Journal of Human Hypertension (2016), 1–8

© 2016 Macmillan Publishers Limited, part of Springer Nature. All rights reserved 0950-9240/16
www.nature.com/jhh

REVIEW
Exercise intensity and hypertension: what’s new?
YN Boutcher and SH Boutcher

One bout of aerobic exercise and regular participation in aerobic exercise has been shown to result in a lowering of office and
ambulatory blood pressure of hypertensive individuals. Higher-intensity aerobic exercise, up to 70% of maximal oxygen
consumption, does not produce a greater hypotensive effect, compared with moderate-intensity aerobic exercise. Intermittent
aerobic and anaerobic exercise, however, performed at an intensity 470% of maximal oxygen uptake has been shown to
significantly reduce office and ambulatory blood pressure of hypertensive individuals. Thus, faster, more intense forms of exercise
can also bring about blood pressure reduction in the hypertensive population. Compared with continuous moderate-intensity
aerobic exercise, high-intensity intermittent exercise typically results in a greater aerobic fitness increase in less time and produces
greater changes in arterial stiffness, endothelial function, insulin resistance and mitochondrial biogenesis. One of the characteristics
of high-intensity intermittent training is that it typically involves markedly lower training volume compared with traditional aerobic
and resistance exercise programmes making it a time-efficient strategy to accrue adaptations and blood pressure benefits. This
review briefly summarizes the results of studies that have examined the effects of single and repeated bouts of aerobic and
resistance exercise on office and ambulatory blood pressure of hypertensive individuals. Then a more detailed summary of studies
examining the effect of high-intensity intermittent exercise and training on hypertension is provided.

Journal of Human Hypertension advance online publication, 8 September 2016; doi:10.1038/jhh.2016.62

INTRODUCTION provided. Regarding search methods two researchers surveyed

Hypertension is one of the major risk factors for cardiovascular Medline and Pubmed databases for meta-analyses and reviews
morbidity. Hypertension worldwide prevalence has been involving aerobic and resistance exercise and their effects on BP in
estimated to be over one billion and treatment costs are hypertensive individuals. To search references on high-intensity
substantial.1 Regular participation in aerobic exercise (continuous exercise the terms HIIE, HIIT and interval sprinting exercise were
walking, jogging and cycling) has been shown to reduce office used separately and associated with hypotension, hypertension,
blood pressure2 (BP) and ambulatory BP (ABP)3 of hypertensive post exercise, BP and ABP. Inclusion criteria for the high-intensity
individuals and promotes general health and improvement in articles were the following: (1) a sample consisting of hypertensive
cardiovascular risk factors.4 Office BP is typically measured once or adults; (2) papers reporting BP responses after HIIE for a minimum
twice using an auscultatory cuff in a sitting, resting position, of 20 min; (3) papers reporting BP responses after a minimum of
whereas ABP involves continuous assessment over hours. One 8 weeks of HIIT; and (4) papers published in English.
bout of resistance exercise (weights) also lowers the office
diastolic BP of hypertensive individuals.2 The number of studies
that have examined the effect of resistance exercise on the BP of THE EFFECT OF AEROBIC AND RESISTANCE EXERCISE ON BP
hypertensive adults, however, is minimal. Research examining the OF HYPERTENSIVE INDIVIDUALS
effect of high-intensity exercise on hypertension is increasing and Aerobic exercise is usually performed by continually running,
promisingly, results indicate that this form of exercise is impactful cycling or swimming for 30–45 min at a moderate intensity.
on hypertension.5 One bout of high-intensity intermittent Frequency of exercise (number of sessions per week) and duration
exercise (HIIE) typically involves mini-bouts of high-intensity (how long each session lasts) are important characteristics of an
exercise lasting from 6 s to 4 min interspersed by rest or exercise programme, but an equally important factor is exercise
light-intensity exercise recovery periods. High-intensity intensity (how hard an individual works during exercise).
intermittent training (HIIT) involves repeated bouts of HIIE over For example, high- compared with moderate-intensity running,
months. HIIT has lower training volume, compared with traditional cycling and swimming has consistently been found to result in
aerobic and resistance exercise programmes, making it a time- greater physiological adaptations. Typically, aerobic exercise has
efficient strategy to achieve BP benefits. The purpose of this been performed on a stationary cycle ergometer or treadmill at a
review is to briefly summarize the results of research examining moderate intensity between 45 and 64% of maximal oxygen
the effect of single and repeated bouts of aerobic and resistance uptake (V_ O2max). V_ O2max is typically assessed by exercising an
exercise on the office BP and ABP of hypertensive individuals. individual to exhaustion on a stationary cycle ergometer or
The issue of optimal exercise intensity will be addressed after treadmill. V_ O2max reflects an individual’s aerobic fitness level and
which a more detailed examination of studies examining the is influenced by the ability to utilize oxygen to fuel aerobic
effect of HIIE and HIIT on the BP of hypertensive individuals will be exercise. Older individuals and those suffering from disease can

Department of Exercise Physiology, School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia. Correspondence: Dr SH
Boutcher, School of Medical Sciences, Faculty of Medicine, University of New South Wales, High Street, Randwick, Sydney, New South Wales 2052, Australia.
E-mail: s.boutcher@unsw.edu.au
Received 9 March 2016; revised 22 June 2016; accepted 15 July 2016
 Exercise and hypertension
YN Boutcher and SH Boutcher
2
exercise to exhaustion but can fail to meet the criterion for (systolic BP 140–159 mm Hg; diastolic BP 90–99 mm Hg).
attaining V_ O2max, which typically includes a final exercise heart Participants exercise once on a treadmill or stationary cycle
rate within ± 10 beats per minute of age-predicted maximal ergometer at an intensity between 40 and 70% of V_ O2max for
heart rate, a plateau in oxygen consumption and a respiratory between 20 and 40 min. Office BP has usually been assessed
exchange ratio of 41.15. In this situation individuals are deemed before exercise and between 1 and 2 h after one bout of exercise.
to have achieved a V_ O2peak. Exercise intensity is typically Collectively, results have shown that one bout of aerobic exercise
expressed by what percentage of V_ O2max an individual utilizes consistently lowers office systolic and diastolic BP of hypertensive
during exercise. For example, moderate-intensity aerobic exercise adults up to 2 h during the post-exercise period7 (Table 1).
is usually performed at a relative intensity of around 45–64% of
V_ O2max or 55–74% of maximal heart rate, whereas hard/vigorous The effect of one bout of aerobic exercise on ABP
aerobic exercise is usually performed at 70–85% of V_ O2max and
95% and above of maximal heart rate. HIIE and HIIT, to be The effect of a single bout of aerobic exercise on post-exercise
discussed later, are typically performed at an intensity between 70 ABP has also been examined. Hypertensive participants typically
and 100+% of V_ O2max although there are intensity issues exercise on a treadmill or stationary cycle ergometer at an
regarding HIIE that involve sprinting (see next paragraph). Some intensity between 40 and 70% of V_ O2max for between 20 and
studies have used maximal heart rate or age-related estimates of 40 min after which ABP is monitored for up to 24 h. Most studies
maximal heart rate to estimate exercise intensity. Thus, exercising have found a significant post-exercise ABP decrease in hyperten-
at 70% of maximal heart rate would equate to around 60% of sive individuals.7 This effect, however, is variable in magnitude
V_ O2max. Other studies have used heart rate reserve to calculate (−2 to 12 mm Hg decrease in systolic and diastolic BP) and
exercise intensity, which is the difference between resting heart duration (4 to 16 h) suggesting that individual and exercise
rate and maximum heart rate. characteristics might contribute to the variability of the aerobic
There is a problem, however, when percent of V_ O2max or per post-exercise hypotension response.8 Collectively, one bout of
cent of maximal power output are used to categorize the exercise aerobic exercise has been found to significantly reduce both the
intensity of HIIE regimens that contain sprinting (for example, a office BP and ABP of hypertensive individuals. Higher-intensity
pedal rate in excess of 100 revolutions per minute). Thus, in some aerobic exercise, compared with moderate-intensity aerobic
studies the intermittent exercise phase is performed as a sprint exercise, has not been found to produce a greater post-exercise
(anaerobic exercise) so energy generation depends mainly on hypotensive effect.2
non-aerobic energy pathways. Consequently, assessing V_ O2
during the sprint phase would not be a valid indicator of exercise The effect of regular aerobic exercise on office BP and ABP
intensity. Although the recovery phase is typically aerobic in It has also been found that hypertensive adults, typically stage 1
nature assessing V_ O2 would not accurately reflect exercise hypertensive, who are exposed to aerobic exercise performed
intensity during sprinting. So there is a problem with using per regularly every week for months, experience a lowering of BP. For
cent of V_ O2max to express intensity during exercise regimens that office BP, a meta-analysis2 found that regular aerobic training was
involve sprinting. Using a percentage of maximal power output associated with a reduction of 8.3 and 5.2 mm Hg for the systolic
(usually in watts) reflects exercise intensity but does not and diastolic BP, respectively, of hypertensive individuals (Table 1).
necessarily reflect the ‘sprinting’ component. For example, a For ABP, results of another meta-analysis3 found that aerobic
person working at 90% of a maximal power output of 200 W could training was associated with a reduction of 3.8 and 3.0 mm Hg for
by cycling at a high resistance (for example, 2 kg) on a cycle daytime systolic and diastolic ABP, respectively, of hypertensive
ergometer but with a non-sprinting pedal cadence (for example, individuals (Table 1). Consistently, involvement in regular bouts of
90 revolutions per minute). So their power output would be 90% aerobic exercise, performed over months, has been found to
of their maximal power output (180 W) but they would not be significantly reduce both the office BP and ABP of hypertensive
sprinting. Similarly, using a percentage of maximal heart rate individuals. Higher-intensity regular aerobic exercise, compared
could have the same problem. Also it is possible to have a with moderate-intensity aerobic exercise, has not been found
sprinting pedal cadence on a stationary cycle ergometer with a to produce a greater reduction in office BP or ABP.2 With regard to
low resistance resulting in an exercise intensity that is at a low exercise-induced hypotension effects during the following 24 h
percentage of maximal power output. Using the example above a the meta-analysis by Cornelissen et al.3 concluded that regular
person working at 60% of their maximal power output (120 W) aerobic exercise significantly decreases daytime but not
could by cycling with a low resistance (for example, 1 kg) on a night-time ambulatory BP of normotensive adults.
cycle ergometer but with a sprinting pedal cadence (for example,
120 revolutions per minute). So their power output would only The effect of one bout of resistance exercise on office BP and ABP
be 60% of their maximal power output (120 W) but they would
Resistance exercise, often termed dynamic resistance exercise, is
be sprinting. So currently, some interval sprinting exercise
usually performed by lifting weights or by performing exercise on
programmes would not be classified as ‘high-intensity’ exercise.
resistance machines. The weight-training protocols used have
It is not clear what is more important; exercising quickly (for
typically involved around eight different exercises, with 8–12
example, sprinting) or exercising at a high intensity (for example,
repetitions, repeated three times, each exercise. The individual
485% of maximal power output). Randomized trials have shown
exercises have typically involved upper arm, abdominal and leg
that high-sprint/low-resistance stationary cycle ergometer exercise
muscles. In studies using one bout of resistance exercise the
results in significant increases in aerobic fitness and muscle mass,
session has typically lasted between 30 and 60 min, and in regular
and significant decreases in body fat, visceral fat and insulin
resistance exercise trials this type of session is repeated 2–3 times
resistance,6 however, the effect of high sprint/low-resistance
per week for months. Dynamic resistance exercise involves
exercise on BP of hypertensive individuals does not appear to
moving joints and muscle against an opposing force, whereas
have been examined.
isometric resistance exercise is performed by contracting muscles
without joint or muscle movement. Only two studies have
The effect of one bout of aerobic exercise on office BP examined the effect of one bout of dynamic resistance
The effects of one bout of aerobic exercise on the BP of exercise on the office BP of hypertensive individuals and a small
hypertensive individuals has typically been investigated by exercise-hypotension effect has been documented7 (Table 1).
exercising individuals who have been mostly stage 1 hypertensive Three studies have examined the effect of one bout of dynamic

Journal of Human Hypertension (2016), 1 – 8 © 2016 Macmillan Publishers Limited, part of Springer Nature.
 Exercise and hypertension
YN Boutcher and SH Boutcher
3
Table 1. Summary of meta-analyses and reviews examining the effect of one bout and regular aerobic and resistance exercise on office BP and ABP
of hypertensive adults

Study design Findings

One bout of aerobic exercise

Office BP
Gomes et al.7 Review: 8 studies, 107 participants ⇩SBP and ⇩DBP up to 2 h post exercise
ABP
Gomes et al.7 Review: 18 studies, 489 participants ⇩SBP and ⇩DBP from 1 to 24 h post exercise

Regular aerobic exercise

Office BP
Cornelissen and Smart2 Meta-analysis: 26 trials, 585 participants ⇩SBP of 8.3 mm Hg and ⇩5.2 mm Hg DBP
ABP
Cornelissen et al.3 Meta-analysis: 6 trials, 147 participants ⇩Daytime SBP of 3.8 mm Hg and 3.0 mm Hg DBP

One bout of dynamic resistance exercise

Office BP
Gomes et al.7 Review: 2 studies, 27 participants ⇩ SBP and DBP up to 1 h post exercise
ABP
Gomes et al. 7
Review: 3 studies, 45 participants ⇩Daytime SBP and ⇩DBP from 1 to 10 h post exercise

Regular dynamic resistance exercise

Office BP
Cornelissen and Smart2 Meta-analysis: 4 trials, 58 participants ⇧SBP of .47 mm Hg and ⇩1 mm Hg DBP
ABP
Cardoso et al.8 Review: 2 trials, 65 participants ⇔ Daytime systolic and diastolic ABP

Regular isometric resistance exercise

Office BP
Carlson et al.9 Meta-analysis: 3 trials, 32 participants ⇩SBP of 4.31 mm Hg and ⇩5.48 mm Hg DBP
Abbreviations: ABP, ambulatory blood pressure; BP, blood pressure; DBP, diastolic blood pressure; SBP, systolic blood pressure. Note: ⇧ increased; ⇩ decreased;
⇔ no change.

resistance exercise on the ABP of hypertensive adults. For 6.77 mm Hg and diastolic BP by 3.96 mm Hg (Table 1). However,
example, Hardy and Tucker9 administered a resistance only three of the studies included in the meta-analysis
programme to hypertensive adults and found a small hypotensive examined hypertensive patients, whereas the other studies
effect on systolic BP lasting 1 h after dynamic resistance exercise. involved normotensive individuals. The hypertensive patients
Similar results for both systolic and diastolic ABP were found recorded a smaller reduction in exercise-induced systolic BP with
by Moraes et al.10 In contrast, Melo et al.11 administered one a 4.31 mm Hg decrease and a slightly greater decrease in diastolic
bout of dynamic resistance exercise to hypertensive males and BP of 5.48 mm Hg (Table 1). Similar to regular dynamic resistance
found a large hypotensive effect lasting up to 10 h. Thus, three exercise more studies need to be conducted in this area using ABP
studies have found that one bout of dynamic resistance exercise to monitor BP change.
reduces daytime ABP of hypertensive adults. Studies examining In summary, office BP and ABP of hypertensive individuals, who
the effect of one bout of isometric resistance exercise on the office have been mostly stage 1 hypertensive, have typically been
BP or ABP of hypertensive individuals do not appear to have been reduced after one bout of aerobic exercise and after participation
carried out. in regular aerobic exercise performed at an intensity of between
40 and 70% of V_ O2max (Table 1). Aerobic exercise intensity does
The effects of regular dynamic resistance exercise on office BP and not appear to have an effect on the BP response of hypertensive
ABP adults. One bout of dynamic resistance exercise (weights) has
been found to have a small but significant reduction of office
Meta-analysis has indicated that regular dynamic resistance
BP and ABP of hypertensive individuals (Table 1). Regular
exercise does not influence office systolic BP of hypertensive
participation in dynamic resistance exercise has been found to
individuals but results in a small reduction in diastolic BP2
have a minimal effect on the office BP and ABP of hypertensive
(Table 1). Similarly, regular dynamic resistance exercise does not
individuals (Table 1). The effect of one bout of isometric resistance
lower the ABP of hypertensive individuals7 (Table 1). Also, similar
exercise on office BP and ABP does not appear to have been
to aerobic exercise, resistance exercise intensity does not appear
examined. Participation in regular isometric resistance exercise
to impact on BP response. The number of studies that have
has a large lowering effect on the office BP of hypertensive
examined the effect of regular dynamic resistance exercise on the
individuals. The number of studies that have examined the effect
office BP and ABP of hypertensive adults, however, is minimal, and
of dynamic and isometric resistance exercise on the BP of
more studies need to be conducted in this area.
hypertensive adults, however, is minimal. One bout of aerobic
exercise and participation in regular aerobic exercise, varying at an
The effects of regular isometric resistance exercise on office BP intensity between 40 and 70% of V_ O2max, have been found to
With regard to regular isometric resistance exercise Carlson et al.12 have a similar influence on the office BP and ABP of hypertensive
conducted a meta-analysis with nine trials and concluded individuals. Resistance exercise intensity also does not appear to
that isometric resistance exercise, carried out for more than 1 h affect BP in the small number of studies published so far. However,
per week for at least 4 weeks, reduced office systolic BP by as discussed below, exercising at an intensity 470%

© 2016 Macmillan Publishers Limited, part of Springer Nature. Journal of Human Hypertension (2016), 1 – 8
 Exercise and hypertension
YN Boutcher and SH Boutcher
4
of V_ O2max, has produced a hypotensive effect in hypertensive women maintained a significant reduction in systolic and diastolic
individuals. BP for 13 h following the 75% exercise compared with 4 h after
the 50% intensity. Thus, both 50 and 75% exercise intensities
The optimal aerobic exercise intensity required to reduce BP of resulted in a significant reduction in BP of hypertensive men and
hypertensive individuals women, however, the 75% intensity produced a larger and longer-
Concerning the optimal aerobic exercise intensity for BP lasting BP reduction (Figure 1). Thus, exercising at a slightly higher
reduction, results of research conducted in the 1990s involving exercise intensity (75% of V_ O2max) produced greater BP reduction
one bout of exercise and hypertensive populations has indicated compared with previous studies using intensities between 40 and
that higher, compared with lower aerobic exercise intensity, had 70% of V_ O2max. Consequently, exercising at an exercise intensity
no greater post-exercise BP reduction.13 However, prior research of 75% of V_ O2max and above also appears to produce an exercise
has typically used only moderate-intensity aerobic exercise. For hypotensive effect in hypertensive individuals. Other studies have
example, Pescatello et al.13 had six hypertensive men perform confirmed this high-intensity effect. For example, Eicher et al.15
30 min of stationary cycling exercise at either 40 or 70% of V_ O2max exposed 45 males, possessing elevated ambulatory BP, to low-
on separate days. No intensity effect was found as both intensities (40% V_ O2peak), moderate- (60% V_ O2peak) and high-intensity (100%
produced an average systolic and diastolic BP reduction of 5 and V_ O2peak) stationary cycle exercise for 45 min. Systolic and diastolic
8 mm Hg, respectively, over a 24 h period. Quinn,14 however, ABP was significantly decreased after the high-intensity exercise,
monitored ABP of hypertensive individuals after a bout of carried out to voluntary exhaustion, compared with the low- and
treadmill running at two differing intensities (50% versus 75%
moderate-intensity exercise bouts. Similar results were found by
V_ O2max). In contrast to prior findings, results showed that the BP
de Morais et al.16 who examined the effects of high- (69% V_ O2peak)
reduction following one bout of aerobic exercise was intensity
dependent. It was found that higher-intensity exercise produced and maximal (100% V_ O2peak)-intensity cycle ergometer exercise
greater BP benefits whereby the hypertensive men and women on 24 h ABP response in 10 type 2 diabetic adults with
averaged a 4 and 9 mm Hg decrease in systolic BP and a 5 and prehypertension. Compared with a control group only the
7 mm Hg decrease in diastolic BP for the 50% and 75% exercise maximal-intensity exercise bout brought about ABP reduction
intensities, respectively.14 The hypertensive men (Figure 1) and that lasted for 8 h after exercise and during sleep. Lima et al.17 had
11 type 2 diabetic patients perform one bout of cycle ergometer
exercise for 20 min at either 63 or 74% V_ O2peak. Both exercise
Control intensities resulted in reduced systolic BP, however, diastolic
165 50%
BP and mean arterial pressure were only reduced after higher-
75%
intensity exercise. Although more research needs to be done on
Systolic blood pressure (mmHg)

160
the intensity issue these results indicate that compared with
155 low-intensity exercise, exercising at an intensity at or above 74%
150 V_ O2max results in significant hypotension effects in hypertensive
and pre-hypertensive individuals.
145

140 The effect of one bout of HIIE and regular training on office BP and
ABP
135 HIIE (one bout of high-intensity exercise) is typically performed at
#
130 * an exercise intensity of 75% of V_ O2max and above. HIIE protocols
*
have varied considerably but typically involve repeated brief
125 sprinting (anaerobic exercise) or high-intensity aerobic exercise
0 1 3 6 12 24
immediately followed by low-intensity exercise or rest. The length
Time (hrs)
of both the exercise and recovery period has varied from 6 s to 4
Control min.6 Typically, HIIE is performed on a stationary cycle ergometer
100
50% or a treadmill at an intensity between 75 and 100% of V_ O2max. A
Diastolic blood pressure (mmHg)

98 small number of studies have studied hypertensive adults

75%
96 although a number of studies have examined adolescents, young
94 men and women, older individuals and a number of patient
92
groups. The most utilized protocol in past research has been the
Wingate test, which consists of 30 s of all-out sprint with a hard
90
resistance. Insight into skeletal muscle adaptations to HIIT
88 (high-intensity exercise training) has mainly been achieved using
86 this type of exercise, however, as this protocol is extremely hard
84 participants have to be highly motivated to tolerate the resulting
* # discomfiture. Other less-demanding HIIT protocols have also been
82
* utilized. For example, an 8 s cycle sprint followed by 12 s of
80 low-intensity cycling for a period of 20 min has shown to bring
0 1 3 6 12 24
about a number of body composition and metabolic changes.18–20
Time (hrs)
The effect of high-sprint/low-resistance versions of HIIT on the BP
Figure 1. Twenty-four hour systolic and diastolic ABP response of of hypertensive individuals does not appear to have been carried
hypertensive men following the exercise sessions as opposed to the out. The majority of HIIT protocols examining BP have typically
control session. Values are means+s.d. *Both the 50 and 75% V̇ O2max involved a longer exercise bout (2–4 min) at 70–80% of V_ O2max
exercise intensities are significantly lower than the control value at
the same time point, P o0.05. #The 75% V̇ O2max intensity is interspersed with rest period periods from 2 to 3 min.6 The results
significantly lower than the control at the same time point, of studies examining the effect of HIIE and HIIT on resting office BP
Po0.05 (adapted from Quinn14). and ABP of hypertensive individuals are summarized in Table 2.

Journal of Human Hypertension (2016), 1 – 8 © 2016 Macmillan Publishers Limited, part of Springer Nature.
 Exercise and hypertension
YN Boutcher and SH Boutcher
5
Table 2. Results of studies examining the effect of one bout of HIIE and participation in regular HIIT on office BP and ABP of hypertensive individuals

Study Systolic BP Diastolic BP Other Treated/ Design Sample Type of HIIE/ Length of exercise Exercise intensity V̇ O2max/
(mm Hg) (mm Hg) measures untreated sizea HIIT bout/intervention (% V̇ O2max/peak) peakincrease

HIIE
Office BP
Tomszak NR NR ⇩MAP T NC 9/0/0 4 × 4 min/ 28 min 85% —
et al.21 (8 mm Hg) 3 min R, T
da Cunha ⇩16 ⇩8 NA T NC 11/0/0 15 × 1 min/ 45 min 75% —
et al.22 2 min R, T
ABP
Ciolac ⇩2.8 ⇔ NA T NC 26/26/0 1 min/2 min 45 min 70% —
et al.23 R, T

HIIT
Office BP
Gunjal ⇩12 ⇩8 ⇩VR U NC 30/0/0 3 × 3–4 min/ 12 weeks 75–80% NA
et al.24 4 min R, T
Mohr ⇩6 ⇔ NA U C 21/21/ 6–10 × 30 s/ 15 weeks All-out sprint NA
et al.25 20 2 min R, S
Nemoto ⇩10 ⇩5 NA U C 12/10/ 5 × 3 min/ 20 weeks 70% ⇧9%
et al.26 10 3 min R, T, W
Parpa ⇩7 ⇩4 ⇧HRV T NC 14/0/0 6 × 2 min/ 12 weeks 70–80% NA
et al.27 2 min R, T
Tjonna ⇩9 ⇩6 ⇧EF, ⇩IR, U NC 42/51/0 4 × 4 min/ 16 weeks 80% ⇧35%
et al.28 ⇧MB 3 min R, T
Munk ⇔ ⇩4 ⇧EF, ⇩IN T C 20/20 4 × 4 min/ 24 weeks 70–80% ⇧17%
et al.29 3 min R, T/C
Rognmo ⇔ ⇔ ⇩AS, ⇧EF, U NC 8/9/0 4 × 4 min/ 10 weeks 80–90% ⇧18%
et al.30 ⇩IR 3 min R, T
⇔ ⇔ NA T NC 7/7/0 7–8 × 2 min/ 16 weeks 80–85% ⇧10%
Warburton 2 min R, T, C
et al.31
Wisloff ⇔ ⇔ ⇧EF, ⇧MB T C 9/9/9 4 × 4 min/ 12 weeks 85% ⇧46%
et al.32 3 min R, T
ABP
Guimaraes ⇩2 ⇩2 ⇩AS T C 26/26/ 13 × 1 min/ 16 weeks 80–90% NA
et al.33 13 2 min R, T
Molmen- ⇩12 ⇩8 ⇧EF, ⇩VR U C 31/28/ 4 × 4 min/ 12 weeks 85–90% ⇧15%
Hansen et al.34 29 3 min R, T
Abbreviations: ABP, ambulatory blood pressure; AS, arterial stiffness; BP, blood pressure; C, control group; C, stationary cycle; EF, endothelial function; HIIE,
high-intensity intermittent exercise; HIIT, high-intensity intermittent training; IN, inflammation; IR, insulin resistance; MAP, mean arterial pressure; MB,
mitochondrial biogenesis; NA, not assessed; NR, not reported; R, recovery; S, swimming; T, treadmill; T, treated with blood pressure medication; U, untreated;
UC, no control group; VR, vascular resistance; W, walking. Note: ⇧ increased; ⇩ decreased; ⇔ no change. aSample size is reported as follows: number of
participants in a HIIE or HIIT group; a moderate continuous aerobic exercise group; and a non-exercise control group.

The effects of one bout of HIIE on office BP by 2 min of less-intense exercise at 50% of heart rate reserve for a
Two studies have examined the effect of HIIE on the office BP of total time of 45 min. Continuous exercise involved walking or
hypertensive individuals. Nine hypertensive patients were running on a treadmill at 60% of heart rate reserve for 47 min.
allocated to a HIIE group,21 which consisted of a warm-up, Following both bouts of exercise, 24 h systolic ABP was reduced
followed by a 4 min bout of treadmill exercise at 95% of peak by 2.8 mm Hg in the HIIE group and by 2.6 mm Hg in the
heart rate, followed by 3 min of low-intensity exercise. Participants continuous group (Table 2). A nonsignificant trend for a reduction
performed four bouts of high-intensity exercise with four 3 min in diastolic ABP was found for the HIIE group. Thus, HIIE and
recovery periods. Following exercise, office mean arterial BP was continuous aerobic exercise resulted in a moderate reduction in
significantly reduced by 8 mm Hg (Table 2). da Cunha et al.22 also 24 h systolic ABP in treated hypertensive individuals.
had 11 hypertensive patients perform one bout of HIIE that
consisted of 1 min of running at 75% of heart rate reserve The effects of HIIT on office BP
followed by 2 min of easier running at 56% of heart rate reserve Examining office BP, Gunjal et al.24 studied the effects of 12 weeks
for 45 min. Following exercise, office systolic and diastolic BP was of HIIT performed on a treadmill on the office BP of 30
significantly reduced (Table 2). hypertensive patients (Table 2). HIIT involved 3–4 min intervals
performed at 80–85% of maximal heart rate, interspaced by 4 min
The effects of one bout of HIIE on ABP active recovery, at 60–70% of maximal heart rate. After 12 weeks,
Ciolac et al.23 have compared the effect of one bout of HIIE and systolic BP decreased by 12 and 8 mm Hg for the HIIT group
continuous aerobic exercise on the ABP of hypertensive (Table 2) and vascular resistance was also significantly reduced. No
individuals. In this study, 52 hypertensive patients were control group was included in the study design. The effects of
randomized to either an HIIE or moderate intensity, continuous, 15 weeks of either HIIT swimming or moderate continuous
aerobic exercise group. HIIE consisted of a warm-up, followed by swimming on the office BP of 21 moderately hypertensive,
1 min of treadmill exercise at 80% of heart rate reserve, followed premenopausal women has also been examined.25 HIIT involved

© 2016 Macmillan Publishers Limited, part of Springer Nature. Journal of Human Hypertension (2016), 1 – 8
 Exercise and hypertension
YN Boutcher and SH Boutcher
6
6–10, 30 s all-out swimming sprints, interspaced by 2 min easy between exercise bouts for a total time of 38 min. Continuous
swimming recovery, whereas continuous swimming involved an training involved walking or running on a treadmill at 70% of
hour of exercise at a moderate intensity. After 15 weeks, systolic maximal heart rate for 47 min. Impressively, after 12 weeks of
BP decreased by 6 and 4 mm Hg for the HIIT and continuous exercise, office systolic ABP was reduced by 12 mm Hg in the HIIT
swimming groups (Table 2). No effect on diastolic BP was found. group and by 4.5 mm Hg in the continuous group. Twenty-four
Systolic BP reduction was similar for both groups, however, HIIT hour ABP was reduced by 8 mm Hg in the HIIT group and by
involved significantly less time and swimming distance. Nemoto 3.5 mm Hg in the continuous exercise group (Figure 2). Reduced
et al.26 had 12 middle-aged and older men and women perform vascular resistance and enhanced flow-mediated dilation were
5 months of high-intensity walking that consisted of five or more found only in the HIIT group. Authors concluded that the BP-
sets of 3 min low-intensity at 40% of V_ O2peak followed by a 3 min reducing effect of exercise in essential hypertension is intensity
high-intensity bout of walking above 70% of V_ O2peak, repeated dependent and that HIIT is an effective method to lower BP,
four times per week, for 5 months. Another two groups acted as a increase aerobic fitness and decrease vascular resistance. The
control and a low-intensity walking group. High-intensity, much greater lowering of ABP after HIIT found in the
compared with low-intensity walking, resulted in a significant Molmen-Hansen et al.34 compared with the Guimaraes et al.33
drop in office systolic BP and a 9% increase in aerobic fitness study is likely explained by the BP medication status of their
(Table 2). hypertensive patients. In the study by Guimaraes et al.33, patients’
Parpa et al.27 exposed one group of 14 type 2 diabetic BP was normalized using BP medication so their average daily
individuals to 12 weeks of 30 min of HIIT, for four times per week. systolic and diastolic BP was 125 and 80 mm Hg. In contrast, the
High-intensity treadmill running consisted of six, 2 min bouts of patients in the study by Molmen-Hansen et al.34 were free of BP
exercise performed at 80–90% of maximal heart rate, separated by medication resulting in a daily systolic and diastolic BP of 153 and
six 2 min easy bouts of exercise performed at 50–60% maximal 93 mm Hg. As more significant reductions in BP have been
heart rate. High-intensity treadmill exercise training resulted in a observed following exercise training in patients with high initial
significant drop in office systolic and diastolic BP and a 9% resting BP it is likely that medicating hypertensive patients will
increase in heart rate variability (Table 2). Tjonna et al.28 also deflate the exercise-induced BP response. Also the finding that
examined office BP (Table 2) by randomizing 32 metabolic HIIT only reduced evening ABP is the opposite to that found by
syndrome patients to either moderate continuous exercise or Cornelissen et al.3 who examined the effect of regular aerobic
aerobic interval training, three times per week, for 16 weeks. exercise on 24 ABP and concluded that daytime but not
High-intensity treadmill running consisted of four, 4 min bouts of night-time ambulatory BP of normotensive adults was reduced.
exercise performed at 80–90% of maximal heart rate, separated by Some studies, however, similar to the results of Molmen-Hansen
four 3 min easy bouts of exercise performed at 50–60% maximal et al.34, have found that higher intensity continuous aerobic
heart rate intensity. The two exercise programmes were equally as exercise resulted in significantly greater night-time compared with
effective at lowering office systolic and diastolic BP but HIIT,
compared with continuous exercise, resulted in a greater increase 160 Baseline Follow-up
in aerobic fitness and also significantly enhanced endothelial
function, insulin signalling and skeletal muscle mitochondrial *
biogenesis. 155 *
Systolic ABP (mmHg)

As shown in Table 2 not all HIIT studies have produced a

significant BP-lowering effect.29–32 The majority of these studies
150
used hypertensive individuals on BP medication, which
normalized their resting BP,29,31,32 which may explain their lack
of exercise-induced hypotension. Despite not lowering their office 145
BP response to 10–24 weeks of HIIT, however, all HIIT groups
increased aerobic fitness, with some groups recording improved
endothelial function,29,32 attenuated inflammation29 and 140
enhanced mitochondrial biogenesis32 (Table 2).
135
The effects of HIIT on ABP HIIT MIT C
With regard to ABP, Guimaraes et al.33 randomized 65 hyperten- 100
Baseline Follow-up
sive patients to either an HIIT, a moderate-intensity continuous
aerobic exercise, or a control group (Table 2). HIIT was performed 95 *
for 40 min on a treadmill with the intensity alternating between *
Diastolic ABP (mmHg)

50% (2 min) and 80% (1 min) of heart rate reserve. This protocol
90
was repeated three times per week for 16 weeks. Continuous
exercise training involved running on a treadmill at 60% of heart
rate reserve for 40 min, three times per week, for 16 weeks. 85
Following 16 weeks of exercise training ABP was significantly
reduced only in participants possessing higher resting BP values 80
independent of exercise training modality. Arterial stiffness,
however, was reduced in the HIIT group only. Authors concluded 75
that HIIT and continuous exercise training were both beneficial for
BP control in treated hypertensives but only HIIT reduced arterial 70
stiffness. Molmen-Hansen et al.34 also examined the effect of HIIT MIT C
HIIT on the ABP of hypertensive adults by randomizing 88 Figure 2. ABP during 24 h displayed as mean value at baseline and
hypertensive patients to either an HIIT or moderate intensity follow-up in the three training groups: aerobic interval group (HIIT);
continuous aerobic exercise training group (Table 2). HIIT moderate-intensity group (MIT); and control group (C). Values are
consisted of a warm-up followed by 4 min of treadmill exercise means+s.d. *Po 0.05 between HIIT and MIT in blood pressure
at 90–95% of maximal heart rate with 3 min of active pause reduction (adapted from Molmen-Hansen et al.34).

Journal of Human Hypertension (2016), 1 – 8 © 2016 Macmillan Publishers Limited, part of Springer Nature.
 Exercise and hypertension
YN Boutcher and SH Boutcher
7
daytime ambulatory BP in hypertensive16 and normotensive regimens. Thus, when exercising on a treadmill, speed, gradient,
individuals.35 Therefore, more research examining the effect of heart rate and rating of perceived exertion should be reported.
exercise intensity and daytime and night-time ambulatory BP When exercising on a stationary cycle ergometer, pedal rate
response of hypertensive and normotensive individuals needs to (revolutions per minute), resistance (kg), watts, heart rate and
performed. rating of perceived exertion should be included. Also the possible
differing effects of HIIE and HIIT on the BP of medicated and
SUMMARY non-medicated hypertensive individuals needs to be clarified.
More studies examining female hypertensive individuals are also
Two uncontrolled studies have shown that HIIE (one bout of
required. Finally, studies showing that HIIE- and HIIT-induced BP
exercise) has a moderately large lowering effect on office BP
reduction results in reduced cardiovascular events associated with
of hypertensive individuals. One other uncontrolled study used
ABP but found a small BP-lowering effect. The lack of a control hypertension4 should be completed. This review was limited to
group in all three studies makes results difficult to interpret so hypertensive individuals and the effects of exercise on clinical BP
future studies, preferably using ABP assessment, containing a is likely to be different in normotensive and pre-hypertensive
control group, need to be carried out. More studies have individuals as cardiovascular haemodynamics are altered in the
examined the effect of HIIT (regular bouts of exercise) on office hypertensive state.
BP and results have generally indicated a moderate lowering
effect on office BP. Again the majority of studies did not use a
control group making results difficult to interpret. Two stronger CONCLUSIONS
designed studies examined ABP of hypertensive individuals after Emerging evidence indicates that exercise performed at an
HIIT and showed a small and a large ABP-lowering effect. The intensity 470% of V_ O2max may have an important role in the
effect of HIIT on both office BP and ABP, however, appears to be control of hypertension. Both HIIT and regular aerobic exercise
medication dependent with untreated hypertensive individuals have been shown to reduce the BP of hypertensive individuals,
displaying greater decreases compared with their treated however, HIIT has been shown to bring about greater adaptations
counterparts. Thus, when medication is taken into account the in physiopathological variables that contribute to the
office BP reduction after HIIT is similar to that occurring after development of hypertension. These effects, together with the
regular aerobic exercise. More well-controlled studies need to be reduced time commitment of HIIT, have important implications for
carried out to confirm this preliminary finding. Compared with the treatment of hypertension.
continuous moderate intensity aerobic exercise, however, HIIT
typically results in greater increases in aerobic fitness in a shorter
period of time and has been shown to have a greater impact on CONFLICT OF INTEREST
arterial stiffness, endothelial function, insulin resistance and The authors declare no conflict of interest.
mitochondrial biogenesis. Because of the minimal number of
studies in this area more research needs to be carried out to
confirm and extend these results. REFERENCES
1 Ostechega Y, Yoon S, Hughes J, Louis T. Hypertension Awareness, Treatment, and
Control: Continued Disparities in Adults—United Sates 2005-2006. No. 3. National
POSSIBLE FACTORS INFLUENCING THE HIGH-INTENSITY Centre for Health Statistics: Hyattsville, MD, USA, 2008, 1–8.
EXERCISE HYPOTENSION EFFECT 2 Cornelissen VA, Smart NA. Exercise training for blood pressure: a systematic
How HIIE and HIIT brings about hypotensive effects is undeter- review and meta-analysis. J Am Heart Assoc 2013; 2(1): e004473.
3 Cornelissen VA, Buys R, Smart NA. Endurance exercise beneficially affects
mined. Factors are likely to be multifactorial and for HIIE could be
ambulatory blood pressure: a systematic review and meta-analysis. J Hypertens
a result of reduced cardiac output, heart rate and vascular
2013; 31(4): 639–648.
resistance.36 For HIIT, influences could also involve a change in 4 Sharman JE, La Gerche A, Coombes JS. Exercise and cardioavscular risk in patients
variables such as increased aerobic fitness37 and decreased insulin with hypertension. Am J Hypertens 2015; 28(2): 147–158.
resistance18 and visceral fat.19 The major direct variable underlying 5 Ciolac EG. High-intensity interval training and hypertension: maximising the
the exercise-induced chronic hypotensive effect appears to be benefits of exercise. Am J Cardiovasc Dis 2012; 2(2): 102–110.
decreased vascular resistance.38 Decreases in arterial stiffness and 6 Boutcher SH. High-intensity intermittent exercise and fat loss. J Obes 2011; 2011:
sympathetic nerve discharge and increases in arterial baroreceptor 868305.
sensitivity are also likely contributors to this decreased vascular 7 Gomes Anunciacao P, Doederlein Polito M. A review on post-exercise hypotension
resistance effect.39 in hypertensive individuals. Arq Bras Cardiol 2011; 96(5): 100–109.
8 Cardosa CG, Gomides RS, Queiroz AC, Pinto LG, da Silveira Lobo, Tinucci T et al.
Acute and chronic effects of aerobic and resistance exercise on ambulatory blood
ISSUES REGARDING THE HIIE- AND HIIT-INDUCED pressure. Clinics 2010; 65(3): 317–325.
9 Hardy DO, Tucker LA. The effects of a single bout of strength training on
HYPOTENSION EFFECT
ambulatory blood pressure in 24 mildly hypertensive men. Am J Health Promot
Large multicentre prospective studies using ABP are needed to 1998; 13: 69–72.
further confirm the HIIE and HIIT hypotensive effect. Also more 10 Moraes MR, Bacurau RF, Ramalho JD, Reis FC, Casarini DE, Chagas JR et al. Increase
research examining the underlying factors influencing the in kinins on post-exercise hypotension in normotensive and hypertensive
hypotensive effect is required. Whether the hypotensive effect, volunteers. Biol Chem 2007; 388(5): 533–543.
reported in training studies, is a true result of HIIT or is a transient 11 Melo CM, Alencar Filho AC, Tinucci T, Mion D, Forjaz CL. Postexercise hypotension
effect of a previous exercise bout must also be considered. The induced by low-intensity resistance exercise in hypertensive women receiving
optimum duration, frequency, intensity and modality of HIIE and captopril. Blood Press Monit 2006; 11: 183–189.
12 Carlson K, Dieberg G, Hess NC, Millar PJ, Smart NA. Isometric exercise training for
HIIT for different hypertensive patient groups (for example, stage 1
blood pressure management: a systematic review and meta-analysis. Mayo Clin
and stage 2) need to be established. In particular, the effectiveness Proc 2014; 89(3): 327–334.
of exercising quickly (for example, sprinting with a low resistance) 13 Pescatello LS, Fargo AE, Leach CN, Scherzer HH. Short-term effect of dynamic
as opposed to exercising at a high intensity (for example, cycling exercise on arterial blood pressure. Circulation 1991; 83: 1557–1561.
less quickly but with a high resistance) needs to be determined. 14 Quinn TJ. Twenty-four hour, ambulatory blood pressure responses
To determine if participants were sprinting or not it is important following acute exercise: impact of exercise intensity. J Hum Hypertens 2000; 14:
for future research to report details regarding their HIIE and HIIT 547–555.

© 2016 Macmillan Publishers Limited, part of Springer Nature. Journal of Human Hypertension (2016), 1 – 8
 Exercise and hypertension
YN Boutcher and SH Boutcher
8
15 Eicher JD, Maresh CM, Tongalis CJ, Thompson PD, Pescatello LS. The 27 Parpa K, Michaelides MA, Brown BS. Effect of high intensity interval training on
additive blood pressure lowering effects of exercise intensity on post-exercise heart rate variability in individuals with type 2 diabetes. J Exer Phys 2009; 12(7):
hypotension. Am Heart J 2010; 160: 513–520. 23–29.
16 de Morais PK, Sales MM, de Almeida JA, Motta-Santos D, de Sousa CV, 28 Tjonna AE, Lee SJ, Rognmo O, Stolen TO, Bye A, Haram PM et al. Aerobic interval
Simoes HG. Effects of aerobic exercise on 24-h ambulatory blood pressure in training versus continuous moderate exercise as a treatment for the metabolic
individuals with type 2 diabetes and prehypertension. J Phys Ther Sci 2015; 27: syndrome: a pilot study. Circulation 2008; 118(4): 346–354.
51–56. 29 Munk PS, Staal EM, Butt NB, Isaksen K, Larsen AI. Aerobic interval training versus
17 Lima LCJ, Assis GV, Hiyane W, Almeida WS, Arsa G, Baldissera V et al. Hypotensive continuous moderate exercise after coronary artery bypass surgery: a randomized
effects of exercise performed around anaerobic threshold in type 2 diabetic study of cardiovascular effects and quality of life. Am Heart J 2009; 158:
patients. Diabetes Res Clin Pract 2008; 81: 216–222. 1031–1037.
18 Trapp EG, Chisholm DJ, Freund J, Boutcher SH. The effects of high-intensity 30 Rognmo O, Hetland E, Helgerud J, Hoff J, Slordahl S. High intensity aerobic
intermittent exercise training on fat loss and fasting insulin levels of interval exercise is superior to moderate intensity exercise for increasing aerobic
young women. Int J Obes 2008; 32(4): 684–691. capacity in patients with coronary artery disease. Eur J Cardiovasc Prev Rehabil
19 Heydari M, Freund J, Boutcher SH. The effect of high-intensity intermittent 2004; 11: 216–222.
exercise on body composition of overweight young males. J Obes 2012; 2012: 31 Warburton DER, McKenzie DC, Haykowsky MJ, Taylor A, Shoemaker P,
480467. Ignaszewski AP et al. Effectiveness of high-intensity interval training for the
20 Dunn SL, Siu W, Freund J, Boutcher SH. The effect of a lifestyle intervention rehabilitation of patients with coronary artery disease. Am J Cardiol 2005; 95:
on metabolic health in young women. Diabetes Metab Syndr Obes 2014; 7: 1080–1084.
437–444. 32 Wisloff U, Stoylen A, Loennechen JP, Bruvold M, Rognmo O, Haram PM et al.
21 Tomszak CR, Thompson RB, Paterson I, Schulte F, Cheng-Baron J, Haennel J et al. Superior cardiovascular effect of aerobic interval training versus moderate
Effect of acute high-intensity interval exercise on postexercise biventricular continuous training in heart failure patients: a randomized study. Circulation 2007;
function in mild heart failure. J Appl Physiol 2011; 110: 98–106. 115(24): 3086–3094.
22 da Cunha GA, Santos Rios AC, Moreno JR, Braga PL, Campbel CSG, Simoes HG 33 Guimaraes GV, Ciolac EG, Carvalho VO, D’Avila M, Bortolotto LA, Bocchi EA. Effects
et al. Post-exercise hypotension in hypertensive individuals submitted to aerobic of continuous vs interval exercise training on blood pressure and arterial stiffness
exercises of alternated intensities and constant intensity exercise. Rev Bras Med in treated hypertension. Hypertens Res 2010; 33: 627–633.
Esporte 2006; 12(6): 281–284. 34 Molmen-Hansen HE, Stolen T, Tjonna AE, Aamot IL, Ekeberg IS, Tyldum GA et al.
23 Ciolac EG, Guimaraes GV, D’Avila VM, Bortolotto LA, Doria EL, Bocchi EA. Acute Aerobic interval training reduces blood pressure and improves myocardial
effects of continuous and interval aerobic exercise on 24-h ambulatory blood function in hypertensive patients. Eur J Prev Cardiol 2011; 19(2): 151–160.
pressure in long-term-treated hypertensive patients. Int J Cardiol 2009; 133: 35 Jones H, George K, Edwards B, Atkinson G. Exercise intensity and blood pressure
381–387. during sleep. Am Heart J 2009; 30(2): 94–99.
24 Gunjal S, Sinde N, Kazi A, Khatri S. Effect of aerobic interval training on blood 36 MacDonald JR. Potential causes, mechansims, and implications of post exercise
pressure and myocardial function in hypertensive patients. Int J Pharma Sci Invest hypotension. J Hum Hypertens 2002; 6: 225–226.
2013; 2(6): 27–31. 37 Milanovic Z, Sporis G, Weston M. Effectiveness of high-intensity interval training
25 Mohr M, Nordsborg NB, Lindenskov A, Steinholm H, Nielson HP, Mortensen J et al. (HIT) and continuous training for V_ O2max improvements: a systematic review and
High-intensity intermittent swimming improves cardiovascular health meta-analysis of controlled trials. Sports Med 2015; 61: 233–239.
status for women with mild hypertension. Biomed Res Int 2014; 2014: 38 Halliwill JR, Taylor JA, Eckberg DL. Impaired sympathetic vascular regulation in
728289. humans after acute dynamic exercise. J Physiol 1996; 495(Pt 1): 279–288.
26 Nemoto K, Gen-Ho H, Masuki S, Okazaki K, Nose H. Effects of high-intensity 39 Halliwill JR, Buck TM, Lacewell AN, Romero SA. Postexercise hypotension and
interval walking training on physical fitness in middle-aged older people. Mayo sustained postexercise vasodilatation: what happens after we exercise. Exp Physiol
Clin Proc 2007; 82(7): 803–811. 2013; 98: 7–18.

Journal of Human Hypertension (2016), 1 – 8 © 2016 Macmillan Publishers Limited, part of Springer Nature.