This document discusses exercise prescription for individuals with hypertension. It begins by defining hypertension and describing the different classifications based on blood pressure levels. It then discusses lifestyle factors that can contribute to hypertension, as well as medications used to treat it. The document recommends that exercise testing may be useful for evaluating blood pressure response to exercise and guiding exercise prescription. For most individuals with controlled blood pressure, light-to-moderate intensity exercise like walking is sufficient without need for testing. The benefits of regular aerobic exercise for lowering blood pressure and reducing cardiac risks are outlined. Factors like medication side effects and target organ disease must be considered when developing an individual's exercise prescription. Moderate intensity aerobic exercise is generally recommended over vigorous exercise.

1. Exercise prescription in
Hypertension
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Amrit Parihar

2. High Blood Pressure as having a resting systolic blood
pressure (SBP) ≥140 mm Hg and/or a resting diastolic
blood pressure (DBP) ≥90 mm Hg, confirmed by a
minimum of two measures taken on at least two separate
days, or taking antihypertensive medication for the
purpose of BP control
Primary hypertension accounts for 95% of all cases and is
a risk factor for the development of CVD and premature
mortality
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3. The known contributors of primary hypertension include
genetic and lifestyle factors such as high-fat and high-salt
diets and physical inactivity
Secondary hypertension accounts for the remaining 5%.
The principal causes of secondary hypertension are
chronic kidney disease, renal artery stenosis,
pheochromocytoma, excessive aldosterone secretion, and
sleep apnea
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4. BP classification SBP (mm Hg) DBP (mm Hg)
Normal <120 <80
Prehypertension 120-139 80-89
Stage 1
Hypertension
140-159 90-99
Stage 2
Hypertension
>160 >100
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5. A variety of medications are available in the treatment of
hypertension. Current guidelines for the management of
hypertension provide specific instructions on the
implementation of pharmacologic therapies.
Most patients treated with medication require more than
one medication to achieve their targeted BP.
Some antihypertensive medications may affect the
physiological response to exercise and therefore must be
taken into consideration during exercise testing and when
prescribing exercise.
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6. Guidelines for the management of hypertension also
emphasize lifestyle modifications that include habitual PA
as initial therapy to lower BP and to prevent or attenuate
progression to hypertension in individuals with
prehypertension.
Other recommended lifestyle changes include smoking
cessation, weight management, reduced sodium intake,
moderation of alcohol consumption, and an overall health
dietary pattern consistent with the Dietary Approaches to
Stop Hypertension diet.
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7. Exercise Testing
Although hypertension is not an indication for exercise
testing, the test may be useful to evaluate the BP response
to exercise which may be useful to guide Ex Rx.
Individuals with hypertension may have an exaggerated
BP response to exercise, even if resting BP is controlled.
Some individuals with prehypertension may also have a
similar response
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8. Recommendations regarding exercise testing for
individuals with hypertension vary depending on their BP
level and the presence of other CVD risk factors target
organ disease, or clinical CVD.
For most asymptomatic individuals with hypertension and
prehypertension adequate BP management prior to
engaging in light-to-moderate intensity exercise programs
such as walking is sufficient with no need for medical
evaluation or exercise testing.
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9. Individuals with hypertension whose BP is not controlled
should consult with their physician prior to initiating an
exercise program to determine if an exercise test is
needed.
Individuals with stage 2 hypertension or with target organ
disease (e.g., left ventricular hypertrophy, retinopathy)
must not engage in any exercise, including exercise
testing, prior to a medical evaluation and adequate BP
management. A medically supervised symptom-limited
exercise test is recommended prior to engaging in an
exercise program for these individuals.
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10. When exercise testing is performed for the specific
purpose of designing the Ex Rx, it is preferred that
individuals take their usual antihypertensive medications
as recommended.
Individuals on β-blocker therapy are likely to have an
attenuated HR response to exercise and reduced maximal
exercise capacity. Individuals on diuretic therapy may
experience hypokalemia and other electrolyte imbalances,
cardiac dysrhythmias, or potentially a false-positive
exercise test.
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11. Exercise Prescription
Chronic aerobic exercise of adequate intensity, duration,
and volume that promotes an increased exercise capacity
leads to reductions in resting SBP and DBP of 5–7 mm Hg
and reductions in exercise SBP at submaximal workloads
in individuals with hypertension.
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12. Regression of cardiac wall thickness and left ventricular
mass in individuals with hypertension who participate in
regular aerobic exercise training and a lower left
ventricular mass in individuals with prehypertension and a
moderate-to-high physical fitness status have also been
reported.
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14. Exercise Training Considerations
Consideration should be given to the level of BP control,
recent changes in antihypertensive drug therapy,
medication-related adverse effects, the presence of target
organ disease, other comorbidities, and age. Adjustments
to the Ex Rx should be made accordingly.
In general, progression should be gradual, avoiding large
increases in any of the FITT components of the Ex Rx,
especially intensity for most individuals with
hypertension.
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15. An exaggerated BP response to relatively low exercise
intensities and at HR levels <85% of the age-predicted
maximal heart rate (HRmax) is likely to occur in some
individuals, even after resting BP is controlled with
antihypertensive medication.
In some cases, an exercise test may be beneficial to
establish the exercise HR corresponding to the
exaggerated BP in these individuals.
It is prudent to maintain SBP ≤220 mm Hg and/or DBP
≤105 mm Hg when exercising.
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16. Although vigorous intensity aerobic exercise is not
necessarily contraindicated in patients with hypertension,
moderate intensity aerobic exercise is generally
recommended to optimize the benefit-to-risk ratio.
Individuals with hypertension are often overweight or
obese. Ex Rx should focus on increasing caloric
expenditure coupled with reducing caloric intake to
facilitate weight reduction.
Inhaling and breath-holding while engaging in the actual
lifting of a weight can result in extremely high BP
responses, dizziness, and even fainting. Thus, such
practice should be avoided during resistance training.
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17. Special Considerations
Exercise testing and vigorous intensity exercise training
for individuals with hypertension at moderate-to-high risk
for cardiac complications should be medically supervised
until the safety of the prescribed activity has been
established.
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18. β-Blockers and diuretics may adversely affect
thermoregulatory function.
β- Blockers may also increase the predisposition to
hypoglycemia in certain individuals (patients with DM
who take insulin) and mask some of the manifestations of
hypoglycemia.
In these situations, educate patients about the signs and
symptoms of heat intolerance and hypoglycemia and the
precautions that should be taken to avoid these situations.
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19. β-Blockers, particularly the nonselective types, may
reduce submaximal and maximal exercise capacity
primarily in patients without myocardial ischemia.
The peak exercise HR achieved during a standardized
exercise stress test should then be used to establish the
exercise training intensity. If the peak exercise HR is not
available, RPE should be used.
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20. Antihypertensive medications such as α-blockers, calcium
channel blockers, and vasodilators may lead to sudden
excessive reductions in post exercise BP. Therefore,
termination of the exercise should be gradual, and the
cool-down period should be extended and carefully
monitored until BP and HR return to near resting levels.
A majority of older individuals are likely to have
hypertension. The exercise related BP reduction is
independent of age. Therefore, older individuals
experience similar exercise induced BP reductions as
younger individuals
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21. The BP-lowering effects of aerobic exercise are
immediate, a physiologic response referred to as post
exercise hypotension. Patients should be made aware of
post exercise hypotension and instructed how to modulate
its effects (e.g., continued very light intensity exercise
such as slow walking).
If an individual with hypertension has ischemia during
exercise, the Ex Rx recommendations for those with CVD
with ischemia should be utilized.
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22. Thank you
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