Exercise for Hypertension: A Prescription Update Integrating Existing Recommendations with Emerging Research
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- Pescatello, L.S., MacDonald, H.V., Lamberti, L. et al. Curr Hypertens Rep (2015) 17: 87. doi:10.1007/s11906-015-0600-y
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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.
KeywordsAerobic exercise Blood pressure Concurrent exercise Postexercise hypotension Prehypertension Resistance exercise
Hypertension is the most common, costly, and preventable cardiovascular disease (CVD) risk factor [1, 2]. Approximately 80 million Americans (33 %) have hypertension (systolic blood pressure [SBP] ≥140 mmHg and/or diastolic blood pressure [DBP] ≥90 mmHg), and another 87 million (36 %) have prehypertension (SBP ≥120–<140 mmHg and/or DBP ≥80–<90 mmHg); amounting to nearly 70 % of Americans with high blood pressure (BP) . Projections indicate that by 2030 over 40 % of adults in the USA will acquire hypertension. From 2010 to 2030, the total direct costs attributed to hypertension are projected to triple from US$130.7 to US$389.9 billion, while the indirect costs due to lost productivity will almost double from US$25.4 to US$42.8 billion . Lifestyle factors, such as participation in regular exercise, are recognized as key modifiable determinants of hypertension. Therefore, there is a need for more intensive efforts to promote these strategies to reduce the significant public health burden of hypertension .
The existing professional exercise recommendations among adults with hypertension [5••]
The FITT of the exercise prescription
Joint National Committee, 7th Report 
American Heart Association 
American College of Sports Medicine 
European Society of Hypertension/ European Society of Cardiology 
Canadian Hypertension Education Program 
Frequency (how often?)
3–4 sessions⋅week−1 ≥ 12 weeks
Most days of the week
Most days of the week
Most, preferably all, days of the week
4–7 days⋅week−1 in addition to habitual, daily activity
Intensity (how hard?)
Moderate to vigorousa
Moderate to high >40–60 % of maximum
Moderate 40–< 60 % of VO2reserve
Time (how long?)
30-60 min continuous or accumulated in bouts ≥10 min each
Accumulation of 30–60 min⋅day−1
Type (what kind?)
Dynamic exercise (Aerobic)
Grade Bb, Class IIa level of evidence Ac
Class I level of evidence A c
Evidence category Ad,e Evidence category Bd,e
Class I level of evidence A–Bf
Dynamic RT 2–3 days⋅week−1, moderate 60–80 % of 1-RM, 8–12 repetitions
Dynamic RT 2–3 days⋅week−1
Dynamic, Isometric, or Handgrip RT
Class IIa level of evidence Bc
Evidence category Bd,h
Despite the general consensus that exercise, particularly aerobic exercise, lowers resting BP, our systematic reviews of 33 meta-analyses on the BP response to exercise [4••] and the existing professional exercise recommendations for hypertension [5••] revealed differences in the recommended components of the Frequency, Intensity, Time, and Type or FITT principle of exercise prescription (Ex Rx) as well as the reported magnitude of the BP reductions that result from them. Therefore, the purposes of this review are to (1) overview the existing professional exercise recommendations for hypertension in terms of the FITT principle of Ex Rx; (2) discuss new and emerging research related to the Ex Rx for hypertension; and (3) present an updated FITT Ex Rx for adults with hypertension from our previous review  that integrates the existing recommendations with new and emerging research.
Systematic Review Methods
The Existing Professional Exercise Recommendations for Hypertension
Prior to overviewing the professional exercise recommendations for hypertension, it is important to define what an Ex Rx is as this definition will organize the discussion that follows. An Ex Rx is the process whereby the recommended exercise regimen is designed in a systematic and individualized manner in terms of the Frequency (How Often?), Intensity (How Hard?), Time (How Long?), and Type (What Kind?), or the FITT principle of Ex Rx [23••]. As previously stated, exercise is recommended as a key lifestyle therapy among adults with hypertension by all professional committees and organizations listed in Table 1. We now overview the existing professional exercise recommendations for hypertension in terms of the FITT principle of Ex Rx while commenting on new and emerging research.
As Table 1 shows, all professional committees/organizations recommend exercising on most, if not all, days of the week with the exception of the Lifestyle Work Group  that recommended exercising 3–4 days per week for at least 12 weeks among adults with hypertension. Our group and others have shown that the reason exercise should be recommended on most, preferably all days, of the week is because BP is lower on the days people exercise compared to the days they do not exercise. This physiological response is termed postexercise hypotension (PEH) [24, 25]. PEH is the immediate reduction in BP of 5–7 mmHg among people with hypertension that occurs after a single, isolated session of aerobic exercise of varying durations (10 to 50 min) and intensities (40 % up to 100 % of maximum oxygen consumption [VO2max]), and these BP reductions are sustained for up to 24 h after the exercise bout [6, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43••].
The merits of PEH as antihypertensive lifestyle are further supported by two recent studies by Liu et al.  and Hecksteden et al.  who found that the BP response to acute exercise was strongly correlated with the more long-term BP response to exercise training. These findings support the long held notion that PEH may account for a significant amount of the magnitude of the BP reduction attributed to exercise training [6, 26, 46]. They also suggest that PEH could be used as a health screening tool to identify individuals with hypertension who respond to aerobic exercise as antihypertensive therapy. For individuals determined not to be responsive, alternative forms of treatment can then be more rapidly applied for the treatment and control of their high BP . In fact, Luttrel and Halliwill’s  conceptual model of recovery from exercise labeled PEH as a “window of opportunity” that can be exploited as a health screening tool to increase the effectiveness of exercise as antihypertensive lifestyle therapy.
Despite the clinical utility of PEH as antihypertensive therapy, only the ACSM  has addressed the merits of PEH by providing graded evidence for the antihypertensive effects of this seemingly important phenomenon. In addition to PEH, another reason for the recommendation of exercising on most, if not all, days of the week is that adults with hypertension are often overweight or obese, and a high frequency (days per week) or volume (metabolic energy equivalents [MET] × minutes per week) of exercise is needed to achieve the caloric expenditure required for initial weight loss and successful maintenance of that weight loss [23••].
The JNC 8  and Lifestyle Work Group , AHA , ACSM , ESH/ESC , and CHEP  all recommend adults with hypertension engage in moderate intensity aerobic exercise (40 % to <60 % VO2max or heart rate [HR] reserve), whereas the intensity of exercise was not specified by JNC 7 . Of note, the Lifestyle Work Group  and AHA  also endorse vigorous intensity (≥60 % VO2max or HR reserve) aerobic exercise for people with hypertension. This endorsement of vigorous intensity aerobic exercise incorporates new and emerging evidence from our laboratory, and others, showing that the magnitude of the BP reductions that result from acute and chronic aerobic exercise occur as a direct function of intensity such that the more rigorous the intensity, the greater the resultant BP reductions [8, 23••, 42, 43••, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58].
High intensity interval training (HIIT) is defined as alternating periods of brief, very high intensity aerobic exercise (>90 % VO2max) separated by recovery periods of lower intensity exercise or rest . Consistent with Eicher et al.’s findings , several investigators have found HIIT to be superior to continuous, moderate intensity aerobic exercise training for eliciting improvements in CVD risk factors when training programs were matched for exercise volume among a variety of populations, including adults with coronary artery disease, congestive heart failure, the metabolic syndrome, and overweight and obesity [49, 50, 56, 57]. Furthermore, the magnitude of the BP reductions following HIIT was greater among samples with higher resting BP; ∼8 mmHg for hypertension  and prehypertension  versus ∼3 mmHg for normal BP . These findings are consistent with the law of initial values that BP will be lowered to the greatest levels among those with higher resting BP . Collectively, these new and emerging findings [42, 43••, 49, 50, 56, 57] indicate that exercise intensity is an important determinant of the BP response to exercise such that increasing levels of physical exertion appear to lower BP in a dose–response pattern.
Holloway and colleagues recently examined the skeletal muscle  and cardiac  adaptations to 4 weeks of HIIT compared to traditional moderate intensity aerobic exercise training among Dahl salt-sensitive rats, an animal model of hypertension. They found HIIT had a negative impact on cardiac function and the overall oxidative capacity of skeletal muscle among the rats with hypertension, whereas moderate intensity aerobic exercise resulted in favorable cardiac and skeletal muscle adaptations. These provocative findings, in addition to the fact that adults with hypertension are predisposed to a transient increase in cardiovascular risk upon sudden vigorous exertion [60, 61, 62], highlight the need for further investigation to determine the benefit-to-risk ratio of exercising at vigorous intensity among adults with hypertension before the current recommendations in Table 1 can be expanded to include vigorous intensity exercise.
All professional organizations and committees recommend exercising at least 30 min per day among people with hypertension. Consistent with the general consensus of most, preferably all, days of the week for the frequency recommendation, there is also a high level agreement among the professional organizations and committees in Table 1 that the duration of exercise should achieve a total of 150 or more minutes per week; an amount that is consistent with the recommendations for the general population [23••, 63, 64].
There is emerging evidence that acute aerobic exercise performed continuously in a single bout or accumulated in shorter bouts throughout the day can lower BP to similar levels and durations among adults with hypertension [43••, 55, 65, 66, 67, 68, 69, 70]. Guidry et al.  compared the effects of a short (15 min) and long (30 min) acute aerobic exercise bout performed at light (40 % VO2max) or moderate (60 % VO2max) intensity on PEH among 45 white, middle-aged overweight men with pre- to stage 1 hypertension. They found an acute bout of aerobic exercise performed for as short as 15 min at light to moderate intensity resulted in PEH for the remainder of the day . In addition, Ciolac and co-investigators  randomized 52 men and women on antihypertensive medication to either 40 min of acute aerobic exercise performed continuously at 60 % HR reserve or an interval aerobic exercise session that alternated between 2 min at 50 % HR reserve and 1 min at 80 % HR reserve to total 40 min. The continuous exercise group lowered ambulatory SBP and DBP 4–8 mmHg, while the interval exercise group lowered ambulatory SBP only 5–6 mmHg over 24 h. Finally, Bhammar and colleagues  compared the effects of fractionized aerobic exercise (three 10-min bouts) interspersed throughout the day (morning, midday, and afternoon) and continuous aerobic exercise (one 30-min bout) performed at 60–65 % VO2max on ambulatory BP among 11 young subjects with prehypertension. They found fractionized exercise was as at least as effective as continuous exercise in eliciting PEH until the following morning. Miyashita and colleagues  found that even shorter bouts of aerobic exercise (10 3-min bouts) interspersed throughout the day were as effective as a 30-min bout of continuous aerobic exercise in eliciting PEH.
Collectively, these findings [66, 71, 72, 73] and others [67, 68, 69, 70, 74] support that PEH is a low threshold phenomenon in terms of the duration of the exercise bout needed to produce the effect; and when these short bouts of exercise are interspersed throughout the day, PEH is a viable therapeutic lifestyle option for BP control among individuals with high BP. Not having the time to exercise is often a major deterrent to starting and maintaining a regular exercise program. For this reason, performing accumulated, shorter exercise bouts throughout the day (i.e., 3 to 10 min to total 30 min or more) would appear to be an attractive therapeutic option among adults with hypertension [43••, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74]. Nonetheless, future research is needed to determine if interspersing shorter bouts of aerobic exercise throughout the day may be used as a behavioral strategy to increase exercise adherence in this population.
There is broad consensus supported by a strong rating of evidence that aerobic exercise should be prescribed as the primary type of exercise for the prevention, treatment, and control of hypertension. This recommendation is made by all professional organizations and committees in Table 1 because aerobic exercise training has been consistently shown to lower BP 5–7 mmHg among those with hypertension, levels that are twice that resulting from dynamic resistance training [6, 16, 17, 18, 19, 20, 21]. The AHA , ACSM , ESH/ESC , and CHEP  recommend that adults with hypertension engage in dynamic resistance training as a supplement to aerobic exercise training, while the JNC 7 , JNC 8 , and Lifestyle Work Group  did not make any specific recommendations regarding dynamic resistance training.
As Table 1 shows, the level of evidence upon which the dynamic resistance training recommendations are made is weak, which may contribute to the lack of consensus among professional organizations and committees regarding the effectiveness of dynamic resistance training as antihypertensive therapy. One possible reason for this weak rating of evidence may be partially attributed to the dearth of primary level studies investigating dynamic resistance training as antihypertensive lifestyle therapy among adults with hypertension. This short-coming likely underestimates the effectiveness of dynamic resistance exercise training as antihypertensive lifestyle therapy due to the law of initial values, which predicts that the largest BP reductions would occur in adults with hypertension [5••, 6, 7, 8, 13, 26].
Indeed, several primary level studies have shown that the BP reductions following dynamic resistance training may be comparable in magnitude to those that result from aerobic exercise training among adults with high BP [43••, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84]. Mota and colleagues  found 16 weeks of moderate intensity dynamic resistance training reduced SBP/DBP about 14/4 mmHg among 32 older women with controlled hypertension. Moraes et al.  found 12 weeks of moderate intensity dynamic resistance training reduced SBP/DBP approximately 16/12 mmHg among 15 middle-aged men with hypertension. In addition, several controlled trials [43••, 50, 76, 77, 78, 81, 86, 87, 88] directly comparing the effectiveness of aerobic exercise training versus dynamic resistance training as antihypertensive therapy found that SBP/DBP were reduced to similar levels among adults with untreated [76, 77] and controlled hypertension [78, 81], with no statistical difference between modalities. BP reductions of this magnitude following dynamic resistance training have also been reported among young [50, 86, 89] and middle-aged [87, 88, 90] adults with prehypertension. These findings suggest that moderate intensity dynamic resistance training may be viable as stand-alone antihypertensive lifestyle therapy among adults with hypertension. Nonetheless, more RCTs are needed to more definitively determine whether the existing professional exercise recommendations for hypertension should be expanded to include dynamic resistance training as stand-alone lifestyle therapy, and more precisely define for what patient populations and FIT features of dynamic resistance training programs would elicit the greatest BP benefits.
Last, it is not well understood how the combined effects of aerobic exercise and dynamic resistance training, termed concurrent exercise training, influence resting BP among adults with hypertension. Concurrent exercise training is defined as aerobic and dynamic resistance training performed in close proximity to each other (i.e., in a single session or on separate days) [43••, 91, 92, 93]. In light of evidence suggesting that dynamic resistance training may be as effective as aerobic exercise training as stand-alone antihypertensive lifestyle therapy among those with hypertension, the antihypertensive effects of concurrent exercise training are worthy of mention [5••, 43••].
Hayashino et al.  performed a meta-analysis of 42 trials, of which 14 were concurrent exercise training trials. Overall, the sample included middle-aged adults with type 2 diabetes mellitus and about 36 % had hypertension. The authors  reported SBP/DBP reductions following aerobic exercise training of 1.7/2.3 mmHg, dynamic resistance training of 2.8/2.3 mmHg, and concurrent exercise training of 3.2/1.9 mmHg, BP reductions that were not different among the three modalities of exercise. Furthermore, Cornelissen and Smart  found in a sample of 93 trials, of which 14 included concurrent exercise training trials, BP was reduced 3.5/2.5 mmHg following aerobic exercise training, 1.8/3.2 mmHg following dynamic resistance training, and 2.2 mmHg (SBP only) following concurrent exercise training, and once again, the BP reductions were not different among the three modality groups. Clearly, further investigation is needed to explore the promising merits of concurrent exercise training as antihypertensive lifestyle therapy.
An Exercise Prescription for Hypertension Update
The FITT Ex Rx recommendations that follow are based upon the existing exercise recommendations for hypertension displayed in Table 1, while integrating the new and emerging research we have discussed in this review.
Aerobic exercise on most, preferably all days of the week and dynamic resistance exercise on 2 to 3 days in that same week.
Moderate intensity aerobic exercise (i.e., 40 to <60 % VO2max or HR reserve; 11–13 rating of perceived exertion [RPE] on the 6–20 Borg Scale [95, 96]) and moderate intensity dynamic resistance exercise (60 % to 80 % one repetition maximum [1-RM]).
Due to emerging evidence that the BP reductions resulting from exercise are dose-dependent upon the intensity of exercise [42, 43••, 49, 50, 51, 52, 56, 57, 72], the intensity recommendation may be expanded in the future to include vigorous intensity pending the results of future research that better establishes the benefits and risks of more rigorous levels of exercise among those with hypertension.
Aerobic exercise should be performed for 30 to 60 min per day that is continuous or accumulated. If accumulated, bouts should be at least 10 min in duration to total 30 to 60 min of exercise per day. Dynamic resistance exercise should consist of two to three sets of 10 to 12 repetitions for 8 to 10 exercises that target the major muscle groups of the upper and lower body. The duration of exercise should total 150 min or more per week.
Examples of aerobic activities may include walking, jogging, cycling, and swimming. Dynamic resistance training equipment may include machine weights, free weights, and resistance bands, as well as functional body weight exercises.
Due to evidence supporting the merits of both dynamic resistance [75, 76, 77, 78, 79, 80, 81, 82, 83, 84] and concurrent exercise training [8, 43••, 94], it seems prudent that adults with hypertension should perform combinations of aerobic and dynamic resistance exercise during a given week. However, due to the weak and limited nature of this literature (Table 1) [4••, 5••], further research is needed to explore the merits of dynamic resistance and concurrent exercise training as antihypertensive therapy.
The FITT principle of Ex Rx relating to progression for healthy adults generally applies to those with hypertension . Progression should be gradual, avoiding large increases in any of the FITT components of the Ex Rx, especially intensity [23••]. Health care and exercise professionals should also consider the level of BP control, recent changes in antihypertensive drug therapy, medication-related adverse and exercise effects, and the presence of target organ disease and/or other comorbidities with adjustments made accordingly [5••, 6, 23••].
Hypertension is arguably one of the most important CVD risk factors due to its high prevalence and medical costs . Indeed, nearly 70 % of Americans have pre- to established hypertension. Aerobic exercise is universally recommended as initial lifestyle therapy for individuals with hypertension because it lowers BP 5–7 mmHg among adults with hypertension. Nonetheless, the components of the FITT principle of Ex Rx differ among the existent recommendations [5••]. Considering both the exercise recommendations for hypertension in Table 1 and new and emerging literature, we have formulated an updated FITT Ex Rx from our previous review  as follows: a combination of 30 min or more per day of moderate intensity aerobic exercise on most, preferably all, days of the week and dynamic resistance exercise 2 to 3 days per week to total 150 min or more of exercise per week. The notable difference in this updated FITT Ex Rx from our previous review is a greater emphasis on inclusion of dynamic resistance exercise in combination with aerobic exercise. Further investigation is needed to more precisely establish the FIT combinations of aerobic and resistance exercise that elicit the greatest BP benefit among adults with hypertension.
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Conflict of Interest
Dr. Pescatello, Dr. MacDonald, and Ms. Lamberti declare that they have no conflicts of interest. Dr. Johnson declares personal fees from the American College of Sports Medicine.
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This article does not contain any studies with human or animal subjects performed by any of the authors.
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