1、Therapeutic role of exercise in treating hypertensionDalynn T.Badenhop,Ph.D.,FACSMProfessor of MedicineDirector,Cardiac RehabilitationMedical College of OhioEducational ObjectiveszTo explain the acute blood pressure response to exercisezTo list the mechanisms by which exercise may improve hypertensi
2、onzTo apply exercise guidelines in treating hypertensionzTo prescribe appropriate drug therapy for active hypertensive patientsOverview of HypertensionzHigh BP is a risk factor for stroke,CHF,angina,renal failure,LVH and MIzHypertension clusters with hyperlipidemia,diabetes and obesityzDrugs have be
3、en effective in treating high BP but because of their side effects and cost,non-pharmacologic alternatives are attractive1997 JNC VI Classification of Blood PressureBlood Pressure CategorySystolicDiastolicOptimal12080Normal130 180 110Overview of HypertensionzJoint National Committee VI(JNC VI)on Pre
4、vention,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 mg/dl40HDL Cholesterol 50Kaplan NM.Dis Mon 19
5、92;38:769-838Cardiovascular Consequences of HypertensionzIndividuals with BP 160/95 have CAD,PVD&stroke that is 3X higher than normalzHTN may lead to retinopathy and nephropathyzHTN is also associated with subclinical changes in the brain and thickening and stiffening of small blood vesselsCardiovas
6、cular Consequences of Hypertension zIncreased cardiac afterload leads to left ventricular hypertrophy and reduced early diastolic fillingzIncreased LV mass is positively associated with CV morbidity and mortality independent of other risk factorszHigh BP also promotes coronary artery calcification,a
7、 predictor of sudden death Hypertension&CVD OutcomeszIncreased BP has a positive and continuous association with CV eventszWithin DBP range of 70-110 mm Hg,there is no threshold below which lower BP does not reduce stroke and CVD riskzA 15/6 mm Hg BP reduction reduced stroke by 34%and CHD by 19%over
8、 5 yearsLifestyle Changes for HypertensionzReduce excess body weight zReduce dietary sodium to 2.4 gms/dayzMaintain adequate dietary intake of potassium,calcium and magnesiumzLimit daily alcohol consumption to 60 mm Hg at 6 METs;SBP 70 mm Hg at 8 METs;DBP 10 mm Hg at any workload.zSubjects in CARDIA
9、 study with exaggerated exercise BP were 1.7 times more likely to develop HTN 5 years laterJ Clin Epidemiol 51(1):1998NIH Consensus Conference on Physical Activity and CV Health(1995)zReview of 47 studies of exercise and HTNz70%of exercise groups decreased SBP by an avg.of 10.5 mm Hg from 154z78%of
10、subjects decreased DBP by an avg.of 8.6 mm Hg from 98zOnly 1 study showed increased BP w/EXzBeneficial responses are 80 times more frequent than negative responsesHagberg,J.,et.al.,NIH,1995:69-71Increasing Lifestyle Activity for Patients with High-Normal Blood Pressure and Stage I HypertensionMedica
11、l College of Ohio Study GroupKevin A.Phelps,D.O.Larry Johnson,M.D.Sandra Puczynski,Ph.D.Dalynn Badenhop,Ph.D.Michael McCreaWendy Boone,RN,M.P.HLifestyle Activity vs.Structured Exercisez JAMA 1999;281(4):327-334 ymoderate-intensity lifestyle activity showed similar or better results versus structured
12、 exercise forximproved cardiovascular fitness xreduced body fatxdecreased total cholesterolxreduced blood pressurexpatient compliance z In the past five years the Surgeon General,CDC,NIH,and ACSM have published position statements on the potential health benefits of lifestyle activityzTwenty-four we
13、ek,physician-directed intervention program to lower BP by increasing physical activityzPatients randomized into two groups:yGroup 1-educational intervention monitored via activity logsyGroup 2-educational intervention monitored via activity logs and pedometerStudy DesignThe Pedometerza small device
14、worn at the waist that counts stepszused successfully in obesity studiesStudy HypotheseszAdding a pedometer yto goal setting will increase the level and frequency of physical activityywill improve BP control of adult patients with high-normal BP or Stage 1 HTNMain Outcome MeasureszBlood Pressure and
15、 BMIzPhysical Activity assessed by:ytwo questionnairesxPhysical Activity Recall Scale(PASE):assessed activity in past seven daysxPhysician-based Assessment and Counseling for Exercise(PACE):assessed readiness for change in level of physical activityPatient Education ToolMethods:Patient Identificatio
16、nzPotential subjects identified by chart audityaverage BP of past three visits in High Normal BP or Stage 1 HTN categoryzExclusion Criteria:yAntihypertensive med useyconfirmed BP 160/100yDx DM,CHF,CAD,CVD,CA,MRypregnant ychild(18 yrs)Methods:Patient RecruitmentzIdentified subjects contacted during r
17、egularly scheduled physician visitzPhysician introduced study to patientzInterested patients met with research assistant for more information about studyMethods:Patient EligibilityzInterested patients had two eligibility visits two weeks apart to confirm elevated BPzIf average BP at two visits confi
18、rmed High-Normal BP or Stage 1 HTN from chart audit,then patient was scheduled for first study visit(t0)Sample CharacteristicsCategoryGroup 1(n=7)(no pedometer)Group 2(n=13)(pedometer)Age(M/SD)61(14.5)54(10)Race Caucasian Non-Caucasian6185Marital Status married not married4385Income Methods:Study Vi
19、sitszResearch Assistantymeasured BP and weight,reviewed activity log at all visitsyadministered PASE and PACE at baseline and completionzPhysicianydiscussed barriers to increasing activityynew activity goal settingyassisted with problem solvingPreliminary ResultszOutcome measures analyzed atybeginni
20、ng of study,week 0(t0)yend of intervention period,week 12(t1)yend of maintenance period,week 24(t2)Change in Systolic BP from Time 0 to Time 1(12 weeks)for both groups122124126128130132134136138140012TimeSystolic BP .Group 1,No Pedometer(n=7)Group 2,Pedometer(n=13)P=.005Change in Systolic BP across
21、time for both groups(24 weeks)122124126128130132134136138140012TimeSystolic BP Group 1,No Pedometer(n=7)Group 2,Pedometer(n=13)P=.005Change in Diastolic BP from Time 0 to Time 1 for both groups(12 weeks)747678808284868890012TimeDiastolic BP(mm Hg)Group 1,No Pedometer(n=7)Group 2,Pedometer(n=13)P=.02
22、2Change in Diastolic BP across time for both groups(24 weeks)747678808284868890012TimeDiastolic BP(mm Hg).Group 1,No Pedometer(n=7)Group 2,Pedometer(n=13)Change in BMI across time for both groups(24 weeks)30.430.530.630.730.830.93131.131.231.331.4012TimeBMIGroup 1,No Pedometer(n=6)Group 2,Pedometer(
23、n=9)Change in PASE across time for both groups(24 weeks)15016017018019020021022023024002TimePASE ScoreGroup 1,No Pedometer(n=6)Group 2,Pedometer(n=12)Preliminary ConclusionszIntervention alone(Group 1)did not significantly improve BPzIntervention plus a pedometer(Group 2)significantly improved BP,bu
24、t only with regular physician visitsPossible Mechanisms of BP Reduction with ExercisezReduced visceral fat independent of changes in body weight or BMIzAltered renal function to increase elimination of sodium leading to reduce fluid volumezAnthropomorphic parameters may not be primary mechansims in
25、causing HTNPossible Mechanisms of BP Reduction with ExercisezLower cardiac output and peripheral vascular resistance at rest and submaximal exerciseyDecreased HRyDecreased sympathetic and increased parasympathetic toneyLower blood catecholamines and plasma renin activityAntihypertensive&Volume Deple
26、ting Effects of Mild Exercise on Essential HTNz20 subjects with HTN(155/100)randomized to Exercise or Control groupzCycle Ergometer Exercise at Blood Lactic Acid Threshold for 60 min.3X/wk for 10 weekszChanges in BP,hemodynamics and humoral factors of EX group compared with control groupUrata,H.,et.
27、al.Hypertension 9:245-252,1987Antihypertensive&Volume Depleting Effects of Mild Exercise on Essential HTNAntihypertensive&Volume Depleting Effects of Mild Exercise on Essential HTNzWhole blood and plasma volume indices were significantly reduced(p 230 mm Hg;DBP 110 mm Hg).Restrictions on participati
28、on in vigorous exercise should be placed on patients with left ventricular hypertrophy.Weight TrainingzResistive exercise produces the most striking increases in BPzResistive exercise results in less of a HR increase compared with aerobic exercise and as a result the“rate pressure product”may be les
29、s than aerobic exercisezAssessment of BP response by handgrip should be considered in patients w/HTNzGrowing evidence that resistive training may be of value for controlling BP Kelemen,et.al.,JAMA 263:2766-71,1990Drug Therapy for Active Hypertensive PatientsHypertension onlyzThiazide diuretics in co
30、mbination with a potassium supplement are effective and inexpensivezDiuretics limit plasma volume expansion and decrease peripheral resistancezOther antihypertensive drugs can be used as monotherapy for this type of patientDrug Therapy for Active Hypertensive PatientsHypertension with other diseases
31、CAD-calcium-channel blocker or a beta-blockerDiabetes-ACE inhibitorLVH but coughs with ACE inhibitor-angiotensin-2-receptor blockerElderly men with prostatism-peripheral alpha-blocker(terazosin,doxazosin)Drug Therapy for Active Hypertensive PatientszBeta1-selective blockers such as atenolol or metop
32、rolol 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 2:75-77,1989Beta-blocker therapy and exercisezNon-selective Beta-blockers may increase a patients disposition to exertional hypertherm
33、ia.So patients should adhere strictly to guidelines for fluid replacementzPatients should use fluid replacement drinks with low concentrations of K+to avoid the risk of hypokalemiaGordon,N.F.,Am J Cardiol 55:74-78,1985Beta-blocker therapy and exercisezExercise therapy is desirable during Beta-blocke
34、r therapy to offset the adverse alterations in lipoprotein metabolism contributed by some Beta-blocker medicationsGordon,N.F.,Compr Ther 14:52-57,1988Beta-blocker therapy and exercisezExercise intensity for patients on Beta-blocker medications should be in accordance with traditional guidelines base
35、d on the results of individualized exercise testing performed on the medication.American College of Sports MedicineGuidelines for Exercise Testing and Prescription,2000Beta-blocker therapy and exercisezNon-selective Beta-blockers dramatically reduce peak aerobic capacity and at the same time increas
36、e a patients rating of perceived exertion for a given amount of work.Kaplan,N.M.,Am J Hypertens 2:75-77,1989Beta-blocker therapy and exercisezPatients treated with Beta-blockers are capable of deriving the expected enhancement of cardiorespiratory fitness during training,irrespective of the type of
37、drug usedBlood,S.M.,J Cardiopulmonary Rehabil 8:141-144,1988SUMMARYzPhysical activity has a therapeutic role in the treatment of hypertensionzNo consistent relationship between reduced weight and lower BPzExercise at lower intensities is effective in treating mild to moderate hypertensionzExercise t
38、esting may help identify exaggerated BP responses to exerciseSUMMARYzExercise prescription for HTN should be based on medical hx and risk factor statuszExercise prescription should be adapted to antihypertensive medications that may affect exercise HR,BP&performancezIncorporating resistive training
39、into the exercise prescription may be of value for controlling blood pressureReferencesChintanadilok,J.,Exercise in Treating Hypertension,PhysSports Med 30:11-23,2002Urata,H.,Antihypertensive and Volume-Depleting Effects of Mild Exercise on Essential Hypertension,Hypertension 9:245-52,1987.Tanabe,Y.
40、,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.
