REVIEW
Assessing the Existing Professional Exercise Recommendations for Hypertension: A Review and Recommendations for Future Research Priorities Linda S. Pescatello, PhD; Hayley V. MacDonald, MS; Garrett I. Ash, MSc; Lauren M. Lamberti, BS; William B. Farquhar, PhD; Ross Arena, PhD, PT; and Blair T. Johnson, PhD Abstract The Eighth Joint National Committee guideline on the management of adult hypertension was recently released. Rather than recommending specific lifestyle modifications as in the Seventh Joint National Committee guideline, the Eighth Joint National Committee endorsed the recommendations of the American Heart Association/American College of Cardiology 2013 Lifestyle Work Group. The Lifestyle Work Group report included systematic reviews and meta-analyses of randomized controlled trials or controlled clinical trials from 2001 through 2011 of “fair to good” quality. In total, 11 reviews qualified for inclusion in the report, 6 of which included blood pressure (BP) as the primary outcome. Three reviews did not find significant reductions in BP, and BP status was not reported in 5. When BP was reported, only 22% of the patients had hypertension. Yet, the group concluded with a strength of evidence categorized as “high” that aerobic exercise training reduces BP by 1 to 5 mm Hg in individuals with hypertension and that the most effective exercise interventions on average included aerobic physical activity of moderate to vigorous intensity for at least 12 weeks, 3 to 4 sessions per week lasting 40 minutes per session. The exercise prescription recommendations of the Lifestyle Work Group deviate from those of other professional organizations and committees including the Seventh Joint National Committee, another American Heart Association scientific statement, the American College of Sports Medicine, the European Society of Hypertension/European Society of Cardiology, and the Canadian Health Education Program. The purposes of this review are to present the existing exercise recommendations for hypertension, discuss reasons for differences in these recommendations, discuss gaps in the literature, and address critical future research needs regarding exercise prescription for hypertension. ª 2015 Mayo Foundation for Medical Education and Research
T
he long-awaited evidence-based guideline from the Eighth Joint National Committee (JNC 8) on the management of adult hypertension was recently released.1 The JNC 8 guideline has generated considerable debate because it departs from established blood pressure (BP) classifications on which treatment was previously based.2-4 Furthermore, rather than recommending specific lifestyle modifications as was done by the Seventh Joint National Committee (JNC 7),2 JNC 8 supported the lifestyle modifications recommended by the American Heart Association (AHA)/American College of Cardiology 2013 Lifestyle Work Group.5
n
Mayo Clin Proc. 2015;90(6):801-812
The Lifestyle Work Group considered evidence only from systematic reviews and metaanalyses published between 2001 and 2011 relating to physical activity and BP. The writing group acknowledged that because of limited resources and time, they could not review every study. Although the group concluded that the strength of evidence for physical activity to lower BP was “high,” the exercise prescription (Ex Rx) for hypertension that they recommended differs from those of other professional organizations and committees including JNC 7,2 another recent AHA scientific statement,6 the American College of Sports Medicine (ACSM),7 the European
Mayo Clin Proc. n June 2015;90(6):801-812 n http://dx.doi.org/10.1016/j.mayocp.2015.04.008 www.mayoclinicproceedings.org n ª 2015 Mayo Foundation for Medical Education and Research
From the Department of Kinesiology (L.S.P., H.V.M., G.I.A., L.M.L.), Center for Health, Intervention, and Prevention (L.S.P., H.V.M., G.I.A., L.M.L., B.T.J.), and Department of Psychology (B.T.J.), University of Connecticut, Storrs, CT; Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE (W.B.F.); and Department of Physical Therapy and Affiliations continued at the end of this article.
801
MAYO CLINIC PROCEEDINGS
ARTICLE HIGHLIGHTS n
n
Exercise is recommended as a key lifestyle therapy for adults with high blood pressure (BP) for the prevention, treatment, and control of hypertension by the Seventh Joint National Committee, the Eighth Joint National Committee, the American Heart Association/American College of Cardiology Lifestyle Work Group, another American Heart Association scientific statement, the American College of Sports Medicine, the European Society of Hypertension/ European Society of Cardiology, and the Canadian Hypertension Education Program. A recurrent theme throughout this review is that there is a substantial lack of evidence on many issues surrounding BP treatment and management in adults with hypertension despite the considerable volume of literature in this area, including exercise prescription (Ex Rx) for hypertension.
n
An Ex Rx is the process whereby the recommended physical activity program is designed in a systematic and individualized manner in terms of the Frequency (how often?), Intensity (how hard?), Time (how long?), and Type (what kind?), known as the FITT principle.
n
The professional organizations and committees included in this review report a wide range in the magnitude of the BP reduction resulting from exercise training (ie, 1-9 mm Hg), and in 2 instances, the magnitude was not specified. There are many possible reasons for the variability in the magnitude of the BP reduction in response to exercise training in the sources discussed in this review, including (1) the review methodology used by the professional organizations and committees to arrive at their conclusions were often based on expert opinion, (2) the lower methodological quality of the exercise and hypertension literature in general, and (3) BP status is often not reported in exercise and hypertension studies, and when it is, most adults enrolled in exercise and hypertension studies do not have hypertension.
n
n
802
Despite the current limitations and differences in the FITT of the recommended Ex Rx for hypertension, the consensus that can be taken from the level of agreement among the various professional recommendations is for adults with pre- to established hypertension to participate in 30 min/d or more of moderate-intensity aerobic exercise on most, if not all, days of the week to total 150 min/wk or more.
Mayo Clin Proc.
n
Society of Hypertension/European Society of Cardiology,8 and the Canadian Hypertension Education Program.9 The purposes of this review are to present the exercise recommendations for hypertension made by these professional organizations and committees, discuss reasons for the differences in these recommendations, present gaps in the literature, and address critical future research needs regarding the prescription of exercise for hypertension. OVERVIEW OF THE JNC 8 GUIDELINE The JNC 8 panel members used rigorous, evidence-based methods guided by 3 critical questions to develop evidence statements and recommendations for BP treatment in adults with hypertension to meet user needs, especially those of primary care clinicians.1 The 3 critical questions were judged by the panel to be those of the highest priority, and they related to hypertension management and addressed thresholds and goals for pharmacological treatment. The panel’s decision to rely solely on evidence from randomized clinical trials (RCTs) versus relying on the totality of evidence that could have been included in addition to RCTs, especially observational studies, systematic reviews, and meta-analyses as well as expert option, is one reason for the debate that has surrounded the release of the JNC 8 guideline.3 Following fundamental scientific methods, higher-quality interventions suggest lower bias and higher validity.10,11 Yet, this “best evidence approach”12 often limits included studies to RCTs exclusively, and despite however strong their methodological quality, RCTs are but one dimension of the literature.10,13-15 Scientific discovery and its translation to clinical practice rely on the replication of findings from independent groups to ensure the robustness of the observed effects across relevant parameters. By gathering all relevant trials related to the underlying phenomenon, meta-analyses and systematic reviews are able to gauge the extent to which trials replicate each other’s findings and evaluate potential reasons for discrepancies among results, such as differences in study populations and the content of the experimental and control arms. Furthermore, even when internally valid RCTs (ie, when differences in study groups are due solely to the different treatments regimes) are included in evidence-based syntheses, the results may not
June 2015;90(6):801-812
n
http://dx.doi.org/10.1016/j.mayocp.2015.04.008 www.mayoclinicproceedings.org
EXERCISE AND HYPERTENSION
be directly applicable to the populations, interventions, or specific outcomes in the guideline recommendations.14 Of importance to this review, and a recurrent theme throughout, is the lack of evidence on many issues surrounding BP treatment and management in adults with hypertension despite the considerable volume of literature in this area.16 Another notable departure by JNC 8 from JNC 7 was the methodology used to make the lifestyle recommendations. The JNC 8 endorsed the evidence-based recommendations of the 2013 AHA/American College of Cardiology Lifestyle Work Group,5 whereas JNC 7 committee members made specific lifestyle recommendations based on a range of study designs as well as expert opinion.2 In contrast to the systematic review methodologies of JNC 8, which included only RCTs, the Lifestyle Work Group included only systematic reviews and meta-analyses of RCTs or controlled clinical trials published from 2001 through 2011 that achieved “fair to good” study quality.6,17,18 A total of 13 reports with physical activity and BP outcomes qualified for inclusion in their study, but 2 meta-analyses were excluded because of “poor” quality.19,20 Thus, 9 meta-analyses,21-29 1 systematic review that examined the effects of aerobic exercise,30 and 1 systematic review that examined the effects of resistance training31 were included (Table 1 describes the sampled reviews, and Supplemental Tables 1 and 2 [available online at http://www.mayoclinicproceedings.org] describe the sampled reviews of the Lifestyle Work Group report in greater detail). Of the 11 systematic reviews and metaanalyses that were included, only 6 (55%) had BP as their primary outcome,21,23-26,29 and 4 (36%) focused on specific clinical populations, including patients with type 2 diabetes28,31 and patients undergoing cardiac rehabilitation.22,27 A key point regarding these 11 reports is that BP status was often not reported (N¼5, 45% of the trials), and when it was, the patients predominantly did not have hypertension (ie, only 22% had hypertension).22,26-28,30 These methodological limitations may explain why only 8 of the 11 reviews observed significant BP reductions following exercise,22-24,26,27,29-31 and they were of small to modest magnitude (approximately 1-5 mm Hg). In addition, other important variables that are known to influence the Mayo Clin Proc. n June 2015;90(6):801-812 www.mayoclinicproceedings.org
n
BP response to exercise, such as patient baseline characteristics (ie, body mass index, BP medication use) and intervention features (ie, attrition, level of exercise supervision) were generally poorly reported. Table 1 describes the exercise intervention features, and Supplemental Table 2 describes the exercise intervention details of the Lifestyle Work Group report in greater detail. EXERCISE RECOMMENDATIONS FOR HYPERTENSION Exercise offers numerous health benefits and is considered safe in apparently healthy individuals as well as all patients with stable medical conditions. Accordingly, it is recommended as a key lifestyle therapy for adults with high BP for the prevention, treatment, and control of hypertension by all the professional committees and organizations listed in Table 2.1,2,5-9 An Ex Rx is the process whereby the recommended physical activity program is designed in a systematic and individualized manner in terms of the Frequency (how often?), Intensity (how hard?), Time (how long?), and Type (what kind?), otherwise known as the FITT principle.33 Despite using systematic approaches, the recommended FITT of the Ex Rx varies across the professional committees and organizations (Table 2). We address areas of agreement and disagreement and comment on the level of evidence on which the various professional committees and organizations made their FITT Ex Rx recommendations. Frequency As Table 2 shows, all professional committees/ organizations recommend exercising on most, if not all, days of the week with the exception of the Lifestyle Work Group that recommended 3 to 4 sessions per week for at least 12 weeks. Our group, among many others, has reported that the reason exercise should be recommended on most, preferably all, days of the week is because BP is lower on the days people exercise compared with the days they do not exercise, a physiologic response termed postexercise hypotension (PEH).7,33,37 Postexercise hypotension is the sustained reduction in BP that occurs immediately after an isolated bout of exercise and persists for up to 24 hours after the bout. Furthermore, there is emerging evidence supporting the notion that the BP reductions
http://dx.doi.org/10.1016/j.mayocp.2015.04.008
803
804
TABLE 1. Reviews Included in the Lifestyle Work Group Report for the Eighth Joint National Committee: Summary of Features, Baseline Samples, and Intervention Characteristics (N¼11)a Review featuresb,c
Reference, year
No. of trials (RCTs)
Patient clinical characteristicsd No. of pts (women)
Evidence ratingg
SBP/DBP (HTN)e
Features of the exercise intervention: level of supervision, FITT, duration, and attrition rate
Resultant BP changef
Lifestyle Work AMSTARExBP Group scale
Aerobic exercise training Guo et al,21 2008 Meta-analysis BP outcome (100% trials) Lee et al,25 2007 Mayo Clin Proc.
Meta-analysis BP outcome (100% trials)
n
June 2015;90(6):801-812
Murphy et al,26 2007
n
Meta-analysis BP outcome (38% trials) Jolly et al,22 2006
1218 (28%) 12 (100%), BMI: NA k¼12 AET vs Qigong, Age: 30-70 k¼2
24 (100%)
1128 (83%) BMI: 25.91.0 (k¼20) Age: 51.612.7
21 (100%), k¼24
5047 (33%) Sedentary CR attendees BMI: NA Age: .05). g The Lifestyle Work Group5 rated the strength of evidence using the National Heart, Lung, and Blood Institute quality scale.17 Johnson et al32 rated the strength of evidence as a percentage of items completely satisfied (18 items total) using the AMSTARExBP (an augmented version of the Assessment of Multiple Systematic Reviews or AMSTAR questionnaire). a
EXERCISE AND HYPERTENSION
TABLE 2. Exercise Prescription Guidelines, Scientific Statements, and Recommendations for the Prevention, Treatment, and Control of Hypertension Made by Various Professional Committees and Organizationsa Professional committee/organization 1
The FITT of the Ex Rx
JNC 8 and AHA/ACC Lifestyle Work Group5
JNC 72
AHA6
ACSM7
ESH/ESC8
Frequency (how often?) Intensity (how hard?)
3-4 sessions/wk 12 wk Moderate to vigorousb
Most days of the week None specified
Time (how long?)
40 min/session
30 min/d
Most days of the week Moderate to high, >40%-60% of maximum 150 min/wk
Type (what kind?) Primary Evidence rating
Aerobic
Aerobic
Aerobic
Most, preferably all, days of the week Moderate 40%-
Assessing the Existing Professional Exercise Recommendations for Hypertension: A Review and Recommendations for Future Research Priorities Linda S. Pescatello, PhD; Hayley V. MacDonald, MS; Garrett I. Ash, MSc; Lauren M. Lamberti, BS; William B. Farquhar, PhD; Ross Arena, PhD, PT; and Blair T. Johnson, PhD Abstract The Eighth Joint National Committee guideline on the management of adult hypertension was recently released. Rather than recommending specific lifestyle modifications as in the Seventh Joint National Committee guideline, the Eighth Joint National Committee endorsed the recommendations of the American Heart Association/American College of Cardiology 2013 Lifestyle Work Group. The Lifestyle Work Group report included systematic reviews and meta-analyses of randomized controlled trials or controlled clinical trials from 2001 through 2011 of “fair to good” quality. In total, 11 reviews qualified for inclusion in the report, 6 of which included blood pressure (BP) as the primary outcome. Three reviews did not find significant reductions in BP, and BP status was not reported in 5. When BP was reported, only 22% of the patients had hypertension. Yet, the group concluded with a strength of evidence categorized as “high” that aerobic exercise training reduces BP by 1 to 5 mm Hg in individuals with hypertension and that the most effective exercise interventions on average included aerobic physical activity of moderate to vigorous intensity for at least 12 weeks, 3 to 4 sessions per week lasting 40 minutes per session. The exercise prescription recommendations of the Lifestyle Work Group deviate from those of other professional organizations and committees including the Seventh Joint National Committee, another American Heart Association scientific statement, the American College of Sports Medicine, the European Society of Hypertension/European Society of Cardiology, and the Canadian Health Education Program. The purposes of this review are to present the existing exercise recommendations for hypertension, discuss reasons for differences in these recommendations, discuss gaps in the literature, and address critical future research needs regarding exercise prescription for hypertension. ª 2015 Mayo Foundation for Medical Education and Research
T
he long-awaited evidence-based guideline from the Eighth Joint National Committee (JNC 8) on the management of adult hypertension was recently released.1 The JNC 8 guideline has generated considerable debate because it departs from established blood pressure (BP) classifications on which treatment was previously based.2-4 Furthermore, rather than recommending specific lifestyle modifications as was done by the Seventh Joint National Committee (JNC 7),2 JNC 8 supported the lifestyle modifications recommended by the American Heart Association (AHA)/American College of Cardiology 2013 Lifestyle Work Group.5
n
Mayo Clin Proc. 2015;90(6):801-812
The Lifestyle Work Group considered evidence only from systematic reviews and metaanalyses published between 2001 and 2011 relating to physical activity and BP. The writing group acknowledged that because of limited resources and time, they could not review every study. Although the group concluded that the strength of evidence for physical activity to lower BP was “high,” the exercise prescription (Ex Rx) for hypertension that they recommended differs from those of other professional organizations and committees including JNC 7,2 another recent AHA scientific statement,6 the American College of Sports Medicine (ACSM),7 the European
Mayo Clin Proc. n June 2015;90(6):801-812 n http://dx.doi.org/10.1016/j.mayocp.2015.04.008 www.mayoclinicproceedings.org n ª 2015 Mayo Foundation for Medical Education and Research
From the Department of Kinesiology (L.S.P., H.V.M., G.I.A., L.M.L.), Center for Health, Intervention, and Prevention (L.S.P., H.V.M., G.I.A., L.M.L., B.T.J.), and Department of Psychology (B.T.J.), University of Connecticut, Storrs, CT; Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE (W.B.F.); and Department of Physical Therapy and Affiliations continued at the end of this article.
801
MAYO CLINIC PROCEEDINGS
ARTICLE HIGHLIGHTS n
n
Exercise is recommended as a key lifestyle therapy for adults with high blood pressure (BP) for the prevention, treatment, and control of hypertension by the Seventh Joint National Committee, the Eighth Joint National Committee, the American Heart Association/American College of Cardiology Lifestyle Work Group, another American Heart Association scientific statement, the American College of Sports Medicine, the European Society of Hypertension/ European Society of Cardiology, and the Canadian Hypertension Education Program. A recurrent theme throughout this review is that there is a substantial lack of evidence on many issues surrounding BP treatment and management in adults with hypertension despite the considerable volume of literature in this area, including exercise prescription (Ex Rx) for hypertension.
n
An Ex Rx is the process whereby the recommended physical activity program is designed in a systematic and individualized manner in terms of the Frequency (how often?), Intensity (how hard?), Time (how long?), and Type (what kind?), known as the FITT principle.
n
The professional organizations and committees included in this review report a wide range in the magnitude of the BP reduction resulting from exercise training (ie, 1-9 mm Hg), and in 2 instances, the magnitude was not specified. There are many possible reasons for the variability in the magnitude of the BP reduction in response to exercise training in the sources discussed in this review, including (1) the review methodology used by the professional organizations and committees to arrive at their conclusions were often based on expert opinion, (2) the lower methodological quality of the exercise and hypertension literature in general, and (3) BP status is often not reported in exercise and hypertension studies, and when it is, most adults enrolled in exercise and hypertension studies do not have hypertension.
n
n
802
Despite the current limitations and differences in the FITT of the recommended Ex Rx for hypertension, the consensus that can be taken from the level of agreement among the various professional recommendations is for adults with pre- to established hypertension to participate in 30 min/d or more of moderate-intensity aerobic exercise on most, if not all, days of the week to total 150 min/wk or more.
Mayo Clin Proc.
n
Society of Hypertension/European Society of Cardiology,8 and the Canadian Hypertension Education Program.9 The purposes of this review are to present the exercise recommendations for hypertension made by these professional organizations and committees, discuss reasons for the differences in these recommendations, present gaps in the literature, and address critical future research needs regarding the prescription of exercise for hypertension. OVERVIEW OF THE JNC 8 GUIDELINE The JNC 8 panel members used rigorous, evidence-based methods guided by 3 critical questions to develop evidence statements and recommendations for BP treatment in adults with hypertension to meet user needs, especially those of primary care clinicians.1 The 3 critical questions were judged by the panel to be those of the highest priority, and they related to hypertension management and addressed thresholds and goals for pharmacological treatment. The panel’s decision to rely solely on evidence from randomized clinical trials (RCTs) versus relying on the totality of evidence that could have been included in addition to RCTs, especially observational studies, systematic reviews, and meta-analyses as well as expert option, is one reason for the debate that has surrounded the release of the JNC 8 guideline.3 Following fundamental scientific methods, higher-quality interventions suggest lower bias and higher validity.10,11 Yet, this “best evidence approach”12 often limits included studies to RCTs exclusively, and despite however strong their methodological quality, RCTs are but one dimension of the literature.10,13-15 Scientific discovery and its translation to clinical practice rely on the replication of findings from independent groups to ensure the robustness of the observed effects across relevant parameters. By gathering all relevant trials related to the underlying phenomenon, meta-analyses and systematic reviews are able to gauge the extent to which trials replicate each other’s findings and evaluate potential reasons for discrepancies among results, such as differences in study populations and the content of the experimental and control arms. Furthermore, even when internally valid RCTs (ie, when differences in study groups are due solely to the different treatments regimes) are included in evidence-based syntheses, the results may not
June 2015;90(6):801-812
n
http://dx.doi.org/10.1016/j.mayocp.2015.04.008 www.mayoclinicproceedings.org
EXERCISE AND HYPERTENSION
be directly applicable to the populations, interventions, or specific outcomes in the guideline recommendations.14 Of importance to this review, and a recurrent theme throughout, is the lack of evidence on many issues surrounding BP treatment and management in adults with hypertension despite the considerable volume of literature in this area.16 Another notable departure by JNC 8 from JNC 7 was the methodology used to make the lifestyle recommendations. The JNC 8 endorsed the evidence-based recommendations of the 2013 AHA/American College of Cardiology Lifestyle Work Group,5 whereas JNC 7 committee members made specific lifestyle recommendations based on a range of study designs as well as expert opinion.2 In contrast to the systematic review methodologies of JNC 8, which included only RCTs, the Lifestyle Work Group included only systematic reviews and meta-analyses of RCTs or controlled clinical trials published from 2001 through 2011 that achieved “fair to good” study quality.6,17,18 A total of 13 reports with physical activity and BP outcomes qualified for inclusion in their study, but 2 meta-analyses were excluded because of “poor” quality.19,20 Thus, 9 meta-analyses,21-29 1 systematic review that examined the effects of aerobic exercise,30 and 1 systematic review that examined the effects of resistance training31 were included (Table 1 describes the sampled reviews, and Supplemental Tables 1 and 2 [available online at http://www.mayoclinicproceedings.org] describe the sampled reviews of the Lifestyle Work Group report in greater detail). Of the 11 systematic reviews and metaanalyses that were included, only 6 (55%) had BP as their primary outcome,21,23-26,29 and 4 (36%) focused on specific clinical populations, including patients with type 2 diabetes28,31 and patients undergoing cardiac rehabilitation.22,27 A key point regarding these 11 reports is that BP status was often not reported (N¼5, 45% of the trials), and when it was, the patients predominantly did not have hypertension (ie, only 22% had hypertension).22,26-28,30 These methodological limitations may explain why only 8 of the 11 reviews observed significant BP reductions following exercise,22-24,26,27,29-31 and they were of small to modest magnitude (approximately 1-5 mm Hg). In addition, other important variables that are known to influence the Mayo Clin Proc. n June 2015;90(6):801-812 www.mayoclinicproceedings.org
n
BP response to exercise, such as patient baseline characteristics (ie, body mass index, BP medication use) and intervention features (ie, attrition, level of exercise supervision) were generally poorly reported. Table 1 describes the exercise intervention features, and Supplemental Table 2 describes the exercise intervention details of the Lifestyle Work Group report in greater detail. EXERCISE RECOMMENDATIONS FOR HYPERTENSION Exercise offers numerous health benefits and is considered safe in apparently healthy individuals as well as all patients with stable medical conditions. Accordingly, it is recommended as a key lifestyle therapy for adults with high BP for the prevention, treatment, and control of hypertension by all the professional committees and organizations listed in Table 2.1,2,5-9 An Ex Rx is the process whereby the recommended physical activity program is designed in a systematic and individualized manner in terms of the Frequency (how often?), Intensity (how hard?), Time (how long?), and Type (what kind?), otherwise known as the FITT principle.33 Despite using systematic approaches, the recommended FITT of the Ex Rx varies across the professional committees and organizations (Table 2). We address areas of agreement and disagreement and comment on the level of evidence on which the various professional committees and organizations made their FITT Ex Rx recommendations. Frequency As Table 2 shows, all professional committees/ organizations recommend exercising on most, if not all, days of the week with the exception of the Lifestyle Work Group that recommended 3 to 4 sessions per week for at least 12 weeks. Our group, among many others, has reported that the reason exercise should be recommended on most, preferably all, days of the week is because BP is lower on the days people exercise compared with the days they do not exercise, a physiologic response termed postexercise hypotension (PEH).7,33,37 Postexercise hypotension is the sustained reduction in BP that occurs immediately after an isolated bout of exercise and persists for up to 24 hours after the bout. Furthermore, there is emerging evidence supporting the notion that the BP reductions
http://dx.doi.org/10.1016/j.mayocp.2015.04.008
803
804
TABLE 1. Reviews Included in the Lifestyle Work Group Report for the Eighth Joint National Committee: Summary of Features, Baseline Samples, and Intervention Characteristics (N¼11)a Review featuresb,c
Reference, year
No. of trials (RCTs)
Patient clinical characteristicsd No. of pts (women)
Evidence ratingg
SBP/DBP (HTN)e
Features of the exercise intervention: level of supervision, FITT, duration, and attrition rate
Resultant BP changef
Lifestyle Work AMSTARExBP Group scale
Aerobic exercise training Guo et al,21 2008 Meta-analysis BP outcome (100% trials) Lee et al,25 2007 Mayo Clin Proc.
Meta-analysis BP outcome (100% trials)
n
June 2015;90(6):801-812
Murphy et al,26 2007
n
Meta-analysis BP outcome (38% trials) Jolly et al,22 2006
1218 (28%) 12 (100%), BMI: NA k¼12 AET vs Qigong, Age: 30-70 k¼2
24 (100%)
1128 (83%) BMI: 25.91.0 (k¼20) Age: 51.612.7
21 (100%), k¼24
5047 (33%) Sedentary CR attendees BMI: NA Age: .05). g The Lifestyle Work Group5 rated the strength of evidence using the National Heart, Lung, and Blood Institute quality scale.17 Johnson et al32 rated the strength of evidence as a percentage of items completely satisfied (18 items total) using the AMSTARExBP (an augmented version of the Assessment of Multiple Systematic Reviews or AMSTAR questionnaire). a
EXERCISE AND HYPERTENSION
TABLE 2. Exercise Prescription Guidelines, Scientific Statements, and Recommendations for the Prevention, Treatment, and Control of Hypertension Made by Various Professional Committees and Organizationsa Professional committee/organization 1
The FITT of the Ex Rx
JNC 8 and AHA/ACC Lifestyle Work Group5
JNC 72
AHA6
ACSM7
ESH/ESC8
Frequency (how often?) Intensity (how hard?)
3-4 sessions/wk 12 wk Moderate to vigorousb
Most days of the week None specified
Time (how long?)
40 min/session
30 min/d
Most days of the week Moderate to high, >40%-60% of maximum 150 min/wk
Type (what kind?) Primary Evidence rating
Aerobic
Aerobic
Aerobic
Most, preferably all, days of the week Moderate 40%-
