7th Brazilian Guideline of Arterial Hypertension: Chapter 6 - Non-pharmacological treatment

Effects of autonomic nervous system activation on endothelial function in response to acute exercise in hypertensive individuals: study protocol for a randomized double-blind study

BACKGROUND

Arterial hypertension has a direct association with endothelial dysfunction and major cardiovascular events. There is evidence showing the benefits of aerobic exercise on flow-mediated dilation (FMD) in hypertensive individuals but little is known about the effect of autonomic nervous system (ANS) activation on FMD of the brachial artery in response to different types of exercise in this specific population. This study aims to examine the effects of ANS activation on FMD of the brachial artery in response to exercise in hypertensive individuals following a session of different types of exercise including aerobic exercise (AE), resistance exercise (RE), or combined exercise (CE).

METHODS

Thirty-nine hypertensive volunteers aged 35 to 55 years will be randomly assigned to two exercise sessions: AE (40 min on a cycle ergometer at 60% of HR reserve), RE (4 lower limb sets with 12 repetitions at 60% 1-RM for 40 min), or CE (RE for 20 min + AE for 20 min). Each exercise group will be randomized to receive either an α1-adrenergic blocker (doxazosin 0.05 mg/kg-1) or placebo. Ultrasound measurement of FMD is performed 10 min before and 10, 40, and 70 min after exercise. ANS activation is monitored using a Finometer and measurements are taken during 10 min before each FMD assessment. Arterial stiffness is assessed by pulse wave velocity (PWV) analysis using a Complior device.

DISCUSSION

We expect to demonstrate the effect of ANS activation on FMD of the brachial artery in hypertensive individuals in response to different types of exercise. This study may give some insight on how to improve exercise prescription for hypertension management.

TRIAL REGISTRATION

https://clinicaltrials.gov and ID "NCT04371757". Registered on May 1, 2020.

Use of low volume, high effort resistance training to manage blood pressure in hypertensive patients inside a public hospital: a proof of concept study

Physical exercise has been shown to have an important role in the prevention and treatment of arterial hypertension. However, the general exercise recommendations are time consuming, which might be detrimental to exercise adoption. Based on this, minimal doses of exercise have been suggested as an alternative approach and this report investigates the feasibility and effects of low volume and high effort resistance training for hypertensive patients in a hospital setting. This is a pilot non-randomized prospective study where 15 sedentary hypertensive patients (11 women and 4 men) performed 24 resistance training sessions over 12 weeks at a public hospital. The resistance training sessions consisted of two sets of four exercises, with a rest interval of two minutes between sets. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured 10 minutes before and 10 minutes after each training. No injuries or intercurrence were reported during the study. SBP decreased significantly when compared the first and last sessions, when the measures were performed at rest (152 ± 16 mmHg vs. 122 ± 9 mmHg vs, p<0.05), and after (137 ± 13 mmHg vs. 115 ± 5 mmHg, p<0.05) the resistance training session. Similarly, DBP also decreased significantly when the values from the last session were compared with the first session, when measured at rest (83 ± 14 mmHg vs 73 ± 9 mmHg, p<0.05). Low volume and high effort resistance training seems to be a feasible non-pharmacological strategy to help controlling blood pressure in hypertensive patients within a hospital.

NOS3 Polymorphisms Can Influence the Effect of Multicomponent Training on Blood Pressure, Nitrite Concentration and Physical Fitness in Prehypertensive and Hypertensive Older Adult Women

Associations of endothelial nitric oxide synthase (NOS3) polymorphisms with hypertension and response to exercise training in prehypertensive and hypertensive older adult women remain unclear. This study used a multicomponent program (various capacities and motor skills) in the physical training intervention. It analyzed the influence of NOS3 polymorphisms [−786T > C, 894G > T (Glu298Asp), and intron 4b/a] on the response of blood pressure (BP), nitrite concentration, and physical fitness in older adult women. Fifty-two participants aged between 50 and 80 underwent body mass index, BP, 6-min walk, elbow flexion, and sit and stand-up tests to assess physical fitness. The intervention duration was 12 weeks, twice a week, on non-consecutive days. Each session lasted 90 min, maintaining an intensity between 13 (moderate) and 15 (intense), controlled by the Subjective Effort Perception Scale. Plasma/blood samples were collected to assess nitrite concentration and genotyping. The statistical analysis included Fisher’s exact test and linear mixed-effects models. The multicomponent training’s positive effect was observed with a similar response in both prehypertensive and hypertensive groups. However, carriers of different genotypes demonstrated different responses to training: the decreases in systolic and diastolic BP and increases in nitrite expected from the physical training were smaller in variant genotype than ancestral genotype carriers, especially in the hypertensive group. At positions −786T > C and Glu298Asp, only the ancestral genotypes showed a decrease in diastolic BP (Δ% = −8.1, and Δ% = −6.5, respectively) and an increase on nitrite (Δ% = 19.1, and Δ% = 24.1, respectively) in the hypertensive group. Our results show that the benefits of a multicomponent training intervention seem to be genotype-dependent. It should be possible to consider genetic variants when selecting an exercise treatment intervention.

Blood Pressure Control and Associated Factors in a Real-World Team-Based Care Center

BACKGROUND

Although team-based care is recommended for patients with hypertension, results of this intervention in a real-world setting are missing in the literature.

OBJECTIVE

To report the results of a real-world long-term team-based care for hypertensive patients we conducted this study.

METHODS

Data of hypertensive patients attending a multidisciplinary treatment center located in the Midwest region of Brazil in June 2017 with at least two follow-up visits were retrospectively assessed. Anthropometric, blood pressure (BP), follow-up time, pharmacological treatment, diabetes and lifestyle data were collected from the last visit to the service. BP values < 140 x 90 mmHg in non-diabetics and < 130 x 80 mmHg in diabetics were considered controlled. A logistic regression model was built to identify variables independently associated to BP control. Significance level adopted p < 0.05.

RESULTS

A total of 1,548 patients were included, with a mean follow-up time of 7.6 ± 7.1 years. Most patients were female (73.6%; n=1,139) with a mean age of 61.8 ±12.8 years. BP control rates in all the sample, and in non-diabetics and diabetics were 68%, 79%, and 37.9%, respectively. Diabetes was inversely associated with BP control (OR 0.16; 95%CI 0.12-0.20; p<0.001) while age ≥ 60 years (OR 1.48; 95%CI 1.15-1.91; p=0.003) and female sex (OR 1.38; 95%CI 1.05-1.82; p=0.020) were directly associated.

CONCLUSIONS

A BP control rate around 70% was found in patients attending a multidisciplinary team care center for hypertension. Focus on patients with diabetes, younger than 60 years and males should be given to further improve these results. (Arq Bras Cardiol. 2020; 115(2):174-181).

Combined Aerobic and Resistance Exercises Evokes Longer Reductions on Ambulatory Blood Pressure in Resistant Hypertension: A Randomized Crossover Trial

Aim

The present study compared the acute effects of aerobic (AER), resistance (RES), and combined (COM) exercises on blood pressure (BP) levels in people with resistant hypertension (RH) and nonresistant hypertension (NON-RH).

Methods

Twenty patients (10 RH and 10 NON-RH) were recruited and randomly performed three exercise sessions and a control session. Ambulatory BP was monitored over 24 hours after each experimental session.

Results

Significant reductions on ambulatory BP were found in people with RH after AER, RES, and COM sessions. Notably, ambulatory BP was reduced during awake-time and night-time periods after COM. On the other hand, the effects of AER were more prominent during awake periods, while RES caused greater reductions during the night-time period. In NON-RH, only RES acutely reduced systolic BP, while diastolic BP was reduced after all exercise sessions. However, the longest postexercise ambulatory hypotension was observed after AER (~11 h) in comparison to RES (~8 h) and COM (~4 h) exercises.

Conclusion

Findings of the present study indicate that AER, RES, and COM exercises elicit systolic and diastolic postexercise ambulatory hypotension in RH patients. Notably, longer hypotension periods were observed after COM exercise. In addition, NON-RH and RH people showed different changes on BP after exercise sessions, suggesting that postexercise hypotension is influenced by the pathophysiological bases of hypertension.

Physical Exercise for Individuals with Hypertension: It Is Time to Emphasize its Benefits on the Brain and Cognition

Hypertension affects more than 40% of adults worldwide and is associated with stroke, myocardial infarction, heart failure, and other cardiovascular diseases. It has also been shown to cause severe functional and structural damage to the brain, leading to cognitive impairment and dementia. Furthermore, it is believed that these cognitive impairments affect the mental ability to maintain productivity at work, ultimately causing social and economic problems. Because hypertension is a chronic condition that requires clinical treatment, strategies with fewer side effects and less-invasive procedures are needed. Physical exercise (PE) has proven to be an efficient and complementary tool for hypertension management, and its peripheral benefits have been widely supported by related studies. However, few studies have specifically examined the potential positive effects of PE on the brain in hypertensive individuals. This narrative review discusses the pathophysiological mechanisms that hypertension promotes in the brain, and suggests PE as an important tool to prevent and reduce cognitive damage caused by hypertension. We also provide PE recommendations for hypertensive individuals, as well as suggestions for promoting PE as a method for increasing cognitive abilities in the brain, particularly for hypertensive individuals.

Matão Controlling Hypertension (MatCH) project: Rationale and design

Background

Hypertension is the main risk factor for most cardiovascular diseases. A coordinated and organized system from the Brazilian Ministry of Healthy involving Family Health Strategy (FHS), a program for the prevention of chronic disease, and the Popular Pharmacy Program (PPP), which subsidizes medications for the population, could allow an earlier identification and better blood pressure (BP) control. Matão Controlling Hypertension (MatCH) is a community-based population project that aims to apply an organized, integrated and coordinated program in the city of Matão, Brazil, involving FHS and PPP in order to actively search, treat and follow-up hypertensive subjects.

Method

This is a population community-based, interventional, follow-up study where all subjects aged ≥ 40 years assisted by the FHS program in Matão will have BP assessed monthly by trained Community Health Agents (CHA) during a domiciliary visit. Identified hypertensive subjects will be referred to FHS physicians for nonpharmacological and pharmacological treatment. Most of the hypertensive drugs used will be available through the PPP. Prevalence of hypertension, awareness, demographics and risk factors will be correlated with BP control. The population study is expected to involve approximately 18.600 subjects. The study period will be four years.

Discussion

Considering that hypertension is asymptomatic in most cases, to reduce the population burden of BP-related deaths and diseases it is essential to detect and treat early all hypertensive patients. If we achieve our large-scale BP control, this program can be applied to other populations from developing countries.