How does exercise treatment compare with antihypertensive medications? A network meta-analysis of 391 randomised controlled trials assessing exercise and medication effects on systolic blood pressure

Abstract

ObjectiveTo compare the effect of exercise regimens and medications on systolic blood pressure (SBP).Data sourcesMedline (via PubMed) and the Cochrane Library.Eligibility criteriaRandomised controlled trials (RCTs) of angiotensin-converting enzyme inhibitors (ACE-I), angiotensin-2 receptor blockers (ARBs), β-blockers, calcium channel blockers (CCBs) and diuretics were identified from existing Cochrane reviews. A previously published meta-analysis of exercise interventions was updated to identify recent RCTs that tested the SBP-lowering effects of endurance, dynamic resistance, isometric resistance, and combined endurance and resistance exercise interventions (up to September 2018).DesignRandom-effects network meta-analysis.OutcomeDifference in mean change from baseline SBP between comparator treatments (change from baseline in one group minus that in the other group) and its 95% credible interval (95% CrI), measured in mmHg.ResultsWe included a total of 391 RCTs, 197 of which evaluated exercise interventions (10 461 participants) and 194 evaluated antihypertensive medications (29 281 participants). No RCTs compared directly exercise against medications. While all medication trials included hypertensive populations, only 56 exercise trials included hypertensive participants (≥140 mmHg), corresponding to 3508 individuals. In a 10% random sample, risk of bias was higher in exercise RCTs, primarily due to lack of blinding and incomplete outcome data. In analyses that combined all populations, antihypertensive medications achieved higher reductions in baseline SBP compared with exercise interventions (mean difference −3.96 mmHg, 95% CrI −5.02 to −2.91). Compared with control, all types of exercise (including combination of endurance and resistance) and all classes of antihypertensive medications were effective in lowering baseline SBP. Among hypertensive populations, there were no detectable differences in the SBP-lowering effects of ACE-I, ARB, β-blocker and diuretic medications when compared with endurance or dynamic resistance exercise. There was no detectable inconsistency between direct and indirect comparisons. Although there was evidence of small-study effects, this affected both medication and exercise trials.ConclusionsThe effect of exercise interventions on SBP remains under-studied, especially among hypertensive populations. Our findings confirm modest but consistent reductions in SBP in many studied exercise interventions across all populations but individuals receiving medications generally achieved greater reductions than those following structured exercise regimens. Assuming equally reliable estimates, the SBP-lowering effect of exercise among hypertensive populations appears similar to that of commonly used antihypertensive medications. Generalisability of these findings to real-world clinical settings should be further evaluated.

Cardiovascular Remodeling Experienced by Real-World, Unsupervised, Young Novice Marathon Runners

“…These findings have been reported previously in an extended cohort of this study, including older runners and finding greater regional distenibility in the descending aorta after marathon running (Bhuva et al, 2020). Though a 4/2 mmHg BP reduction seems small, this is highly consistent with the effect of exercise on BP reported in large meta-analyses, which is comparable with the effect of antihypertensive medication (Cornelissen and Smart, 2013;Naci et al, 2018) and also on aortic pulse wave velocity (Ashor et al, 2014). In terms of clinical relevance, if sustained, a 2 mmHg systolic BP reduction would be expected to reduce mortality from stroke by 10% and from vascular and ischemic heart disease by 7%, even in a low-risk, normotensive population (Lewington et al, 2002), underscoring the important role of increased physical activity in public health policy.…”

Post-exercise Hypotension Produced by Supramaximal Interval Exercise is Potentiated by Angiotensin Receptor Blockers

“…Nonetheless, it is difficult to draw conclusions from these studies due to differences among intensities, type of exercise (resistance vs. endurance), and kind of medication [14][15][16][17][18]. While the scientific literature is currently inconclusive, hypertensive individuals receiving ARB engage in physical activity programs, and the effects of this association need to be evaluated [19].…”

Benefits of exercise training on blood pressure and beyond in cardiovascular diseases

“…Other studies and meta-analyses have also evaluated the impact of ET on BP, [11][12][13] including one with water ET. In comparison to the prior meta-analysis by Naci et al, 11 the same issue plagues both reviews/analyses, specifically a dearth of RCTs of ET in the population with HTN (N ¼ 1057 exercise HTN patients in the current study and N ¼ 3508 in the study by Naci et al).…”

“…Other studies and meta-analyses have also evaluated the impact of ET on BP, [11][12][13] including one with water ET. In comparison to the prior meta-analysis by Naci et al, 11 the same issue plagues both reviews/analyses, specifically a dearth of RCTs of ET in the population with HTN (N ¼ 1057 exercise HTN patients in the current study and N ¼ 3508 in the study by Naci et al). While ET is proven equal to medications, as suggested by Naci et al, or slightly inferior to medications as firstline therapy, as the current study suggests, this does not impact a recommendation for ET for all individuals as either first-line or as an adjunct to initial therapy in uncomplicated HTN.…”