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Effects of aerobic exercise intensity on ambulatory blood pressure : a look at unmedicated middle age… Fletcher, Derek; Hik, Ryan; Snow, Jamie; Stroh, Sarah Aug 31, 2011

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Derek Fletcher, Ryan Hik, Jamie Snow  & Sarah Stroh RSPT 578    Raised blood pressure (BP) greater than 140/90 mmHg (WHO, 2010) ? Most common reason for Canadians to visit a physician or take medication    (Public Health Agency of Canada, 2009)  ? Cost the Canadian health care system 2.3 billion (physician, medication and laboratory costs) in 2003 (Public Health Agency of Canada, 2009) ? #1 Risk factor for stroke   (Heart & Stroke Foundation of BC & Yukon, 2010)  ?  Major risk factor for:  ? coronary heart disease (CHD) ? heart failure ? peripheral arterial disease ? renal insufficiency  (Heart & Stroke Foundation of BC & Yukon, 2010)   ? Every 20 mmHg above 115 mmHg systolic BP (SBP) & 10 mmHg above 75 mmHg diastolic BP (DBP) ? Risk of mortality and morbidity ? 2x (Kokkinos et al, 2009)  ? 5 mmHg decrease in DBP ? 21%? risk of CHD ? 34% ? risk of stroke over 5 years  (Kokkinos et al, 2009)  ? 2 mmHg decrease in SBP ? 4% ? CHD mortality  ? 6% ? Stroke mortality  (Whelton, 1994)  ? Current clinical standard (Chavanu et al., 2008) ? Measurement of BP at a single point in time ? Usually in clinical setting ? Quick and convenient  ? Traditional  ? BP fluctuates ? White Coat Syndrome  ?  Gold standard (Chavanu et al., 2008) ? Portable, self- inflating sphygmomanometer worn continuously ? Readings at regular intervals over a 24-48 hour period (ie. every 15 min, every hour) ? Provides a continuous record of blood pressure during the patient?s daily activities  ? Expensive ? Can be disruptive to daily life    ? AMBP deemed more accurate reflection of patient?s ?true? blood pressure levels         (Stergiou et al., 2002; Kleinert et al., 1984 & Chavanu et al., 2008) ? Dippers vs Non-Dippers (Nami et al., 2000) ? OBP dx vs AMBP dx (Chavanu et al., 2008)  ? AMBP measurements usually lower  (Cooper et al., 2000; Suissa et al., 1998; Grimm et al., 1996)  ?  AMBP shows less change  (Arroll et al., 1992; Hagberg & Brown, 1995)   1. Lifestyle modifications ?indispensable? part of the management of high BP ? Diet ? *Exercise* ? Stress management  2. Medication  ? Used concurrently, or not at all   (National Heart, Lung, and Blood Institute, 2003) ? ACSM (2006) ? Aerobic exercise performed for 20-60 mins, at 50-85% HRR , 3-5 days/wk  ? Clinically (National Heart, Lung, and Blood Institute, 2003) ? Moderate intensity aerobic exercise performed for at least 30 mins, most days of the wk       *NB. Both are specific to hypertensive patients ? Parameters are vague  ? What is the most effective exercise prescription to reduce high blood pressure? (FITT)  ? What variables within FITT are most important for the management of BP?   ? Discrepancies regarding the optimal intensity   ? Low and moderate intensity yield similar results to those with higher intensity      (Kelley & Kelley, 2001; Fagard & Cornelissen, 2007 & Pascatello et al, 2004)  ? Higher intensities yield greater decreases than moderate (Cooper, Moore, McKenna & Riddoch 2000)   ? MDs & PTs should prescribe exercise that is both acceptable to patient AND lead to clinically meaningful reductions in BP ? How Much by When?  ? Refinement of Clinical Practice Guidelines   (ie. ACSM)  ? Adjusting definition of AMBP hypertension    Systematically review the literature to determine the optimal intensity of an aerobic exercise program to yield the greatest reductions in AMBP ? P ? mean age <65 yrs, OBP hypertension dx, no serious co-morbidities,  not on antihypertensive meds ? I  ? aerobic exercise program > 4weeks ? C ? exercise intensities ? O ? mean daytime AMBP (SBP, DBP) ? S ? systematic review of RCTs ? Medline OvidSP ? EMBASE OvidSP ? CINAHL ? SportDISCUS ? PEDro ? Cochrane Systematic Review  ? Grey Literature 1. hypertens*.mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier] 2. High blood pressure or hypertension/ 3. 24 hour blood pressure monitor* or Blood Pressure Monitoring, Ambulatory/ 4. ambulatory blood pressure monitor*.mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier] 5. exp Exercise/ 6. exp Sports/ 7. exp Exercise Therapy/ 8. Motor Activity/ 9. (walk* or exercise* or physical activit* or sport*).mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier] ? 15. limit 14 to (("all adult (19 plus years)" or "adult (19 to 44 years)" or "young adult and adult (19-24 and 19-44)" or "middle age (45 to 64 years)" or "middle aged (45 plus years)" or "all aged (65 and over)" or "aged (80 and over)") and english and humans) ? PEDro (11) ? Methodological quality of intervention studies ? Van Tulder (2) ? Compliance and dropout ? Additional (1) ? Construct Validity   ? Performed independently by 2 reviewers  ? Used standardized form  ? In case of discrepancy, a third reviewer ? tie-breaker  * 3 criteria from PEDro removed    (/11) ? Performed independently by 2 reviewers  ? Used standardized form  ? In case of discrepancy, a third reviewer served as tie-breaker   Cooper, A.R., Moore, L.A., McKenna, J. &  Riddoch, C.J. (2000).  What is the magnitude of blood pressure response to a program of moderate intensity exercise? Randomized controlled trial of sedentary adults with unmedicated hypertension.   British Journal of General Practice, 50, 958-962.  Blumenthal, J.A., Sherwood, A., Gulette, E.C., Babyak, M. et al. (2000).   Exercise and Weight Loss Reduce Blood Pressure  in Men and Women with Mild Hypertension: Effects on Cardiovascular, Metabolic, and Hemodynamic Functioning.   Archives of Internal  Medicine. 160,  1947-1958.  Study Exercise Type Duration of session Intensity Frequency  Program Length   N (treatment/control) Cooper (2000) Walking (Unsup) 30 mins ?Moderate? 5x/wk 6 wks 47/39 Blumenthal (2000) Cycling Ergo/ Walking/ Jogging (Sup) 35 minutes + 10 mins of warm up & cool down 70-85% of HRR 3-4x/wk 24 wks 54/24 Study Group Baseline mean SBP Follow-up mean SBP P value  Baseline mean DBP Follow-up mean DBP P value Cooper (2000) I 139.8 (+/-12.7) 137.0 (+/-9.3) 0.059 89.5 (+/-9.6) 87.7 (+/- 9.4) 0.095 C 135.7 (+/-9.3) 136.3 (+/-8.6) 0.059 87.6 (+/-8.5) 88.5 (+/-7.6) 0.095 Blumenthal (2000)  I (ex only)  * * * * * * C * * * * * * * No values reported ? AMBP significantly different between all groups (WM ? EX ? CON)  (p < 0.001)  ? SBP & DBP significantly lower in Intervention groups (WM & EX Only) vs Controls  ? SBP, p = 0.02 ? DBP, p = 0.002   ? Unable to do meta-analyses ? Unable to do forest plots  ? WHY? ? Only 1 study (Cooper) with reported data that included means and SDs ? Statistician resource not available  ? Very few high quality studies in the literature that assess the effect of various intensities of aerobic exercise programs on AMBP  ? Cooper ? no statistically significant change  ? Blumenthal ? statistically significant change, we just don?t know how much  At this time we are unable to conclude which intensity of an aerobic exercise program is most effective at reducing ambulatory blood pressure   ? Lack of studies using AMBP ? Poor methodological quality  ? Pre-post ? No control group ? Unsupervised ? No stringent monitoring of exercise intensity  ? Methodological issues  ? Unsupervised exercise  ? No stringent exercise intensity monitoring  ? No reporting of means & SDs  ? Heterogeneity - Apples vs Oranges ? Redo previous research on the effect of regular aerobic exercise on reducing blood pressure  ? Use AMBP monitoring ? Systematically manipulate FITT variables  ? High methodological quality RCTs ? Supervised exercise (attend class) ? Stringent monitoring of intensity levels (HR monitor) ? Include all outcome data   ? American College of Sports Medicine. ACSM?s Guidelines for Exercise Testing and Prescription, 7th ed, Baltimore, MD: Lippincott Williams & Wilkins, 2006.  ? Arroll B. & Beaglehole, R. (1992). Does physical activity lower blood pressure: a critical review of the clinical trial. J Clin Epidemiol. 45: 439-447, 1992.  ? Blumenthal, J.A., Sherwood, A., Gulette, E.C., Babyak, M. et al. (2000). Exercise and Weight Loss Reduce Blood Pressure in Men and Women with Mild Hypertension: Effects on Cardiovascular, Metabolic, and Hemodynamic Functioning. Archives of Internal Medicine. 160,  1947-1958.   ? Chavanu K, Merkel J, Quan AM. (2008). Role of ambulatory blood pressure monitoring in the management of hypertension. American Journal of Health System Pharmarcy. 65:209-218, 2008.   ? Cooper, A.R., Moore, L.A., McKenna, J. & Riddoch, C.J. (2000). What is the magnitude   of blood pressure response to a program of moderate intensity exercise? Randomized controlled trial of sedentary adults with unmedicated hypertension. British Journal of General Practice, 50, 958-962, 2000.   ? Fagard, R. & Cornelissen, V. (2007). Effect of exercise on blood pressure control in   hypertensive patients. European Journal of Cardiovascular Prevention Rehabilitation. 14:12-17, 2007    ? Hagberg, J.M., Brown M.D., Does exercise training play a role in the treatment of essential hypertension? J Cardiovasc Risk 1995; 2: 296-302  ? Heart & Stroke Foundation, 2008. High Blood Pressure. Retrieved April 1st, 2010 from:http://www.heartandstroke.bc.ca/site/c.kpIPKXOyFmG/b.3644465/k.2AE3/High_blood_pressure_hypertension.htm?src=home   ? Heart & Stroke Foundation, 2008. Statistics. Retrieved April 1st, 2010 from:  (http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3483991/k.34A8/Statistics.htm)   ? Kelley, G. & Kelley, K. Aerobic Exercise and Resting Blood Pressure in Older Adults: A   Meta-analytic Review of Randomized Controlled Trials. Journal of Gerontology: Medical Times. 56: 5, 2001.   ? Kleinert HD, Harshfield GA, Pickering TG et al. What is the value of home blood   pressure measurement in patients with mild hypertension? Hypertension. 6:574-8, 1984.   ? Kokkinos, P. F., Giannelou, A.,  Manolis, A., & Pittaras, A. Physical Activity in the   Prevention and Management of High Blood Pressure. Hellenic Journal of Cardiology. 50:52-59, 2009  ? Kokkinos, P.F., Narayan, P. & Papademetriou, V. (2001) Exercise as hypertensiontherapy. Cardiology Clinics. 19: 507-516.  ? Maher, C.G., Sherrington, C, Herbert, R.D., Moseley, A.M., Elkins, M. (2003).Reliability of the PEDro scale for rating quality of randomized controlled trials. Physical Therapy, 83 (8), 713-21.  ? Mengden T., Vetter H., Tisler A (2001). Telemonitoring of home blood pressure. Blood Pressure Monitoring. 6:185-9, 2001.  ? Moreira, W.D., Fuchs, F.D., Ribeiro, J.P., & Appel, L.J. (1999).  The effects of two aerobic training intensities on ambulatory blood pressure in hypertensive patients: results of a randomized trial. Clinical Epidemiology, 52(7), 637-642.  ? National Heart, Lung, and Blood Institute. (2003).  The 7th report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Retrieved April 1, 2010 at: http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf.        ? Pater, C. (2005). Beyond the Evidence of the New Hypertension Guidelines. Bloodpressure measurement ? is it good enough for accurate diagnosis of hypertension?Time might be in, for a paradigm shift. Current Control Trials in CardiovascularMedicine. 6(1): 6.  ? Pescatello, L., Franklin, B., Fagard, R., Farquard, W., Kelley, G. & Ray, C. Exercise and Hypertension: American College of Sports Medicine. Medicine & Science in Sports & Exercise. 533-553, 2004.   ? Public Health Agency of Canada.(2009). Hypertension Facts and Figures. Retrieved July20, 2010 from: http://www.phac-aspc.gc.ca/cd-mc/cvd-mcv/hypertension_figures-eng.php.  ? Rogers MA, Small D, Buchan DA et al. Home monitoring service improves mean arterial pressure in patients with essential hypertension: a randomized, controlled trial. Ann Intern Med. 134:1024-32, 2001.   ? Staessen JA, Fagard RH, Lijnen PJ et al. Mean and range of the ambulatory pressure in normotensive subjects from a meta-analysis of 23 studies. Am J Cardiol. 67:723-7, 1991.  ? Stergiou GS, Efstathiou SP, Skeva II et al. (2002) Assessment of drug effects on bloodpressure and pulse pressure using clinic, home and ambulatory measurements. J Hum Hypertension. 16:729-35.  ? Whelton, P.K. (1994). Epidemiology of Hypertension. Lancet. 344: 101-106.  ? Whelton, S.P., Chin, A., Xue Xin, & He, J. (2002). Effect of aerobic exercise on blood pressure: a meta-analysis of randomized controlled trials.  Annals of Internal Medicine. 136(7), 493-503. 

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