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Exercise recommendations to lower blood pressure from professional committees and organizations

Exercise recommendations to lower blood pressure from professional committees and organizations
The FITT of the Ex Rx Professional committee/organization
JNC 8[1] and AHA/ACC Lifestyle Work Group[2] AHA[3] ACSM[4] ESH/ESC[5] CHEP[6]
Frequency
(how often?)

3 to 4 sessions/week

≥12 weeks		 Most days of the week Most, preferably all, days of the week 5 to 7 days/week 4 to 7 days/week in addition to habitual daily activity
Intensity
(how hard?)		 Moderate to vigorous* Moderate to high, >40 to 60% of maximum Moderate 40 to <60% of VO2reserve Moderate* Moderate*
Time
(how long?)		 40 minutes/session 150 minutes/week 30 to 60 minutes continuous or accumulated in bouts ≥10 minutes each ≥30 minutes/day Accumulation of 30 to 60 minutes/day
Type
(what kind?)
Primary		 Aerobic Aerobic Aerobic Aerobic Dynamic exercise (aerobic)
Evidence rating

"High"¶Δ

Grade B¶Δ

Class IIa level of evidence A◊		 Class 1 level of evidence A◊ Evidence category A,§¥ evidence category B§¥ Class 1 level of evidence A-B‡ Grade D†,**
Adjuvant   Dynamic RT

Dynamic RT

2 to 3 days/week

Moderate 60 to 80%

1-RM, 8 to 12 repetitions

Dynamic RT

2 to 3 days/week		 Dynamic, isometric, or handgrip RT
Evidence rating   Class IIa level of evidence B◊ Evidence category B§,¶¶   Grade D†
BP reduction
(mmHg)		 1 to 5   5 to 7 among those with hypertension 2 to 3 overall; 5 to 7 among those with hypertension  

ACC: American College of Cardiology; ACSM: American College of Sports Medicine; AHA: American Heart Association; BP: blood pressure; CHEP: Canadian Hypertension Education Program; ESC: European Society of Cardiology; ESH: European Society of Hypertension; Ex Rx: exercise prescription; FITT: Frequency, Intensity, Time, and Type of the exercise prescription; JNC 8: Eighth Joint National Committee; NHLBI: National Heart, Lung, and Blood Institute; RT: resistance training; 1-RM: one repetition maximum; VO2reserve: oxygen uptake reserve.

* Moderate intensity is defined as 40 to <60% VO2reserve or an intensity that causes noticeable increases in heart rate and breathing; vigorous or high intensity is defined as ≥60% VO2reserve or an intensity that causes substantial increases in heart rate and breathing.

¶ The NHLBI[2] rating system grades the strength of the evidence (Evidence Statement) and the strength of the recommendation(s) (Evidence Recommendation); adapted from the US Preventive Services Task Force.[7]

Δ The Lifestyle Work Group rated the Evidence Statement for aerobic exercise to lower blood pressure as "high"†; the Evidence Recommendation for the Ex Rx (or FITT) to lower blood pressure was rated grade B or "moderate"; corresponding to class IIa level of evidence A◊.

◊ Classification of recommendations and level of evidence per AHA guideline criteria.[3,8,9]

§ NHLBI grading of evidence.[10]

¥ The strength of evidence was rated: Evidence category B§ for the immediate effects of aerobic exercise or postexercise hypotension; evidence category A§ for aerobic exercise to lower blood pressure; evidence category B§ for the recommended aerobic Ex Rx (or FITT) to lower blood pressure.

‡ ESC recommendations.[11]

† CHEP graded recommendations by the underlying evidence[12] using grade A (strongest evidence, based on high-quality studies) to grade D (weakest evidence, based on low-power imprecise studies or expert opinion alone).

** CHEP assigned grade D† to "higher intensity exercise is not more effective."

¶¶ The strength of evidence was rated evidence category C‡ for the immediate effects of dynamic resistance exercise or postexercise hypotension.
References:
  1. James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8) [published correction appears in JAMA 2014; 311:1809]. JAMA 2014; 311:507.
  2. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published correction appears in J Am Coll Cardiol 2014; 63:3027]. J Am Coll Cardiol 2014; 63:2960.
  3. Brook RD, Appel LJ, Rubenfire M, et al. American Heart Association Professional Education Committee of the Council for High Blood Pressure Research, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity. Beyond medications and diet: alternative approaches to lowering blood pressure; a scientific statement from the American Heart Association. Hypertension 2013; 61:1360.
  4. Pescatello LS, Franklin BA, Fagard R, et al. American College of Sports Medicine position stand: exercise and hypertension. Med Sci Sports Exerc 2004; 36:533.
  5. Mancia G, Fagard R, Narkiewicz K, et al. Task Force for the Management of Arterial Hypertension of the European Society of Hypertension and the European Society of Cardiology. 2013 ESH/ESC Practice Guidelines for the Management of Arterial Hypertension. Blood Press 2014; 23:3.
  6. Dasgupta K, Quinn RR, Zarnke KB, et al. The 2014 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol 2014; 30:485.
  7. U.S. Preventive Services Task Force Procedure Manual. Available at: http://www.uspreventiveservicestaskforce.org/Page/Name/procedure-manual. Published July 2008.
  8. American Heart Association. Methodology Manual and Policies from the ACCF/AHA Task Force on Practice Guidelines. American Heart Association website. Available at: http://assets.cardiosource.com/Methodology_Manual_for_ACC_AHA_Writing_Committees.pdf. Published June 2010.
  9. Gibbons RJ, Smith S, Antman E. American College of Cardiology/American Heart Association clinical practice guidelines, Part I: where do they come from? Circulation 2003; 107:2979.
  10. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults – the evidence report: National Institutes of Health [published correction appears in Obes Res 1998; 6:464]. Obes Res 1998; 6:51S.
  11. Writing ESC guidelines. European Society of Cardiology.
  12. McAlister FA. The Canadian Hypertension Education Program – a unique Canadian initiative. Can J Cardiol 2006; 22:559.

Original table modified for this publication. From: Pescatello LS, MacDonald HV, Ash GI, et al. Assessing the Existing Professional Exercise Recommendations for Hypertension: A Review and Recommendations for Future Research Priorities. Mayo Clin Proc 2015; 90:801. Table used with the permission of Elsevier Inc. All rights reserved.

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