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Exercise and hypertension: facts and uncertainties.

In 1986 the World Health Organization (WHO) and the International Society of Hypertension (ISH) stated very tentatively that “increased physical activity is likely to reduce the risk of cardiovascular disease and is appropriate in mildly hypertensives”. In 1991 a consensus document entitled Physical exercise in the management of hypertension was published by the World Hypertension League which concluded that exercise programmes can contribute to the management of hypertension, enhance the sense of well being, and may improve life expectancy. In 1992 the WHO/ ISH recommended lifestyle interventions such as weight reduction in the overweight, reduction of alcohol consumption, regular mild exercise in sedentary subjects, and salt restriction in the primary prevention of hypertension. In 1993 this was followed by a memorandum of the WHO/ISH which stated that “it appears reasonable to advise that eVorts to lower blood pressure by lifestyle modifications, including exercise, should normally precede any decision about the necessity of drug treatment of mild hypertension”. At approximately the same time the US Joint National Committee on the Detection, Evaluation and Treatment of High Blood Pressure stated that physicians should vigorously encourage their hypertensive patients to adopt lifestyle modifications, including increased physical activity. The American College of Sports Medicine recommended endurance exercise to reduce the incidence of hypertension in susceptible individuals and as the initial treatment strategy for individuals with mild to moderate hypertension. Since then, regular exercise has been widely advocated as an eVective tool in the non-pharmacological treatment of hypertension and as an adjunct to its pharmacological treatment. Nevertheless, the evidence on which this view is based is sometimes challenged. 8 In this review I will try to summarise the evidence for the role of exercise in the treatment of hypertension and also point out areas that are still uncertain. Hypertension, cardiovascular risk and treatment Cardiovascular risk and blood pressure are positively correlated: the higher the blood pressure, the higher the risk of both stroke and coronary events. The current dividing line between normotension and hypertension lies at the level of blood pressure above which intervention has been shown to reduce the risk. The operational classification of hypertension by the World Health Organization/International Society of Hypertension is shown in table 1. The worldwide prevalence of hypertension is high. In most countries 15–25% of the adult population have raised blood pressure at screening. In most of these individuals blood pressure is mildly elevated. Lowering of blood pressure in patients with hypertension by pharmacological treatment significantly reduces the risk of stroke and myocardial infarction. The reduction of mortality from myocardial infarction is, however, less than predicted from observational studies. There is considerable suspicion that some of the drugs used may have adverse eVects which partly counteract the benefits of the blood pressure reduction. Nonpharmacological blood pressure reduction— for instance, by regular exercise—therefore seems an attractive alternative. However, no prospective randomised trials have been performed to show that exercise training reduces cardiovascular morbidity and mortality in hypertensive patients. The evidence that regular exercise has hypotensive eYcacy comes from both epidemiological and intervention studies.