-Hypertension-

1. -Hypertension- Exercise For Special Populations Dr. Chaloupka T/R 10:50 Fall 08’ Cynthia Nieves John Stevenson Kim Brozosky Ryan Dunphy

3. What Is Hypertension? • Hypertension Is: Chronic High Blood Presure at a level above 140/90

4. ValuesTo Know OVER 50YRS: NORMAL = Less than 160/90

5. Strategies To Avoid HT:

6. CASE STUDIES:

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8. Authors: Kazuko Ishikawa-Tawata, Toshiki Ota, Hirofumi Tanaka American Journal of Hypertension, Volume 16, August 2003 (pp. 629-633)‏ How much Exercise is Required to Lower Blood Pressure in Essential Hypertensives: A Dose-Response Study

9. To determine the amount of aerobic exercise needed to lower BP in hypertensive individuals Purpose

10. Subjects: 207 hypertensive individuals 5 Groups (studied over 8 weeks @ 50% VO2max)‏ Control group 30-60 min/wk aerobic exercise 61-90 min/wk aerobic exercise 91-120 min/wk aerobic exercise >120 min/wk aerobic exercise Methods

11. Control Group: No change in BP 30-60 min/wk: Moderate drop in BP Remaining Groups: Significant drop in BP Results

12. Even minimal activity can lower BP in sedentary hypertensives Exercise beyond 61-90 min/wk yields diminishing returns in decreased BP Frequency is not important, as long as weekly exercise amount is consistent Limiting Factor-subjects were not assigned to groups at random Discussion

13. Moderate-intensity aerobic exercise for 60 minutes or more per week is sufficient to significantly lower BP Conclusion

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16. Cardio respiratory fitness and risk of nonfatal cardiovascular disease in women and men with hypertensionStudyExamined: • 8147 men and 1268 women aged 18 to 84 years old- majority was white and from middle and upper socioeconomic strata • Between 1971 and 2002 at Cooper Clinic, Dallas, TX. • Free of CVD, normal resting electrocardiograms, were able to complete an exercise stress test at least 85%, and had HTN based on physician diagnosis or measured resting blood pressure over 140/90 mmHg.

17. Maximal Treadmill ExerciseBalke- Ware Protocol • Low- 20% • Moderate- 40% • High- upper 40% • Highly correlated with measured maximal oxygen uptake. • Max heart rate was achieved during exercise testing (101% ± 8% in men) and (100% ± 9% in women) • To standardize exercise performance, estimated maximal metabolic equivalent from final treadmill speed and grade.

18. Clinical Examination • Follow up- Mail back health survey between 1982 and 2004. • Conducted after an overnight fast of at least 12h. • BMI was computed from measured height and weight. • Resting BP was measured in the seated position using auscultator methods with a mercury sphygmomanometer. • Serum samples were analyzed for lipids and glucose using standardized bioassays. • Diabetes and dyslipidemia was based on a history of physician diagnosis or measured phenotypes that met clinical thresholds for each condition. • Smoking habits and alcohol intake were obtained from a questionnaire. (drinks per wk of alcohol intake were computed with one drink standardized to 12 ounces of beer, 5 ounces of wine, and 1.5 ounces of hard liquor.

19. Assessment of Outcomes • Non fatal CVD end points were obtained using case finding questions for a physician diagnosis of myocardial infarction or stroke, and for having coronary revascularization procedure. • Participates were asked whether a physician had ever told them that they had a heart attack or stroke, or if they had undergone any coronary interventions. (if yes participants were asked to report the yr of the diagnosis or procedure) • Primary outcome was CVD events (MI, coronary revascularization, and stroke.) • Also examined coronary heart disease events as a separate end point. • The percentage of agreement between reported events and medical record review was 88%, 100%, and 89% for MI, revascularization procedures, and stroke.

20. Results • Low fit individuals were slightly younger than those in the moderate and high fitness categories and CVD risk factors were often less favorable. • Compared with noncases, individuals who developed CVD were older, had lower CRF, and had higher prevalence of major CVD risk factors. • Men with moderate and high CRF had a 14% and 34% lower risk of CVD events than men with low CRF. • The inverse association between CRF and CVD events remained significant after additional adjustment for BMI, resting BP, diabetes, and dyslipidemia. • In women, rates of total CVD events were inversely associated with CRF. Women with moderate and high CRF had a 6% and 51% lower risk of CVD events than women with low CRF.

21. In men, a significant inverse gradient of age and examination year adjusted CVD rates were seen across incremental CRF levels within each HTN group. • Men in the lowest CRF group had a 1.6- to 2.6 fold higher rate of total CVD events than men in the highest CRF group. • In women CRF was inversely associated with CVD rates within HTN groups; however, the rate differences were not statistically significant.

22. Discussion • The CRF is inversely associated with the risk of all-cause and CVD mortality in initially asymptomatic women and men. • Statistical power often is insufficient to examine the association between CRF and CVD within populations groups that have higher CVD rates because of the presence of clinically manifest disease, such as HTN. • This suggest that physical activity and CRF may favorably influence the etiologic pathway between HTN and fatal clinical CVD events. • CRF is inversely associated with the incidence of nonfatal CVD events in women and men with HTN. • The CRF can be enhanced in most individuals, including those with HTN, through participation in physical activities such as brisk walking, cycling, and jogging, for 30 min or more on most days of the week. • Believe that clinicians should consider the potential independent cardio protective benefits of physical activity and CRF and counsel their sedentary hypertensive patients to become more physically active and improve their CRFs cornerstone of HTN management and primary CVD prevention.

23. Exercise capacity and 24 hr blood pressure in pre hypertensive men and womenassessed the relationship between fitness and 24-h ambulatory BP in pre hypertensive men and women.

24. Participants • Made a routine visit to the Cardiology Clinic at Tzanio Hospital, Women’s Social Welfare clinic and a private Cardiology Clinic between 1998 and 2003. • 923 subjects gave a written consent to undergo an exercise tolerance test and wear an ambulatory monitor for 24h. • Of the 923 subjects, identified 650 pre hypertensive men and women with no evidence of coronary heart disease. • 243 were women and 407 were men (30-79 years old) • Subjects were included if they were: 1)not taking any cardiac, antihypertensive, or other medication that would affect BP, 2) had resting systolic BP of 120 to 139 mm Hg or resting diastolic BP of 80 to 89 mmHg, 3) had no apparent chronic disease, 4) did not use tobacco products for at least 1 yr, 5) were not alcoholics. • Those who achieved 90% or more of the age predicted max heart rate had a normal exercise tolerance that were included in final analysis.

25. Method • Had a ETT- exercise Tolerance test • Assessed exercise capacity and 24-h BP in 407 men (51 +- 11 years) and 243 women (age 54 +-10 years) with resting systolic BP 120 to 139 mm Hg and diastolic BP of 80 to 89 mm Hg, defined as hypertension. • Fitness categories: low, moderate, and high; were established according to exercise time and age. • To determine whether increased fitness is associated with lower BP during 24 h, assessed the relationship between peak exercise time as assessed by a graded exercise test and 24 h BP in pre-hypertensive men and women. • 24 hr arterial BP readings were obtained using a noninvasive ambulatory monitor. • The risk for developing hypertension in sedentary men with normal BP at rest is approximately 35% to 70% higher when compared to their physically active peers.

26. Exercise Testing, Fitness Assessment, and Classification • Resting BP and HR were recorded before the graded exercise test. The BP measurements began after subjects were seated in a chair for 5 min with their backs supported and arms supported at heart level. Three BP readings were taken at 2 min intervals between readings. The third reading was recorded as the rest BP. The HR at this time was recorded as the resting HR. Standing BP and HR were than assessed after the subject was standing for at least 1 min.

27. Physical fitness was assessed by the Bruce Protocol. Exercise HR was recorded continuously and exercise BP was assessed at the end of each stage and at peak exercise. Exercise capacity was recorded as peak exercise time in minutes. Peak exercise workload was estimated on the basis of the speed and grade of the treadmill and recorded as metabolic Equivalents. • For more accurate estimated workload assessment of fitness, participants were not allowed to lean against handles of the treadmill. • During exercise BP was recorded at 2 min of each exercise stage and peak exercise, and within 1 min after the cessation of exercise. • All resting and exercise BP assessments were made by indirect arm- cuff sphygmomanometer in the right arm.

28. Results • Fitness status was inversely associated with ambulatory BP in both genders. • Individuals in the lowest fitness category had significantly higher 24h, daytime, and night time BP than those in the moderate and high fitness categories. • For men, differences between low and moderate fitness categories were 6/4 mm Hg, 8/4 mm Hg, and 7/3 mm Hg for 24 h daytime, and night time BP. • For women, the differences were 8/5 mm Hg, 9/5 mm Hg, and 8/7 mm Hg for 24 h daytime, and night time BP. • Similar differences were evident in both genders between low and high fitness category. • Men were significantly younger and had higher body weight, BMI, but lower resting HR than women. After adjusting for age, BMI, and resting HR, the daytime, night time, and 24 h systolic BP were significantly Lower in men and women therefore the analysis was stratified by gender.

29. MEN In moderate fitness category were significantly younger than men in the low and high fitness categories. Body weight and BMI were lower in the high fitness category when compared to those in the moderate and low fitness categories. Peak exercise time and met level were significantly different among all fitness categories. Resting systolic BP and HR were similar among all fitness categories. Age and resting HR were inversely associated with fitness status, even after adjusting for BMI. Exercise tie was inversely related with all ambulatory BP values. BP values were higher in the low fitness versus moderate and high fitness men. Men in low fitness category had higher 24 h, daytime systolic and diastolic BP than men in the moderate and high fitness categories. Comparisons between moderate and high fitness categories revealed no significant differences in any BP values. WOMEN In moderate and high fitness category had lower body weight and BMI than women in low fitness category. High fitness women were older than those in the moderate fitness category. Resting diastolic BP was also lower in the high versus low fitness women. Peak exercise time and met level were significantly different amount the 3 fitness categories. Resting systolic BP was similar, the distribution of the daytime ambulatory systolic BP was normal. Age, resting diastolic BP, and HR were inversely associated with exercise time, even after adjusting for BMI. No association was observed between fitness status and resting systolic BP. BP values were significantly higher in the low fitness versus moderate and high fitness women. After adjusting for age, resting diastolic BP, HR, and BMI, women in the moderate and high fitness categories had significantly lower 24 h, daytime, and night time systolic BP and night time only diastolic BP than women in the low fitness category. All BP values were similar between those in the moderate and high fitness categories. Results

30. Conclusion • Moderate physical activity promotes lower BP during a 24 h period in pre hypertensive men and women. • The risk for developing hypertension is likely to be lowered if moderate intensity physical activity in this vulnerable population is encouraged. • Higher levels are associated with lower BP during a 24 h period in pre hypertensive, middle aged men and women. • The daytime, night time, and 24h systolic BP and night time diastolic BP for men in the moderate fitness category were 8/4, 7/3, and 6/4 mm Hg lower than men in the low fitness category. The BP values were very similar between the moderate and high fitness categories. • Women in the moderate fitness category were 9/5, 6/7, and 6/6 mm Hg, lower than the BP of women in the lowest fitness category. BP values were very similar between the moderate and high fitness category. • Only the 24h diastolic BP was lower by 2 to 3 mm Hg in those who reported engaging in some physical activity for at least once a week during the previous 2 months versus those who reported engaging in no physical activity during the same period.

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33. Case Study # : • Title: Effects of School-Based Aerobic Exercise on Blood Pressure in Adolescent Girls at Risk for Hypertension. • Authors: Craig Ewart, Deborah Young, James Hagberg • Source: American Journal of Public Health: June 1998

34. Evaluated: • Effects of aerobic exercise physical education on blood pressure • Who: High-risk, predominantly African-American adolescent girls. • Age=9th grade.

35. INTRODUCTION:

36. Setup: • 88 girls split into 2 sections. • 1 group STANDARD gym class • 1 group AEROBIC EXERCISE specific class -vs-

37. TESTING: • Technicians were unaware of the girls experimental status. • All measures assessed in a quiet lab room at the school. • BP was assessed in a sitting position after 15min of rest. • Ave of 3 readings determined eligibility

38. Length of Study: • 3 YEARS! • Alternating semesters to allow all students to experience everything

39. POST-TEST • ONLY the aerobic students increases their estimated cardiorespiratory fitness. • The aerobic group also had a greater decrease in systolic blood pressure than standard education group!  Systolic B-P C-R Fitness 

40. Negatives of Study: • Not enough follow up.

41. CONCLUSION: “Aerobic exercise physical education is a feasible and effective health promotion strategy for high-risk adolescent girls.” HES conclusion: PREVENTION IS KEY!!!

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44. Acute Aerobic Exercise Reduces Ambulatory Blood Pressure in Borderline Hypertensive Men and Women By: Kimberly A. Brownley, Sheila G. West, Alan L. Hinderliter, and Kathleen C. Light

45. 13 Men 7 white 6 black 18 Women 9 white 9 black 31 Healthy Subjects Ages 21-47 • Subjects reported minimal physical activity • Filled out consent forms, medical history, and physical activity questionnaires • All subjects were considered normotensive or borderline hypertensive

46. TEST GROUP 20 minutes of moderate intensity bicycle ergometer Rate of 50 rpm Workload between 60-70% CONTROL GROUP Rest day Both days wore an Accutracker II monitor Laboratory Testing

47. SBP DBP Heart Rate Accutracker II recorded: Work Home Sleep Both Days Measured:

48. RESULTS • Exercise Day vs. Control Day • The 11 subjects with elevated BP had lower readings on exercise days • The effects of exercise were effective for 5 hours • No significant differences in normotensive group

49. -THE END-ANY QUESTIONS?