society, increasing the risk of diabetes, cardiovascular and liver diseases. Inadequate energy balance resulting from excessive energy intake and insufficient physical activity (PA) is one of the main factors contributing to the incidence of obesity and the development of metabolic syndrome (MetS). Treatment options for obesity include lifestyle modifications, pharmacotherapy and bariatric surgery, with the latter being the most effective treatment. Lifestyle interventions involving increased PA and reduced caloric intake improve metabolic outcomes. Early implementation of exercise leads to improved physical fitness, better glycemic control and lipid profile. Undertaking systematic PA is associated with better quality of life, improves insulin sensitivity, causes additional weight loss, reduces its adverse effects on bone mass and results in better body composition. In this narrative review we summarized the current state of knowledge on the impact of PA on the components of MetS and the latest recommendations for PA in patients with MetS.

Effects of crossover point exercise and high-intensity interval training on vascular health in young overweight females

This study investigated the effects of 10 weeks of crossover point (COP) exercise training and high-intensity interval training (HIIT) on cardiovascular risk factors and vascular health in overweight young women. Overweight young women were randomized into HIIT and COP groups. Participants in the HIIT group (n = 10; age = 22 ± 2, body mass index (BMI) = 25.72 ± 0.90) and COP group (n = 10, age = 21 ± 2, BMI = 25.90 ± 1.90) took part in 10 weeks of HIIT and COP exercise training, respectively. Cardiorespiratory fitness, cardiovascular health, and oxidative stress indicators were measured before and after the intervention period. After 10 weeks of exercise intervention, both COP exercise and HIIT led to a significant increase in maximal oxygen uptake (p < 0.001). The systolic blood pressure (p = 0.006), diastolic blood pressure (p = 0.006), and brachial-ankle pulse wave velocity (p = 0.002) were significantly decreased in both COP group and HIIT group, while serum interleukin-6 levels were increased in HIIT and COP groups. The present study shows that a training program at COP could be an effective strategy to protect vascular health.

2023 TAMIS/TSOC/TACVPR Consensus Statement for Patients with Acute Myocardial Infarction Rehabilitation

Cardiac rehabilitation is a comprehensive intervention recommended in international and Taiwanese guidelines for patients with acute myocardial infarction. Evidence supports that cardiac rehabilitation improves the health-related quality of life, enhances exercise capacity, reduces readmission rates, and promotes survival in patients with cardiovascular disease. The cardiac rehabilitation team is comprehensive and multidisciplinary. The inpatient, outpatient, and maintenance phases are included in cardiac rehabilitation. All patients admitted with acute myocardial infarction should be referred to the rehabilitation department as soon as clinically feasible. Pre-exercise evaluation, including exercise testing, helps physicians identify the risks of cardiac rehabilitation and organize appropriate exercise prescriptions. Therefore, the Taiwan Myocardial Infarction Society (TAMIS), Taiwan Society of Cardiology (TSOC), and Taiwan Academy of Cardiovascular and Pulmonary Rehabilitation (TACVPR) address this consensus statement to assist healthcare practitioners in performing cardiac rehabilitation in patients with acute myocardial infarction.

Effect of High-Intensity Interval Training on Exercise Capacity, Blood Pressure, and Autonomic Responses in Patients With Hypertension: A Systematic Review and Meta-analysis

CONTEXT

Despite the well-known positive effects of exercise in hypertensive patients, the best mode of exercise is still under discussion.

OBJECTIVE

A systematic review of the literature, synthesizing data on the effects of high-intensity interval training (HIIT) on peak oxygen consumption (VO2 peak), blood pressure (BP), cardiac autonomic modulation, and resting heart rate (HR) in patients with hypertension.

DATA SOURCES

MEDLINE (via PubMed), CENTRAL, PEDro database, and SciELO (from the earliest date available to December 31, 2020).

STUDY SELECTION

Randomized controlled trials (RCTs) that evaluated the effects of HIIT in hypertensive patients.

STUDY DESIGN

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Level 2.

DATA EXTRACTION

Mean differences (MDs) with a 95% CI were calculated, and heterogeneity was assessed using the I2 test.

RESULTS

Nine RCTs encompassing 569 patients met the eligibility criteria and were included in the systematic review. Five trials compared supervised HIIT with moderate-intensity continuous training (MICT) and a control; 1 trial compared HIIT with MICT, and 3 compared HIIT with a control. In comparison with MICT, HIIT improved VO2 peak MD (3.3 mL.kg-1.min-1; 95% CI, 1.4-5.3; N = 130). In comparison with controls, HIIT improved VO2 peak MD (4.4 mL.kg-1.min-1; 95% CI, 2.5-6.2; N = 162).

CONCLUSION

Despite the low quality of the evidence, HIIT is superior to MICT in improving VO2 peak in patients with hypertension. HIIT effectively improved VO2 peak, BP, and resting HR when compared with controls. HIIT appears to be safe only when performed in a supervised manner for stage 1 hypertension patients without associated risk factors.

Comparison of the Determination of Some Antihypertensive Drugs in Clinical Human Plasma Samples by Solvent Front Position Extraction and Precipitation Modes

The determination of the selected antihypertensive drugs in human plasma samples with the novel solvent front position extraction (SFPE) technique is presented. The SFPE procedure combined with LC-MS/MS analysis was used for the first time to prepare a clinical sample containing the drugs mentioned above from different therapeutic groups. The effectiveness of our approach was compared with the precipitation method. The latter technique is usually used to prepare biological samples in routine laboratories. During the experiments, the substances of interest and the internal standard were separated from other matrix components using a prototype horizontal chamber for thin-layer chromatography/high-performance thin-layer chromatography (TLC/HPTLC) with a moving pipette powered by a 3D mechanism, which distributed the solvent on the adsorbent layer. Detection of the six antihypertensive drugs was performed by liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) in multiple reaction monitoring (MRM) mode. Results obtained by SFPE were very satisfactory (linearity R² ≥ 0.981; %RSD ≤ 6%; LOD and LOQ were in the range of 0.06-9.78 ng/mL and 0.17-29.64 ng/mL, respectively). The recovery was in the range of 79.88-120.36%. Intra-day and inter-day precision had a percentage coefficient of variation (CV) in the range of 1.10-9.74%. The procedure is simple and highly effective. It includes the automation of TLC chromatogram development, which significantly reduced the number of manual operations performed, the time of sample preparation and solvent consumption.

VH-4-A Bioactive Peptide from Soybean and Exercise Training Constrict Hypertension in Rats through Activating Cell Survival and AMPKα1, Sirt1, PGC1α, and FoX3α

Hypertension is a chronic disease related to age, which affects tens of millions of people around the world. It is an important risk factor that causes myocardial infarction, heart failure, stroke, and kidney damage. Bioactive peptide VHVV (VH-4) from soybean has shown several biological activities. Physical exercise is a cornerstone of non-pharmacologic treatment for hypertension and has established itself as an effective and complementary strategy for managing hypertension. The present study evaluates the efficacy of VH-4 supplement and swimming exercise training in preventing hypertension in spontaneously hypertensive rats (SHR). SHR animals were treated with VH-4 (25 mg/kg by intraperitoneal administration) and swimming exercise (1 h daily) for eight weeks, and the hemodynamic parameters, histology, and cell survival pathway protein expression were examined. In SHR rats, increased heart weight, blood pressure, and histological aberrations were observed. Cell survival protein p-PI3K and p-AKT and antiapoptosis proteins Bcl2 and Bcl-XL expression decreased in SHR animals. SIRT1 and FOXO3 were decreased in hypertensive rats. Both bioactive peptide VH-4 treatment and swimming exercise training in hypertensive rats increased the cell survival proteins p-PI3K and p-AKT and AMPKα1, Sirt1, PGC1α, and FoX3α proteins. Soy peptide VH-4, along with exercise, acts synergistically and prevents hypertension by activating cell survival and AMPKα1, Sirt1, PGC1α, and FoX3α proteins.

Effect of fixed 7.5 minutes' moderate intensity exercise bouts on body composition and blood pressure among sedentary adults with prehypertension in Western-Kenya

Prehypertension is a modifiable risk factor for cardiovascular disease observed to affect an estimated 25-59% of global population and closely associated with body composition. Without appropriate interventions, one-third of individuals with prehypertension would develop full-blown hypertension within 4 years. The existing exercise recommendations need substitutes that appeal more yet accord similar or better outcomes in desire to halt this progression. This study evaluated the effect of Fixed 7.5-minute Moderate Intensity Exercise (F-7.5m-MIE) bouts on Body Composition and Blood Pressure (BP) among sedentary adults with prehypertension in Western-Kenya in a Randomized Control Trial (RCT) performed throughout the day compared to the single-continuous 30-60-minute bouts performed 3 to 5 times weekly. This RCT, with three arms of Experimental Group1 (EG1) performing the F-7.5m-MIE bouts, Experimental Group 2 (EG2) performing current World Health Organization (WHO) recommendation of ≥30-min bouts, and, control group (CG), was conducted among 665 consenting pre-hypertensive sedentary adults enrolled from western Kenya. EG1 and EG2 performed similar weekly cumulative minutes of moderate intensity exercises. Adherence was determined using activity monitors and exercise logs. Data regarding demographic characteristics, heart rate, BP, and anthropometric measures were collected at baseline and 12th week follow-up. Data regarding univariate, bivariate and multivariate (repeated measurements between and within groups) analysis were conducted using STATA version 13 at 5% level of significance. The study revealed that males (92.1% in EG1, 92% in EG2 and 96.3% in CG) and females (94.6% in EG1, 89.3% in EG2 and 95% in CG) in the three arms completed the exercise at follow-up respectively. At 12th week follow-up from all exercise groups, males' and females' measurements for waist-hip-ratio, waist-height-ratio, systolic BP (SBP), heart rate and pulse pressure showed significant drops from baseline, while diastolic BP (DBP) and body mass index (BMI) reported mixed results for males and females from the various treatments. Both treatments demonstrated favourable outcomes. However, differences in the change between baseline and endpoint yielded mixed outcomes (SBP; p<0.05 for both males and females, DBP; p<0.05 for males and females, waist-height-ratio; p = 0.01 and <0.05 for males and females respectively, waist-hip-ratio; P = 0.01 and >0.05 for males and females respectively, BMI; p>0.05 for both males and females, heart rate; p<0.05 for males and females and pulse pressure; p = 0.01 and >0.05 for males and females respectively). The study design however could not test for superiority. The study demonstrated that the F-7.5m- MIE treatment programme and the WHO recommended 3-5 times weekly bouts of 30-60 minutes regime produced comparably similar favourable outcomes in adherence and BP reductions with improved body composition. Trial registration: Trial registered with Pan African Clinical Trial Registry (www.pactr.org): no. PACTR202107584701552. (S3 Text).

Physical Exercise in Resistant Hypertension: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Physical exercise reduces blood pressure (BP) in patients with hypertension in general but more evidence is needed specifically for a high-risk phenotype associated with intensive medication, resistant hypertension (RH). In this systematic review and meta-analysis, we aimed to summarize current evidence of the exercise effects on BP in patients with RH. A systematic search was conducted in PubMed, Web of Science and Cochrane Library (from inception to 3rd November, 2021). A random effects meta-analysis was performed when at least two trials assessed the effect of either acute or regular exercise (vs. a control condition) on the same outcome. Ten studies (N = 380 participants; 51% female; mean age 52 to 67 years) were included in the review, of which four (N = 58) and six (N = 322) assessed the effects of acute and regular exercise, respectively. Evidence overall suggests that a single bout of acute exercise results in a short-term (≤ 24 h) reduction of BP, although no meta-analysis could be performed. As for regular exercise, three randomized controlled trials (N = 144, 50% female) could be meta-analyzed, which showed that exercise training intervention (8-12 weeks, 3 sessions/week) significantly reduces 24-h (-9.9 mmHg, 95% confidence interval -15.4-4.4 for systolic BP; and -5 mmHg, -7.0-3.0 for diastolic BP) and daytime ambulatory BP (-11.7 mmHg, -17.8-5.7; and -7.4 mmHg, -11.9-2.9). In summary, physical exercise appears as an effective option to reduce BP in patients with RH, although more research is needed to confirm these findings as well as to determine the most effective exercise characteristics.

Effects of the self-management training program on self-management behavior and blood pressure levels among elderly people with hypertension

Objective

To determine the effects of the Self-Management Training Program on self-management behavior and blood pressure (BP) levels among elderly people with hypertension (HT).

Methods

This study was based on a quasi-experimental design using sampling groups composed of elderly residents of Pathum Thani Province with HT. Simple random sampling was applied to two sampling groups, an experimental group and a control group. However, the experimental group had been on the Self-Management Training Program based on the Creer concept. The Program's contents included small-group health-education sessions and the patients’ manual, Self-Management Training Skills for Self-Management Behavior. Small group discussions were held for self-reflection, to stimulate follow-up for self-management behavior training during home visits. The Self-Management Training Program was compared with programs involving the more usual care. Data were collected using the Self-Management Behavior for Hypertension Control Questionnaire and BP assessment tests. Data were analyzed using a descriptive statistic, chi-square test, pair t-test, repeated-measures Analysis of Variance (ANOVA), and repeated-measures Analysis Covariance (ANCOVA).

Results

It was found that at 13 weeks after entering the program, the experimental group demonstrated a significantly lower systolic and diastolic BP with a baseline statistical significance (P < 0.005), and that at the 4th week and the 13th week, there was a decrease in BP in the experimental group. The experimental group also had above-baseline self-management behavior scores that were higher than in the control group (P < 0.01).

Conclusions

Results from this study show that the Self-Management Program was useful for BP control and promoted sustainable self-management behavior.

Comparison of different types of exercise training on resting blood pressure in 30-45 years old adults: a randomised controlled trial

Hypertension is the most metastasizing non-communicable disease, which has affected more than 1.4 billion people, worldwide. Exercise is the core management strategy for hypertensive individuals. Extensive literature is available for each kind of exercise that is isometric hand grip training (IHGT), resistance training (RT), and aerobic training (AT). However, the comparison between these exercise regimens has not been done in a single trial. The trial was conducted on 126 subjects in Hisar, an urban area of Haryana (INDIA), from July 2017 to December 2018. Subjects were randomly assigned to four groups: control (n=33), IHGT (n=32), RT (n=31), and AT (n=30). Study variables were measured at baseline, 2nd week, 4th week, 6th week, and also after the 8th week of intervention. Experimental groups showed significant reduction in all the components of blood pressure in comparison to control group. The RT group showed maximum reduction in blood pressure in comparison to other regimens (systolic blood pressure: RT > IHGT > AT; diastolic blood pressure: RT > AT > IHGT). However, the difference between the groups is not statistically significant (P>0.05). The study findings reveal that different kind of exercise regimens are equally effective in lowering blood pressure among pre hypertensive and stage 1 hypertension adults.

Nonpharmacological Management of Resistant Hypertension

PURPOSE OF REVIEW

In the United States (US), 46% of adults have hypertension (systolic blood pressure ≥ 130 mmHg, diastolic blood pressure ≥ 80 mmHg). Approximately, 16% of patients with hypertension have apparent treatment-resistant hypertension (aTRH) and the incidence of true resistant hypertension (RHT) is thought to be much lower (~ 2%). These patients with RHT are at a higher risk for adverse events and worse clinical outcomes.

RECENT FINDINGS

Although lifestyle interventions have proven to be effective as the first line of defense in treating hypertension, their role in the management of patients with RHT is not well established. Despite fewer in number, available studies examining lifestyle interventions in patients with RHT do indeed show promising results. In this review, we aim to discuss the role of common lifestyle interventions such as physical activity, exercise, weight loss, and dietary modifications on blood pressure control in patients with RHT.

Characteristics of the athlete's heart in aged hypertensive and normotensive subjects

BACKGROUND

Both hypertension and age-related impairment of the cardiac condition are known to be improved by regular physical training. As relatively few studies have been reported about the older, hypertensive patients, the aim of this study was to establish cardiac benefits of active lifestyle in these subjects.

METHODS

Two-dimensionally guided M-mode, Doppler- and tissue Doppler echocardiography was performed in 199 normo- and hypertensive, active and sedentary older (age>60 yrs.) men (111) and women (88). Results were compared either by ANOVA, or by Kruskall-Wallis test.

RESULTS

The left ventricular muscle index (LVMI), which is higher in young active than in sedentary persons, proved to be smaller in the active than sedentary older subjects: men normotensives: actives 83 vs. sedentary ones 98, hypertensives: actives 88 vs. sedentary ones 107, women normotensives: actives 77 vs. sedentary ones 89 g/m3. Diastolic function was better in the active groups demonstrated both by the ratio of the early to atrial peak blood flow velocities (men: normotensives: actives 1.03 vs. sedentary ones 0.76, women normotensives: actives 1.21 vs. sedentary ones 0.9, hypertensives: actives 1.04 vs. sedentary ones 0.88). The tissue Doppler results were also better in the active groups; the difference between the active and sedentary groups was more marked in the normotensive male groups than in the hypertensive ones.

CONCLUSIONS

Active lifestyle prevents age-related pathological LV hypertrophy, and attenuates the LV diastolic dysfunction.

The effect of exercise training on blood pressure in menopause and postmenopausal women: A systematic review of randomized controlled trials

The prevalence of hypertension is higher in postmenopausal than in premenopausal women. Regular exercise training has been shown to be effective in addressing hypertension. The aim of this systematic review was to synthesize the effect of exercise training on systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) in menopausal and postmenopausal women. This review was reported according to the PRISMA statement and registered in PROSPERO. The literature search was done in MEDLINE, Embase, Cochrane CENTRAL and ClinicalTrials. Randomized controlled trials involving menopausal and postmenopausal women undergoing exercise training were included. Two blinded reviewers assessed risk of bias in the included studies by using the Cochrane Risk of Bias tool. A random-effects model was used for all analyses. Significance was set at P < 0.05. Compared with the control group, exercise training resulted in clinically significant reductions on SBP (MD -3.43 mmHg; 95% CI, -5.16, -1.71; P < 0.0001), DBP (MD, -2.25 mmHg; 95% CI, -3.40, -1.11; P = 0.0001) and MAP (MD, -3.48 mmHg; 95% CI, -5.84, -1.11; P = 0.004). Aerobic training (AT) did not produce a significant reduction in SBP, DBP and MAP (P >0.05). Combined training (CT) generated larger reductions. Exercise training generated small but clinically relevant reductions in SBP, DBP and MAP in menopausal and postmenopausal women, younger or older than 65 years, with prehypertension or hypertension. AT did not lead to a clinically relevant improvement in blood pressure (BP) in this population. In addition, CT showed the largest reductions in SBP, DBP and MAP.

The Road to Better Management in Resistant Hypertension-Diagnostic and Therapeutic Insights

Resistant hypertension (R-HTN) implies a higher mortality and morbidity compared to non-R-HTN due to increased cardiovascular risk and associated adverse outcomes—greater risk of developing chronic kidney disease, heart failure, stroke and myocardial infarction. R-HTN is considered when failing to lower blood pressure below 140/90 mmHg despite adequate lifestyle measures and optimal treatment with at least three medications, including a diuretic, and usually a blocker of the renin-angiotensin system and a calcium channel blocker, at maximally tolerated doses. Hereby, we discuss the diagnostic and therapeutic approach to a better management of R-HTN. Excluding pseudoresistance, secondary hypertension, white-coat hypertension and medication non-adherence is an important step when diagnosing R-HTN. Most recently different phenotypes associated to R-HTN have been described, specifically refractory and controlled R-HTN and masked uncontrolled hypertension. Optimizing the three-drug regimen, including the diuretic treatment, adding a mineralocorticoid receptor antagonist as the fourth drug, a β-blocker as the fifth drug and an α1-blocker or a peripheral vasodilator as a final option when failing to achieve target blood pressure values are current recommendations regarding the correct management of R-HTN.

Utilizing Machine Learning Techniques to Predict the Efficacy of Aerobic Exercise Intervention on Young Hypertensive Patients Based on Cardiopulmonary Exercise Testing

Recently, the incidence of hypertension has significantly increased among young adults. While aerobic exercise intervention (AEI) has long been recognized as an effective treatment, individual differences in response to AEI can seriously influence clinicians' decisions. In particular, only a few studies have been conducted to predict the efficacy of AEI on lowering blood pressure (BP) in young hypertensive patients. As such, this paper aims to explore the implications of various cardiopulmonary metabolic indicators in the field by mining patients' cardiopulmonary exercise testing (CPET) data before making treatment plans. CPET data are collected "breath by breath" by using an oxygenation analyzer attached to a mask and then divided into four phases: resting, warm-up, exercise, and recovery. To mitigate the effects of redundant information and noise in the CPET data, a sparse representation classifier based on analytic dictionary learning was designed to accurately predict the individual responsiveness to AEI. Importantly, the experimental results showed that the model presented herein performed better than the baseline method based on BP change and traditional machine learning models. Furthermore, the data from the exercise phase were found to produce the best predictions compared with the data from other phases. This study paves the way towards the customization of personalized aerobic exercise programs for young hypertensive patients.

Low- and moderate-intensity aerobic exercise acutely reduce blood pressure in adults with high-normal/grade I hypertension

The aim of the study is to compare the acute effects of low- and moderate-intensity aerobic exercise on post-exercise blood pressure in active adults with high-normal/grade I hypertension. Thirteen physically active adults (67.0 ± 8.7 years) randomly completed two aerobic exercise sessions of 30 minutes at low (30% heart rate reserve [HRres]) and moderate (60% HRres) intensity. Blood pressure was assessed pre-session and every hour until 3 hours after. Systolic blood pressure decreased after both exercise intensities without significant differences between sessions at 1 hour after the session (30%: -10.0 ± 12.6% vs 60%: -11.4 ± 12.7 mm Hg, P > .05). Three hours after the 60% session, the systolic blood pressure remained significantly lower than baseline (139.9 ± 12.9 to 129.3 ± 11.9 mm Hg, P < .05), but without significant differences between sessions. No relevant changes were observed in diastolic and mean blood pressure. In conclusion, a single session of aerobic exercise acutely reduces systolic blood pressure in active adults with high-normal/grade I hypertension.

Resistant hypertension: new insights and therapeutic perspectives

Resistant hypertension (RH) is a concept that currently goes beyond the classical definition of blood pressure ≥140/90 mmHg in subjects receiving three or more drugs of different classes at maximally tolerated doses. Here, we review the clinical relevance of RH and the different types of RH-associated phenotypes, namely refractory hypertension, controlled resistant hypertension, and masked uncontrolled hypertension. We also discuss current drug strategies and future treatments for these high-risk phenotypes.

Exercise training reduces arterial stiffness in adults with hypertension: a systematic review and meta-analysis

OBJECTIVE

Arterial stiffness, namely pulse wave velocity (PWV), is an emerging biomarker in the assessment of vascular health. This meta-analysis aims to determine the effects of exercise training on PWV in patients with hypertension, and to identify the possible moderator variables (e.g. type of exercise) of the effect of exercise on PWV.

METHODS

MEDLINE, EMBASE, Cochrane and Web of Science were searched up until July 2019 for randomized controlled trials assessing the effect of exercise interventions lasting 4 or more weeks on PWV in adults with hypertension. Random-effects modelling was used to compare changes from pre to postintervention in PWV between exercise and control groups. Data were reported as weighted mean difference (WMD) and 95% confidence interval (95% CI). Protocol registration: PROSPERO registration number CRD42019138658.

RESULTS

We included 14 trials (15 interventions), involving five aerobic, two dynamic resistance, six combined and two isometric resistance groups, totalling 642 participants with hypertension. PWV was significantly reduced by exercise training [(WMD (95% CI) = -0.76 m/s (-1.05 to -0.47)]. Analysis of moderator variables showed that aerobic exercise [WMD (95% CI) = -0.70 m/s (-1.20 to -0.19)], combined exercise [WMD (95% CI) = -0.74 m/s (-1.41 to -0.08)] and isometric resistance exercise [WMD (95% CI) = -0.98 m/s (-1.24 to -0.73)] reduced PWV. There was no significant reduction in PWV in participants undertaking dynamic resistance training [WMD (95% CI) = -0.58 (-1.58 to 0.42)].

CONCLUSION

This meta-analysis supports that exercise interventions based on aerobic, combined or isometric exercise are suitable to improve PWV in adults with hypertension.

Predicting Optimal Hypertension Treatment Pathways Using Recurrent Neural Networks

BACKGROUND

In ambulatory care settings, physicians largely rely on clinical guidelines and guideline-based clinical decision support (CDS) systems to make decisions on hypertension treatment. However, current clinical evidence, which is the knowledge base of clinical guidelines, is insufficient to support definitive optimal treatment.

OBJECTIVE

The goal of this study is to test the feasibility of using deep learning predictive models to identify optimal hypertension treatment pathways for individual patients, based on empirical data available from an electronic health record database.

MATERIALS AND METHODS

This study used data on 245,499 unique patients who were initially diagnosed with essential hypertension and received anti-hypertensive treatment from January 1, 2001 to December 31, 2010 in ambulatory care settings. We used recurrent neural networks (RNN), including long short-term memory (LSTM) and bi-directional LSTM, to create risk-adapted models to predict the probability of reaching the BP control targets associated with different BP treatment regimens. The ratios for the training set, the validation set, and the test set were 6:2:2. The samples for each set were independently randomly drawn from individual years with corresponding proportions.

RESULTS

The LSTM models achieved high accuracy when predicting individual probability of reaching BP goals on different treatments: for systolic BP (<140 mmHg), diastolic BP (<90 mmHg), and both systolic BP and diastolic BP (<140/90 mmHg), F1-scores were 0.928, 0.960, and 0.913, respectively.

CONCLUSIONS

The results demonstrated the potential of using predictive models to select optimal hypertension treatment pathways. Along with clinical guidelines and guideline-based CDS systems, the LSTM models could be used as a powerful decision-support tool to form risk-adapted, personalized strategies for hypertension treatment plans, especially for difficult-to-treat patients.

Prevalence of and factors associated with hypertension among the hill tribe population aged 35 years and over in northern Thailand: a cross-sectional study

BACKGROUND

Hypertension (HT) is a serious noncommunicable disease that can lead to several health problems when it is not detected or is not properly diagnosed and treated in a timely manner, particularly in individuals living in poor economic and education conditions. The hill tribe population in northern Thailand is a vulnerable population with limited information available regarding HT.

METHODS

The study aimed to estimate the prevalence of HT and to determine the factors associated with HT among individuals from hill tribes aged 35 years and over and living in northern Thailand. A cross-sectional study was conducted to gather essential information from six main hill tribe groups: the Akha, Lahu, Karen, Hmong, Yao and Lisu tribes in Chiang Rai Province. A simple random method was used to select 30 hill tribe villages (5 villages for each tribe). People aged 35 years and over who lived in the selected villages were invited to participate in the study. A validated questionnaire and a 5-mL blood specimen were used as research instruments. A face-to-face interview was conducted to collect data after informed consent was obtained, and 5-mL blood specimens were drawn to determine the lipid profiles of the participants. Logistic regression was performed to determine the factors associated with HT at the significance level of α = 0.05.

RESULTS

A total of 1,287 participants were recruited into the study: 60.5% were females, 30.4% were aged 35-44 years, 65.4% were illiterate, and 83.1% were married. The overall prevalence of HT was 24.3%, and the Yao tribe had the highest prevalence at 18.5%. In the multivariable analysis, three variables were found to be associated with HT: marital status, ability to read Thai, and exercise behavior. Those who were single and divorced had a 2.55 (95% CI = 1.23-5.06) and 2.69 times greater chance (95% CI = 1.10-6.59), respectively, of developing HT than those who were married. Those who could not read Thai had a 2.13 times greater chance (95% CI = 1.50-3.01) of developing HT than those who could read, and those who did not exercise and who exercised sometimes had a 1.96 (95% CI = 1.07-3.58) and 2.24 times greater chance (95% CI = 1.21-4.13), respectively, of developing HT than those who regularly exercised.

CONCLUSION

A health screening program for the identification of new HT among the hill tribe population urgently needs to be implemented, followed by the introduction of a proper exercise program to reduce the risk of HT, particularly for those who are illiterate and for single or divorced people.

200.000 IU of vitamin D does not reduce resting Blood Pressure and Inhibit Post-Exercise Hypotension in elderly women: a pilot study

Given the scarcity of studies with elderly and the existence of studies investigating the effect of vitamin D supplementation in PEH (post exercise hypotension), this study evaluated the effect of a single megadose of vitamin D on resting blood pressure (RBP) and post-exercise hypotension (PEH) in the elderly. 11 hypertensive elderly women (70.3 ± 1.7 years) received a single megadose of 200.000 IU of cholecalciferol or a placebo, orally, through capsules. On day 7, the subjects performed 30 minutes of aerobic exercise with blood pressure measurement before exercise and every 10 minutes after exercise during 60 minutes, besides cardiac autonomic modulation. RBP did not significantly change. Exercise promoted significant systolic PEH only in one moment post exercise in treated group and in the placebo group promoted significant systolic PEH at four moments. Significant diastolic PEH did not occur in any of the groups. Sympathovagal activity increased at post exercise balance in supplemented subjects at 20 min, 40 min, 50 min and 60 min when compared to rest; this increase was not observed in the placebo. A megadose of vitamin D did not reduce RBP, promoted partial inhibition of systolic PEH and increased sympathovagal balance.

Nordic Walking Promoted Weight Loss in Overweight and Obese People: A Systematic Review for Future Exercise Prescription

The aim of this systematic review was to analyze the effect of Nordic Walking (NW) on anthropometric parameters, body composition, cardiovascular parameters, aerobic capacity, blood sample, and glucose tolerance in overweight and obese subjects. The main keywords "Nordic Walking" or "Pole Walking", associated with either "obese", "obesity", "overweight", or "weight loss" were used on the online database MEDLINE, PubMed, SPORTDiscus and Scopus. Additionally, references of the studies included were screened to identify eligible articles. Applying the inclusion and exclusion criteria, ten manuscripts were considered as eligible for this review. The results of the studies were categorized in several domains with regard to "anthropometric parameters and body composition", "cardiovascular parameters and aerobic capacity", and "blood sample and glucose tolerance". The results showed positive effects on the anthropometric parameters, body composition, cardiovascular parameters, blood sample, and glucose tolerance. The greatest improvements were observed in supervised and high weekly frequency of NW interventions. NW could be considered as an effective modality through which to involve the obese in physical activity. For weight loss, NW should be prescribed 4-5 times per week, at least 60 min per session, preferably combined with diet control.

Achieving control of resistant hypertension: Not just the number of blood pressure medications

Resistant hypertension (RH) has a prevalence of around 12% and is associated with an increased risk of cardiovascular disease, progression to end-stage renal disease, and even mortality. In 2017, the American College of Cardiology and American Heart Association released updated guidelines that detail steps to ensure proper diagnosis of RH, including the exclusion of pseudoresistance. Lifestyle modifications, such as low salt diet and physical exercise, remain at the forefront of optimizing blood pressure control. Secondary causes of RH also need to be investigated, including screening for obstructive sleep apnea. Notably, the guidelines demonstrate a major change in medication management recommendations to include mineralocorticoid receptor antagonists. In addition to advances in medication optimization, there are several device-based therapies that have been showing efficacy in the treatment of RH. Renal denervation therapy has struggled to show efficacy for blood pressure control, but with a re-designed catheter device, it is once again being tested in clinical trials. Carotid baroreceptor activation therapy (BAT) via an implantable pulse generator has been shown to be effective in lowering blood pressure both acutely and in long-term follow up data, but there is some concern about the safety profile. Both a second-generation pulse generator and an endovascular implant are being tested in new clinical trials with hopes for improved safety profiles while maintaining therapeutic efficacy. Both renal denervation and carotid BAT need continued study before widespread clinical implementation. Central arteriovenous anastomosis has emerged as another possible therapy and is being actively explored. The ongoing pursuit of blood pressure control is a vital part of minimizing adverse patient outcomes. The future landscape appears hopeful for helping patients achieve blood pressure goals not only through the optimization of antihypertensive medications but also through device-based therapies in select individuals.