Skip to main content

Advertisement

Log in

Increasing Physical Activity for the Treatment of Hypertension: A Systematic Review and Meta-Analysis

  • Review Article
  • Published:
Sports Medicine Aims and scope Submit manuscript

Abstract

Background

Low physical activity has been identified as a major risk factor for cardiovascular disease. Medical societies therefore recommend increased physical activity be part of any antihypertensive therapy.

Objective

Focusing on patient-relevant outcomes such as mortality and cardiovascular events, this review was conducted to assess the long-term effects of interventions aiming at increasing physical activity in comparison with no such interventions on adult patients with essential hypertension.

Data sources

We searched for high-quality systematic reviews in MEDLINE, EMBASE, Cochrane Database of Systematic Reviews (Cochrane Reviews), Database of Abstracts of Reviews of Effects (Other Reviews) and Health Technology Assessment Database (Technology Assessments) published between 1997 and February 2009 and for randomized controlled trials (RCTs) in MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (Clinical Trials) published before September 2012. Additional studies were identified by hand searching reference lists of reviews.

Study selection

RCTs with at least 24 weeks’ follow-up that evaluated the effect of increased physical activity on the blood pressure of adults with essential hypertension were included in our review. Primary outcomes were all-cause mortality, cardiovascular morbidity and mortality, end-stage renal disease, quality of life and adverse events.

Study appraisal and synthesis methods

When appropriate, we used random effects meta-analyses to determine mean difference with 95 % confidence intervals for each endpoint. All data were analysed using the Review Manager software version 5.0.24 from the Cochrane Collaboration.

Results

None of the included nine trials, covering 891 patients with hypertension, provided sufficient data on patient-relevant outcomes such as mortality, cardiovascular events or injuries related to physical activity. Information on changes in systolic and diastolic blood pressure was provided for all included trials. The majority of the included RCTs reported that increased physical activity led to a decrease in systolic and diastolic blood pressure of 5–10 and 1–6 mmHg, respectively, but due to marked heterogeneity in the meta-analyses both for systolic and diastolic blood pressure (I2 = 70.0 and 73.0 %), no effect estimates were provided.

Limitations

About 50 % of the included trials were small, evaluating at most 20 participants per study group, and more than twothirds were deemed to have a high risk of bias.

Conclusions

Although a decrease in blood pressure is shown to be a consequence of increased physical activity, RCTs of appropriate study size and quality that examine potential patient-relevant benefits or harms still need to be conducted to evaluate whether physical activity really improves the health of patients with essential hypertension.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. World Health Organisation. Fact sheet no. 317—cardiovascular diseases (CVDs). 2011. http://www.who.int/mediacentre/factsheets/fs317/en/index.html. Accessed 29 Aug 2012.

  2. Kannel WB. Blood pressure as a cardiovascular risk factor: prevention and treatment. JAMA. 1996;275(20):1571–6.

    Article  PubMed  CAS  Google Scholar 

  3. World Health Organisation. Chronic disease—key risk factors include high cholesterol, high blood pressure, low fruit and vegetable intake. 2003. http://www.who.int/entity/dietphysicalactivity/media/en/gsfs_chronic_disease.pdf. Accessed 2 Jan 2012.

  4. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206–52.

    Article  PubMed  CAS  Google Scholar 

  5. Daskalopoulou SS, Khan NA, Quinn RR, et al. The 2012 Canadian hypertension education program recommendations for the management of hypertension: blood pressure measurement, diagnosis, assessment of risk, and therapy. Can J Cardiol. 2012;28(3):270–87.

    Article  PubMed  Google Scholar 

  6. Deutsche Hochdruckliga, Deutsche Hypertonie Gesellschaft. Leitlinien zur Behandlung der arteriellen Hypertonie. 2008. http://www.awmf.org/uploads/tx_szleitlinien/046-001_S2_Behandlung_der_arteriellen_Hypertonie_06-2008_06-2013.pdf. Accessed 2 Jan 2012.

  7. European Society of Hypertension, European Society of Cardiology. 2007 guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2007;25(6):1105–87.

    Article  Google Scholar 

  8. National Institute for Clinical Excellence. Hypertension: the clinical management of primary hypertension in adults. Clinical Guideline 127: methods, evidence, and recommendations. 2011. http://www.nice.org.uk/nicemedia/live/13561/56007/56007.pdf. Accessed 2 Jan 2012.

  9. Sandvik L, Erikssen J, Thaulow E, et al. Physical fitness as a predictor of mortality among healthy, middle-aged Norwegian men. N Engl J Med. 1993;328(8):533–7.

    Article  PubMed  CAS  Google Scholar 

  10. Sui X, LaMonte MJ, Laditka JN, et al. Cardiorespiratory fitness and adiposity as mortality predictors in older adults. JAMA. 2007;298(21):2507–16.

    Article  PubMed  CAS  Google Scholar 

  11. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364(9438):937–52.

    Article  PubMed  Google Scholar 

  12. Fagard RH. Exercise is good for your blood pressure: effects of endurance training and resistance training. Clin Exp Pharmacol Physiol. 2006;33(9):853–6.

    Article  PubMed  CAS  Google Scholar 

  13. Cornelissen VA, Fagard RH. Effect of resistance training on resting blood pressure: a meta-analysis of randomized controlled trials. J Hypertens. 2005;23(2):251–9.

    Article  PubMed  CAS  Google Scholar 

  14. Cornelissen VA, Fagard RH. Effects of endurance training on blood pressure, blood pressure-regulating mechanisms, and cardiovascular risk factors. Hypertension. 2005;46(4):667–75.

    Article  PubMed  CAS  Google Scholar 

  15. Halbert JA, Silagy CA, Finucane P, et al. The effectiveness of exercise training in lowering blood pressure: a meta-analysis of randomised controlled trials of 4 weeks or longer. J Hum Hypertens. 1997;11(10):641–9.

    Article  PubMed  CAS  Google Scholar 

  16. Institute for Quality and Efficiency in Health Care. Benefit assessment of non-drug treatment strategies in patients with essential hypertension: weight reduction. IQWiG reports—commission no. A05-21A, full report (German). 2006. https://www.iqwig.de/download/A05-21A_Abschlussbericht_Gewichtsreduktion_bei_Bluthochdruck_neu.pdf. Accessed 2 Jan 2012.

  17. Institute for Quality and Efficiency in Health Care. Benefit assessment of non-drug treatment strategies in patients with essential hypertension: sodium reduction, IQWiG reports—commission no. A05-21B, full report (German). 2009. https://www.iqwig.de/download/A05-21B_Rapid_Report_Nichtmedikamentoese_Behandlungsstrategien_bei_Hypertonie_Kochsalzreduktion.pdf. Accessed 2 Jan 2012.

  18. Institute for Quality and Efficiency in Health Care. Benefit assessment of non-drug treatment strategies in patients with essential hypertension: stress-coping interventions, IQWiG reports—commission no. A05-21F, full report (German). 2012. https://www.iqwig.de/download/A05-21F_Rapid-Report_Nichtmedikamentoese_Behandlungsstrategien_bei_Hypertonie_Stressbewaeltigung_neu.pdf. Accessed 8 Sep 2012.

  19. Institute for Quality and Efficiency in Health Care. Benefit assessment of non-drug treatment strategies in patients with essential hypertension: Special diets without the primary aim of reducing weight or salt intake, IQWiG reports—commission No. A05-21C, full report (German). 2012. https://www.iqwig.de/download/A05-21C_RR_Spezielle_Ernaehrungsformen_bei_Hypertonie.pdf. Accessed 8 Sep 2012.

  20. Institute for Quality and Efficiency in Health Care. Cessation of smoking in essential hypertension, IQWiG reports—commission no. A05-21G, full report (German). 2012. https://www.iqwig.de/download/A05-21G-Rapid-Report_Nichtmedikamentoese_Behandlungsstrategien_bei_Hypertonie_Rauchverzicht.pdf. Accessed 8 Sep 2012.

  21. Institute for Quality and Efficiency in Health Care. Reduction of alcohol consumption in essential hypertension, IQWiG reports—commission no. A05-21E, full report (German). 2012. https://www.iqwig.de/download/A05-21E_Rapid_Report_Reduktion_des_Alkoholkonsums_bei_Hypertonie.pdf. Accessed 8 Sep 2012.

  22. Horvath K, Jeitler K, Siering U, et al. Long-term effects of weight-reducing interventions in hypertensive patients: systematic review and meta-analysis. Arch Intern Med. 2008;168(6):571–80.

    Article  PubMed  CAS  Google Scholar 

  23. Matyas E, Jeitler K, Horvath K, et al. Benefit assessment of salt reduction in patients with hypertension: systematic overview. J Hypertens. 2011;29(5):821–8.

    Article  PubMed  CAS  Google Scholar 

  24. Siebenhofer A, Horvath K, Jeitler K, et al. Long-term effects of weight-reducing drugs in hypertensive patients. Cochrane Database Syst Rev. 2009;(3):CD007654.

  25. Siebenhofer A, Jeitler K, Berghold A, et al. Long-term effects of weight-reducing diets in hypertensive patients. Cochrane Database Syst Rev. 2011;(9):CD008274.

  26. Institute for Quality and Efficiency in Health Care. Benefit assessment of non-drug treatment strategies in patients with essential hypertension: increase of physical activity, IQWiG reports—commission no. A05-21D, full report (German). 2010. https://www.iqwig.de/download/A05-21D_Rapid-Report_Nichtmedikamentoese_Behandlungsstrategien_bei_Hypertonie_Steigerung_der_koerperlichen_Aktivitaet.pdf. Accessed 2 Jan 2012.

  27. Institute for Quality and Efficiency in Health Care. Benefit assessment of non-drug treatment strategies in patients with essential hypertension: increase of physical activity, IQWiG reports—commission no. A05-21D, executive summary. 2010. https://www.iqwig.de/download/A05-21D_Executive_summary_Increase_of_physical_activity_in_essential_hypertension.pdf. Accessed 2 Jan 2012.

  28. Jadad AR, Murray WE. Randomized controlled trials: questions, answers and musings. 2nd ed. Malden: BMJ Books; 2007.

    Book  Google Scholar 

  29. Oxman AD, Guyatt GH. Validation of an index of the quality of review articles. J Clin Epidemiol. 1991;44(11):1271–8.

    Article  PubMed  CAS  Google Scholar 

  30. Oxman AD, Guyatt GH, Singer J, et al. Agreement among reviewers of review articles. J Clin Epidemiol. 1991;44(1):91–8.

    Article  PubMed  CAS  Google Scholar 

  31. Institute for Quality and Efficiency in Health Care. General methods: version 4.0. 2011. https://www.iqwig.de/download/General_Methods_4-0.pdf. Accessed 2 Jan 2012.

  32. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–88.

    Article  PubMed  CAS  Google Scholar 

  33. Arroll B, Beaglehole R. Salt restriction and physical activity in treated hypertensives. N Z Med J. 1003;1995(108):266–8.

    Google Scholar 

  34. Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–60.

    Article  PubMed  Google Scholar 

  35. Dickinson HO, Mason JM, Nicolson DJ, et al. Lifestyle interventions to reduce raised blood pressure: a systematic review of randomized controlled trials. J Hypertens. 2006;24(2):215–33.

    Article  PubMed  CAS  Google Scholar 

  36. Whelton SP, Chin A, Xin X, et al. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med. 2002;136(7):493–503.

    Article  PubMed  Google Scholar 

  37. Yeh GY, Wang C, Wayne PM, et al. The effect of tai chi exercise on blood pressure: a systematic review. Prev Cardiol. 2008;11(2):82–9.

    Article  PubMed  Google Scholar 

  38. Cleroux J, Feldman RD, Petrella RJ. Lifestyle modifications to prevent and control hypertension. 4. Recommendations on physical exercise training. Canadian Hypertension Society, Canadian Coalition for High Blood Pressure Prevention and Control, Laboratory Centre for Disease Control at Health Canada, Heart and Stroke Foundation of Canada. CMAJ. 1999;160(9 Suppl):S21–8.

  39. Ebrahim S, Smith GD. Lowering blood pressure: a systematic review of sustained effects of non-pharmacological interventions. J Public Health Med. 1998;20(4):441–8.

    Article  PubMed  CAS  Google Scholar 

  40. Kelley G. Dynamic resistance exercise and resting blood pressure in adults: a meta-analysis. J Appl Physiol. 1997;82(5):1559–65.

    PubMed  CAS  Google Scholar 

  41. Kelley GA, Kelley KA, Tran ZV. Aerobic exercise and resting blood pressure: a meta-analytic review of randomized, controlled trials. Prev Cardiol. 2001;4(2):73–80.

    Article  PubMed  Google Scholar 

  42. Kelley GA, Sharpe Kelley K. Aerobic exercise and resting blood pressure in older adults: a meta-analytic review of randomized controlled trials. J Gerontol A Biol Sci Med Sci. 2001;56(5):M298–303.

    Article  PubMed  CAS  Google Scholar 

  43. Lee MS, Pittler MH, Taylor-Piliae RE, et al. Tai chi for cardiovascular disease and its risk factors: a systematic review. J Hypertens. 2007;25(9):1974–5.

    Article  PubMed  CAS  Google Scholar 

  44. North of England Hypertension Guideline Development Group. Essential hypertension: managing adult patients in primpary care. 2004. http://www.nice.org.uk/nicemedia/pdf/CG18background.pdf. Accessed 2 Jan 2012.

  45. Petrella RJ. How effective is exercise training for the treatment of hypertension? Clin J Sport Med. 1998;8(3):224–31.

    Article  PubMed  CAS  Google Scholar 

  46. Anderssen S, Haaland A, Hjermann I, et al. Oslo Diet and Exercise Study: a one-year randomized intervention trial. Effect on hemostatic variables and other coronary risk factors. Nutr Metab Cardiovasc Dis. 1995;5:189–200.

    Google Scholar 

  47. Anderssen S, Holme I, Urdal P, et al. Diet and exercise intervention have favourable effects on blood pressure in mild hypertensives: the Oslo Diet and Exercise Study (ODES). Blood Press. 1995;4(6):343–9.

    Article  PubMed  CAS  Google Scholar 

  48. Cononie CC, Graves JE, Pollock ML, et al. Effect of exercise training on blood pressure in 70- to 79-yr-old men and women. Med Sci Sports Exerc. 1991;23(4):505–11.

    PubMed  CAS  Google Scholar 

  49. Hagberg JM, Graves JE, Limacher M, et al. Cardiovascular responses of 70- to 79-yr-old men and women to exercise training. J Appl Physiol. 1989;66(6):2589–94.

    Article  PubMed  CAS  Google Scholar 

  50. Hagberg JM, Montain SJ, Martin WH 3rd, et al. Effect of exercise training in 60- to 69-year-old persons with essential hypertension. Am J Cardiol. 1989;64(5):348–53.

    Article  PubMed  CAS  Google Scholar 

  51. Halbert JA, Silagy CA, Finucane P, et al. Recruitment of older adults for a randomized, controlled trial of exercise advice in a general practice setting. J Am Geriatr Soc. 1999;47(4):477–81.

    PubMed  CAS  Google Scholar 

  52. Halbert JA, Silagy CA, Finucane PM, et al. Physical activity and cardiovascular risk factors: effect of advice from an exercise specialist in Australian general practice. Med J Aust. 2000;173(2):84–7.

    PubMed  CAS  Google Scholar 

  53. Lee L-L, Arthur A, Avis M. Evaluating a community-based walking intervention for hypertensive older people in Taiwan: a randomized controlled trial. Prev Med. 2007;44(2):160–6.

    Article  PubMed  CAS  Google Scholar 

  54. Sohn AJ, Hasnain M, Sinacore JM. Impact of exercise (walking) on blood pressure levels in African American adults with newly diagnosed hypertension. Ethn Dis. 2007;17(3):503–7.

    PubMed  Google Scholar 

  55. Sridhar B, Haleagrahara N, Bhat R, et al. Increase in the heart rate variability with deep breathing in diabetic patients after 12-month exercise training. Tohoku J Exp Med. 2010;220(2):107–13.

    Article  PubMed  Google Scholar 

  56. The ODES Investigators. The Oslo Diet and Exercise Study (ODES): design and objectives. Control Clin Trials. 1993;14(3):229–43.

    Article  Google Scholar 

  57. Tsuda K, Yoshikawa A, Kimura K, et al. Effects of mild aerobic physical exercise on membrane fluidity of erythrocytes in essential hypertension. Clin Exp Pharmacol Physiol. 2003;30(5–6):382–6.

    Article  PubMed  CAS  Google Scholar 

  58. Psaty BM, Lumley T, Furberg CD, et al. Health outcomes associated with various antihypertensive therapies used as first-line agents: a network meta-analysis. JAMA. 2003;289(19):2534–44.

    Article  PubMed  CAS  Google Scholar 

  59. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). JAMA. 2000;283(15):1967–75.

    Article  Google Scholar 

  60. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288(23):2981–97.

    Article  Google Scholar 

  61. Dahlöf B, Devereux RB, Kjeldsen SE, et al. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet. 2002;359(9311):995–1003.

    Article  PubMed  Google Scholar 

  62. Messerli FH. Implications of discontinuation of doxazosin arm of ALLHAT. Lancet. 2000;355(9207):863–4.

    Article  PubMed  CAS  Google Scholar 

  63. Neal B, MacMahon S, Chapman N. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. Lancet. 2000;356(9246):1955–64.

    Article  PubMed  CAS  Google Scholar 

  64. Pahor M, Psaty BM, Alderman MH, et al. Health outcomes associated with calcium antagonists compared with other first-line antihypertensive therapies: a meta-analysis of randomised controlled trials. Lancet. 2000;356(9246):1949–54.

    Article  PubMed  CAS  Google Scholar 

  65. Psaty BM, Smith NL, Siscovick DS, et al. Health outcomes associated with antihypertensive therapies used as first-line agents: a systematic review and meta-analysis. JAMA. 1997;277(9):739–45.

    Article  PubMed  CAS  Google Scholar 

  66. Institute for Quality and Efficiency in Health Care. Benefit assessment of non-drug treatment strategies in patients with diabetes mellitus type 2: increase of physical activity, IQWiG reports—commission No. A05-06A, full report (German). 2012. https://www.iqwig.de/download/A05-06A_RR_Steigerung_der_koerperlichen_Aktivitaet_bei_Diabetes_mellitus_Typ_2_%282%29.pdf. Accessed 8 Sep 2012.

  67. Brown MJ. Hypertension and ethnic group. BMJ. 2006;332(7545):833–6.

    Article  PubMed  CAS  Google Scholar 

  68. Cornelissen VA, Fagard RH, Coeckelberghs E, et al. Impact of resistance training on blood pressure and other cardiovascular risk factors: a meta-analysis of randomized, controlled trials. Hypertension. 2011;58(5):950–8.

    Article  PubMed  CAS  Google Scholar 

  69. Rossi A, Dikareva A, Bacon SL, et al. The impact of physical activity on mortality in patients with high blood pressure: a systematic review. J Hypertens. 2012;30(7):1277–88.

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

We thank Anika Maas und Ursula Pueringer for their assistance in reviewing the literature and Phillip Elliott for final editing of the manuscript. This review was for the most part commissioned by and conducted in collaboration with IQWiG, the German Institute for Quality and Efficiency in Health Care. All authors had full access to all the data in the review. Thomas Semlitsch, Klaus Jeitler, Karl Horvath, Eva Nagele, Nicole Pignitter and Andrea Siebenhofer were involved as external experts in the preparation of the report A05-21D, “Benefit Assessment of Non-Drug Treatment Strategies in Patients with Essential Hypertension: Increase of Physical Activity”, for the German Institute for Quality and Efficiency in Health Care (IQWiG). Lars G. Hemkens, Christoph Schuermann, Kirsten H. Herrmann and Siw Waffenschmidt were employees of IQWiG. None of the authors has a financial interest in this manuscript or a conflict of interest to declare. Thomas Semlitsch takes responsibility for the integrity of the data and the accuracy of the data analysis.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Thomas Semlitsch.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (PDF 71 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Semlitsch, T., Jeitler, K., Hemkens, L.G. et al. Increasing Physical Activity for the Treatment of Hypertension: A Systematic Review and Meta-Analysis. Sports Med 43, 1009–1023 (2013). https://doi.org/10.1007/s40279-013-0065-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40279-013-0065-6

Keywords

Navigation