Hypertension and

Resistance Training
Paul Sorace, MS, ACSM RCEP, CSCS*D, Thomas P. Mahady, MS, CSCS, and Nicole Brignola
Hackensack University Medical Center, Hackensack, New Jersey
S U M M A R Y
HYPERTENSION (HTN) IS A
COMMON CARDIOVASCULAR
DISEASE AND MAJOR HEALTH
PROBLEM IN THE UNITED STATES
AND AROUND THE WORLD.
REGULAR EXERCISE AND PHYSI-
CAL ACTIVITY HAVE BENEFICIAL
EFFECTS ON PREVENTING AND
LOWERING HTN. THIS COLUMN
REVIEWS HTN, PRESCRIBED HTN
MEDICATIONS, AND RESISTANCE
TRAINING BENEFITS SPECIFIC TO
BLOOD PRESSURE AND HTN.
OVERVIEW OF HYPERTENSION
H
ypertension (HTN; blood
pressure that is greater than
the normal range) is dened as
a chronic medical condition affecting
more than 65 million individuals in the
United States (5), with Americans
spending $37 billion annually on ofce
visits, medications, and laboratory tests
related to the treatment of HTN alone
(2). HTN predisposes persons to in-
creased risk of coronary artery disease,
which may increase the risk of heart
attack, heart failure, stroke, and kidney
disease (3). The relationship between
blood pressure and cardiovascular dis-
ease risk is independent of other risk
factors, but the risks continue to in-
crease with the presence of additional
risk factors such as diabetes and dysli-
pidemia (3). For example, the 10-year
risk for coronary heart disease is
greater in someone who has increased
total cholesterol and increased systolic
blood pressure as apposed to someone
who has only increased systolic blood
pressure (3).
Reductions in morbidity and mortality
have been mainly attributed to the
increased availability and use of various
drugs and lifestyle treatments. Some of
the common medications prescribed to
treat HTN include:
Diuretics decrease the rate of uid
reabsorption in the tubules of the
kidneys and increase the rate of
urine output, reducing the total
amount of uid in the body, thereby
lowering blood pressure. Potassium
levels will drop with diuretics in-
creasing the risk of hypokalemia.
Because potassium regulates blood
ow through skeletal muscle tissue,
the risk of rhabdomyolysis (break-
down of muscle bers) is increased.
Beta blockers bind to beta-adreno-
ceptors and thereby block the binding
of norepinephrine and epinephrine
(adrenaline) to these receptors. As
a result, the heart beats more slowly
and with less contractility, thereby
reducing blood pressure. Beta block-
ers also help blood vessels relax and
dilate to improve blood ow. Beta
blockers reduce heart rate and cardiac
output. Reductions in heart rate and
cardiac output play a role in de-
creasing
_
VO
2max
, thus potentially
reducing exercise performance.
Angiotensin-converting enzyme
(ACE) inhibitors control blood pres-
sure by inhibiting the formation of
angiotensin II. Angiotensin II causes
arteries to constrict and thereby
increases blood pressure. (Although
ACE inhibitors and beta blockers
reduce systolic and diastolic pressure
during exercise, the overall response
to dynamic and static activities is not
impaired with these drugs because
catecholamine action to drive po-
tassium back into the cell is not
impaired.)
ACE receptor blockers block the
action of angiotensin II, which allows
blood vessels to dilate and thereby
reduce blood pressure.
Calcium channel blockers lower blood
pressure by preventing calcium from
entering the cells of the heart and
blood vessel walls. Calcium ions
excite the contractile process of the
heart and arterial muscles. Systolic
and diastolic blood pressures are
reduced during exercise because of
the vasodilatory effects, which may
result in light headedness and pe-
ripheral edema post-exercise. Because
of the risk of orthostatic hypoten-
sion (decrease in blood pressure
occurring when an individual arises
from a seated or lying position; can
cause light headedness or fainting),
caution should be used when tran-
sitioning from seated or lying re-
sistance training (RT) exercises.
Guidelines are based upon the Seventh
Report of the Joint National Committee
on Prevention, Detection, Evaluation,
Peter Ronai, MS, CSCS*D, NSCA-
CPT*D, ACSM RCEP
Column Editor
Special Populations
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and Treatment of High Blood Pressure
released in 2003 for both patients and
physicians in tracking and initiating
antihypertensive treatments (see Table
1) (3).
Prehypertension is not considered a
disease category, and the treatment
plan is to encourage lifestyle modica-
tions (e.g., physical activity, sodium
restriction) to prevent cardiovascular
disease or HTN from developing (3,8).
However, drug therapy may be initi-
ated in persons with prehypertension if
other medical conditions are present
(e.g., diabetes) and lifestyle modica-
tions are unsuccessful at lowering blood
pressure to 130/80 mm Hg or less (3).
Antihypertensive medications are indi-
cated for stage 1 and 2 HTN (3).
BENEFITS OF RT AND EFFECTS ON
BLOOD PRESSURE
Substantial research indicates that
regular cardiopulmonary exercise has
a favorable effect on lowering overall
blood pressure and should be the main
emphasis of an exercise program de-
signed to prevent and control HTN
(1,8,9). Research has demonstrated
that the effects of RT on resting blood
pressure are equivocal (1). However,
there is evidence to indicate that RT
can lower resting blood pressure
(1,4,6). A meta-analysis by Kelley and
Kelley (6) indicated that engaging in
regular RT resulted in approximately
a 2% decrease in systolic pressure and
a 4% reduction in diastolic pressure.
This reduction by itself may seem
insignicant but when it is combined
with the additive effects of other
healthy lifestyle habits (e.g., cardiopul-
monary exercise, reduced sodium in-
take, weight loss if needed), it adds up
to a more substantial decrease in
resting blood pressure. In addition,
a systolic blood pressure reduction of
3 mm Hg has been associated with
reduced cardiac morbidity by 59%,
stroke by 814%, and all-cause mortal-
ity by 4% (9). However, the majority of
the outcomes in these 2 meta-analyses
(4,6) were based on resting blood
pressures below 140 mm Hg and/or
90 mm Hg. More research is needed
regarding the effects of RT on blood
pressure in persons with HTN.
The specic effects RT and exercise
have on lowering blood pressure are
uncertain, but it is likely that a number
of different mechanisms are involved
(e.g., neural and vascular) (1,10). These
potential mechanisms include:
Chronic exercise (decreased total
peripheral resistance)
Acute exercise (postexercise hypo-
tension by sympathetic inhibition
and altered vascular responsiveness)
Reduced sympathetic nervous activ-
ity and circulating norepinephrine
Improved endothelial function
Vascular remodeling
Genetic inuences
RT has cardioprotective effects other
than lowering resting blood pressure.
Regular RT has been shown to reduce
the blood pressure response to maxi-
mal exercise and improve heart rate
recovery after cardiopulmonary exer-
cise (7). RT prolongs the onset of peak
cardiovascular responses, decreases the
cardiovascular response to exertion,
and improves recovery from maximal
exertion (7). These effects are bene-
cial, since the rate of increase in blood
pressure and heart rate can cause
a cardiac event. Activities requiring
physical exertion (e.g., yard work,
activities that involve lifting or carry-
ing) will become safer to perform,
because hemodynamic responses may
be less as a result of regular RT.
SAFETY ISSUES WITH RT IN
INDIVIDUALS WITH HTN
The American Heart Association rec-
ommends that uncontrolled HTN
(.180/110 mm Hg) be an absolute
contraindication for RT (10). A client
with such a resting blood pressure
should seek medical evaluation to lower
his or her blood pressure before start-
ing RT. HTN of .160/.100 mm Hg
is a relative contraindication for RT
(10). This person should consult with
a physician before initiating RT (10).
High-intensity RT (80100% 1-rep
maximum) can invoke excessive ele-
vations in blood pressure (10). As
a result, RT at this intensity should be
avoided in persons with HTN. How-
ever, there is evidence that RT results
in a more favorable balance in myo-
cardial oxygen supply and demand
than aerobic exercise due to the lower
heart rate and higher myocardial (di-
astolic) perfusion pressure (10). Mod-
erate intensity RT (4060% 1-rep
maximum) appears to be safe for
individuals with controlled HTN (10).
CONCLUSION
More research is needed in this area,
particularly RT effects on blood
Table 1
Classification of blood pressure for adults ages 18 years of age or older
BP classication Systolic BP, mm Hg Diastolic BP, mm Hg Lifestyle modication
Normal ,120 and ,80 Encourage
Prehypertension 120139 or 8089 Yes
Stage 1 hypertension 140159 or 9099 Yes
Stage 2 hypertension .160 or .100 Yes
BP = blood pressure.
*Information obtained from Chobanian et al. (3).
VOLUME 31 | NUMBER 1 | FEBRUARY 2009
34
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pressure in individuals with HTN, with
and without the inuence of antihy-
pertensive medications. A need also
exists for studies that analyze data with
an intention-to-treat approach, so the
effectiveness of RTas a nonpharmaco-
logical intervention can be determined
(6). This is particularly important for
determining the role of RT in manag-
ing prehypertension.
RT is benecial for persons with or at
risk for HTN. Evidence indicates that
RT can lower blood pressure and also
reduce the cardiovascular response to
physical activities. Increased muscular
strengthandendurance oftenenable per-
sons to be more physically active, which
can help control or prevent HTN.
It is important that exercise professio-
nals understand HTN, its risks, medica-
tion effects, and RT benets and effects
on blood pressure. This will enable
them to help their clients who have or
are at risk for HTN, while minimizing
the risks with participating in RT.
Paul Sorace is a clinical exercise
physiologist at Hackensack University
Medical Center and an instructor for the
American Academy of Personal Training
(AAPT).
Thomas P. Mahady is the senior
exercise physiologist for The Cardiac
Prevention & Rehabilitation Program
at Hackensack University Medical Center
and an adjunct professor at William
Paterson University in Wayne, New Jersey.
Nicole Brignola is a recent graduate
from William Paterson University.
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