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Brief Report
August 4, 2021

Effect of Exercise Training on Ambulatory Blood Pressure Among Patients With Resistant Hypertension: A Randomized Clinical Trial

Author Affiliations
  • 1Institute of Biomedicine (iBiMED), School of Health Sciences, University of Aveiro, Aveiro, Portugal
  • 2Cardiology Department, Hospital Infante D. Pedro, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
  • 3Research Center in Sports Sciences, Health and Human Development (CIDESD), University Institute of Maia, Maia, Portugal
  • 4Centre for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
  • 5Hypertension and Cardiovascular Risk Unit, Unidade Local de Saúde Matosinhos, Matosinhos, Portugal
  • 6University of Coimbra, Cytogenetics and Genomics Laboratory, Institute of Cellular and Molecular Biology, Coimbra, Portugal
  • 7Coimbra Institute for Clinical and Biomedical Research (iCBR) and Center of Investigation on Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine and Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
  • 8Research Centre in Physical Activity, Health and Leisure (CIAFEL), Faculty of Sport, University of Porto, Porto, Portugal
  • 9Center for Health Technology and Services Research (CINTESIS.UA), School of Health Sciences, University of Aveiro, Aveiro, Portugal
  • 10Heart Institute, School of Medicine, University of São Paulo, São Paulo, Brazil
  • 11Department of Kinesiology, University of Connecticut, Storrs
  • 12OncoMove, Associação de Investigação de Cuidados de Suporte em Oncologia (AICSO), Vila Nova de Gaia, Portugal
JAMA Cardiol. 2021;6(11):1317-1323. doi:10.1001/jamacardio.2021.2735
Key Points

Question  Is aerobic exercise training an effective antihypertensive treatment in patients with resistant hypertension?

Findings  In this randomized clinical trial including 53 patients, a 12-week exercise training intervention promoted a clinically meaningful reduction in 24-hour and daytime ambulatory systolic and diastolic blood pressure.

Meaning  The findings show that aerobic exercise added to optimized medical therapy reduces blood pressure in patients with low responsiveness to drug treatment and has the potential to be incorporated in the standard care of these patients.


Importance  Limited evidence suggests exercise reduces blood pressure (BP) in individuals with resistant hypertension, a clinical population with low responsiveness to drug therapy.

Objective  To determine whether an aerobic exercise training intervention reduces ambulatory BP among patients with resistant hypertension.

Design, Settings, and Participants  The Exercise Training in the Treatment of Resistant Hypertension (EnRicH) trial is a prospective, 2-center, single-blinded randomized clinical trial performed at 2 hospital centers in Portugal from March 2017 to December 2019. A total of 60 patients with a diagnosis of resistant hypertension aged 40 to 75 years were prospectively enrolled and observed at the hospitals’ hypertension outpatient clinic.

Interventions  Patients were randomly assigned in a 1:1 ratio to a 12-week moderate-intensity aerobic exercise training program (exercise group) or a usual care control group. The exercise group performed three 40-minute supervised sessions per week in addition to usual care.

Main Outcomes and Measures  The powered primary efficacy measure was 24-hour ambulatory systolic BP change from baseline. Secondary outcomes included daytime and nighttime ambulatory BP, office BP, and cardiorespiratory fitness.

Results  A total of 53 patients completed the study, including 26 in the exercise group and 27 in the control group. Of these, 24 (45%) were women, and the mean (SD) age was 60.1 (8.7) years. Compared with the control group, among those in the exercise group, 24-hour ambulatory systolic BP was reduced by 7.1 mm Hg (95% CI, −12.8 to −1.4; P = .02). Additionally, 24-hour ambulatory diastolic BP (−5.1 mm Hg; 95% CI, −7.9 to −2.3; P = .001), daytime systolic BP (−8.4 mm Hg; 95% CI, −14.3 to −2.5; P = .006), and daytime diastolic BP (−5.7 mm Hg; 95% CI, −9.0 to −2.4; P = .001) were reduced in the exercise group compared with the control group. Office systolic BP (−10.0 mm Hg; 95% CI, −17.6 to −2.5; P = .01) and cardiorespiratory fitness (5.05 mL/kg per minute of oxygen consumption; 95% CI, 3.5 to 6.6; P < .001) also improved in the exercise group compared with the control group.

Conclusions and Relevance  A 12-week aerobic exercise program reduced 24-hour and daytime ambulatory BP as well as office systolic BP in patients with resistant hypertension. These findings provide clinicians with evidence to embrace moderate-intensity aerobic exercise as a standard coadjutant therapy targeting this patient population.

Trial Registration  ClinicalTrials.gov Identifier: NCT03090529

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