Exercise equally effective to antihypertensive medication to lower SBP in hypertensives

How does exercise treatment compare with antihypertensive medications? A network meta-analysis of 391 randomised controlled trials assessing exercise and medication effects on systolic blood pressure

Literature - Naci H, Salcher-Konrad M, Dias S, et al., - Br J Sports Med 2018. doi: 10.1136/bjsports-2018-099921

Introduction and methods

As a consequence of the continuing rise of the burden of CVD in the population, the use of medications targeting high blood pressure (BP) is also increasing [1,2]. This increase may be associated with a higher incidence of adverse events at the population level, because more people take multiple medications and since polypharmacy is associated with a risk for drug-related morbidity and mortality [3,4]. Meanwhile, relatively little attention has been given to promoting the wider adoption of non-pharmacological interventions such as exercise.

The benefits of exercise on CVD risk factors and CVD is well-established [5-10]. The effect of exercise on systolic BP (SBP) are also well-documented. A previous meta-analysis showed that SBP was reduced after both endurance, dynamic resistance and isometric resistance exercise regimens [11]. A previous meta-epidemiological study aimed to evaluate the comparative effectiveness of pharmacological and non-pharmacological interventions on mortality. This study found that structured exercise interventions were equally effective as several common medications, with regard to the mortality benefits in secondary prevention of CHD, rehabilitation after stroke, treatment of heart failure and prevention of diabetes. In that analysis, however, the evidence on the mortality benefits was scarcer for exercise than for pharmacotherapy.

This is a network meta-analysis to systematically compare the SBP-lowering effects of exercise and medications, considering different types and intensities of exercise and different classes and doses of antihypertensive medications. For this analysis, 194 medication RCTs were included and one previously published, comprehensive review on exercise interventions was updated, to ultimately include 197 RCTs.

Main results

  • Across all populations, both antihypertensive medications and exercise interventions were effective in lowering SBP from baseline as compared with the control group (mean difference medications: -8.80 mmHg, 95%Credible Interval (CrI): -9.58 to -8.02, mean dif exercise: -4.84 mmHg, 95%CI: -5.55 to -4.13).
  • Greater SBP reductions were seen in populations receiving medications than in those participating in physical activity interventions (-3.96, 95%CrI: -5.02 to -2.91).
  • All tested types of exercise (endurance, resistance, isometric, and combinations of endurance and resistance) were effective in lowering SBP, and resulted in similar reductions from baseline, except for the combination of endurance and resistance training, which was more effective than dynamic resistance alone (-2.98, 95%CrI: -5.04 to -0.93).
  • All classes of antihypertensive medications (ACE inhibitors, ARB, CCG, diuretics) were effective in lowering SBP.
  • The SBP-lowering effect of most medication classes (ACE inhibitors, ARB and diuretics) did not differ significantly from the effect of isometric resistance and the combination of endurance and dynamic resistance exercises.
  • A dose-gradient in SBP-lowering effect was seen for antihypertensive medications, but it was unclear whether the same is true for different exercise intensities.
  • In hypertensive populations (SBP ≥140 mmHG), exercise reduced SBP by 8.96 mmHg (95%CrI: -10.27 to -7.64), and no significant difference was seen with the effect of medications on SBP (0.18, 95%CrI: -1.35 to 1.68). Different types of exercise appeared similar to medications in their SBP-lowering effect.


A comparative meta-analysis of commonly used antihypertensive medications and exercise interventions, showed that individuals that received medications achieved greater SBP reductions than those following structured exercise regimens. In hypertensive populations, however, different types of exercise appeared equally effective as compared with antihypertensive pharmacotherapy.

It should be noted that the number of studies on the effects of exercise and the number of participants included therein were much smaller than for antihypertensive medication. No RCT directly compared the SBP-lowering effect of antihypertensive medication and structured exercise.


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