|Year : 2020 | Volume
| Issue : 5 | Page : 227-234
Acute and chronic effects of combined exercise on ambulatory blood pressure and its variability in hypertensive postmenopausal women
Larissa Aparecida Santos Matias1, Igor Moraes Mariano1, Jaqueline Pontes Batista1, Tállita Cristina Ferreira de Souza1, Ana Luiza Amaral1, Juliene Gonçalves Costa Dechichi1, Mateus de Lima Rodrigues1, Victor Hugo Vilarinho Carrijo1, Thulio Marquez Cunha2, Guilherme Morais Puga1
1 Laboratory of Cardiorespiratory and Metabolic Physiology, Physical Education Department, Federal University of Uberlândia, Uberlândia, MG, Brazil
2 Department of Pneumology, School of Medicine, Federal University of Uberlândia, Uberlândia, MG, Brazil
|Date of Submission||04-Aug-2020|
|Date of Acceptance||02-Oct-2020|
|Date of Web Publication||27-Oct-2020|
Prof. Guilherme Morais Puga
Rua Benjamin Constant, 1286 - Nossa Senhora Aparecida, Uberlandia, MG, 38400-678
Source of Support: This study was financially supported by FAPEMIG (Grant n°: APQ-00750-14), CAPES (Grand n°: 001) and CNPq (Grant n°: 456443/2014 and 2794078/2013)., Conflict of Interest: None
The aim of this study was to investigate the acute and chronic effects, and their correlation, after combined aerobic and resistance exercises in blood pressure (BP) and its variability (BPV) in hypertensive postmenopausal women. Fourteen hypertensive postmenopausal women monitored BP at rest and during 24 h by ambulatory BP monitoring in a control day without exercise performance a pretraining (baseline), after an acute exercise session (acute), and after a chronic exercise training for 10 weeks (chronic). After exercise training, systolic BP (SBP, Δ = −150 mmHg.24 h), diastolic BP (DBP, Δ = −96 mmHg.24 h), and mean BP (MBP, Δ = −95 mmHg.24 h) area under the curve were smaller than baseline measurements (P < 0.05) with no difference between acute and baseline measurements. The SBP (ΔSD24 = −2, ΔSDdn = −1.7, and ΔARV24 = −1.9 mmHg), DBP (ΔSD24 = −0.9, ΔSDdn = −0.8, and ΔARV24 = −0.9 mmHg), and MBP (ΔSD24 = −1.5, ΔSDdn = −1.3, and ΔARV24 = −1.2 mmHg) variability reduced in acute session in relation to baseline, with no chronic effects. There are moderate correlations between acute and chronic responses in wake SBP, sleep DBP, and SD24. In conclusion, combined exercise reduces ambulatory BP chronically but not acutely. In contrast, BPV decreases after an acute session but not chronically. Awake SBP, sleep DBP, and SD24 indices are promising candidates to predict individual cardiovascular responses to exercise.
Keywords: Blood pressure variability, exercise, hypertension, menopause, postexercise hypotension
|How to cite this article:|
Matias LA, Mariano IM, Batista JP, de Souza TC, Amaral AL, Dechichi JG, de Lima Rodrigues M, Carrijo VH, Cunha TM, Puga GM. Acute and chronic effects of combined exercise on ambulatory blood pressure and its variability in hypertensive postmenopausal women. Chin J Physiol 2020;63:227-34
|How to cite this URL:|
Matias LA, Mariano IM, Batista JP, de Souza TC, Amaral AL, Dechichi JG, de Lima Rodrigues M, Carrijo VH, Cunha TM, Puga GM. Acute and chronic effects of combined exercise on ambulatory blood pressure and its variability in hypertensive postmenopausal women. Chin J Physiol [serial online] 2020 [cited 2021 Sep 22];63:227-34. Available from: https://www.cjphysiology.org/text.asp?2020/63/5/227/299252
| Introduction|| |
Hypertension (HT) is one of the main preventable factors associated with premature death and cardiovascular disease globally, being responsible for a high socioeconomic cost. It is characterized by elevated resting blood pressure (BP) and often associated with risk of cardiovascular events, brain accidents, and renal diseases. With aging, differences in BP behavior are observed between sexes, with a higher prevalence in women from the fifth decade of life, that coincides with menopause, resulting in high rates of cardiovascular death in this population. This prevalence can be explained by the physiological transition to nonreproductive phase in women, characterized by estrogen deficiency, changes in lipid profile, weight gain, sedentarism, and onset of cardiometabolic diseases, such as HT.
For treating HT, regular physical exercise is recommended, among which we highlight combined exercise (aerobic and resistance exercises in the same session). Despite being less studied than aerobic or resistance exercise alone, combined exercises have shown positive cardiovascular results (e.g., BP, vascular function, and oxidative stress) whether performed acute,, or chronically,,, in both patients with normal BP and HT, and also in hypertensive women after menopause. Some studies suggested that there is a positive correlation between acute-postexercise hypotension and BP reduction after chronic exercise training. These findings suggest that the changes in BP after acute exercise may predict the chronic responses of the exercise and it may influence the exercise prescription.,,
BP at rest has been used to compare postexercise hypotension, but this measure limits the temporal analysis of BP behavior. Thus, ambulatory BP monitoring (ABPM) began to be used as a noninvasive method to assess BP and its patterns during daily activities for 24 h that allows to understand the idiosyncrasies of circadian BP patterns in HT. Evaluating these patterns makes it available to identify complementary cardiovascular health indices in HT, such as BP variability (BPV). Increased BPV is independently associated with risk of cardiovascular events and mortality, mortality rates in HT, and with an increase in subsequent cardiovascular events,, making this an important assessment in groups at higher cardiovascular risk.
In this way, it is important to know the behavior of ABPM and BPV in hypertensive ones, as these values may be indicative of morbidity and mortality in this population. Thefore, the purpose of this study was to investigate the acute and chronic effects of combined exercise in ABPM and BPV in hypertensive postmenopausal women. We also investigated the relationship between these acute and chronic effects. Our hypothesis is that there will be falls in BP and BPV acute and chronically.
| Materials and Methods|| |
The study was approved by the local ethics committee of the Federal University of Uberlândia (n° 71285317.4.0000.5152) and submitted to “clinicaltrial.gov” (n° NCT03160989). All the volunteers that agreed to participate in the study signed an informed consent term, and the experiments were conformed to the principles of the Helsinki Declaration. After being recruited from traditional media (TV, radio, and posters), the volunteers answered an anamnesis questionnaire and performed the anthropometric, ergometric, and maximal repetition (1RM) evaluations. Following this, they were submitted to ABPM on three occasions: at rest without exercise performance and before exercise training (baseline), after a single acute combined exercise session (acute), and after combined exercise training for 10 weeks (chronic). Anthropometry and 1RM test were reevaluated, and the participants were again submitted to ABPM at rest, without exercise practice 48–72 h after the last exercise training session.
The eligibility criteria to participate in the study were as follows: HT under drug treatment (except beta-blockers), postmenopausal women (1 year of permanent amenorrhea), aged between 50 and 70 years, nonsmokers, without diabetes, who are not under cancer treatment, or with any pathology that impedes the practice of physical exercises. The exclusion criteria were as follows: change in antihypertensive drug dosage, not able to perform the exercise training, and not complete 80% of exercise sessions in 10 weeks.
Body mass was calculated using a Filizola scale brand (Filizola, Brazil). The height was measured with a Sanny fixed stadiometer. Waist, hip, and abdomen circumferences were measured using a Sanny (São Paulo, Brazil) inelastic tape measure, 0.5 cm wide. Waist circumference was measured between the last rib and the iliac crest at its smallest perimeter; abdominal circumference was measured at the umbilical scar, and hip circumference was measured at the largest perimeter of gluteus. Bioimpedance was performed on the Biodynamics model 450c (Biodynamics, Shoreline, WA, USA) device using the instrument's own reading software to estimate total lean mass, fat mass, and body fat percentage.
Exercise intensity tests
The intensity of resistance exercise was prescribed based on the 1RM test. After two familiarization sessions, the 1RM test was performed to obtain the maximum load (in kg) in all exercises except for squat on Swiss ball (fixed 10–18 kg external load) and abdominal crunch (body weight only). After 5 weeks of training, a new 1RM test was performed to adjust the training intensity.
To prescribe aerobic exercise, a familiarization session on treadmill was performed, and the intensity was determined by a treadmill incremental test. For this test, a Quark CPET (Cosmed, Rome, Italy) spirometer was used, and it consisted of 1% incline increments each 2 min until volunteers reached voluntary exhaustion at fixed velocity (5.5 km/h). The treadmill inclination at which the participants reached the heart rate zone between ventilatory thresholds 1 and 2 was considered as an intensity target. After 5 weeks of training, intensity was readjusted by the treadmill inclination corresponding to the heart rate zone between ventilatory thresholds.
The combined aerobic and resistance exercise training was performed for 10 weeks, three times a week on nonconsecutive days. Each session lasted 45 min, divided into 5 min of warm-up and 20 min of each type of exercise. The order of aerobic and resistance exercises was reversed at each training session. The resistance training consisted of seven weight machine exercises in series format: leg press 45°, bench press, lat pull-down, squat on Swiss ball, peck deck, seated row, and abdominal crunch. For each exercise, except abdominal crunch, two sets of 15 repetitions were performed in the intensity of 60%–70% of 1RM with a 40-s interval between sets and exercises. The aerobic exercise consisted of 20 min on treadmill at a fixed velocity (5.5 km/h), and intensity imposed by inclination using heart rate zone between ventilatory 1 and 2 intensities determined previously.
Resting and ambulatory blood pressure
To measure resting BP and heart rate, the OMRON HEM-7113 automatic monitor was used. Resting measures were performed on two occasions (Baseline and Chronic phases), three times daily on 3 nonconsecutive days, with 1-min interval between measurements (considering the average for analysis), in seated position, and preceded by 15 min of absolute rest. Resting BP was also measured before all exercise sessions to ensure safety.
The 24-h ABPM was performed using a Dyna Mapa+ (Cardios, Brazil), and it was always prepared in the morning (between 7 am and 9 am). It was scheduled to perform measurements every 15 min between 7 am and 11 pm and every 30 min between 11 pm and 7 am on three occasions: (1) baseline assessment without exercise – BASELINE, (2) acute evaluation after a single exercise session – ACUTE, and (3) posttraining evaluation CHRONIC between 48 and 72 h after the last exercise session to remove the acute effect of the last session [Figure 1]. The baseline and acute sessions were performed in randomized order. The values of the area under the curve (AUC) and BPV were calculated based on systolic BP (SBP), diastolic BP (DBP), and mean BP (MBP) measures in 24-h, sleep, and awake phases.
|Figure 1: Experimental design. ABPM: Ambulatory blood pressure monitoring; BASELINE: ABPM at rest; ACUTE: ABPM shortly after an exercise session; CHRONIC: ABPM at rest after 10 weeks of exercise training|
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Blood pressure variability
BPV was analyzed by three different indices: 24-h standard deviation (SD24), the mean diurnal and nocturnal deviations weighted for the duration of the daytime and nighttime interval (SDdn), and the average real variability (ARV24) that averages the absolute differences oweighted by the time interval between consecutive readings.
The sample calculation (minimum of 9) for paired t-test was performed by G*Power 188.8.131.52 software (Universität Düsseldorf, Düsseldorf, Germany), considering a power of 95% and an alpha error of 0.05, using mean variations of −3.2 ± 2.2 mmHg posttraining SBP as the main variable, what are feasible average values according to the literature. Results were presented as mean ± standard deviation. To verify data normality, the Shapiro–Wilk test was used. AUC was calculated by trapezoidal method to evaluate the behavior of the variables over time using GraphPad Prism 6 software (GraphPad Software Inc., San Diego, CA, USA). A paired t-test (or Wilcoxon in nonparametric data) was applied to analyze the results comparing the baseline and acute measurements and the baseline and posttraining (CHRONIC) measurements. The relationships between variations of acute and chronic in relation to baseline data were performed using Pearson correlation (or Spearman in nonparametric data). All analyses were performed using SPSS software version 25 (IBM Corporation, Armonk, NY, USA). The significance level was set at P < 0.05.
| Results|| |
Fourteen volunteers completed the entire study (58.8±1.0 years; 68.5±2.2 kg of weight; 27.7±1.2 kg/m2 of body mass index - BMI, and 7.2±1.5 years after menopause). Three participants used angiotensin-converting enzyme (1 of them associated with thiazide diuretics), 9 used angiotensin AT1 receptor blockers (5 of them associated with thiazide diuretics), and 2 used only thiazide diuretics. There were no changes in drugs or dosages during the study.
The general characteristics of the volunteers are presented in [Table 1]. The mean percentage of treadmill inclination in aerobic exercise was 4 ± 0.3%, and the heart rate zone of training was between 135 and 145 bpm. No difference was found in the evaluation of hip and abdomen circumferences nor for waist–hip ratio between BASELINE and CHRONIC. There were a significant reduction (P < 0.05) in body mass (−1.2%), BMI (−1.2%), fat percentage (−2.9%), fat mass (−3%), and waist circumference (−2.1%) and an increase in lean mass (+1.7%). We found a significant increase in maximum strength measured in all the exercises by 1RM test. The values of resting BP and heart rate did not change significantly when comparing baseline and posttraining (CHRONIC) measurements.
[Figure 2] shows the values of BP variation in relation to rest over time and their respective AUC. In AUC analysis, we found a significant reduction in SBP, DBP, and MBP when comparing BASELINE (−88 ± 60, −181 ± 41, and − 173 ± 42 mmHg. 24 h) and CHRONIC measurements (−261 ± 46, −310 ± 36, and − 293 ± 37 mmHg.24 h).
|Figure 2: Blood pressure variation: systolic blood pressure (a), diastolic blood pressure (b), mean blood pressure (c) and their respective areas under the curve: systolic blood pressure (d), diastolic blood pressure (e), mean blood pressure (f). *P < 0.05 difference from baseline.|
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[Table 2] presents SBP, DBP, and MBP values in 24-h, sleep, and wake analysis. We find no significant changes between ACUTE and CHRONIC measurements in relation to BASELINE. We found positive moderate correlations between acute and chronic responses in awake SBP (P = 0.021, r = 0.61) and sleep DBP (P = 0.019, r = 0.62). [Table 3], in its turn, presents the results of BPV. We found a significant reduction in the three parameters analyzed (SD24, SDdn, and ARV24) in ACUTE compared to the BASELINE measurement, without CHRONIC effects. BPV showed moderate-to-strong correlations between ACUTE and CHRONIC responses in SD24 (SBP and DBP).
Considering that reductions of 5 mmHg in SBP are sufficient to reduce the risk of stroke by 13%, we divided the sample into responsive (n = 5) and nonresponsive (n = 9) from this cutoff point (considering the exercise chronic effects). This analysis shows no significant differences between subgroups' general characteristics. However, it is important to highlight that the values are higher in the responsive group in order to change the classifications of BMI (30.2 = obesity, against 26.6 = overweight; kg/m2) and waist circumference (88.0 = high risk, against 81.9 = moderate risk; cm).
| Discussion|| |
The main results of the present study were reductions in SBP, DBP, and MBP over 24 h [Figure 2]d, [Figure 2]e, [Figure 2]f chronically but not acutely without statistical effects in raw ambulatorial BP. In addition, we found a reduction in SBP, DBP, and MBP variability (except DBP ARV24) after a single session in all analyzed parameters but without chronic changes. Finally, the acute variations of BP and BPV had moderate-to-strong correlations (0.61–0.72) with the chronic variations in sleep DBP, wake SBP, and SD24 (SBP and DBP).
Positive effects in BP responses were observed at high cardiometabolic risk or in healthy populations after acute exercise. Although some studies have evaluated BP after an acute combined exercise session,,,, only some of them evaluate BP for 24 h., In this sense, the absence of falls in the 24-h BP in the present study was similar to those with comparable exercise volume and intensity in populations with BP in normal levels, but smaller than in populations with higher BP. In addition, these hypotensive effects have a similar magnitude to aerobic exercise in the 1st h but with a shorter duration. This same pattern was demonstrated in studies with BP measurements for up to 120 min after exercise., It is worth mentioning that maybe the intensity of the aerobic exercise that makes up the combined session could be determinant of this hypotensive effect. Aerobic exercise may decrease BP better than resistance exercise, so if the magnitude and duration of the BP reduction are probably less after resistance exercise, the aerobic exercise may be determinant to BP reduction after combined exercise., These authors reinforce this information which also showed that combined exercise had better results lowering BP than resistance exercise alone.
Although there was no reduction in 24-h BP acutely, our results also showed that all indexes of BPV decrease in SBP, DBP, and MBP. The BPV also improve its classification in SBP: SD24 changed from average (13.0 ± 0.6 mmHg) to low risk (11.0 ± 0.5 mmHg), while ARV24 changed from high (10.9 ± 0.3 mmHg) to average (9.0 ± 0.5 mmHg). Thus, since SBP variations can be associated with risk of cardiovascular events in hypertensive patients, the acute session of combined exercise was able to reduce BPV and may reduce the risk of mortality in these populations.
Regarding the chronic effects of combined exercise training, our results showed ambulatory BP reduction after combined exercise training, and these results corroborate the positive effects in SBP and DBP in hypertensive patients, with similar results specifically in hypertensive postmenopausal women. In similar studies to the present, Son et al. and Lima et al. have found better BP results with combined training than ours in hypertensive postmenopausal women and hypertensive adults, respectively. The literature does not yet support that postmenopausal women may have different BP responses after exercise comparing with other populations with different ages, sexes, or diseases. However, many changes after menopause, such as increase in body fat, physical inactivity, oxidative stress, and more important, the lack of estrogen, can alter BP regulation and increase the incidence of HT., However, some differences must be highlighted, which may explain the most significant BP improvement in other,,, studies: (1) the age of the volunteers (75 ± 2 and 68 ± 5 against 59 ± 1 years in ours); (2) the use of different antihypertensive drugs that can mitigate the exercise effects for lowering baseline pressure levels, besides that apparently these drugs have responses that may have or not additive effects with exercise depending on the drug class. This hypothesis needs more studies, especially in chronic exercise interventions, to better understand; (3) the higher exercise volume on the other studies, and especially (4) higher initial BP in their studies (112 ± 4 mmHg of MBP in Son et al.'s study against 93 ± 4 mmHg in ours and 128 ± 12 mmHg of 24-h SBP in Lima et al.'s study against 123 ± 7 mmHg in ours), being that the posttraining BP values of these studies approached ours. However, it is worth mentioning that, even with these characteristics that could limit the training responses, we demonstrate falls in SBP, DBP, and MBP (by AUC) in this population, suggesting this as a good strategy for BP maintenance even in well-controlled ones.
It is noteworthy that the majority of the studies investigating the effects of chronic exercise on BPV were associated with aerobic,,, or resistance exercises and there is a lack of studies with combined exercises. Besides that, idiosyncratic characteristics of this intervention and population such as exercise intensity and the use of antihypertensive drugs, seems to be related to the BPV variations. Like ours, some studies have found no changes in chronic BPV responses, especially with healthy participants., However, in general, reductions of BPV after chronic exercise in populations with cardiovascular dysfunctions seem to be expected,, what did not happen in the present study.
One possible explanation for the lack of results in BPV after chronic exercise is that the worse vascular health of postmenopausal women mitigates these responses. This gains relevance as BPV seems to be influenced by endothelium and vascular smooth muscle adaptations to exercise training and pharmacological interventions. Besides that, there are indications that these responses are dependent on autonomic regulation, which presents clearer responses after acute than chronic exercise. It is also important to note that improvements in BPV appear to be independent of BP reductions.,
When comparing acute and chronic responses to exercise, we identified reductions in CHRONIC but not ACUTE BP, which can be explained by the more pronounced acute responses in populations with high BP, while chronic exercise demonstrates consistent responses even in normal BP patients. We also demonstrated moderate correlations between ACUTE and CHRONIC responses of wake SBP and sleep DBP but not in the 24-h values. This is not a unanimous response pattern, since the 24-h values showed moderate to strong correlations from aerobic and resistance exercises., However, after combined exercise with a similar population to the present study, there is no relationship between acute and chronic responses. Moreover, the method used seems to affect these responses as different from the traditional method; the eccentric combined exercise obtained moderate correlations between responses in ACUTE and CHRONIC SBP. In addition, we identified moderate to strong positive correlations between acute and chronic variations in SD24 of SBP (r = 0.65) and DBP (r = 0.72), signaling that the SD24 can be a candidate to determine the individual's future responsiveness to the proposed physical training. To our knowledge, this is the first study to show relationships between acute and chronic BPV responses.
The present study presents some limitations, such as few volunteers, which can generate reduced analysis power and therefore increase the chance of type 2 error (false negatives), although the sample size was estimated based on previous studies, and even with possibly reduced analysis power, we found statistically significant differences, which mitigates this gap; there is no untrained group, although the aim of the study was to investigate the relationship of acute and chronic responses after exercise training; existence of polytherapies and the nonstandardization of doses, and active principles. On the other hand, some characteristics minimized these limitations, such as training intensities corresponded to the same relative effort, and they all took the same drug and dosage for at least 1 year to be adapted to the drug effects. Thus, the results cannot be generalized to other exercise types, drug classes, or populations. However, they suggest that moderate intensity combined exercise may be a good strategy to maintain cardiovascular health in hypertensive postmenopausal women, especially considering the low adherence to antihypertensive drug treatments. However, this is an incipient response, and further studies are needed to elucidate the influence of various classes of antihypertensive drugs and characteristics of exercise load control on exercise training responses, besides the ability of ACUTE responses to predict CHRONIC as a way to allow individualization of training.
| Conclusion|| |
Combined aerobic and resistance exercise can be used for hypertensive postmenopausal women to improve BP responses and may reduce the risk of cardiovascular events and/or mortality due to both reduction of 24-h ambulatory BP chronically and acute improvement in BPV. Moreover, awake SBP, sleep DBP, and SD24 indices are promising candidates to predict individual cardiovascular responses to the proposed exercise.
We appreciate the collaboration of the laboratory technicians and the Physical Education Department from Federal University of Uberlândia. This study was funded by the Foundation for Research of the State of Minas Gerais (FAPEMIG; Grant n°: APQ-00750-14) and National Council for Scientific and Technological Development (CNPq; Grant n°: 456443/2014 and 2794078/2013).
Financial support and sponsorship
This study was financially supported by FAPEMIG (Grant n°: APQ-00750-14), CAPES (Grand n°: 001) and CNPq (Grant n°: 456443/2014 and 2794078/2013).
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]