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Therapeutic role of exercise in treating hypertension Dalynn T. Badenhop, Ph.D., FACSM Professor of Medicine Director, Cardiac Rehabilitation Medical College.

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Presentation on theme: "Therapeutic role of exercise in treating hypertension Dalynn T. Badenhop, Ph.D., FACSM Professor of Medicine Director, Cardiac Rehabilitation Medical College."— Presentation transcript:

1 Therapeutic role of exercise in treating hypertension Dalynn T. Badenhop, Ph.D., FACSM Professor of Medicine Director, Cardiac Rehabilitation Medical College of Ohio

2 Educational Objectives zTo explain the acute blood pressure response to exercise zTo list the mechanisms by which exercise may improve hypertension zTo apply exercise guidelines in treating hypertension zTo prescribe appropriate drug therapy for active hypertensive patients

3 Overview of Hypertension zHigh BP is a risk factor for stroke, CHF, angina, renal failure, LVH and MI zHypertension clusters with hyperlipidemia, diabetes and obesity zDrugs have been effective in treating high BP but because of their side effects and cost, non-pharmacologic alternatives are attractive

4 1997 JNC VI Classification of Blood Pressure Blood Pressure CategorySystolicDiastolic Optimal<120<80 Normal<130<85 High Normal130-13985-89 Hypertension Stage 1 (Mild)140-15990-99 Stage 2 (Moderate)160-179100-109 Stage 3 (Severe)> 180> 110

5 Overview of Hypertension zJoint National Committee VI (JNC VI) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (1997) y50 million hypertensive patients in the U.S. zNational Health and Nutrition Examination Survey III (NHANES III) (1995) yonly 21% of treated hypertensive patients have BP controlled to <140/90 mm Hg y35% of hypertensive patients are unaware of their condition zHigh-normal BP is associated with an incresed risk of cardiovascular disease yN Eng J Med 2001; 345; 1291-7

6 Pathophysiology of Hypertension zEssential hypertension is characterized by increased DBP and related arteriolar vasoconstriction leading to increased SBP zBP is mainly determined by cardiac output and total peripheral resistance zHigh blood pressure may be linked to age- related vascular stiffening

7 Pathophysiology of Hypertension zHigh blood pressure is also associated with obesity, salt intake, low potassium intake, physical inactivity, heavy alcohol use and psychological stress zIntra-abdominal fat and hyperinsulinemia may play a role in the pathogenesis of hypertension

8 Prevalence of Other Risk Factors With Hypertension Risk FactorPercent Smoking35 LDL Cholesterol >140 mg/dl40 HDL Cholesterol < 40 mg/dl25 Obesity40 Diabetes15 Hyperinsulinemia50 Sedentary lifestyle>50 Kaplan NM. Dis Mon 1992; 38:769-838

9 Cardiovascular Consequences of Hypertension zIndividuals with BP > 160/95 have CAD, PVD & stroke that is 3X higher than normal zHTN may lead to retinopathy and nephropathy zHTN is also associated with subclinical changes in the brain and thickening and stiffening of small blood vessels

10 Cardiovascular Consequences of Hypertension zIncreased cardiac afterload leads to left ventricular hypertrophy and reduced early diastolic filling zIncreased LV mass is positively associated with CV morbidity and mortality independent of other risk factors zHigh BP also promotes coronary artery calcification, a predictor of sudden death

11 Hypertension & CVD Outcomes zIncreased BP has a positive and continuous association with CV events zWithin DBP range of 70-110 mm Hg, there is no threshold below which lower BP does not reduce stroke and CVD risk zA 15/6 mm Hg BP reduction reduced stroke by 34% and CHD by 19% over 5 years

12 Lifestyle Changes for Hypertension zReduce excess body weight zReduce dietary sodium to < 2.4 gms/day zMaintain adequate dietary intake of potassium, calcium and magnesium zLimit daily alcohol consumption to < 2 oz. of whiskey, 10 oz. of wine, 24 oz. of beer zExercise moderately each day zEngage in meditation or relaxation daily zCessation of smoking

13 JNC VI Blood Pressure Classification

14 Medical Therapy and Implications for Exercise Training zPharmacologic and nonpharmocologic treatment can reduce morbidity zSome antihypertensive agents have side- effects and some worsen other risk factors zExercise and diet improve multiple risk factors with virtually no side-effects zExercise may reduce or eliminate the need for antihypertensive medications

15 Acute BP Response to Exercise

16 Exaggerated BP Response to Exercise zAmong normotensive men who had an exercise test between 1971-1982, those who developed HTN in 1986 were 2.4 times more likely to have had an exaggerated BP response to exercise zExaggerated BP response increased future hypertension risk by 300% after adjusting for all other risk factors

17 Exaggerated BP Response to Exercise zExaggerated BP was change from rest in SBP >60 mm Hg at 6 METs; SBP > 70 mm Hg at 8 METs; DBP > 10 mm Hg at any workload. zSubjects in CARDIA study with exaggerated exercise BP were 1.7 times more likely to develop HTN 5 years later J Clin Epidemiol 51 (1): 1998

18 NIH Consensus Conference on Physical Activity and CV Health (1995) zReview of 47 studies of exercise and HTN z70% of exercise groups decreased SBP by an avg. of 10.5 mm Hg from 154 z78% of subjects decreased DBP by an avg. of 8.6 mm Hg from 98 zOnly 1 study showed increased BP w/ EX zBeneficial responses are 80 times more frequent than negative responses Hagberg, J., et.al., NIH, 1995: 69-71

19 Increasing Lifestyle Activity for Patients with High- Normal Blood Pressure and Stage I Hypertension Medical College of Ohio Study Group Kevin A. Phelps, D.O. Larry Johnson, M.D. Sandra Puczynski, Ph.D. Dalynn Badenhop, Ph.D. Michael McCrea Wendy Boone, RN, M.P.H

20 Lifestyle Activity vs. Structured Exercise zJAMA 1999; 281(4): 327-334 ymoderate-intensity lifestyle activity showed similar or better results versus structured exercise for ximproved cardiovascular fitness xreduced body fat xdecreased total cholesterol xreduced blood pressure xpatient compliance zIn the past five years the Surgeon General, CDC, NIH, and ACSM have published position statements on the potential health benefits of lifestyle activity

21 zTwenty-four week, physician-directed intervention program to lower BP by increasing physical activity zPatients randomized into two groups: yGroup 1 - educational intervention monitored via activity logs yGroup 2 - educational intervention monitored via activity logs and pedometer Study Design

22 The Pedometer za small device worn at the waist that counts steps zused successfully in obesity studies

23 Study Hypotheses zAdding a pedometer yto goal setting will increase the level and frequency of physical activity ywill improve BP control of adult patients with high-normal BP or Stage 1 HTN

24 Main Outcome Measures zBlood Pressure and BMI zPhysical Activity assessed by: ytwo questionnaires xPhysical Activity Recall Scale (PASE): assessed activity in past seven days xPhysician-based Assessment and Counseling for Exercise (PACE) : assessed readiness for change in level of physical activity

25 Patient Education Tool

26 Methods: Patient Identification zPotential subjects identified by chart audit yaverage BP of past three visits in High Normal BP or Stage 1 HTN category zExclusion Criteria: yAntihypertensive med use confirmed BP 160/100 yDx DM, CHF, CAD, CVD, CA, MR ypregnant ychild (< 18 yrs)

27 Methods: Patient Recruitment zIdentified subjects contacted during regularly scheduled physician visit zPhysician introduced study to patient zInterested patients met with research assistant for more information about study

28 Methods: Patient Eligibility zInterested patients had two eligibility visits two weeks apart to confirm elevated BP zIf average BP at two visits confirmed High-Normal BP or Stage 1 HTN from chart audit, then patient was scheduled for first study visit (t 0 )

29 Sample Characteristics

30 Methods: Study Visits zResearch Assistant ymeasured BP and weight, reviewed activity log at all visits yadministered PASE and PACE at baseline and completion zPhysician ydiscussed barriers to increasing activity ynew activity goal setting yassisted with problem solving

31 Preliminary Results zOutcome measures analyzed at ybeginning of study, week 0 (t 0 ) yend of intervention period, week 12 (t 1 ) yend of maintenance period, week 24 (t 2 )

32 Change in Systolic BP from Time 0 to Time 1 (12 weeks) for both groups P =.005

33 Change in Systolic BP across time for both groups (24 weeks)

34 Change in Diastolic BP from Time 0 to Time 1 for both groups (12 weeks)

35 Change in Diastolic BP across time for both groups (24 weeks)

36 Change in BMI across time for both groups (24 weeks)

37 Change in PASE across time for both groups (24 weeks)

38 Preliminary Conclusions zIntervention alone (Group 1) did not significantly improve BP zIntervention plus a pedometer (Group 2) significantly improved BP, but only with regular physician visits

39 Possible Mechanisms of BP Reduction with Exercise zReduced visceral fat independent of changes in body weight or BMI zAltered renal function to increase elimination of sodium leading to reduce fluid volume zAnthropomorphic parameters may not be primary mechansims in causing HTN

40 Possible Mechanisms of BP Reduction with Exercise zLower cardiac output and peripheral vascular resistance at rest and submaximal exercise yDecreased HR yDecreased sympathetic and increased parasympathetic tone yLower blood catecholamines and plasma renin activity

41 Antihypertensive & Volume Depleting Effects of Mild Exercise on Essential HTN z20 subjects with HTN (155/100) randomized to Exercise or Control group zCycle Ergometer Exercise at Blood Lactic Acid Threshold for 60 min. 3X/wk for 10 weeks zChanges in BP, hemodynamics and humoral factors of EX group compared with control group Urata, H., et. al. Hypertension 9:245-252,1987

42 Antihypertensive & Volume Depleting Effects of Mild Exercise on Essential HTN

43 zWhole blood and plasma volume indices were significantly reduced (p < 0.05) zChange in serum Na+:serum K+ positively correlated with change in SBP zPlasma NE concentrations at rest & Workload @ BLAT during GXTs were reduced zChange in resting NE correlated with change in mean BP Urata, H., et. al. Hypertension 9:245-252, 1987

44 Changes in Taurine & other Amino Acids in Response to Mild Exercise zBlood pressures were significantly decreased by 14.8/6.6 mmHg in the EX group but not the Control group zSerum concentration increases of taurine (26%), cystine (287%), asparagine (11%), histidine (6%) and lysine (7%) in the EX zSerum taurine was negatively correlated with the change in plasma NE Tanabe, Y, et. al., Clin & Exper Hyper 11:149-165, 1989

45 Changes in Taurine & other Amino Acids in Response to Mild Exercise

46

47 Exercise Prescriptions for Patients With Borderline-to-Moderate Hypertension Patient evaluation Look for lipid disorders, DM, retinopathy, neuropathy, PVD, renal insufficiency, LV dysfunction, silent MI/ischemia osteoarthritis, osteoporosis Exercise testingGXT with modified Naughton protocol, R/O asymptomatic ischemic CAD, radionuclide Exercise typeAerobic, low-impact activities: walking, biking, swimming, tai chi, stepper, treadmill walking

48 Modified Naughton Treadmill Protocol

49 Exercise Prescriptions for Patients With Borderline-to-Moderate Hypertension Frequency5 days/week as a minimum IntensityStart at 50-60% maximum HRR & slowly increase to 70%; within 6 weeks work at 85% HRR or from 50-90% of maximal heart rate DurationStart with 20-30 min/day of continuous activity for first 3 wk, then 30-45 min/day for next 4-6 wk, and 60 min/day as maintenance

50 Exercise Prescriptions for Patients With Borderline-to-Moderate Hypertension zExcessive rises in blood pressure should be avoided during exercise (SBP > 230 mm Hg; DBP > 110 mm Hg). Restrictions on participation in vigorous exercise should be placed on patients with left ventricular hypertrophy.

51 Weight Training zResistive exercise produces the most striking increases in BP zResistive exercise results in less of a HR increase compared with aerobic exercise and as a result the rate pressure product may be less than aerobic exercise zAssessment of BP response by handgrip should be considered in patients w/ HTN zGrowing evidence that resistive training may be of value for controlling BP Kelemen, et.al., JAMA 263:2766- 71,1990

52 Drug Therapy for Active Hypertensive Patients Hypertension only zThiazide diuretics in combination with a potassium supplement are effective and inexpensive zDiuretics limit plasma volume expansion and decrease peripheral resistance zOther antihypertensive drugs can be used as monotherapy for this type of patient

53 Drug Therapy for Active Hypertensive Patients Hypertension with other diseases CAD - calcium-channel blocker or a beta- blocker Diabetes - ACE inhibitor LVH but coughs with ACE inhibitor - angiotensin-2-receptor blocker Elderly men with prostatism - peripheral alpha-blocker (terazosin, doxazosin)

54 Drug Therapy for Active Hypertensive Patients zBeta 1 -selective blockers such as atenolol or metoprolol are preferable to non-selective agents such as propranolol, nadolol or pindolol for hypertensive patients engaged in regular exercise Kaplan, N.M., Am J Hypertens 2:75-77,1989

55 Beta-blocker therapy and exercise zNon-selective Beta-blockers may increase a patients disposition to exertional hyperthermia. So patients should adhere strictly to guidelines for fluid replacement zPatients should use fluid replacement drinks with low concentrations of K + to avoid the risk of hypokalemia Gordon, N.F., Am J Cardiol 55: 74-78,1985

56 Beta-blocker therapy and exercise zExercise therapy is desirable during Beta-blocker therapy to offset the adverse alterations in lipoprotein metabolism contributed by some Beta-blocker medications Gordon, N.F., Compr Ther 14: 52-57, 1988

57 Beta-blocker therapy and exercise zExercise intensity for patients on Beta- blocker medications should be in accordance with traditional guidelines based on the results of individualized exercise testing performed on the medication. American College of Sports Medicine Guidelines for Exercise Testing and Prescription, 2000

58 Beta-blocker therapy and exercise zNon-selective Beta-blockers dramatically reduce peak aerobic capacity and at the same time increase a patients rating of perceived exertion for a given amount of work. Kaplan, N.M., Am J Hypertens 2:75-77,1989

59 Beta-blocker therapy and exercise zPatients treated with Beta-blockers are capable of deriving the expected enhancement of cardiorespiratory fitness during training, irrespective of the type of drug used Blood, S.M., J Cardiopulmonary Rehabil 8: 141-144, 1988

60 SUMMARY zPhysical activity has a therapeutic role in the treatment of hypertension zNo consistent relationship between reduced weight and lower BP zExercise at lower intensities is effective in treating mild to moderate hypertension zExercise testing may help identify exaggerated BP responses to exercise

61 SUMMARY zExercise prescription for HTN should be based on medical hx and risk factor status zExercise prescription should be adapted to antihypertensive medications that may affect exercise HR, BP & performance zIncorporating resistive training into the exercise prescription may be of value for controlling blood pressure

62 References Chintanadilok, J., Exercise in Treating Hypertension, PhysSports Med 30: 11-23, 2002 Urata, H., Antihypertensive and Volume-Depleting Effects of Mild Exercise on Essential Hypertension, Hypertension 9: 245-52, 1987. Tanabe, Y., Changes in Serum Concentration of Taurine and Other Amino Acids in Clinical Antihypertensive Exercise Therapy, Clin and Exper Hyper A11: 149-165, 1989. American College of Sports Medicine, Physical Activity, Physical Fitness and Hypertension, Med Sci Sports Exerc 25: i - x, 1993. ACSMs Resource Manual for Guidelines for Exercise Testing and Prescription, Baltimore, Williams & Wilkins, p. 275-280, 1998.


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