Hypertension

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Cardiovascular fitness and physical activity appear to be the main risk factors for hypertension. Various forms of exercise training have been found to reduce blood pressure significantly in normal and hypertensive individuals of all ages and in both healthy and non-healthy populations (including people with metabolic syndrome, type II diabetes, chronic kidney failure and overweight).

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What is hypertension?

Hypertension is defined a blood pressure above a certain level (i.e. hypertension is high or elevated blood pressure). Blood pressure is typically quoted in two numbers: systolic and diastolic. Systolic blood pressure is the pressure in the artery when the heart is in systole (i.e. when the heart is contracting) and diastolic blood pressure is the pressure in an artery when the heart is in diastole (i.e. when the heart is relaxed). Therefore, systolic blood pressure is much higher than diastolic blood pressure. High blood pressure or hypertension is widely regarded as a very significant risk factor for cardiovascular disease in general and coronary artery disease in particular. The following table sets out the classification of hypertension in the context of overall blood pressure measurements (Williams et al.):

Blood pressure category Systolic (mmHg) Diastolic (mmHg)
Optimal blood pressure <120 <80
Normal blood pressure <130 <85
High-normal blood pressure 130 – 139 85 – 89
Grade 1 hypertension (mild) 140 – 159 90 – 99
Grade 2 hypertension (moderate) 160 – 179 100 – 109
Grade 3 hypertension (severe) >180 >110
Isolated systolic hypertension (Grade 1) 140 – 159 <90
Isolated systolic hypertension (Grade 2) >160 <90

Hypertension is most typically defined as an average systolic blood pressure of >140mmHg, diastolic blood pressure of >90mmHg, or use of antihypertensive medication. The bracket below this (130 – 139/85 – 89mmHg) is typically referred to as pre-hypertension or high blood pressure.


How does hypertension relate to all-cause mortality?

Hypertension is thought to increase the risk of cardiovascular disease, cardiovascular disease mortality and all-cause mortality. A small number of prospective cohort studies have been performed to assess this, as shown in the following table:

Study Description Finding
Wei et al. The researchers performed a prospective cohort study with 2,629 Mexican Americans using the San Antonio Heart Study cohort with a 7 – 8-year follow-up in order to assess the association between baseline hypertension and cardiovascular disease, cardiovascular disease mortality and all-cause mortality. The researchers reported that individuals with high blood pressure had a 1.6 and 2.7 times greater rate of all-cause and cardiovascular disease mortality, respectively.
Antikainen et al. The researchers performed a prospective 15-year cohort study with 2 independent cross-sectional random samples of 10,333 men and 11,160 women aged 25 – 64 years in the North Karelia and Kuopio provinces in eastern Finland in order to assess the association between baseline hypertension and cardiovascular disease, cardiovascular disease mortality and all-cause mortality. The researchers reported that coronary heart disease, stroke, cardiovascular disease and all-cause mortality increased with increasing systolic blood pressure.

Similarly, actually performing an intervention to reduce high blood pressure is believed to reduce the rate cardiovascular disease, cardiovascular disease mortality and all-cause mortality. This can be seen by the systematic reviews and meta-analyses in the following table:

Study Description Finding
Pearce et al. The researchers performed a systematic review and meta-analysis to assess the short-term effects of drug treatment of hypertension in the elderly (>60 years of age) on stroke, major coronary events and cardiovascular disease mortality and all-cause mortality rates. They included 8 randomized, controlled trials involving 15,990 patients treated for an average of 4.6 years in their meta-analysis. The researchers found that the mean treatment effect on blood pressure was 15/6mmHg. They reported that this reduction resulted in a decrease in the risks of a fatal or nonfatal major coronary event by 18%, a fatal or nonfatal stroke by 35%, and all-cause mortality by 15%.
Blood Pressure Lowering Treatment Trialists’ Collaboration The researchers performed a systematic review and meta-analysis to assess the effects of different blood-pressure-lowering treatments (e.g. angiotensin-converting-enzyme [ACE] inhibitors, calcium antagonists, angiotensin-receptor blockers [ARBs] and diuretics or beta-blockers) on the risks of major cardiovascular events, cardiovascular disease mortality and all-cause mortality rates. The researchers included 29 trials with 162,341 participants and the mean age of the subjects was 65 years. The researchers found that blood-pressure lowering using ACE inhibitors and calcium-antagonists led to 22% and 18% lower risks of major cardiovascular events, respectively, but only ACE-inhibitors led to a 20% reduced rate of cardiovascular disease mortality and a 12% reduction in all-cause mortality.
Blood Pressure Lowering Treatment Trialists’ Collaboration The researchers performed a systematic review and meta-analysis to assess the effects of different treatment regimens designed to lower blood pressure in younger (<65 years) and older (>65 years) adults. The researchers included 31 trials with 190,606 subjects. The researchers reported that blood pressure reduction produces similar proportional decreases in the risks of cardiovascular events in younger (<65 years) and older (≥65 years) adults. However, they did not assess the effects of this reduction in blood pressure on either cardiovascular disease mortality or all-cause mortality rates.
Gueyffier et al. The researchers performed a systematic review and meta-analysis to assess the effects of drug treatment of hypertension in the very old (>80 years of age) on stroke, major coronary events and cardiovascular disease mortality and all-cause mortality rates. The meta-analysis of data included 1,670 subjects aged >80 years. The researchers reported that while the treatment caused a reduction in strokes of 34%, in major cardiovascular events of 22% and a reduction in heart failure of 39%, there was no effect on cardiovascular disease mortality and all-cause mortality rates.
Briasoulis et al. The researchers performed a systematic review of prospective randomized trials to assess the effects of antihypertensive treatment on cardiovascular disease mortality, all-cause mortality, stroke and heart failure in patients >65 years of age. The researchers included 18 clinical studies with 59,285 controls and 55,569 hypertensive patients with an average follow-up period of 3.44 years and a mean patient age of 71 years. The researchers analyzed the studies in two groups: those comparing an antihypertensive medication with a placebo group (mean blood pressure reduction of 27.3/11.1mmHg) and those comparing two antihypertensive medications (mean blood pressure reduction of >17/6mmHg). The researchers reported that in the first group, the reduction in blood pressure to <150/80mmHg was associated with a large improvement in stroke, heart failure, and cardiovascular and all-cause mortality.
Heerspink et al. The researchers performed a systematic review of randomized controlled trials to assess the effects of antihypertensive treatment on cardiovascular disease mortality, all-cause mortality, stroke and heart failure in in patients on dialysis. The researchers identified 8 relevant trials, including 1,679 patients and 495 cardiovascular events. The researchers found that blood pressure lowering treatment was associated with a 29% lower risks of cardiovascular events, a 29% lower risk of cardiovascular mortality, and a 20% lower risk of all-cause mortality.
Agarwal and Sinha The researchers performed a systematic review of randomized controlled trials to assess the effects of antihypertensive treatment on cardiovascular disease mortality, all-cause mortality, stroke and heart failure in in patients on dialysis. The researchers identified 5 trials, including 1,202 patients. The researchers reported that blood pressure-lowering treatment was associated with a 31% lower risk of cardiovascular events and a 23% reduction in all-cause mortality.

Based on these studies, it appears that lowering blood pressure in the general population and in at risk groups, such as those with coronary artery disease and chronic kidney disease, is definitely associated with lower all-cause mortality. However, whether lowering blood pressure in the very old is also associated with lower all-cause mortality appears uncertain.


What is the prevalence of hypertension?

Hypertension is extremely prevalent worldwide but particularly so in Western countries and in older people. Using a standard definition of hypertension as an average systolic blood pressure of >140mmHg, diastolic blood pressure of >90mmHg, or use of antihypertensive medication, the prevalence of hypertension in various geographies is shown in the table below:

Study Population Prevalence
Burt et al. United States non-Hispanic black adults >18 years 32.4%
Burt et al. United States non-Hispanic white adults >18 years 23.3%
Burt et al. United States Mexican American adults >18 years 22.6%
Kearney et al. Rural India male adults 3.4%
Kearney et al. Rural India female adults 6.8%
Kearney et al. Polish male adults 68.9%
Kearney et al. Polish female adults 72.5%
Kearney et al. Worldwide male adults 26.6%
Kearney et al. Worldwide female adults 26.1%

Based on the above studies, it seems that the worldwide prevalence of hypertension in adult populations is around 26% but can range from 4 – 73% depending upon the gender and geography of the individuals being tested.


Are physical activity and cardiovascular fitness risk factors for hypertension?

The following table sets out several  studies that show the extent to physical activity and cardiovascular fitness are risk factors for hypertension in various populations:

Study Description Finding
Haapanen et al. The researchers assessed effect of the total amount and intensity of leisure time physical activity on the risk of hypertension in a cohort of 1,340 men and 1,500 women aged 35 – 63 years over a 10-year follow-up period. The researchers found that in comparison with the most active tertile, the least active tertile had a 1.7 times greater risk of developing hypertension.
Hu et al. The researchers assessed the effects of regular physical activity on the risk of hypertension in both normal weight and overweight males and females by prospectively following 8,302 Finnish males and 9,139 females aged 25 – 64 years with no history of antihypertensive medication use, coronary heart disease, stroke, and heart failure at baseline. The researchers found that individuals who participating in moderate or high levels of physical activity had a 1.2 and 1.4 times lower risk of developing hypertension than those who did not partake in any physical activity. This relationship remained in individuals who were overweight.
Pereira et al. The researchers assessed the effects of regular physical activity on the risk of hypertension in black and white males and females using the Atherosclerosis Risk in Communities (ARIC) Study, a population-based prospective study in the US, including 7,459 black and white adults aged 45 – 65 years. Hypertension was defined as blood pressure >140/90mmHg or device or antihypertensive medication use. The subjects were follow-up over a period of 6 years. The researchers found that white men in the highest quartile of leisure physical activity had a 34% lower risk of developing hypertension compared to the least active, even after adjustment for age, baseline blood pressure, education, body mass index, waist-hip ratio, parental history of hypertension, cigarette smoking, alcohol consumption and diet.
Hayashi et al. The researchers assessed the association between the duration of a walk to work and leisure-time physical activity with the risk for hypertension in a prospective cohort study involving 6,017 Japanese men 35 – 60 years of age with systolic blood pressure <140 mmHg and diastolic blood pressure <90mmHg, normal glucose intolerance and no history of hypertension or diabetes at baseline. The researchers reported that the duration of the walk to work was associated with a lower risk for incident hypertension. Specifically, in comparison with a walk to work of <10 minutes, walks of 11 – 20 and >21 minutes were associated with a 1.14 and a 1.41 times lower risk of incident hypertension.
Bassett et al. The researchers assessed associations between ethnicity, leisure-time physical activity and hypertension in 16,246 adults in the third National Health and Nutrition Examination Survey. The researchers reported that in comparison with the most sedentary group, the most active group had a 1.4 times lower risk of developing hypertension.
Nakanishi et al. The researchers assessed the associations between leisure-time physical activity and hypertension in 2,548 normotensive Japanese male office workers aged 35 – 59 years and with no history of cardiovascular disease at baseline. The researchers followed-up the subjects over a 7 year period. Hypertension was defined as systolic blood pressure as >140mmHg and/or diastolic blood pressure of >90mmHg or use of antihypertensive medication. The researchers reported that in comparison with the lowest quartile of daily life energy expenditure, those individuals in the second, third and fourth quartiles had a 16%, 25% and 46% lower risk of developing hypertension.
Barlow et al. The researchers assessed the association between cardiorespiratory fitness and incident hypertension in 4,884 normotensive women, using the Aerobics Center Longitudinal Study (Dallas, Texas). The researchers reported that in comparison with low-fitness females, the prevalence of hypertension among the moderate- and high-fitness females was 60% and 79% lower, respectively. After adjusting for confounding factors, the researchers found that moderate- and high-fitness females were 1.65 and 2.86 times less likely to develop hypertension than low-fitness females, respectively.
Blair et al. The researchers assessed the association between cardiorespiratory fitness and incident hypertension in in 4,820 normotensive men and 1,219 women aged 20 – 65 years with no history of cardiovascular disease. The researchers followed up the subjects for 1 – 12 years. The researchers reported that after adjusting for sex, age, follow-up interval, baseline blood pressure and baseline body-mass index, subjects with low levels of physical fitness were 1.52 times more likely to develop hypertension than those with high levels of physical fitness.
Chase et al. The researchers assessed the association between physical activity, cardiorespiratory fitness and the prospective development of hypertension in 6,601 initially normotensive males aged 20 – 82 years using the Aerobics Center Longitudinal Study (ACLS). The researchers reported that in terms of physical activity, the walker/jogger/runner group and sport/fitness groups had 1.12 and 1.30 times lower risks of developing hypertension, respectively. Similarly, in comparison with the low-cardiovascular-fitness group, the middle and high cardiovascular-fitness groups had 1.15 and 1.39 times lower risks of developing hypertension, respectively. The researchers observed that these associations remained after adjusting for body mass index (BMI), smoking, alcohol intake, resting systolic blood pressure, baseline health status, and family history of diseases.

Based on these studies, it seems clear that low levels of cardiovascular fitness and low levels of physical activity are significant risk factors for developing hypertension.


Is diet a risk factor for hypertension?

The following table sets out several  studies that have been performed that assess the dietary risk factors that have been proposed to contribute to a greater or lesser risk of hypertension in various populations:

Study Description Finding
Ford and Cooper The researchers assessed the risk factors for hypertension using data from the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study (1971 – 1984) in 7,073 subjects without hypertension at baseline over a follow-up period of 10 years. The researchers found that body mass index (BMI) was a risk factor for incident hypertension in both white and black individuals, while lack of education was a risk factor in white females. On the other hand, dietary consumption of sodium, calcium, and potassium was not a risk factor for hypertension.
Ascherio et al. The researchers assessed the association of various dietary components and the risk of developing hypertension prospectively in 30,681 predominantly white US male health professionals, 40 – 75 years old, without hypertension at baseline, over 4 years of follow-up. The researchers reported that age, relative weight and alcohol consumption were the most significant risk factors for the development of hypertension. To a lesser degree, the researchers reported that dietary fiber, potassium and magnesium were each significantly associated with a lower risk of developing hypertension. The researchers reported that they did not observe any significant associations between sodium, total fat, or saturated, trans-unsaturated and polyunsaturated fat and the risk of developing hypertension.
Ascherio et al. The researchers assessed association between dietary intakes and blood pressure levels in a cross-sectional sample of 805 men aged 40 – 69 years without hypertension, coronary heart disease or cancer. The researchers reported that after controlling for confounding factors, blood pressure levels were inversely associated with the intake of fruit. However, calcium and magnesium intake were not significantly associated with blood pressure levels.
Ascherio et al. The researchers assessed the association of various dietary components and the risk of developing hypertension prospectively in 41,541 predominantly white US female nurses, aged 38 – 63 years, without hypertension and baseline, over 4 years of follow-up. The researchers reported that age, relative weight and alcohol consumption were the most significant risk factors for the development of hypertension. The researchers reported that dietary calcium, magnesium, potassium, and fiber were not significantly associated with a lower risk of developing hypertension.
Witteman et al. The researchers assessed the association of various dietary components and the risk of developing hypertension prospectively in 58,218 predominantly white US female registered nurses, 34 – 59 years old over 4 years of follow-up. The researchers reported that age, relative weight, and alcohol consumption were the most significant risk factors for the development of hypertension. To a lesser degree, the researchers reported that dietary calcium and magnesium were each significantly associated with a lower risk of developing hypertension. The researchers reported that they did not observe any significant associations between potassium, fiber and saturated and polyunsaturated fat intake and the risk of developing hypertension.
Fuchs et al. The researchers assessed whether alcohol consumption was a risk factor for hypertension and whether there is a threshold level for this association. They performed a cohort study including 8,334 white and black individuals aged 45 – 64 years at baseline, who were partaking in the Atherosclerosis Risk in Communities (ARIC) Study, and who were free of hypertension and coronary heart disease at baseline. The subjects were followed-up after 6 years and hypertension was defined as a systolic blood pressure >140mmHg or diastolic blood pressure >90mmHg or use of antihypertensive medication. The researchers found that consuming large amounts of alcohol (>210g per week) led to a 1.2, 2.0 and 2.3 times greater risk of developing hypertension in white males, white females and black males, respectively. However, consuming low-to-moderate amounts of alcohol (1 – 209g per week) led to a 1.1 times greater lower risk of developing hypertension in white individuals and black females but a 1.7 times greater risk of developing hypertension in black males.

Based on these studies, it seems that dietary factors are less important than age, relative weight and alcohol consumption in relation to the risk of developing hypertension. It is difficult to assess whether dietary calcium, magnesium, potassium, sodium and fiber affect the risk of developing hypertension in normotensive individuals.


What are the other risk factors for hypertension?

The following table sets out several  studies that have been performed that assess the varying factors that contribute to a greater or lesser risk of hypertension in various populations (excluding dietary factors, physical activity and cardiovascular fitness):

Study Description Finding
Wang et al. The researchers assessed the risk factors for hypertension in 4,549 American Indian subjects who were taking part in the 3 exams of the Strong Heart Study were used. In this study, hypertension was defined as systolic blood pressure >140 mmHg, diastolic blood pressure >90mm Hg, or current use of antihypertensive medication. The researchers found that age, diabetes, and macro- or micro-albuminuria were independently significant risk factors of hypertension.
Jonas et al. The researchers assessed whether symptoms of anxiety and depression affect the risk of hypertension, using the National Health and Nutrition Examination I Epidemiologic Follow-up Study in a population-based cohort of 2,992 initially normotensive persons followed for 7 – 16 years. The researchers found that in white individuals aged 45 – 64 years, high anxiety and high depression led to a 1.8 times greater risk of incident hypertension while in blacks individuals aged 25 – 64 years, high anxiety and high depression led to a 2.7 and 3.0 times greater risk of incident hypertension, respectively.
Jonas and Lando The researchers assessed whether baseline negative affect alter the risk of hypertension, using a population-based cohort of 3,310 initially normotensive and chronic disease-free persons in the NHANES I Epidemiologic Follow-up Study over a follow-up period of up to 22 years. The researchers assessed hypertension as self-reported, use of antihypertensive medications, or incident blood pressure >160/95mmHg. The researchers found that greater negative affect was associated with increased risk of incident hypertension and high negative affect was associated with a 1.7, 3.1 and 1.6 times greater risk of incident hypertension in white females, black females and both black and white males, respectively.
Davidson et al. The researchers assessed whether baseline depressive symptoms could alter the risk of hypertension using a prospective, multicenter, epidemiological cohort of 3,343 young adults aged 23 – 35 years and without hypertension at baseline who were then followed up for 5 years. Hypertension was defined as blood pressure >160/95mmHg or the use of antihypertensive medication. The researchers found that those subjects with high scores (>16) on the Center for Epidemiological Studies Depression (CES-D) Scale were at displayed a 2.1 times greater risk for hypertension incidence than those with low CES-D scores (<7) even after adjustment for confounding factors including age, physical activity, alcohol consumption, parental history of hypertension, education, presence of diabetes mellitus or heart disease, sex and race).
Skarfors et al. The researchers assessed the risk factors for hypertension in a cohort of 2,322 middle-aged men over a 10 year follow-up period. At baseline, 19.6% of the subjects were hypertensive, defined as diastolic blood pressure >95mmHg or use of antihypertensive medication. At follow-up, researchers found that 34.7% were hypertensive. The researchers found that blood pressure at baseline was the strongest predictor of incident hypertension. Additionally, fasting and late insulin levels at intravenous glucose testing, significant change in body mass index from baseline to follow-up, and heredity for hypertension were also risk factors.
Folsom et al. The researchers assessed the risk factors for hypertension in a cohort of 41,837 females aged 55 – 69 years. The researchers found that females who developed hypertension were 2.1 times more likely to be in the upper tertile of waist-to-hip ratio than those who did not. They found that when this model was adjusted for age, body mass index (BMI), cigarette smoking, physical activity, alcohol intake and education level, the odds ratio was reduced to 1.6 but this was still significant.
Leung et al. The researchers assessed the risk factors for hypertension in 6,193 students from randomly selected secondary schools in Hong Kong. The researchers found that a high waist circumference (>85 percentile) was associated with a 2.4 times greater risk of hypertension while exercising 2 or more times per week associated with a 3.6 times lower risk of hypertension.
Okosun et al. The researchers assessed the association between abdominal obesity and the risk of hypertension in the US adult population, using data from the third US National Health and Nutrition Examination Surveys, 1988 – 1994. Abdominal obesity was defined as waist circumference >102cm in males and >88 cm in females while hypertension was defined as systolic blood pressure >140mmHg, diastolic blood pressure >90mmHg, or use of antihypertensive medication. The researchers reported that abdominal obesity was associated with a 2 – 3 times greater risk of hypertension.
Ford and Cooper The researchers assessed the risk factors for hypertension using data from the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study (1971 – 1984) in 7,073 subjects without hypertension at baseline over a follow-up period of 10 years. The researchers found that body mass index (BMI) was a risk factor for incident hypertension in both white and black individuals, while lack of education was a risk factor in white females. On the other hand, dietary consumption of sodium, calcium, and potassium was not a risk factor for hypertension.
Onal et al. The researchers assessed the risk factors for hypertension in 423 subjects from the European side of Istanbul aged >25 years. The researchers found that 35.5% of the subjects were hypertensive, while 35.9% were obese, 27.9% were overweight and 2.1% were underweight. The researchers reported that increased age, body mass index (BMI) and smoking were all associated with a greater risk of hypertension.
Lindberg et al. The researchers assessed whether snoring and excessive daytime sleepiness (i.e. the main symptoms of obstructive sleep apnea syndrome) were risk factors for hypertension in a random sample of 6,779 women aged 20 – 99 years. The researchers grouped the subjects into four categories: no excessive daytime sleepiness or snoring (control group), snoring but no excessive daytime sleepiness, excessive daytime sleepiness but no snoring and snoring and excessive daytime sleepiness. The researchers reported that the prevalence of hypertension was lowest in the reference group (8.7%) and highest in the group displaying both snoring and excessive daytime sleepiness (26.3%). The researchers found that snoring and excessive daytime sleepiness led to a 1.8 times greater risk of displaying hypertension than the control group condition.
Ohayon et al. The researchers assessed the relationship between hypertension and three forms of sleep-disordered breathing (chronic snoring, breathing pauses and obstructive sleep apnea syndrome) in a sample of 13,057 individuals aged 15 – 100 years taken from non-institutionalized population of the UK, Germany and Italy. The researchers observed that obstructive sleep apnea syndrome was prevalent in 1.9% of the UK sample, 1.8% of the German sample and 1.1% of the Italian sample. The researchers reported that obstructive sleep apnea syndrome led to a 9.7 times greater risk of displaying hypertension, even after controlling for confounding effects of age, gender, obesity, smoking, alcohol consumption, life stress and heart and renal diseases.
Grote et al. The researchers assessed whether sleep-related breathing disorder, as assessed by a respiratory disturbance index (RDI), was a risk factor for elevated blood pressure in 1,190 consecutive patients referred for diagnosis of sleep-related breathing disorder. The researchers found that the RDI was independently and linearly associated with daytime systolic and diastolic blood pressures and heart rate at rest. Taking hypertension as a blood pressure >160/95mmHg, the researchers found that the risk of hypertension was increased with sleep-related breathing disorder severity. Specifically, those with a RDI of >40 had a 4.2 times greater risk of hypertension than those with an RDI of <5. The researchers found that this relationship remained significant even after controlling for confounding factors including body mass index (BMI), age, alcohol/nicotine consumption, and cholesterol level.
Carlson et al. The researchers assessed whether body mass index (BMI) and sleep apnea were risk factors for elevated blood pressure and hypertension in 377 consecutive subjects admitted to a sleep laboratory. The researchers found that the risk of hypertension increased with increasing age, BMI and presence of sleep apnea. The researchers observed that a combination of obesity and sleep apnea led to a 3.9 times greater risk of hypertension in comparison with normal weight individuals without sleep apnea.
Young et al. The researchers assessed whether sleep-disordered breathing was a risk factor for elevated blood pressure and hypertension independent of confounding factors in 1,060 males and females aged 30 – 60 years who completed an overnight protocol in the Wisconsin Sleep Cohort Study. The researchers found that blood pressure increased linearly with increasing apnea-hypopnea index. The researchers observed that those individuals with an apnea-hypopnea index of 15 had a 1.8 times greater risk of having hypertension than those with an index of 0.
Gangwisch et al. The researchers assessed whether short sleep duration was a risk factor for hypertension incidence using the first National Health and Nutrition Examination Survey in 4,810 individuals over an 8 – 10 year follow-up period between 1982 and 1992. The researchers reported that sleep durations of <5 hours per night were associated with a 2.1 times greater risk of hypertension in subjects between the ages of 32 – 59 years and this relationship remained significant even after adjusting for confounding factors.

Based on these studies, it appears that an older age, a high body mass index (indicating overweight or obesity), a high waist circumference, sleep-related breathing disorders and short sleep duration are all associated with a higher risk of hypertension.


Does exercise affect blood pressure in healthy people?

A number of exercise interventions have been performed to assess the effects of general exercise, physical activity or aerobic exercise on blood pressure in healthy populations, as shown in the table below:

Study Description Finding
Cononie et al. The researchers assessed the effects of 6 months of resistance or endurance exercise training on blood pressure in 49 elderly people aged 70 – 79 years. The resistance training comprised 1 set of 8 – 12 repetitions on 10 Nautilus machines, 3 times per week. The endurance training group progressed toward training at up to  75 – 85% of VO2-max for 35 – 45 minutes, 3 times per week. The researchers reported that resistance training did not alter blood pressure but endurance training led to significant reductions in diastolic and mean blood pressure.
Kingwell et al. The researchers assessed the effects on blood pressure of 4-weeks of 3 different exercise routines in 14 normotensive individuals. The different exercise programs comprised: 1 hour of walking at 50% of maximal work capacity, 5 days per week; 15-minutes high-intensity cycling sessions at 80 – 90% of maximal work capacity, 5 days per week; and 30-minute moderate-intensity cycling sessions at 65 – 70% of maximal work capacity, 3 days per week. The researchers reported that the moderate cycling program produced the greatest blood pressure reduction (5/3mmHg) in comparison with walking (3/2mmHg) and high-intensity cycling (no change).
Whelton et al. The reviewers performed a meta-analysis of randomized controlled trials to assess the effects of aerobic exercise on blood pressure. They identified 54 randomized, controlled trials using 2,419 subjects. The researchers reported that aerobic exercise was associated with a significant reduction in both systolic and diastolic blood pressure of 3.84 and 2.58mmHg, respectively.
Cornelissen and Fagard The reviewers performed a meta-analysis of randomized controlled trials to assess the effects of endurance training on resting and ambulatory blood pressure, blood pressure-regulating mechanisms and cardiovascular risk factors. They identified 72 trials including 3,936 subjects. The reviewers found that endurance training was associated with significant reductions in resting and daytime ambulatory blood pressure of 3.0/2.4 and 3.3/3.5mmHg, respectively.
Murphy et al. The reviewers performed a meta-analysis to assess the effects of walking on various cardiovascular risk factors, including blood pressure. The reviewers identified 24 randomised controlled trials of walking. The reviewers reported that that walking interventions significantly increased VO2-max, decreased bodyweight, decreased body mass index (BMI), reduced body fat percentage and reduced resting diastolic blood pressure in previously sedentary adults.

Based on these studies and reviews, it appears that general exercise, including aerobic or endurance training, is effective for reducing hypertension in healthy individuals. In general exercise interventions are associated with reductions in systolic and diastolic blood pressures of around 3 – 5mmgHg, although this includes trials as short as 4 weeks.


Does exercise affect blood pressure in hypertensive people?

A large number of exercise interventions have been performed to assess the effects of general exercise, physical activity or aerobic exercise on blood pressure in hypertensive individuals. The findings of these studies and reviews are shown in the table below:

Study Description Finding
Hagberg et al. The researchers assessed the effects of 9 months of low- or moderate-intensity exercise training on blood pressure in hypertensive elderly males and females (mean age 64 ± 3 years). The low- and moderate-intensity groups trained at 53 and 73% of VO2-max, respectively. The researchers found that diastolic blood pressure decreased significantly by 11 – 12 mmHg in both training groups while systolic blood pressure decreased significantly by 20mmHg in the low-intensity and non-significantly by 8mmHg in the moderate-intensity training group.
Stewart et al. The researchers performed a randomized controlled trial to assess the effects of 6 months of exercise training on blood pressure in 104 hypertensive elderly males and females aged 55 – 75 years The exercising subjects performed combined aerobic and resistance training while control subjects followed usual care physical activity and diet advice. The subjects had untreated systolic and diastolic blood pressures of 130 – 159 and 85 – 99mmHg. The researchers reported that the exercise group significantly reduced systolic and diastolic blood pressures by 5.3 and 3.7mmHg while controls reduced 4.5 and 1.5mmHg. The systolic blood pressure reduction was not significantly different between the exercise and control groups but the diastolic blood pressure reduction was significantly different.
Duncan et al. The researchers assessed the effects of a 16-week aerobic exercise program on blood pressure in 56 hypertensive patients with baseline diastolic blood pressure of 140/90mmHg. The researchers reported that the exercise group significantly reduced both systolic and diastolic blood pressures, compared with the control group. The researchers reported that reductions in systolic blood pressure was 10.3 and 15.5 mm Hg for normoadrenergic, and hyperadrenergic groups, respectively, while diastolic changes were similar and also significant.
Matsusaki et al. The researchers assessed the effects of 10 weeks of either low or high workload exercise in 26 mild hypertensive patients. The low workload group performed bicycle ergometer exercise at 50% of VO2-max for 60 minutes, 3 times a week while the high workload group performed the same routine but at 75% of VO2-max. The researchers found that the low workload group displayed significantly greater reductions in systolic (9mmHg) and diastolic (6mmHg) blood pressures while reductions in the high workload group in systolic (3mmHg) and diastolic (5mmHg) blood pressure were not statistically significant.
Cononie et al. The researchers assessed the effects of 6 months of resistance or endurance exercise training on blood pressure in 49 elderly people aged 70 – 79 years, some of whom were mildly hypertensive (>140/90mmHg). The resistance training comprised 1 set of 8 – 12 repetitions on 10 Nautilus machines, 3 times per week. The endurance training group progressed toward training at up to  75 – 85% of VO2-max for 35 – 45 minutes, 3 times per week. The researchers reported that resistance training did not alter blood pressure but endurance training led to significant reductions in diastolic and mean blood pressure. Moreover, mildly hypertensive subjects performing endurance exercise reduced their systolic, diastolic, and mean blood pressure by 8, 9, and 8mm Hg, respectively.
Nelson et al. The researchers assessed the effects of a two different 4-week exercise programs on blood-pressure in 13 untreated patients with hypertension. The subjects were divided into 2 groups, one of which performed 45 minutes of bicycling at 60 – 70% of maximum work capacity, 3 times per week while the other performed 45 minutes bicycling 7 times per week. The researchers reported that the 3-times per week group reduced blood pressure by 11/9mmHg while the 7-times per week group reduced blood pressure by 16/11mmHg. The researchers therefore concluded that moderate regular exercise lowers blood pressure and is therefore an important non-pharmacological method for treating hypertension.
Martin et al. The researchers performed a prospective randomized controlled trial to assess the effects of aerobic exercise training in 27 males with mild hypertension. The researchers randomly allocated the subjects to one of two groups: an aerobic exercise group and a control group. The aerobic exercise comprised walking, jogging or stationary bicycling for 30 minutes, 4 times a week, at 65 – 80% of maximal heart rate. The control group performed slow calisthenics and stretching for the same duration and frequency. The researchers reported that the aerobic exercise group decreased diastolic blood pressure by 9.6 ± 4.7mmHg and systolic blood pressure by 6.4 ± 9.1mmHg but neither changed significantly in the control group.
Blumenthal et al. The researchers performed a prospective randomized controlled trial to assess the effects of a 4-month program of aerobic exercise training, strength and flexibility training in 99 males and females with mild hypertension (140 – 180/90 – 105mmHg). The researchers randomly allocated the subjects to one of two groups: an exercise group and a control group. The researchers reported that the exercise group did not display greater reductions in blood pressure than subjects in the control group and only reduced systolic and diastolic blood pressure non-significantly by 1.0 ± 16mmHg and 1.2 ± 10mmHg, respectively.
Roman et al. The researchers performed a prospective randomized controlled trial to assess the effects of a long-term training program in 30 chronic hypertensive female patients, over 4 stages: 3 months training at 70% of maximal heart rate, 3 months without training, 1 year training at 70% of maximal heart rate, and 1 year training with increasing intensity training >70% of maximal heart rate. The researchers found that resting systolic and diastolic blood pressure reduced significantly by 21/17mmHg from 182/114 to 161/97mmHg but increased again once training was discontinued.
Kokkinos et al. The researchers assessed the effects of moderate-intensity exercise on blood pressure and left ventricular hypertrophy in African-American men with severe hypertension. They randomly assigned 46 men 35 – 76 years of age to either an exercise plus antihypertensive medication group or to an antihypertensive medication only group for a 16-week intervention. The exercise comprised aerobic training for 3 times per week at 60 – 80% of maximal heart rate. The researchers observed a significant reduction in diastolic blood pressure of 5mmHg from 88 ± 7 to 83 ± 8mmHg in the antihypertensive medication plus exercise group but there was no significant change in the antihypertensive medication only group. Systolic blood pressure also showed a trend to reduce in the antihypertensive medication plus exercise group from 138 ± 10mmHg to 131 ± 15mmHg but there was no change in the antihypertensive medication only group.
Kinoshita et al. The researchers assessed the effects of 10 weeks of exercise at the lactate threshold in 21 patients with hypertension. The researchers allocated the subjects to either a control group or to an exercise group. The researchers observed significant reductions in blood pressure of 13/7mmHg from 154 ± 3/100 ± 2 to 141 ± 3/93 ± 3mmHg but they did not observe any changes in the control group. The researchers also identified that those individuals in the exercise group who displayed a very large response to exercise (>10mmHg fall in mean blood pressure) also had a significantly higher cardiac index, serum Na:K ratio and lower total peripheral resistance in than non-responders.
Cade et al. The researchers assessed the effects of a 3-month exercise program on blood pressure in 105 patients with diastolic hypertension. The researchers reported that in 4 of the patients, the decrease in mean blood pressure was <5 mmHg but in all others, there was a significant reduction: specifically, in 58 of the 105 patients who were not using antihypertensive medication, mean blood pressure decreased by 15mmHg.
Motoyama et al. The researchers assessed the effects of a 9-month, low-intensity aerobic training program on blood pressure in elderly hypertensive patients who were receiving antihypertensive medication. The researchers allocated the subjects to either an exercise group (mean age 75.4 ± 5.4 years) who walked on a treadmill at the lactate threshold for 30 minutes 3 – 6 times a week for 9 months while a control group (mean age 73.1 ± 4.2 years) did no exercise. The researchers reported that resting systolic and diastolic blood pressures reduced significantly by 15 ± 8 and 11 ± 6mmHg, respectively while no significant changes in blood pressure were observed in the control group.
Seals et al. The researchers assessed the effects of 12 weeks of aerobic exercise on blood pressure in 10 post-menopausal women with mild-to-moderate hypertension ranging from 130 – 159/85 – 99mmHg. The subjects performed moderate-intensity aerobic exercise (walking). The researchers reported that both systolic and diastolic blood pressure were significantly lowered by 10 – 12 and 5 – 7mm Hg, respectively, with the range encompassing differences between measurements in the sitting and standing positions. The researchers concluded that regular aerobic exercise can produce clinically important reductions in resting blood pressure in postmenopausal women with mild to moderately elevated baseline blood pressure.
Tanaka et al. The researchers assessed the effects of 10 weeks of a closely-supervised swimming training program on blood pressure in 18 previously sedentary males and females aged 48 ± 2 years with stage 1 or 2 hypertension. The researchers allocated the subjects into an exercise group and a control group. The researchers reported that systolic blood pressure of the exercise group fell significantly from 150 ± 5 to 144 ± 4mmHg but diastolic blood pressure did not change significantly. However, there were no significant changes in either variable in the control group.
Zanettini et al. The researchers assessed the effects of aerobic exercise on resting and 24-hour blood pressure in 14 sedentary subjects with untreated diastolic blood pressure between 90 – 104mmHg. The researchers completed a 12-week supervised exercise program. The researchers reported that the exercise-training led to an increase in aerobic fitness as measured by VO2-max of 24% and that this was associated with a significant reduction in resting systolic and diastolic blood pressure.
Cornelissen and Fagard The reviewers performed a meta-analysis of randomized controlled trials to assess the effects of endurance training on resting and ambulatory blood pressure, blood pressure-regulating mechanisms and cardiovascular risk factors in both normotensive and hypertensive individuals. They identified 72 trials including 3,936 subjects. The reviewers found that endurance training was associated with significant reductions in resting and daytime ambulatory blood pressure of 3.0/2.4 and 3.3/3.5mmHg, respectively. They reported that the reductions in resting blood pressure in the 30 hypertensive study groups was 6.9/4.9mmHg, which was greater than that in the normotensive groups.

Based on these studies and reviews, it appears that aerobic and general exercise including aerobic or endurance training is effective for reducing hypertension in mild-to-severely hypertensive people of all ages. Following longer exercise interventions, reductions in blood pressure of approximately 20 – 30/10 – 20mmHg can be achieved.


Does exercise affect blood pressure in other populations?

A number of exercise interventions have been performed to assess the effects of general exercise, physical activity or aerobic exercise on hypertension in overweight, obese and diseased populations. The findings of these studies are shown in the table below:

Study Description Finding
Reid et al. The researchers performed a randomized, parallel-group, crossover study to assess the effects of 12 weeks of exercise and weight loss on cardiovascular risk factors, including hypertension, in 30 overweight individuals. The subjects performed exercise 3 times per week at 70% of maximum work capacity for 30 minutes and dietary modification was performed in order to achieve weight loss of 4,200kJ per day dietary restriction. The subjects performed either exercise or weight loss or a combination of both in a randomized, counterbalanced order. The researchers observed that although bodyweight did not change in the exercise-only condition, it fell significantly in both with weight loss and combined weight loss and exercise conditions. Additionally, the researchers observed that the corresponding effects on blood pressure were also significant.
Johnson et al. The researchers assessed the quantity of exercise required to reduce the prevalence of the various elements of metabolic syndrome, which include high blood pressure (>130mmHg systolic or >85mmHg diastolic). The researchers randomly allocated 334 individuals with metabolic syndrome to a 6-month control group or to 1 of 3 different 8-month exercise training groups: 1) low-volume-moderate-intensity exercise at 40 – 55% of VO2-max, equivalent to walking 19 km per week, 2) low-volume-high-intensity exercise at 65 – 80% of VO2-max equivalent to jogging 19 km per week, and 3) high-volume-high-intensity exercise at 65 – 80% of VO2-max equivalent to jogging 32 km per week. The researchers found that across all 3 exercising groups, the prevalence of individuals with high blood pressure decreased significantly as a result of the exercise interventions.
Christ et al. The researchers assessed the effects of diet and exercise on blood pressure in 52 individuals with both the metabolic syndrome and hypertension. The subjects followed either a dietary weight management program or a dietary weight management program with exercise for 36 months or acted as a non-treatment control group. The researchers reported that body mass index (BMI) and blood pressure measurements significantly reduced over time in both the dietary weight management program and the dietary weight management program plus exercise groups (to 151 ± 8/75 ± 10mmHg and to 139 ± 12/71 ± 8mmHg).
Watkins et al. The researchers assessed the effects of a 6-month exercise program of either aerobic exercise training only or aerobic exercise combined with weight loss on cardiovascular risk factors associated with the metabolic syndrome (formerly called syndrome X) in 53 men and women with hyperinsulinemia, dyslipidemia, and high blood pressure characteristics of the metabolic syndrome. The researchers randomly assigned the subjects to either an exercise-only group or to a weight-loss and exercise group. The researchers reported that diastolic blood pressure was significantly reduced in the weight-loss and exercise group (from 96 ± 4 to 87 ± 5mmHg) but only showed a non-significant trend to reduce in the exercise-only group (93 ± 4 to 89 ± 5mmHg).
Cauza et al. The researchers performed a randomized controlled trial to compare the effects of a 4-month strength training program compared with a similar-length aerobic endurance training program on various outcomes in individual with type II diabetes mellitus. The strength training program was progressive and comprised exercises bench press, shoulder press, lat pull downs, biceps curls, triceps extensions, exercises for abdominal muscles, leg press, calf raises and leg extensions. The program used 3 – 6 sets of 10 – 15 repetitions. The aerobic exercise program was performed on a cycle ergometer, 3 days per week starting at 15 minutes per session and increasing by 5 minutes every 4 weeks. The total exercise time per week, excluding warm-up and cool down, was 90 minutes in the last 4 weeks. The researchers reported significant reductions from baseline in systolic and diastolic blood pressure for both strength and endurance training programs of 19/8 and 20/13mmHg, respectively, with no significant differences between groups.
Chudyk and Petrella The reviewers performed a systematic review to assess the effect of aerobic or resistance exercise training on cardiovascular risk factors, including blood pressure, in patients with type 2 diabetes. The reviewers found 34 studies, of which most investigated aerobic exercise alone, while 10 reported combined exercise training. The reviewers reported that aerobic exercise alone and aerobic exercise in combination with resistance training significantly improved systolic blood pressure by 6.08 and 3.59 mmHg, respectively.
Boyce et al. The researchers assessed the effects of 4 months of exercise training on various factors including blood pressure and renal function in 16 subjects with chronic kidney failure who were not yet on dialysis. The researchers reported that resting systolic and diastolic blood pressures decreased significantly by 22/9mmHg as a result of the exercise training (from 146 ± 15.7/87 ± 9mmHg to 124 ± 17.5/78 ± 9.5mmHg).

Based on these studies, it appears that general exercise, including aerobic exercise or endurance training, is effective for reducing hypertension in various different non-healthy populations, including overweight, metabolic syndrome, type II diabetes and chronic kidney failure.


Does resistance-training affect blood pressure?

A small number of exercise interventions have been performed to assess the effects of resistance training on blood pressure in various different populations, as shown in the table below:

Study Description Finding
Cononie et al. The researchers assessed the effects of 6 months of resistance or endurance exercise training on blood pressure in 49 elderly people aged 70 – 79 years. The resistance training comprised 1 set of 8 – 12 repetitions on 10 Nautilus machines, 3 times per week. The endurance training group progressed toward training at up to  75 – 85% of VO2-max for 35 – 45 minutes, 3 times per week. The researchers reported that resistance training did not alter blood pressure but endurance training led to significant reductions in diastolic and mean blood pressure.
Cornelissen and Fagard The reviewers performed a meta-analysis of randomized controlled trials to assess the effects of resistance training on blood pressure in healthy sedentary adults. The reviewers identified 9 randomized controlled trials, involving 341 subjects. The reviewers ascertained that the net changes in blood pressure resulting from resistance training averaged 3.2/3.5mmHg (when weighted for the number of trained participants) and 6.0/4.7mmHg (when weighted by the reciprocal of the variance for the blood pressure change). The researchers therefore concluded that moderate intensity resistance training could be used as part of a non-pharmacological intervention strategy to prevent and combat high blood pressure.
Kelley and Kelley The reviewers performed a meta-analysis of randomized controlled trials to assess the effects of resistance training on blood pressure in adults.  The researchers identified 11 studies including 320 subjects. The reviewers reported that resistance training led to a reduction in systolic and diastolic blood pressure of 2% and 4%, respectively. They therefore concluded that progressive resistance exercise is effective for reducing resting systolic and diastolic blood pressure in adults.
Cornelissen et al. The reviewers assess the effects of resistance training on blood pressure and other cardiovascular risk factors in adults. They identified 28 randomized, controlled trials lasting >4 weeks in 1,012 healthy adults aged >18 years. The reviewers found that resistance training produced a significant reduction in blood pressure reduction in the 28 normotensive or pre-hypertensive study groups of 3.9/3.9mmHg but only a non-significant trend towards a reduction in the 5 hypertensive study groups of 4.1/1.5mmHg.

Based on these studies and reviews, it appears that resistance training is effective for reducing high blood pressure. Resistance training appears able to reduce systolic and diastolic blood pressure by around 2% and 4% or by around 3 – 6 and 3 – 5mmHg, respectively.


Conclusions

Based on the above studies and analysis, the following conclusions can be drawn about hypertension:

Area Conclusion
Cardiovascular fitness and physical activity are key risk factors Low levels of cardiovascular fitness and low levels of physical activity are both significant risk factors for developing hypertension.
Dietary factors are less significant risk factors Dietary factors are less important than age, relative weight and alcohol consumption in relation to the risk of developing hypertension. It is difficult to assess whether dietary calcium, magnesium, potassium, sodium and fiber affect the risk of developing hypertension in normotensive individuals.
Age, weight and sleep are important risk factors An older age, a high body mass index (indicating overweight or obesity), a high waist circumference, sleep-related breathing disorders and short sleep duration are all associated with a higher risk of hypertension.
Exercise reduces blood pressure in healthy people General exercise, including aerobic or endurance training is effective for reducing hypertension general exercise, including aerobic or endurance training, is effective for reducing hypertension in healthy individuals. In general exercise interventions are associated with reductions in systolic and diastolic blood pressures of around 3 – 5mmgHg, although this includes trials as short as 4 weeks.
Exercise reduces blood pressure in hypertensive people General exercise including aerobic or endurance training is effective for reducing hypertension in mild-to-severely hypertensive people of all ages. Following longer exercise interventions, reductions in blood pressure of approximately 20 – 30/10 – 20mmHg can be achieved.
Exercise reduces blood pressure in various populations General exercise, including aerobic exercise or endurance training, is effective for reducing hypertension in various different non-healthy populations, including overweight, metabolic syndrome, type II diabetes and chronic kidney failure.
Resistance training is effective for reducing high blood pressure Resistance training is effective for reducing high blood pressure and appears able to reduce systolic and diastolic blood pressure by around 2% and 4% or by around 3 – 6 and 3 – 5mmHg, respectively.

In general, cardiovascular fitness and physical activity appear to be the main risk factors for hypertension and various forms of exercise training have been found to reduce blood pressure significantly in normal and hypertensive individuals of all ages and in both healthy and non-healthy populations (including people with metabolic syndrome, type II diabetes, chronic kidney failure and overweight).


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