Journal of Human Hypertension (2000) 14, 547–553
 2000 Macmillan Publishers Ltd All rights reserved 0950-9240/00 $15.00
www.nature.com/jhh
ORIGINAL ARTICLE
Twenty-four hour, ambulatory blood
pressure responses following acute
exercise: impact of exercise intensity
TJ Quinn
University of New Hampshire Department of Kinesiology, Durham, NH 03824, USA
Objectives: Mild to moderate acute, endurance exercise
has generally been shown to reduce blood pressure
(BP) in hypertensive (HT) individuals. Whether a slightly
more strenuous bout of exercise can elicit a greater and
more prolonged BP reduction is unknown. Therefore,
the purpose of this study was to examine the effects of
two, 30-min exercise bouts, conducted at 50% and 75%
of maximal oxygen uptake (VO2max), on the quantity
and quality of BP reduction over a 24-h period.
Methods: Sixteen, Stage 1 and 2 non-medicated, HT (8
men/8 women) subjects were matched with normotensive (NT) men and women (n ⴝ 16). All subjects were
evaluated for VO2max with a symptom-limited treadmill
test and then completed a 30-min exercise bout at 50%
and 75% of VO2max as well as a control (no exercise)
session in random fashion on separate days. Twentyfour hour ambulatory BPs were measured after both the
exercise and control settings. Data was assessed at 1,
3, 6, 12, and 24 h post-exercise and control session.
Results: A repeated-measures ANOVA showed non-sig-
nificant differences between HT men and women and
that both exercise intensities, relative to the control session, significantly (P ⬍ 0.05) reduced systolic (S) and
diastolic (D) BPs. NT subjects showed non-significant
reductions following both intensities. The reductions in
the HT men and women averaged 4 and 9 mm Hg
(SBP)/5 and 7 mm Hg (DBP) for 50% and 75%, respectively. On average, the HT subjects (men and women
combined) maintained significant SBP reductions for
13 h after the 75% bout compared to 4 h after the 50%
intensity. Likewise, DBP was reduced for an average of
11 h following the 75% bout compared to 4 h after the
50% intensity.
Conclusions: These results suggest that an exercise
bout conducted between 50–75% VO2max significantly
decreases SBP and DBP in HT subjects and that a
greater and longer-lasting absolute reduction is evident
following a 75% of maximum bout of exercise.
Journal of Human Hypertension (2000) 14, 547–553
Keywords: treadmill exercise; humans; men; women
Introduction
Twenty-five percent of the United States adult population is hypertensive (HT)1 and those individuals
with blood pressure (BP) values exceeding 160/95
mm Hg have a 150–300% higher annual incidence
rate for coronary artery disease (CAD), congestive
heart failure (CHF), intermittent claudication, and
stroke as compared to normotensive (NT) subjects.2
It is clear that aggressive pharmacological therapies
in individuals with marked elevations (Stage 3 and
4) in arterial BP have resulted in dramatic
reductions in myocardial infarction (MI) and
stroke.3,4 Less clear, though (due, primarily, from
inadequately powered studies), is the benefit of this
pharmacological therapy, especially in certain
female ethnic groups5 with mild to moderate hypertensive disease due to the possible deleterious side
effects of these medications on other risk factors
Correspondence: Timothy J Quinn, PhD, University of New
Hampshire, Department of Kinesiology, Field House – #35, Durham, NH 03824, USA. E-mail: tjq얀christa.unh.edu
Received 8 February 2000; revised 23 March 2000; accepted 6
June 2000
known to impact CAD.3,6 This has led physicians
and allied health care professionals to examine alternative therapies in an effort to reduce arterial BP in
these populations. The Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure7 recommends increased physical activity as one alternative therapy and research
involving exercise training in HT populations suggests that the majority (75%) of subjects involved
in these studies8–12 exhibit significant reductions in
arterial BP.
Previous research involving acute exercise in HT
populations suggested that exercise intensity had
little impact on either the quantity or quality (length
of time) of any BP reduction.13,14 However, most of
this research has involved only short-term (1–12 h)
post-exercise BP evaluations and very few data are
available using ambulatory BP measurements. In the
only acute exercise/ambulatory BP study, Brownley
et al15 reported a significant reduction in systolic BP
(SBP) for up to 5 h post-exercise following 20 mins
of cycle ergometry conducted at 60–70% of age-predicted maximal heart rate. Marceau et al,13 in a training study, have suggested that the reduction following exercise is intensity-dependent. They found that
Blood pressure reduction following exercise
TJ Quinn
548
higher intensity exercise produced greater benefits
especially during the evening and sleeping hours as
compared to lower intensity exercise. Thus, if previous investigators monitored BP following exercise
only during the waking hours, they would logically
conclude no difference attributable to exercise
intensity.
In addition, in those studies that have studied
exercise intensity, only mild to moderate activity
has been researched. Pescatello et al14 studied six
HT men for 24-h following exercise conducted at
40% and 70% of maximal oxygen uptake (VO2max)
on separate days. No intensity effect was observed
but there was an average systolic (S) and diastolic
(D) BP reduction of 5 and 8 mm Hg, respectively
over the 24-h period. Further, Marceau et al13 studied previously sedentary, HT men (n ⫽ 8) and one
woman in an effort to evaluate training programmes
conducted at 50 and 70% of VO2max. They found a
5-mm Hg reduction, regardless of training intensity,
in both SBP and DBP measurements over 24 h.
Finally, Rueckert et al16 found SBP and DBP to be
significantly reduced for 2 h post-treadmill exercise
conducted at one moderate (70% VO2max) intensity.
However, these reductions returned to baseline during the ambulatory period. In the only study to
assess a strenuous exercise bout, Somers et al17
reported an 8 mm Hg reduction in both SBP and
DBP in 12 HT subjects following graded cycle ergometry to maximal voluntary capacity. Blood pressure returned to pre-exercise values after 1 h.
Four13–15,17 of these studies used cycle ergometry
as the exercise modality. It is important to study
weight-dependent activity, such as walking, conducted at different exercise intensities, and to track
the BP response for 24 h. This may allow allied
health-care professionals to prescribe these types of
activities routinely.
Therefore, the major purpose of the present study
was to determine the impact of acute, weight-dependent exercise, conducted at different intensities, on
BP-lowering quantity and quality in HT men and
women. Secondly, since there are only limited data
on HT women regarding acute exercise and BP
reductions, it is important to determine if gender
differences exist during this post-exercise period.
Materials and methods
Subjects
Sixteen men (n ⫽ 8) and women (n ⫽ 8) with
documented Stage 1 and 2 HT were recruited and
subsequently qualified to participate. None of the
subjects were on medication known to treat high BP.
An additional 16, NT, men and women subjects
were matched with the HT subjects according to age,
body composition, and functional capacity. None of
the subjects were regular (ie, three times per week)
exercisers. Table 1 shows subject characteristics.
Procedures
Prospective HT subjects reported to the Exercise
Physiology Laboratory on three separate occasions
Journal of Human Hypertension
to document either Stage 1 or 2 BP elevations. An
informed consent, approved by the Institutional
Review Board, was read and signed prior to any
measurements. Blood pressure was evaluated by the
same, trained investigator via auscultation using the
appropriate sized cuff and a mercury sphygmomanometer following AHA guidelines and procedures
documented by Hagberg et al.18 Pressures were
recorded in both arms and BP was measured three
times per visit. Subsequently, during the study, only
the arm which had the highest BP recordings was
measured. Once the study criteria (ie, Stage 1 or 2
BP elevation) had been met, HT subjects were
required to obtain health history records as well as
permission from their personal physician. They then
reported to the laboratory four additional times.
The first session was to assess body composition
via skinfold measures and to perform a maximal
oxygen uptake (VO2max) test on the treadmill. Skinfold sites included the tricep, subscapula, suprailiac, abdominal, and thigh. Percent body fat was
determined using the equations developed by Jackson, Pollock and Ward.19,20 A Modified Astrand protocol21 was used for the VO2max test and BP, heart
rate, 12-lead ECG rhythm, and expired respiratory
gases were monitored and measured. This protocol
allows the subject to self-select his/her walking or
running speed and then the grade is increased by
2.5% every 2 min. The participants inspired room
air through a Parkinson-Cowan dry gas meter for
volume determination and expired gases were analysed with Ametek oxygen and carbon dioxide analysers. The dry gas meter and the analysers were
calibrated prior to each test. A computerised gas
analysis system which gives printouts every 30 sec
for ventilation (VE), VO2, VCO2 and respiratory
exchange ratio was used. Subjects were excluded
from the study if the treadmill test was stopped for
reasons other than fatigue or if 2 mm or more of STsegment depression occurred on the ECG. Once
these tests had been completed, NT subjects were
recruited in an effort to match on age, gender, body
composition, and functional capacity. The same
tests (except the pre-exercise BP screenings) were
performed on the NT subjects.
All subjects then reported to the laboratory three
additional times, at the same time of day (08.00) to
perform two, 30-min exercise bouts conducted at
50% and 75% of maximum as well as a sitting control session in random fashion on separate days with
at least 3 days separating trials. The 75% trial was
selected to provide a relatively high degree of
physiological stress. Recently, it has been shown
that training of HT subjects can occur and be maintained in the 75–85% of maximum range.22 Therefore, this intensity had practical implications. The
subjects were asked to avoid caffeine for the initial
24-h study and to record all food and significant
activity during the time-period. Since this study
involved a repeated-measures design, it was
important to replicate diet for each additional trial.
Diets were analysed for total calories (kcals), percentages of kcals from carbohydrate, fat, and protein, and sodium intake. Prior to and after each exercise session total body mass was obtained. Subjects
Blood pressure reduction following exercise
TJ Quinn
549
Table 1 Normotensive (NT) and hypertensive (HT) subject characteristics (mean ± s.d.)
NT
Age (yrs)
Ht (cm)a
Wt (kg)a
% Fat
VO2max (ml/kg/min)
SBP (mm Hg)
DBP (mm Hg)
a
HT
Men
Women
Men
Women
39.7 (4.2)
176.5 (10.4)
79.1 (5.2)
20.3 (3.2)
41.4 (5.3)
124 (6)
81 (4)
38.3 (3.3)
163.8 (7.5)
63.2 (4.0)
24.6 (6.0)
36.5 (7.4)
118 (8)
72 (8)
41.3 (8.9)
178.3 (9.6)
86.4 (7.1)
21.2 (4.5)
40.1 (4.9)
153 (12)
92 (6)
43.6 (7.4)
160.0 (6.2)
66.8 (6.9)
26.0 (8.2)
36.3 (6.2)
152 (11)
93 (4)
Men were significantly taller and heavier than the women.
were instructed to drink water in an amount equivalent to any weight lost. Following each of these sessions, subjects sat quietly for 30 mins and BP was
taken by auscultation every 10 mins. The subjects
were fitted with the ambulatory BP system (Suntech
Accutracker II, Suntech Medical Instruments, Inc,
USA) during the recovery period. The ambulatory
system had been calibrated against a mercury sphygmomanometer according to the manufacturer’s
instructions prior to each session. Subjects were
instructed on how the device worked and, when
activated, to hold their arm as still as possible. The
ambulatory unit was programmed to take measurements every 15 min during the waking hours and
once an hour during sleep. Each subject came back
to the laboratory the following morning and the data
were downloaded to the computer for evaluation.
During the control session, subjects sat quietly for
30 min and then wore the ambulatory unit for the
next 24-h period.
Statistical analyses
Differences between variables were analysed using
an ANOVA with repeated-measures design followed
by a Tukey post hoc test, if necessary. Dependent
variables included heart rate (HR), SBP, and DBP.
Descriptive variables were analysed with a Student’s
t-test. Significance was determined at the P ⬍ 0.05
level.
Results
Diet/total body mass
Diet was not significantly different across the three
trials. However, men consumed significantly (P ⬍
0.05) more kcals than women (2325 ± 418 vs 1985
± 379 kcals, respectively) and HT subjects tended to
consume more than NT participants (2490 ± 910 vs
2205 ± 875 kcals, respectively) although this was not
statistically significant. There were no differences
relative to sodium intake and caffeine ingestion was
controlled in the study. The 75% exercise bout
yielded slightly greater losses in total body mass
(range ⫽ 0.8–1.1 kg) as compared to the 50% bout
(range ⫽ 0.2–0.6 kg) but this was not statistically significant. Subjects drank water equivalent to their
weight loss prior to leaving the laboratory.
Exercise tests
None of the subjects (HT or NT) exhibited any
untoward signs or symptoms during the maximal
test or the two exercise intensity tests. Further, all
of the subjects were able to complete both 30-min
exercise bouts with no overt symptoms of distress.
Exercise SBP/DBP for all HT subjects averaged 164
± 12 mm Hg/94 ± 5 mm Hg for the 50% bout and
189 ± 17 mm Hg/96 ± 6 mm Hg for the 75% bout.
Ambulatory systolic and diastolic blood pressures
Hypertensive men and women were not significantly different (except that HT women maintained
significant SBP reductions through the 12-h
measurement point after the 75% bout) and
responded similarly during the post-exercise BP
measurement periods. Regardless, since there are
few data regarding HT women in the literature, the
figures are broken down by gender to show specific
responses. In HT men, the 75% exercise intensity
significantly reduced SBP for 10.5 h while the 50%
bout reduced SBP for an average of 5.8 h (Figure 1).
The DBP in HT men was reduced for an average of
11.9 h following the 75% bout as compared to 5.5 h
after the 50% bout (Figure 2). The HT women
responded in a similar fashion in that subjects significantly reduced SBP for 15.4 h after the 75% bout
(Figure 1) while the 50% bout resulted in a significant lowering which lasted, on average, 2.7 h (Figure
2). The DBP in HT women was reduced for an average of 9.8 h following the 75% bout as compared to
2.9 h after the 50% bout. The quantity (length of
reduction) of SBP and DBP reduction in both the HT
men and women was significantly reduced following the 75% workbout as compared to the 50% exercise bout (P ⬍ 0.05). In general, when HT men and
women are pooled together, the 75% session yielded
larger (up to 10 mm Hg, SBP; 9 mm Hg, DBP, P ⬍
0.05) and longer-lasting (up to 12 h, P ⬍ 0.05)
reductions.
Heart rate
Figure 3 shows HR responses of HT men and women
(combined). Exercise HRs during the 75% of
VO2max bout averaged 88% of HRmax while the
50% of VO2max bout was conducted at 69% of
Journal of Human Hypertension
Blood pressure reduction following exercise
TJ Quinn
550
Figure 1 Twenty-four hour SBP response of hypertensive men
and women following the exercise sessions as compared to the
control session (closed symbols = men; open symbols = women).
Values are means ± s.d. *Both the 50 and 75% VO2max exercise
intensities are significantly lower than the control value at the
same timepoint, P ⬍ 0.05. #The 75% VO2 max exercise intensity
is significantly lower than the control at the same timepoint, P
⬍ 0.05.
HRmax. The 24-h recovery HRs during the 75% of
VO2max bout were significantly lower at each time
point as compared to both the control and 50% of
VO2max workbout.
Discussion
The major results of this study suggest that: (1) a
75% of VO2max workload appears to offer a more
sustained and substantial reduction in both SBP and
DBP as compared to a 50% workbout in HT men
and women; (2) Stage 1 and 2 HT men and women
respond in a similar fashion relative to BP reduction
following exercise; and (3) exercise up to 75% of
maximal oxygen uptake appears safe and is well-tolerated in Stage 1 and 2 HT men and women. This
is the first acute, 24-h ambulatory BP study that has
Journal of Human Hypertension
Figure 2 Twenty-four hour DBP response of hypertensive men
and women following the exercise sessions as compared to the
control session (closed symbols = men; open symbols = women).
Values are means ± s.d. *Both the 50 and 75% VO2 max exercise
intensities are significantly lower than the control value at the
same timepoint, P ⬍ 0.05. #The 75% VO2max exercise intensity
is significantly lower than the control at the same timepoint, P
⬍ 0.05.
compared men and women, suggesting no gender
difference. Investigators who have used long-term,
exercise training18,23,24 in the control of elevated BP
generally report no substantial difference between
HT men and women. This acute, exercise study
appears to corroborate those findings.
Ambulatory BP
The fact that higher intensity exercise had a more
profound effect on BP reduction in both HT men and
women is unique and tends to conflict with some
early research involving either acute BP14 responses
or exercise training.18,24,25 Most adaptations to exercise training are directly proportional to the intensity of the activity.21 The present study does support
Blood pressure reduction following exercise
TJ Quinn
Figure 3 Average heart rate responses of HT men and women
according to exercise intensity. Values are means ± s.d. *Fifty
percent workbout is significantly lower than the control at the
same time point, P ⬍ 0.05. **The 75% workbout is significantly
lower than the control at the same timepoint, P ⬍ 0.05. Pre, preexercise; Exercise, average exercise heartrate; 0, 1, 3, 6, 12, 24,
hours post-exercise.
this concept. However, Pescatello et al14 showed
that 30 mins of cycling exercise conducted at 40%
of VO2max produced the same BP-lowering effect as
a 70% of VO2max workbout. This study involved
only six HT males, some of whom were on BP-lowering medications prior to the study, and only nonweight bearing activity. Likewise, Hagberg et al18
found SBP equally lowered by exercise conducted
for three, 15-min sessions at either 50 or 70% of
VO2max in older HT patients. Brownley et al15 studied only one exercise intensity and found SBP to be
significantly lower for 5 h post-exercise as compared
to a non-exercise day. Exercise intensity, in the
aforementioned activity and BP studies,14,15,18 was
controlled in the range of 40% to 70% of VO2max.
Exercise, in this range would be categorised as ‘light
to moderate’ activity. The present study established
a slightly higher intensity (75% VO2max) than previous research to determine if a slight increase in
physiological stress could elicit a more profound
BP-lowering effect. These data suggest that a slightly
higher exercise intensity does elicit a greater effect
on BP than that observed in previous studies.
Marceau et al13 may have documented why these
lower intensities provided the same positive effect
on BP as the higher intensity exercise. They showed,
in nine HT subjects, that training at 50% and 70%
of VO2max resulted in significant reductions in BP
but that the degree of reduction varied throughout
the day depending on intensity. It appears that the
50% workload elicited its positive BP-reduction
primarily during the waking hours while the 75%
bout exhibited its maximal effect during the evening
and sleeping hours. Therefore, in studies that only
measured post-exercise BP during the waking hours
it would be expected that the lower intensity exercise would produce similar effects as the higher
intensity workout. It is worth clarifying again that
the work by Marceau and colleagues was a training
study while the present study involves acute exercise. Regardless, the present acute study supports
this finding. It can be seen from Figures 1 and 2,
that SBP and DBP are lower following the 75% as
compared to the 50% bout.
The mechanism of this increased post-exercise BP
reduction with higher intensity exercise is poorly
understood. Rueckert et al16 in an acute exercise
study reported BP reductions lasting up to 2 h. They
found that the ‘post-exercise hypotension’ followed
a biphasic pattern: the initial drop (first 30 mins)
was due to a decrease in total and regional vascular
resistance followed by a drop in cardiac output
(CO). While CO was not measured in this study, it
is possible that CO was depressed for a longer period
following the 75% bout due to the significantly
reduced HR response as compared to the 50% bout
(Figure 3).
Chronic exercise training studies suggest other
mechanisms thought to be involved including
increases in peripheral blood flow,26 vasodilatory
metabolities,27 a reduction in alpha-adrenergic
responsiveness,28 a heightened arterial baro-receptor
sensitivity,29 and a decreased resting sympathetic
nerve discharge following exercise.30 These other
mechanisms may play an important role in BP
reduction following low intensity exercise. The
question of whether the hypotensive effect reported
in training studies is a true result of training or is a
transient effect of a previous exercise bout must be
considered. Somers et al17 have suggested that the
hypotensive effect is indeed a result of training since
most acute studies reported only short-term BP
reductions. However, the present study results
coupled with findings by Pescatello et al14 and
Brownley et al15 suggest that the duration of the
hypotensive effect is substantially longer than 1–2 h.
Perhaps it is possible that the longer the post-exercise hypotensive effect, the more likely the accumulation of these acute exercise effects become more
important when considering explanations for BP
lowering induced by chronic exercise.
While it is clear that motivated subjects can be
endurance trained at 75–85% of maximum, it is
unlikely that the vast majority of the population
would choose to do so on their own volition due
to the initial discomfort and, perhaps, an increased
potential for injury. Interestingly, however, the subjects in this study did not perceive either exercise
intensity to be overly stressful. Regardless and of
more practical concern, the accumulation of exercise effects may be of particular importance,
especially in a HT population. Recently, the Centers
for Disease Control and Prevention and the American College of Sports Medicine31 recommended a
public health statement stating that ‘every US adult
should accumulate 30 min or more of moderate
intensity physical activity on most, and preferably
all, days of the week’. If HT patients could perform
higher intensity work for short periods of time but
do this several times per day then the BP reductions
would be very applicable to the general HT population. If acute BP reductions could be accumulated
then activity conducted at 75% of maximum may be
a clinically significant recommendation that allied
health care professionals could share with their
patients. Clearly, more work in this area is warranted.
551
Journal of Human Hypertension
Blood pressure reduction following exercise
TJ Quinn
552
Most of the ambulatory BP studies have shown
short-term (1–2 h) reductions in SBP and DBP.16,17
However, the data from the present study agree with
those of Pescatello et al14 who showed BP
reductions lasting 12.7 h and Brownley et al.15
Again, Marceau et al13 have shown that exercise
intensity impacts BP reductions in different ways.
That is, higher intensity exercise decreases BP during evening and sleeping hours whereas, lower
intensity exercise reduced BP exclusively during the
waking period. The data from the present study support this but also suggest that the higher intensity
exercise elicited the effect throughout both the waking and sleeping periods. One might speculate that
perhaps, over time, the training programme used by
Marceau et al13 provided a dampening effect of what
was observed during the waking hours of this
present acute response study.
6
7
8
9
10
Conclusions
The results of this study suggest that exercise conducted at either 50% or 75% of maximum aerobic
capacity elicits significant reductions in both SBP
and DBP in HT men and women. However, a bout
conducted at 75% of VO2max does appear to yield
a larger and longer-lasting BP reduction as compared to the 50% intensity. These data suggest that
exercise is a valuable tool for short-term control of
BP in HT adults. Further work should be performed
to determine if shorter durations of exercise, conducted more than once daily result in BP reductions
and whether these reductions can be maintained
longer than 10–12 h post-activity. If significant
reductions can be attained then it may be possible
for health care professions to reduce medication
amounts for HT individuals.
11
12
13
14
15
16
Acknowledgements
Special thanks are extended to Dr Robert Kertzer
and Dr Robert W Kenefick who provided their time
as well as critical comments during the preparation
of this manuscript. Also, many thanks to the volunteer subjects for their time and patience.
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