Hypertension is a prevalent cardiovascular risk factor in Europe, with values between 30% and 45% and increasing with aging.1 In the United States, hypertension affects 29.6% of adults and 71.6% of older adults.2 In Portugal, the overall prevalence of hypertension among the adult population aged 18 to 90 years is 42.2%, with a much higher prevalence in older adults (74.9%) in comparison with adults younger than 35 years old (6.8%) and 35 to 64 years old (46.9%).3
A single exercise session, either aerobic4–15 or resistance,16–19 is a well-established intervention promoting a transient reduction in blood pressure in the period after exercise to values less than those observed before exercise, a phenomenon designated as postexercise hypotension.20 This reduction has been observed in middle-aged persons with normotension7,15 and with hypertension,4–6,12–14,19 as well as in older adults both with normotension9 and hypertension.8,10,11,16,18 The clinical utility of this transient decrease in blood pressure in patients with hypertension is related to the duration of the effect in the period of time subsequent to the exercise even when performing mild exercise and simulated activities of daily living.12 Therefore, this approach may have a role as a nonpharmacological intervention assisting in the control of hypertension.21–24 Previous studies assessing blood pressure after exercise with auscultatory devices showed a decrease in blood pressure for up to 9010,25,26 and 120 minutes27 in persons with hypertension. In addition, studies using ambulatory blood pressure monitors reported a decrease for up to 75 and 8.7 hours4 compared with rest. Indeed, the reduction in blood pressure as a result of a single session of exercise seems especially relevant for assisting in the control of blood pressure during day-time periods when blood pressure is typically at its highest levels28 and for allowing the performance of activities of daily living at lower levels of blood pressure.12
Despite evidence related to postexercise blood pressure reduction as a result of a single session of aerobic exercise in old adults with hypertension,8,10,11,18 there is a lack of studies enrolling very old adults with hypertension (>80 years old). The study of this particular age group seems pertinent, as the prevalence of hypertension increases steeply with age2,3 and the demographics of our country, as well as other westernized countries, are changing as adults aged older than 80 years are representing a larger and increasing segment of the overall population.29 In addition, results are less predictable in this age group because one of the mechanisms previously proposed to explain the transient decrease in blood pressure following aerobic exercise—a decrease in peripheral vascular resistance21,24—could be particularly limited in this age group due to the increased arterial stiffness with aging.30 In this sense, this study aims to assess the acute effects of a single session of aerobic exercise on postexercise blood pressure in very old adults with hypertension.
Participants (5 men and 13 women), aged between 80 and 90 years, were recruited in 3 community centers. We recruited participants of both sexes, as the transient reduction in blood pressure after exercise does not appear to be affected by sex.28 Participants were randomly assigned, by the method of minimization,31 into 2 groups of 9—the group that participated in a single session of aerobic exercise and the control group. Noninstitutionalized older adults (aged ≥80 years) with diagnosed essential arterial hypertension (systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or being medicated for hypertension) according to the recommendations of the European Society of Cardiology/European Society of Hypertension1 were considered eligible to participate in the study if they were able to walk without assistance. Exclusion criteria included participation in regular exercise sessions (>2 hours per week) in the 12 months previous to the study, diabetes, smoking, uncontrolled hypertension, unstable angina pectoris, or any contraindication or medical condition that would limit participation in exercise (eg, peripheral arterial occlusive disease and musculoskeletal disorder). The ethics committee of the Faculty of Sport of University of Porto approved the study. Written informed consent was obtained, and all procedures were conducted in accordance with the Declaration of Helsinki.
Procedures and Measurements
On the basis of inspection of their medical records in the community centers, potential participants in the study were asked to participate. Those who agreed to participate received detailed explanations about the procedures and were familiarized with the experimental protocol, the monitoring techniques, and apparatus.
Participants were asked to avoid intense or strenuous exercise and caffeine-containing products or alcohol consumption 48 hours before the beginning of the study. In addition, no large meals were allowed within 3 hours before the study. The evaluation room was kept quiet, and speaking was not allowed during blood pressure measurements.
Initially, height and weight measurements were attained using a standard wall-mounted stadiometer and scale, respectively. Body mass index (BMI) was calculated from the ratio of weight (kg) to squared height (m2). Participants rested 5 minutes in a seated position before the assessment of blood pressure. Resting systolic and diastolic blood pressures and heart rate were measured by an oscillometric method using a digital automatic blood pressure monitor (M6, Omron Healthcare Co, Kyoto, Japan). This device was validated according to the International Protocol criteria and can be used to evaluate blood pressure in older persons.32 Participants sat down, resting their right arm on a table so the brachial artery was level with the heart. Two measurements were then obtained at intervals of 1 minute, and their average was recorded. If there was more than 5 mm Hg of difference between the 2 readings, 1 more reading was obtained for averaging.33,34 Participants were then randomly assigned, by the method of minimization,31 into the exercise or the control group. Minimization was based on age, sex, and medication.
The exercise group participated in a session of aerobic exercise containing 2 periods of 10 minutes of walking at an intensity of 40% to 60% of the heart rate reserve, with a recovery period of 5-minute in-between. Participants walked on a large, flat, quiet, open space. The 5-minute recovery between each period of walking consisted of active recovery (gentle walking) for 2 minutes and 3 minutes of passive recovery in a sitting position. Before and after the 2 periods of walking, participants performed 5 minutes of warm-up (stretching exercises, active mobilization exercises, and gentle walking) and 5 minutes of cool-down (gentle walking and stretching exercises), respectively. Thus, the overall duration of the exercise session was 35 minutes, that is, 5 minutes of warm-up, 2 periods of 10 minutes of aerobic exercise (walking) with a recovery period of 5-minute in-between, and 5 minutes of cool-down. The exercise intensity for the 2 periods of 10 minutes of walking was calculated as 40% to 60% of the heart rate reserve. The theoretical maximum heart rate of this population group was calculated using the formula of Tanaka: 208 bpm − (age × 0.7).35 During the session, the heart rate was continuously monitored with a heart rate monitor (Polar Electro RS100, Kempele, Finland), and the walking velocity was adjusted to ensure that each participant achieved the exercise intensity previously determined. The control group did not engage in any physical exercise, remaining seated during the 35 minutes. After the exercise session or the control period, the participants remained at rest in the seated position for 40 minutes, during which time no intake of water or other fluid was allowed. Heart rate and blood pressure were measured at rest, immediately after the exercise session, at 20 and 40 minutes after the end of the exercise session. All the assessments were conducted at the same time of the day (morning) by the same examiner.
The data were analyzed using SPSS software version 17.0 (SPSS Inc, Chicago, IL). The normality of the data distribution was tested with the Shapiro-Wilk test. The data were normally distributed. Descriptive statistics were used to calculate the mean and standard deviation. The Student independent t test was used for comparisons between groups in age, weight, height, BMI, baseline heart rate, and systolic and diastolic blood pressures. The chi-square test was used for comparisons between groups regarding sex and medication. To examine the effect of the exercise session on heart rate, systolic and diastolic blood pressure, a 2 × 4 repeated-measures analysis of variance (rest/exercise × baseline/post/20/40 min) was used to compare results between groups over time (group × time). When a significant group × time interaction was observed, post hoc means comparisons were performed using Bonferroni tests. Effect size was reported using the partial eta-squared (ηp2). Values 0.01 ≤ ηp2 < 0.06 represent a small effect, values 0.06 ≤ ηp2 < 0.14 represent a medium effect, and values ηp2 < 0.14 represent a large effect.36 The Pearson correlation or the Spearman rho tests were used to test associations between the changes in systolic and diastolic blood pressures (from baseline to 40 minutes postexercise) with the variables (age, sex, BMI, baseline systolic and diastolic blood pressures, and medication) that could potentially have an influence on it. The level of significance was set as P ≤ .05.
There were no significant differences between groups in age, proportion of women, anthropometric measurements, medication, and baseline values of blood pressure and heart rate (Table 1).
Systolic blood pressure changed significantly over time (F3,24 = 7.044; P = .001; ηp2 < 0.468), with a significant interaction for group × time (F3,24 = 6.698; P = .002; ηp2 < 0.153). The exercise group showed a significantly lower systolic blood pressure at 20 and 40 minutes postexercise compared with the values at baseline. In the control group, no differences were observed in comparison with baseline (Table 2).
No differences were observed in diastolic blood pressure in either group. Diastolic blood pressure did not change significantly over time (F3,24 = 0.436; P = .729; ηp2 < 0.052), and there was no observed interaction for group × time (F3,24 = 0.113; P = .952; ηp2 < 0.014) (Table 2).
Regarding heart rate, the comparison of groups in time revealed an effect of time (F3,24 = 7.485; P = .001; ηp2 < 0.483) with a significant interaction for group × time (F3,24 = 6.054; P = .003; ηp2 < 0.431). The heart rate in the control group did not change, whereas in the exercise group, the heart rate measured after the cool-down period was significantly higher than the heart rate measured at baseline, 20 and 40 minutes postexercise (Table 2).
The changes in blood pressure (from baseline to the final assessment) were not correlated with age, sex, anthropometrics, medication, and resting blood pressure. Namely, no associations were found between the change in systolic blood pressure and age (r = 0.183; P = .637), BMI (r = −0.084; P = .830) or resting systolic blood pressure (r = 0.062; P = .874).
The results of this study indicate that a single session of aerobic exercise promotes short-term beneficial effects in older adults with hypertension by lowering systolic blood pressure for up to 40 minutes after the session to values lower than those observed at baseline.
The intensity and duration of exercise also seemed to be key factors to postexercise blood pressure reduction. In a very elegant study, Pescatello and colleagues6 showed that exercise intensity influences the blood pressure response after exercise cessation. They submitted 49 men with hypertension to 2 exercise bouts, 1 at 40% and the other at 60% of maximal oxygen consumption, and observed greater postexercise blood pressure reduction after the exercise bout performed at an intensity of 60%. Quinn40 assessed the effects of 2 exercise sessions lasting 30 minutes, conducted at 50% and 75% of maximal oxygen uptake, on blood pressure reduction over a 24-hour period in persons with normotension and hypertension, and observed a significant decrease only in the group with hypertension. In addition, a session of exercise performed at 75% of maximal oxygen uptake induced greater and longer-lasting absolute reductions in blood pressure. Likewise, exercise sessions lasting longer promoted greater decreases in blood pressure; nevertheless, exercise of moderate intensity may be as brief as 10 minutes in duration to decrease resting blood pressure.23 In this study, 2 periods of 10 minutes was used because our sample was composed of participants older than 80 years. Therefore, a short-duration session was used, but the session was within the time period required to potentially reduce postexercise blood pressure.23 Shorter exercise sessions are better tolerated by this age group, which makes our approach attractive from a clinical point of view.
Despite being a recognized phenomenon, the mechanisms responsible for postexercise blood pressure reduction are not completely understood. It has been suggested that the acute and transient decrease in systolic blood pressure is related to decreased cardiac output and/or peripheral vascular resistance.21,24 The decrease in peripheral vascular resistance seems to be related to the release of vasodilator agents (nitric oxide, prostaglandins, and adenosine).41,42 Nonetheless, recent studies have indicated that sustained vasodilatation after exercise is mainly dependent on the activation of histamine H1 and H2 receptors.21 Beyond local vasodilator mechanisms, the combination of centrally mediated reduction in sympathetic nerve activity21 and attenuation of signal transduction from sympathetic nerve activation into vasoconstriction also contributes to the decrease in blood pressure after exercise.43 However, the contribution of each 1 of these mechanisms to the postexercise blood pressure response is different depending on the age of the persons. In older adults, like the participants in this study, in whom structural and functional vascular changes are expected and in whom arterial stiffness limits vasodilation,24 the decrease in blood pressure depends mainly on cardiac output.10,11 On the basis of previous evidence,10 one can speculate that the decrease in systolic blood pressure observed in this study could be attributable to a reduction in cardiac output due to a decrease in stroke volume as a result of a lower left ventricular end-diastolic volume. On the contrary, the lack of changes in diastolic blood pressure could be related to the limited vasodilation of older adults in comparison with younger adults.
The results of this study are promising, as postexercise blood pressure reduction seems to be important in the long term. In fact, it has been suggested that this transient reduction contributes directly to the chronic reductions in blood pressure observed after exercise training programs in persons with hypertension.44 Two recent studies showed that in adults with hypertension, the magnitude of the acute decrease in blood pressure after aerobic exercise could predict long-term blood pressure reductions induced by participation in aerobic exercise training.45,46 It is important to mention that older adults (aged 80 years and older) also benefit, as do younger adults with hypertension, from the participation in exercise training programs. Indeed, chronic reductions in systolic blood pressure have been reported in adults aged 80 years and older as a result of 6 months of aerobic exercise training.47 These observations reinforce the need for future studies assessing the acute and chronic effects of physical exercise on blood pressure in older adults, aged 80 years and older, with hypertension.
This study has some limitations. First, the short period of time used to monitor the blood pressure after exercise may have masked possible longer-lasting effects of greater magnitude because the greatest reductions in systolic blood pressure were observed in the last assessment (40 minutes postexercise). An ambulatory blood pressure assessment would enable measuring the duration of the exercise effects and whether they persist under conditions of daily living. Second, another limitation relates to the determination of exercise intensity through the theoretical maximum heart rate, an indirect indicator. Third, the control condition was conducted in the sitting position, whereas the exercise was conducted in standing position. Nevertheless, we found it impractical to keep the participants in the control group resting for 35 minutes in a standing position. Fourth, the use of a between-group design is also a limitation; it is recommended that future studies in this age group use a within-subject repeated-measures design.
The results of this study suggest that a single session of aerobic exercise acutely reduces blood pressure in very old adults with hypertension. These results add evidence supporting the importance of physical activity and aerobic exercise as a nonpharmacological strategy to control hypertension even in very old adults.
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