Do the combined blood pressure effects of exercise and antihypertensive medications add up to the sum of their parts? A systematic meta-review

Abstract

Objective: To compare the blood pressure (BP) effects of exercise alone (EXalone), medication alone (MEDSalone) and combined (EX+MEDScombined) among adults with hypertension.

Data sources: PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus and the Cochrane Library.

Eligibility criteria: Randomised controlled trails (RCTs) or meta-analyses (MAs) of controlled trials that: (1) involved healthy adults>18 year with hypertension; (2) investigated exercise and BP; (3) reported preintervention and postintervention BP and (4) were published in English. RCTs had an EX+MEDScombined arm; and an EXalone arm and/or an MEDSalone arm; and MAs performed moderator analyses.

Design: A systematic network MA and meta-review with the evidence graded using the Physical Activity Guidelines for Americans Advisory Committee system.

Outcome: The BP response for EXalone, MEDSalone and EX+MEDScombined and compared with each other.

Results: Twelve RCTs qualified with 342 subjects (60% women) who were mostly physically inactive, middle-aged to older adults. There were 13 qualifying MAs with 28 468 participants (~50% women) who were mostly Caucasian or Asian. Most RCTs were aerobic (83.3%), while the MAs involved traditional (46%) and alternative (54%) exercise types. Strong evidence demonstrates EXalone, MEDSalone and EX+MEDScombined reduce BP and EX+MEDScombined elicit BP reductions less than the sum of their parts. Strong evidence indicates EX+MEDScombined potentiate the BP effects of MEDSalone. Although the evidence is stronger for alternative than traditional types of exercise, EXaloneelicits greater BP reductions than MEDSalone.

Conclusions: The combined BP effects of exercise and medications are not additive or synergistic, but when combined they bolster the antihypertensive effects of MEDSalone.

Prospero registration number: The protocol is registered at PROSPERO CRD42020181754.

Keywords: cardiovascular; exercise; heart disease; pharmacology; physical activity.

Figure 1

A summary of the primary literature systematic original and updated search selection process. N=The number of potentially qualifying articles from the original search. N^U=The number of potentially qualifying articles from the updated search. N^M=The number of potentially qualifying articles from the manual search.CINAHL, Cumulative Index to Nursing and Allied Health Literature.

Figure 2

A summary of secondary literature original and updated systematic search selection process. N=The number of potentially qualifying articles from the original search. N^U=The number of potentially qualifying articles from the updated search. ^aAll six qualifying meta-analyses also emerged as qualifying from the physical activity guidelines for Americans Advisory Committee scientific report original search.

Figure 3

A summary of the original and updated Physical Activity Guidelines Advisory Committee Scientific Report secondary literature systematic search selection process. N=The number of potentially qualifying articles from the original search. N^U=The number of potentially qualifying articles from the updated search. ^aOf the 15 meta-analyses qualifying from the original Physical Activity Guidelines for Americans scientific report search, eight of these conducted moderator analyses and qualified for this meta-review. CINAHL, Cumulative Index to Nursing and Allied Health Literature.