Therapeuticroleofexercise

intreatinghypertensionDalynnT.Badenhop,Ph.D.,FACSMProfessorofMedicineDirector,CardiacRehabilitationMedicalCollegeofOhioTherapeuticroleofexercise

1EducationalObjectivesToexplaintheacutebloodpressureresponsetoexerciseTolistthemechanismsbywhichexercisemayimprovehypertensionToapplyexerciseguidelinesintreatinghypertensionToprescribeappropriatedrugtherapyforactivehypertensivepatientsEducationalObjectivesToexpla2OverviewofHypertensionHighBPisariskfactorforstroke,CHF,angina,renalfailure,LVHandMIHypertensionclusterswithhyperlipidemia,diabetesandobesityDrugshavebeeneffectiveintreatinghighBPbutbecauseoftheirsideeffectsandcost,non-pharmacologicalternativesareattractiveOverviewofHypertensionHighB31997JNCVIClassificationofBloodPressureBloodPressureCategorySystolicDiastolicOptimal<120<80Normal<130<85HighNormal130-13985-89HypertensionStage1(Mild)140-15990-99Stage2(Moderate)160-179100-109Stage3(Severe)>180>1101997JNCVIClassificationof4OverviewofHypertensionJointNationalCommitteeVI(JNCVI)onPrevention,Detection,Evaluation,andTreatmentofHighBloodPressure(1997)50millionhypertensivepatientsintheU.S.NationalHealthandNutritionExaminationSurveyIII(NHANESIII)(1995)only21%oftreatedhypertensivepatientshaveBPcontrolledto<140/90mmHg35%ofhypertensivepatientsareunawareoftheirconditionHigh-normalBPisassociatedwithanincresedriskofcardiovasculardiseaseNEngJMed2001;345;1291-7OverviewofHypertensionJoint5PathophysiologyofHypertensionEssentialhypertensionischaracterizedbyincreasedDBPandrelatedarteriolarvasoconstrictionleadingtoincreasedSBPBPismainlydeterminedbycardiacoutputandtotalperipheralresistanceHighbloodpressuremaybelinkedtoage-relatedvascularstiffeningPathophysiologyofHypertensio6PathophysiologyofHypertensionHighbloodpressureisalsoassociatedwithobesity,saltintake,lowpotassiumintake,physicalinactivity,heavyalcoholuseandpsychologicalstressIntra-abdominalfatandhyperinsulinemiamayplayaroleinthepathogenesisofhypertensionPathophysiologyofHypertensio7PrevalenceofOtherRiskFactorsWithHypertensionRiskFactorPercentSmoking35LDLCholesterol>140mg/dl40HDLCholesterol<40mg/dl25Obesity40Diabetes15Hyperinsulinemia50Sedentarylifestyle>50KaplanNM.DisMon1992;38:769-838PrevalenceofOtherRiskFacto8CardiovascularConsequences

ofHypertensionIndividualswithBP>160/95haveCAD,PVD&strokethatis3XhigherthannormalHTNmayleadtoretinopathyandnephropathyHTNisalsoassociatedwithsubclinicalchangesinthebrainandthickeningandstiffeningofsmallbloodvesselsCardiovascularConsequences

o9CardiovascularConsequences

ofHypertension

IncreasedcardiacafterloadleadstoleftventricularhypertrophyandreducedearlydiastolicfillingIncreasedLVmassispositivelyassociatedwithCVmorbidityandmortalityindependentofotherriskfactorsHighBPalsopromotescoronaryarterycalcification,apredictorofsuddendeathCardiovascularConsequences

o10Hypertension&CVDOutcomesIncreasedBPhasapositiveandcontinuousassociationwithCVeventsWithinDBPrangeof70-110mmHg,thereisnothresholdbelowwhichlowerBPdoesnotreducestrokeandCVDriskA15/6mmHgBPreductionreducedstrokeby34%andCHDby19%over5yearsHypertension&CVDOutcomesInc11LifestyleChanges

forHypertensionReduceexcessbodyweightReducedietarysodiumto<2.4gms/dayMaintainadequatedietaryintakeofpotassium,calciumandmagnesiumLimitdailyalcoholconsumptionto<2oz.ofwhiskey,10oz.ofwine,24oz.ofbeerExercisemoderatelyeachdayEngageinmeditationorrelaxationdailyCessationofsmokingLifestyleChanges

forHyperte12JNCVIBloodPressureClassificationJNCVIBloodPressureClassifi13MedicalTherapyand

ImplicationsforExerciseTrainingPharmacologicandnonpharmocologictreatmentcanreducemorbiditySomeantihypertensiveagentshaveside-effectsandsomeworsenotherriskfactorsExerciseanddietimprovemultipleriskfactorswithvirtuallynoside-effectsExercisemayreduceoreliminatetheneedforantihypertensivemedicationsMedicalTherapyand

Implicati14AcuteBPResponsetoExerciseAcuteBPResponsetoExercise15ExaggeratedBPResponse

toExerciseAmongnormotensivemenwhohadanexercisetestbetween1971-1982,thosewhodevelopedHTNin1986were2.4timesmorelikelytohavehadanexaggeratedBPresponsetoexerciseExaggeratedBPresponseincreasedfuturehypertensionriskby300%afteradjustingforallotherriskfactorsExaggeratedBPResponse

toEx16ExaggeratedBPResponse

toExerciseExaggeratedBPwaschangefromrestinSBP>60mmHgat6METs;SBP>70mmHgat8METs;DBP>10mmHgatanyworkload.SubjectsinCARDIAstudywithexaggeratedexerciseBPwere1.7timesmorelikelytodevelopHTN5yearslaterJClinEpidemiol51(1):1998ExaggeratedBPResponse

toEx17NIHConsensusConferenceonPhysicalActivityandCVHealth(1995)Reviewof47studiesofexerciseandHTN70%ofexercisegroupsdecreasedSBPbyanavg.of10.5mmHgfrom15478%ofsubjectsdecreasedDBPbyanavg.of8.6mmHgfrom98Only1studyshowedincreasedBPw/EXBeneficialresponsesare80timesmorefrequentthannegativeresponsesHagberg,J.,et.al.,NIH,1995:69-71NIHConsensusConferenceonPh18IncreasingLifestyleActivityforPatientswithHigh-NormalBloodPressureandStageIHypertensionMedicalCollegeofOhioStudyGroupKevinA.Phelps,D.O.LarryJohnson,M.D. SandraPuczynski,Ph.D.DalynnBadenhop,Ph.D. MichaelMcCreaWendyBoone,RN,M.P.HIncreasingLifestyleActivity19LifestyleActivityvs.

StructuredExerciseJAMA1999;281(4):327-334

moderate-intensitylifestyleactivityshowedsimilarorbetterresultsversusstructuredexerciseforimprovedcardiovascularfitnessreducedbodyfatdecreasedtotalcholesterolreducedbloodpressurepatientcompliance

InthepastfiveyearstheSurgeonGeneral,CDC,NIH,andACSMhavepublishedpositionstatementsonthepotentialhealthbenefitsoflifestyleactivityLifestyleActivityvs.

Structu20Twenty-fourweek,physician-directedinterventionprogramtolowerBPbyincreasingphysicalactivityPatientsrandomizedintotwogroups:Group1-educationalinterventionmonitoredviaactivitylogsGroup2-educationalinterventionmonitoredviaactivitylogsandpedometerStudyDesignTwenty-fourweek,physician-di21ThePedometerasmalldevicewornatthewaistthatcountsstepsusedsuccessfullyinobesitystudiesThePedometerasmalldevicewo22StudyHypothesesAddingapedometertogoalsettingwillincreasethelevelandfrequencyofphysicalactivitywillimproveBPcontrolofadultpatientswithhigh-normalBPorStage1HTNStudyHypothesesAddingapedom23MainOutcomeMeasuresBloodPressureandBMIPhysicalActivityassessedby:twoquestionnairesPhysicalActivityRecallScale(PASE): assessedactivityinpastsevendaysPhysician-basedAssessmentandCounselingforExercise(PACE): assessedreadinessforchangeinlevelofphysicalactivityMainOutcomeMeasuresBloodPre24PatientEducationToolPatientEducationTool25Methods:PatientIdentificationPotentialsubjectsidentifiedbychartauditaverageBPofpastthreevisitsinHighNormalBPorStage1HTNcategoryExclusionCriteria:AntihypertensivemeduseconfirmedBP3160/100DxDM,CHF,CAD,CVD,CA,MRpregnantchild(<18yrs)Methods:PatientIdentificatio26Methods:PatientRecruitmentIdentifiedsubjectscontactedduringregularlyscheduledphysicianvisitPhysicianintroducedstudytopatientInterestedpatientsmetwithresearchassistantformoreinformationaboutstudyMethods:PatientRecruitmentId27Methods:PatientEligibilityInterestedpatientshadtwoeligibilityvisitstwoweeksaparttoconfirmelevatedBPIfaverageBPattwovisitsconfirmedHigh-NormalBPorStage1HTNfromchartaudit,thenpatientwasscheduledforfirststudyvisit(t0)Methods:PatientEligibilityIn28SampleCharacteristicsSampleCharacteristics29Methods:StudyVisitsResearchAssistantmeasuredBPandweight,reviewedactivitylogatallvisitsadministeredPASEandPACEatbaselineandcompletionPhysiciandiscussedbarrierstoincreasingactivitynewactivitygoalsettingassistedwithproblemsolvingMethods:StudyVisitsResearch30PreliminaryResultsOutcomemeasuresanalyzedatbeginningofstudy,week0(t0)endofinterventionperiod,week12(t1)endofmaintenanceperiod,week24(t2)PreliminaryResults31ChangeinSystolicBPfromTime0toTime1(12weeks)forbothgroupsP=.005ChangeinSystolicBPfromTim32ChangeinSystolicBPacrosstimeforbothgroups(24weeks)ChangeinSystolicBPacrosst33ChangeinDiastolicBPfromTime0toTime1forbothgroups(12weeks)ChangeinDiastolicBPfromTi34ChangeinDiastolicBPacrosstimeforbothgroups(24weeks)ChangeinDiastolicBPacross35ChangeinBMIacrosstimeforbothgroups(24weeks)ChangeinBMIacrosstimefor36ChangeinPASEacrosstimeforbothgroups(24weeks)

ChangeinPASEacrosstimefor37PreliminaryConclusionsInterventionalone(Group1)didnotsignificantlyimproveBPInterventionplusapedometer(Group2)significantlyimprovedBP,butonlywithregularphysicianvisitsPreliminaryConclusionsInterve38PossibleMechanismsofBPReductionwithExerciseReducedvisceralfatindependentofchangesinbodyweightorBMIAlteredrenalfunctiontoincreaseeliminationofsodiumleadingtoreducefluidvolumeAnthropomorphicparametersmaynotbeprimarymechansimsincausingHTNPossibleMechanismsofBPRedu39PossibleMechanismsofBPReductionwithExerciseLowercardiacoutputandperipheralvascularresistanceatrestandsubmaximalexerciseDecreasedHRDecreasedsympatheticandincreasedparasympathetictoneLowerbloodcatecholaminesandplasmareninactivityPossibleMechanismsofBPRedu40Antihypertensive&VolumeDepletingEffectsofMildExerciseonEssentialHTN20subjectswithHTN(155/100)randomizedtoExerciseorControlgroupCycleErgometerExerciseatBloodLacticAcidThresholdfor60min.3X/wkfor10weeksChangesinBP,hemodynamicsandhumoralfactorsofEXgroupcomparedwithcontrolgroupUrata,H.,et.al.Hypertension9:245-252,1987Antihypertensive&VolumeDepl41Antihypertensive&VolumeDepletingEffectsofMildExerciseonEssentialHTNAntihypertensive&VolumeDepl42Antihypertensive&VolumeDepletingEffectsofMildExerciseonEssentialHTNWholebloodandplasmavolumeindicesweresignificantlyreduced(p<0.05)ChangeinserumNa+:serumK+positivelycorrelatedwithchangeinSBPPlasmaNEconcentrationsatrest&Workload@BLATduringGXT’swerereducedChangeinrestingNEcorrelatedwithchangeinmeanBPUrata,H.,et.al.Hypertension9:245-252,1987Antihypertensive&VolumeDepl43ChangesinTaurine&otherAminoAcidsin

ResponsetoMildExercise

Bloodpressuresweresignificantlydecreasedby14.8/6.6mmHgintheEXgroupbutnottheControlgroupSerumconcentrationincreasesoftaurine(26%),cystine(287%),asparagine(11%),histidine(6%)andlysine(7%)intheEXSerumtaurinewasnegativelycorrelatedwiththechangeinplasmaNETanabe,Y,et.al.,Clin&ExperHyper11:149-165,1989ChangesinTaurine&otherAmi44ChangesinTaurine&otherAminoAcidsin

ResponsetoMildExerciseChangesinTaurine&otherAmi45高血壓英文課件Therapeuticroleofexerciseintreating46ExercisePrescriptionsforPatientsWithBorderline-to-ModerateHypertensionPatientevaluationLookforlipiddisorders,DM,retinopathy,neuropathy,PVD,renalinsufficiency,LVdysfunction,silentMI/ischemiaosteoarthritis,osteoporosisExercisetestingGXTwithmodifiedNaughtonprotocol,R/OasymptomaticischemicCAD,radionuclideExercisetypeAerobic,low-impactactivities:walking,biking,swimming,taichi,stepper,treadmillwalkingExercisePrescriptionsforPat47ModifiedNaughton

TreadmillProtocolModifiedNaughton

TreadmillP48ExercisePrescriptionsforPatientsWithBorderline-to-ModerateHypertensionFrequency5days/weekasaminimumIntensityStartat50-60%maximumHRR&slowlyincreaseto70%;within6weeksworkat85%HRRorfrom50-90%ofmaximalheartrateDurationStartwith20-30min/dayofcontinuousactivityforfirst3wk,then30-45min/dayfornext4-6wk,and60min/dayasmaintenanceExercisePrescriptionsforPat49ExercisePrescriptionsforPatientsWithBorderline-to-ModerateHypertensionExcessiverisesinbloodpressureshouldbeavoidedduringexercise(SBP>230mmHg;DBP>110mmHg).Restrictionsonparticipationinvigorousexerciseshouldbeplacedonpatientswithleftventricularhypertrophy.ExercisePrescriptionsforPat50WeightTrainingResistiveexerciseproducesthemoststrikingincreasesinBPResistiveexerciseresultsinlessofaHRincreasecomparedwithaerobicexerciseandasaresultthe“ratepressureproduct”maybelessthanaerobicexerciseAssessmentofBPresponsebyhandgripshouldbeconsideredinpatientsw/HTNGrowingevidencethatresistivetrainingmaybeofvalueforcontrollingBPKelemen,et.al.,JAMA263:2766-71,1990WeightTrainingResistiveexerc51DrugTherapyforActiveHypertensivePatientsHypertensiononlyThiazidediureticsincombinationwithapotassiumsupplementareeffectiveandinexpensiveDiureticslimitplasmavolumeexpansionanddecreaseperipheralresistanceOtherantihypertensivedrugscanbeusedasmonotherapyforthistypeofpatientDrugTherapyforActiveHypert52DrugTherapyforActiveHypertensivePatientsHypertensionwithotherdiseasesCAD-calcium-channelblockerorabeta- blockerDiabetes-ACEinhibitorLVHbutcoughswithACEinhibitor-angiotensin-2-receptorblockerElderlymenwithprostatism-peripheralalpha-blocker(terazosin,doxazosin)DrugTherapyforActiveHypert53DrugTherapyforActiveHypertensivePatientsBeta1-selectiveblockerssuchasatenololormetoprololarepreferabletonon-selectiveagentssuchaspropranolol,nadololorpindololforhypertensivepatientsengagedinregularexercise

Kaplan,N.M.,AmJHypertens2:75-77,1989DrugTherapyforActiveHypert54Beta-blockertherapy

andexerciseNon-selectiveBeta-blockersmayincreaseapatient’sdispositiontoexertionalhyperthermia.SopatientsshouldadherestrictlytoguidelinesforfluidreplacementPatientsshouldusefluidreplacementdrinkswithlowconcentrationsofK+toavoidtheriskofhypokalemiaGordon,N.F.,AmJCardiol55:74-78,1985Beta-blockertherapy

andexer55Beta-blockertherapy

andexerciseExercisetherapyisdesirableduringBeta-blockertherapytooffsettheadversealterationsinlipoproteinmetabolismcontributedbysomeBeta-blockermedicationsGordon,N.F.,ComprTher14:52-57,1988Beta-blockertherapy

andexer56Beta-blockertherapy

andexerciseExerciseintensityforpatientsonBeta-blockermedicationsshouldbeinaccordancewithtraditionalguidelinesbasedontheresultsofindividualizedexercisetestingperformedonthemedication.AmericanCollegeofSportsMedicineGuidelinesforExerciseTestingandPrescription,2000Beta-blockertherapy

andexer57Beta-blockertherapy

andexerciseNon-selectiveBeta-blockersdramaticallyreducepeakaerobiccapacityandatthesametimeincreaseapatient’sratingofperceivedexertionforagivenamountof