Journal of Human Hypertension (2014) 28, 367–371

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ORIGINAL ARTICLE
The impact of aerobic exercise on blood pressure variability
N Pagonas1, F Dimeo2, F Bauer1, F Seibert1, F Kiziler1, W Zidek1 and TH Westhoff1

There is increasing evidence that blood pressure variability (BPV, variation of blood pressure over time) constitutes a strong
and independent marker of cardiovascular risk. The all-cause mortality is 450% greater in subjects with a standard deviation
of inter-visit blood pressure 45 mm Hg. Regular aerobic exercise reduces blood pressure and is recommended by current
hypertension guidelines as a basic lifestyle modification. It remains elusive, however, whether aerobic exercise is able to reduce BPV
as well. In total, 72 hypertensive subjects were randomly assigned to an 8–12-week treadmill exercise program (target lactate
2.0±0.5 mmol l  1) or sedentary control. Blood pressure was measured by 24 h-ambulatory blood pressure monitoring (ABP). Two
aspects of BPV were assessed: the variability of ABP and the variability of blood pressure on exertion. The coefficient of variation
(CV) was used as a statistical measure of BPV. The CV of systolic daytime ABP was defined as primary outcome. The exercise
program significantly decreased systolic and diastolic daytime ABP by 6.2±10.2 mm Hg (Po0.01) and 3.0±6.3 mm Hg (P ¼ 0.04),
respectively. Moreover, it reduced blood pressure on exertion and increased physical performance (Po0.05 each). Exercise
had no impact, however, on the CV of daytime (10.2±2.7 vs. 9.8±2.6%, P ¼ 0.30) and night-time systolic (8.9±3.2 vs. 10.5±4.1%,
P ¼ 0.10) and diastolic ABP (daytime 11.5±3.3 vs. 11.5±3.1%, night-time 12.0±4.3 vs. 13.8±5.2%; P40.05 each). Regular aerobic
exercise is a helpful adjunct to control blood pressure in hypertension, but it has no effect on 24 h- BPV, an independent predictor
of cardiovascular risk.

Journal of Human Hypertension (2014) 28, 367–371; doi:10.1038/jhh.2013.121; published online 28 November 2013
Keywords: blood pressure variability; exercise; ambulatory blood pressure monitoring

INTRODUCTION guidelines.4,9 Hypertensives are encouraged to ‘engage in aerobic

Hypertension is a cardiovascular risk factor of outstanding exercise on a regular basis, such as walking, jogging or swimming
importance and accounts for B50% of vascular risk.1 For for 30–45 min daily’.4 A recent meta-analysis indicated a mean
decades the individual’s mean or ‘usual’ blood pressure was reduction of 8 mm Hg systolic and 5 mm Hg diastolic by regular
regarded as the main determinant of blood pressure-related exercise in patients with hypertension.10 Beyond resting and ABP,
vascular risk (‘usual blood pressure hypothesis’). In recent years exercise reduces blood pressure on exertion.11 Several mechanisms,
there has been increasing evidence that the variability of to date not completely identified, are responsible for the blood
systolic blood pressure constitutes an additional independent pressure lowering effect of exercise.12–14 It remains elusive,
cardiovascular risk factor.2,3 A recent example was provided by the however, whether aerobic exercise is able to reduce BPV as well.
data obtained in the general population of the PAMELA study, in If so, more light would be shed on the beneficial cardiovascular
which blood pressure variability (BPV) showed a positive effects of exercise and physicians could even more motivate their
relationship with the 12-year incidence of cardiovascular patients to engage in sports on a regular basis.
mortality, independently of the 24 h mean blood pressure The present work investigates the impact of an aerobic exercise
values.4 Moreover, it was demonstrated that the risk of all-cause program on BPV in a randomized controlled setting.
mortality was 450% greater in subjects in whom the standard
deviation (s.d.) of the average of a three-visit systolic blood
pressure was X5 mm Hg than in subjects in whom the s.d. was MATERIALS AND METHODS
less than this value.5 In 2010, a post hoc analysis of six studies Design and outcomes
including the ASCOT trial attracted considerable attention: We performed a parallel group randomized controlled trial on the impact
Variability of systolic blood pressure proved to be a strong of an aerobic exercise program on BPV. Participants were randomly
predictor of stroke, independent of mean systolic blood pressure.6 assigned to an exercise program or sedentary control. The primary
Current hypertension guidelines encompass the risk associated outcome was a change in systolic BPV measured as the CV of systolic
with BPV and therefore recommend ambulatory blood pressure daytime ABP. Secondary outcomes were changes in diastolic ABP
(ABP) measurement.7,8 BPV represents the variation of blood variability, BPV on exertion, ABP itself and physical performance.
pressure over time. It can be calculated for various periods (beat-
to-beat, hour-to-hour, day-to-day or over weeks and seasons). BPV Intervention and protocol
can be expressed by different statistical measures, for example, The aerobic exercise program consisted of walking on a treadmill
the coefficient of variation (CV) or s.d. according to an interval-training pattern. Training was performed in the
Regular physical exercise reduces blood pressure and is broadly hospital. Patients were supervised during training by a study nurse and a
recommended by current American and European hypertension physician. The initial duration of training sessions was 30 min. During the

1
Department of Nephrology, Charité–Campus Benjamin Franklin, Berlin, Germany and 2Department of Sports Medicine, Charité–Campus Benjamin Franklin, Berlin, Germany.
Correspondence: Dr TH Westhoff, Department of Nephrology, Charité–Campus Benjamin Franklin, Hindenburgdamm 30, Berlin 12200, Germany.
E-mail: timm.westhoff@charite.de
Received 15 April 2013; revised 6 August 2013; accepted 10 September 2013; published online 28 November 2013
 Exercise and blood pressure variability
N Pagonas et al
368
first week, training consisted of five workloads of 3 min; between ranging from 6–20 with ‘6’ corresponding to a ‘very, very light effort’ and
workloads, patients walked with half-speed for 3 min. Exercise duration ‘20’ corresponding to ‘exhaustion’. Assessment of maximal oxygen uptake
was gradually increased to four times 5 min per day in the second week, is the gold standard for the determination of physical performance.18
three times 8 min per day in the third, three times 10 min per day in the However, validity of results depends on subjects exercising until
fourth and two times 15 min per day in the fifth week. In the sixth and exhaustion. Therefore, we additionally present lactate and heart rate
further weeks, exercise was progressively increased to 30, 32 and 36 min curves. This method does not depend on compliance and allows a reliable
and carried out without interruption. Training sessions were carried out and valid estimation of physical performance.19 Lactate concentration in
three times weekly for 8–12 weeks with a target-lactate concentration of capillary blood was determined at the end of each workload (Ebioplus,
2.0±0.5 mmol l  1 in capillary blood slightly above the aerobic threshold Eppendorf, Hamburg, Germany). Comparison of lactate concentrations and
as described previously.15,16 Subjects were asked to participate for 12 blood pressure on exertion was performed using the data of the individual
weeks and—if not able to schedule the three-times weekly training workloads reached at both baseline and follow-up examination. The
sessions for the whole period—a minimum of 8 weeks. Assessment of follow-up blood pressure measurement and the exercise test in the
24 h-ABP monitoring and physical performance were conducted before training group were conducted within 5 days after the last training session.
and after the observation period. 24 h-ABP monitoring was performed
using Spacelabs 90 207 monitors (Spacelabs, Redmond, WA, USA). The
intervals between single measurements were set to be 20 min during
daytime (0600 h to 2200 h) and 30 min during night-time. Calculation of BPV
We assessed the effect of exercise on two aspects of BPV: First, the
intraindividual systolic and diastolic variability at daytime and night-time
Eligibility criteria and study population ABP. Secondly, the BPV on exertion. The CV of daytime systolic blood
Patients were recruited from our hypertension outpatient clinic and by pressure was the primary endpoint of the trial. The CV was calculated
press announcement. Inclusion criteria were current antihypertensive according to the equation: CV ¼ s.d./mean. BPV on exertion was assessed
treatment with at least one antihypertensive drug and/or office blood by the CV of the systolic and diastolic blood pressure values obtained
pressure X140/90 mm Hg. Exclusion criteria were regular engagement in during the treadmill stress tests.
physical exercise training in the past 4 weeks prior to inclusion in the
study, symptomatic peripheral arterial occlusive disease, aortic insuffi-
ciency or stenosis 4stage I, hypertrophic obstructive cardiomyopathy,
congestive heart failure (4NYHA II), uncontrolled cardiac arrhythmia with Study size calculation
hemodynamic relevance, systolic office BP X180 mm Hg, signs of acute Based on the results of the ASCOT-BPLA trial a decrease of the CV of
ischemia in exercise ECG, change of antihypertensive medication in the systolic blood pressure from 10 to 8% has to be regarded as clinically
past 4 weeks prior to inclusion in the study or during follow-up period. significant, as it reduces the incidence of stroke.20 Our previous work
A total of 87 subjects were assessed for eligibility to participate in the trial. indicated a CV in systolic ABP of 10±3% at baseline.15–17 A sample size of
A total of 72 patients, who met the inclusion criteria, were randomized by 29 per group has 80% power to detect an exercise-induced decrease of CV
lot to either the exercise group (36 patients) or the control group (36 from 10–8% with a s.d. of 3% using a one-sided significance level of 0.05.
patients, Figure 1). A total of three patients in the exercise group and three We estimated the drop-out rate to be 15% leading to an overall sample
in the control group had to be excluded from analysis due to size of 69 patients. For reasons of security we enrolled 72 patients.
discontinuation of the exercise programme (two patients) and protocol
violation in terms of changes in the antihypertensive medication (one
patient in the exercise group and three patients in the control group). The Table 1. Baseline characteristics
attendance rate to the training sessions was 96%. The study population
encompassed 33 patients (16 and 17 in the exercise and control group Exercise Control P-value
respectively) who fulfilled the criteria of resistant hypertension. The blood (n ¼ 36) (n ¼ 36)
pressure-lowering effects of exercise in this part of the population have
been already published.17 Patients’ characteristics including concomitant Female 19 (52.8%) 22 (61.1%) 0.63
diseases and antihypertensive medication are presented in Table 1. The Male 17 (47.2%) 14 (38.9%)
median number of antihypertensive drugs for each patient ranged from Age (years) 65.3 (42–79) 67.7 (43–77) 0.14
1 to 7. The preexisting antihypertensive medication remained unchanged Body mass index (kg m  2) 28.3±4.6 29.5± 4.5 0.26
throughout the study and all patients were repeatedly requested to take
care of an accurate drug intake. Written informed consent was obtained Concomitant diseases
from all participants before inclusion in the study. The study was approved Diabetes mellitus 6 (16.7%) 8 (22.2%) 0.55
by the local ethics committee at the Charité Berlin. Hyperlipidemia 21 (58.3%) 21 (58.3%) 0.81
(Ex-) Smoking 7 (19.4%) 4 (11.1%) 0.51
Family history of 20 (55.5%) 17 (47.2%) 0.77
Assessment of physical performance cardiovascular disease
Assessment of physical performance was carried out by a treadmill stress- Coronary heart disease 2 (5.6%) 4 (11.1%) 0.41
test using a modified Bruce protocol (begin with 3 km h  1, increase of Atrial fibrillation 1 (2.8%) 3 (8.3%) 0.61
speed by 1.4 km h  1 after 3 min, thereafter increase of elevation by 3% at
constant speed) under continuous ECG-monitoring and assessment of Antihypertensive medication
oxygen uptake and CO2 release. In this protocol each workload Number of 3 (1–6) 4 (1–7) 0.21
corresponds to an increase of 25 W for a patient of 75 kg weight. The antihypertensive drugs
level of perceived exertion was assessed by the 15-point Borg scale Beta-blocker 19 (52.8%) 23 (63.9%) 0.47
ACE inhibitor 12 (33.3%) 13 (36.1%) 1.0
Angiotensin receptor 17 (47.2%) 19 (52.8%) 0.81
blocker
Calcium channel blocker 22 (61.1%) 21 (58.3%) 1.0
Aliskiren 5 (13.9%) 4 (11.1%) 1.0
Diuretic 19 (52.8%) 24 (66.7%) 0.34
Other antihypertensive 7 (19.4%) 7 (19.4%) 1.0
drugs
Age and number of antihypertensive drugs are presented as median and
range. Body mass index is presented as mean±s.d. Intergroup differences
were tested by unpaired two-tailed t-test (age, body mass index), Fisher’s
exact test (gender, concomitant diseases, category of antihypertensive
drugs) or Pearson’s w2 test (number of antihypertensive drugs).
Figure 1. Trial profile.

Journal of Human Hypertension (2014) 367 – 371 & 2014 Macmillan Publishers Limited
 Exercise and blood pressure variability
N Pagonas et al
369
Statistical analysis (P ¼ 0.21) and diastolic (P ¼ 0.69) ABP at night-time. The exercise
Numeric data are presented as mean±s.d., number of antihypertensive program led to a significant increase of physical performance by
drugs as median and range. Data were tested for normal distribution by increasing maximal oxygen uptake in the exercise group without
the Kolmogorov–Smirnov test. Intergroup differences at baseline were changes in the control group (Table 3). Accordingly, lactate and
tested by unpaired two-tailed t-tests for numeric parameters. Comparison heart rate curves showed a significant right shift indicating an
of categorical parameters was performed by Fisher’s exact test in case of improvement of physical performance (Figure 2).
dichotomy and by Pearson-w2-test in case of polychotomy. Changes of The exercise program had no impact, however, on the primary
numeric parameters from baseline to follow-up were analyzed using an
analysis of covariance (ANCOVA) model. Previous data indicate that use of outcome, the systolic BPV. The CV of daytime systolic ABP did not
beta blockers and calcium channel blockers have a significant impact on change in response to the exercise program (10.2±2.7 vs.
BPV.21 Therefore, these parameters were included in addition to baseline 9.8±2.6%, P ¼ 0.30). The CV of night-time systolic BP did not
values as covariates in the ANCOVA model. The CV served as statistical differ significantly from baseline to follow-up either (8.9±3.2 vs.
measure for BPV. The CV was calculated as described above. Po0.05 was 10.5±4.1%, P ¼ 0.10). Moreover, exercise did not have significant
regarded significant. Physical performance was analyzed by paired two- effects on daytime and night-time CV of the diastolic ABP (P40.05
tailed t-tests using data of workload levels reached at both baseline and each). There was, however, a statistical trend in the CV of daytime
follow-up treadmill stress-tests. All statistical analysis was done using SPSS diastolic ABP (P ¼ 0.06). This trend resulted from an increase of the
Statistics 19 (SPSS Inc, Chicago, IL, USA). CV in the control group (12.9±3.3 vs. 13.6±3.8%), whereas the CV
in the exercise group remained exactly unchanged (11.5±3.3 vs.
11.5±3.1%). Treadmill stress tests were used to analyze BPV on
RESULTS exertion. Blood pressure values at rest and at the workload levels
At baseline, exercise and control groups showed no significant reached at both baseline and control were included in the
differences in gender, age, number of antihypertensive drugs, analysis. CV of systolic and diastolic blood pressure were
body mass index and concomitant diseases including diabetes unaffected by the exercise program (Table 3, P40.05 each).
mellitus, hyperlipidemia, smoking habits and coronary heart
disease as presented in Table 1. We found no difference in any
parameter of blood pressure and BPV between the groups at DISCUSSION
baseline. The mean follow-up period was 9.6±1.8 weeks in the The present study investigates the effect of regular aerobic
exercise group and 10.0±2.0 weeks in the control group exercise on ambulatory BPV for the first time. Our data confirm
(P ¼ 0.46). Exercise led to a significant reduction of daytime that exercise is a helpful adjunct to reduce blood pressure.
systolic and diastolic ABP (Po0.001 and P ¼ 0.04 respectively, It demonstrates, however, that aerobic exercise is not able to
Table 2). However, exercise did not significantly affect the systolic reduce BPV. Recent meta-analyses revealed an exercise-induced

Table 2. Changes of ABP and BPV from baseline to follow-up

Exercise (n ¼ 36, 3 dropouts) Control (n ¼ 36, 3 dropouts) P-value

Baseline Follow-up Delta Baseline Follow-up Delta

Daytime systolic ABP (mm Hg) 137.9±12.3 131.7±9.4  6.2±10.2 133.1±12.1 135.1±13.2 2.0±9.4 o0.01
Daytime diastolic ABP (mm Hg) 78.1±8.9 75.1±9.1  3.0±6.3 73.8±6.4 74.6±6.9 0.8±4.8 0.04
Night-time systolic ABP (mm Hg) 128.2±14.6 125.9±11.1  2.2±12.4 125.4±13.8 127.2±14.2 1.7±7.7 0.21
Night-time diastolic ABP (mm Hg) 70.6±9.2 68.5±9.3  2.1±7.4 66.9±7.7 66.5±8.3  0.4±5.9 0.69
CV of daytime systolic ABP (%) 10.2±2.7 9.8±2.6  0.4±3.1 11.5±3.1 10.8±3.0  0.7±4.0 0.30
CV of daytime diastolic ABP (%) 11.5±3.3 11.5±3.1 0.1±3.8 12.9±3.3 13.6±3.8 0.7±4.2 0.06
CV of night-time systolic ABP (%) 8.9±3.2 10.5±4.1 1.6±4.0 9.1±3.5 9.3±3.1 0.2±3.7 0.10
CV of night-time diastolic ABP (%) 12.0±4.3 13.8±5.2 1.8±5.6 12.6±4.4 13.4±4.7 0.8±4.2 0.58
Abbreviation: CV, coefficient of variation. Data presented as mean±s.d. Intergroup differences in the changes of parameters from baseline to follow-up were
analyzed using an ANCOVA model adjusted for baseline value, use of beta-blockers and calcium channel blockers. Po0.05 was regarded significant (bold
type). Delta, change of parameter in observation period.

Table 3. Blood pressure and BPV on exertion

Exercise (n ¼ 36, 3 dropouts) Control (n ¼ 36, 3 dropouts) P-value

Baseline Follow-up Delta Baseline Follow-up Delta

1
Maximal oxygen uptake (ml kg min) 24.4±4.6 25.3±4.2 0.9±3.4 22.4±5.1 21.1±5.0  1.4±1.7 0.001
Mean systolic BP on exertion (mm Hg) 175.4±22.1 157.2±17.3  18.2±21.4 171.4±22.5 164.5±20.0  6.7±15.0 0.02
Mean diastolic BP on exertion (mm Hg) 78.7±8.4 71.4 ±7.2  7.3±7.5 77.8±10.4 75.1±10.8  2.7±9.4 0.03
CV of systolic BP on exertion (%) 15.4±7.9 13.0±5.6  2.4±9.1 15.3±5.5 13.7±5.3  1.6±7.1 0.54
CV of diastolic BP on exertion (%) 7.7±4.5 7.3±3.7  0.4 ±4.3 6.5±3.7 8.2±4.1 1.8±5.6 0.21
Abbreviation: CV, coefficient of variation. Data presented as mean±s.d. Intergroup differences in the changes of parameters from baseline to follow-up were
analyzed using an ANCOVA model adjusted for baseline value, use of beta-blockers and calcium channel blockers. Blood pressure (BP) on exertion corresponds
to mean blood pressure of workload levels reached at treadmill stress tests of both baseline and follow. Po0.05 was regarded significant (bold type). Delta,
change of parameter in observation period.

& 2014 Macmillan Publishers Limited Journal of Human Hypertension (2014) 367 – 371
 Exercise and blood pressure variability
N Pagonas et al
370
Exercise Control patients with mild hypertension. In patients with hypertension a
6
8
Pre decrease of the low-frequency variability has been demonstrated,26
whereas no exercise-induced changes have been found in healthy

Lactate (mmol/l)
Lactate (mmol/l)

6 Post
4 subjects.27,28
4 The mechanisms responsible for the blood pressure-lowering
2 effect of exercise are incompletely understood. A reduction of
2
sympathetic tone, however, is reported consistently in the
0 0 * * *
different studies and is regarded as a mechanism of crucial
* * * *
relevance.12–14 This antihypertensive mechanism of exercise is
150 150 therefore partially comparable to the effects of a beta blocker.
Interestingly, recent studies have demonstrated that–in accor-
Heart rate (1/min)
Heart rate (1/min)

dance with our findings on the effects of exercise–beta blockers

100 100 reduce blood pressure without affecting BPV.6,21 In contrast,
calcium channel blockers and diuretics reduce both blood
pressure and BPV.21 This phenomenon is discussed as a
50
* * * * * *
50 potential reason for the reduced potency of beta blockers in
stroke prevention, for example, in the ASCOT trial.6 Does this
20 20 mean that regular exercise is an antihypertensive intervention of
15
the ‘beta blocker type’, potentially evoking a lower reduction of
15
RPE (6-20)
RPE (6-20)

cardiovascular risk than other blood pressure lowering

10 10 approaches? There are three main refutations for this
5 5
hypothesis: first, the exercise-induced reduction of sympathetic
* * * * * * tone does not only affect beta—but also alpha adrenoceptors.
0 0 Second, the reduction of sympathetic tone is only one of various
0 3 6 9 12 15 18 0 3 6 9 12 15 18
Duration of test (min) Duration of test (min)
antihypertensive mechanisms of exercise.15 Finally, regular
exercise reduces cardiovascular risk by a multitude of factors: It
Figure 2. Physical performance in treadmill stress-tests at baseline induces a reduction of weight in obese patients, decreases
and follow-up (post) in exercise and control group. Workload was LDL-cholesterol while increasing HDL-cholesterol, augments
increased every 3 min according to a modified Bruce protocol, as insulin sensitivity and reduces endothelial dysfunction.29 Thus,
described in the text. Data of lactate, heart rate and rate of
perceived exertion (RPE) according to Borg scale corresponds to regular exercise still constitutes an ideal ‘multi-pill’ in
workload levels reached at both examinations. Data is presented as hypertension.
mean±s.d. Differences from baseline to follow-up were analysed by The exact reasons for the lacking effect of exercise on BPV
paired two-tailed t-tests, *Po0.01 was regarded significant. remain elusive. The pharmacological reduction of blood pressure
is usually associated with a baroreflex resetting, which is the basis
for a reduction of BPV.30 It may be speculated that this resetting
does not take place to the same extent in exercise-induced
reduction of blood pressure of B7–8 mm Hg systolic and reduction of blood pressure due to the recurrent episodes of
5 mm Hg diastolic.10,22 In the present study the daytime systolic higher blood pressure during the training. Another possible
ABP was reduced by  6.2±10.2 mm Hg and the diastolic by explanation is an increase in vagal tone. Heart rate variability is
 3.0±6.3 mm Hg. Thus, the present exercise program proved to known to be increased by regular exercise and an increase of
be effective and led to a reduction of blood pressure in the vagal tone with parallel decrease of sympathetic tone is the
anticipated range. Remarkably, the decrease was assessed in ABP preferred explanation for this phenomenon.31 As long as
and not in office blood pressure. The risk of hypertensive antihypertensive medication reduces sympathetic activity, the
cardiovascular complications correlates better with ABP than pre-existing medication in most of the patients in this trial may
with office pressure.7 Apart from its blood pressure-lowering have already exhausted any elbowroom for further reduction
effect, the exercise program proved to be efficient in terms of through exercise training. This may explain the discrepancy
physical performance. Maximal oxygen uptake was higher at to the results from an earlier study in untreated patients, which
follow-up than at baseline. In accordance with the improvement showed a reduction of the beat-to-beat variability measured in
of maximal oxygen uptake, the right-shift of lactate and heart rate periods of 30 s.26 Further studies are needed to assess the effect of
curves indicated an improvement of physical performance exercise on BPV by combining short-term and long-term variability
(Figure 2). parameters and ideally an ambulatory beat-to-beat measurement
In contrast to the improvement of physical performance and over 24 h.
the reduction of blood pressure, the exercise program failed to The present study is limited by the lack of data on visit-to-visit
affect the variability of blood pressure. We analyzed two different variability. As described above, this parameter is a valuable
aspects of BPV: The intraindividual systolic and diastolic variability additional marker of BPV with a documented impact on
of ABP at daytime and night-time and the BPV on exertion. cardiovascular risk.5 Is it possible that the beta blocker therapy
Exercise did not have a significant effect on any of these taken by a part of the study population prevented an effect of
parameters. As shown by the study size calculation, the trial was exercise on BPV? This possibility cannot finally be excluded but
powered sufficiently to investigate the impact of exercise on BPV. there are four reasons why this potential reason is probably not of
There is solid evidence that the variability of ABP constitutes essential relevance: first, only about half of the participants in the
an independent cardiovascular risk factor.4,7,23 Sander et al.24 exercise group were on beta blockers. Second, data were adjusted
provided evidence that an increased daytime systolic variability is for use of beta blockers in the ANCOVA model. Third, beta
associated with the development of early atherosclerosis and a blockers do not affect the exercise-induced long-term effects on
greater 3-year incidence of cardiovascular morbidity and mortality. blood pressure.16 Fourth, intake of beta blockers reduces blood
Similar evidence supporting the association of the CV of daytime pressure without any effects on BPV.6 As calcium channel blockers
BPV with the cardiovascular mortality has been provided by affect BPV, data were adjusted for these antihypertensives as well.
Kikuya et al.25 Previous studies have assessed the effect of exercise Finally, the study may be limited by the variable duration of the
on beat-to-beat variability in healthy subjects and untreated exercise period (8–12 weeks).

Journal of Human Hypertension (2014) 367 – 371 & 2014 Macmillan Publishers Limited
 Exercise and blood pressure variability
N Pagonas et al
371
CONCLUSION 10 Cornelissen VA, Buys R, Smart NA. Endurance exercise beneficially affects
This study demonstrated that regular aerobic exercise reduces ambulatory blood pressure: a systematic review and meta-analysis. J Hypertens
blood pressure without a decrease of BPV. This phenomenon is 2013; 31(4): 639–648.
comparable to the effects of beta blockers on blood pressure and 11 Cornelissen VA, Verheyden B, Aubert AE, Fagard RH. Effects of aerobic training
intensity on resting, exercise and post-exercise blood pressure, heart rate and
BPV. Despite the lacking effect on BPV exercise should be
heart-rate variability. J Hum Hypertens 2010; 24(3): 175–182.
routinely recommended to hypertensives as a basic lifestyle 12 Duncan JJ, Farr JE, Upton SJ, Hagan RD, Oglesby ME, Blair SN. The effects of
modification: It potently reduces blood pressure and elicits a aerobic exercise on plasma catecholamines and blood pressure in patients with
multitude of further beneficial cardiovascular effects. mild essential hypertension. JAMA 1985; 254(18): 2609–2613.
13 Nelson L, Jennings GL, Esler MD, Korner PI. Effect of changing levels of physical
activity on blood-pressure and haemodynamics in essential hypertension. Lancet
What is known about this topic 1986; 2(8505): 473–476.
 Blood pressure variability (BPV) is a strong and independent marker of 14 Martinez DG, Nicolau JC, Lage RL, Toschi-Dias E, de Matos LD, Alves MJ et al.
cardiovascular risk. Effects of long-term exercise training on autonomic control in myocardial
 Ambulatory measurement of BPV is recommended by the current infarction patients. Hypertension 2011; 58(6): 1049–1056.
hypertension guidelines. 15 Westhoff TH, Franke N, Schmidt S, Vallbracht-Israng K, Meissner R, Yildirim H et al.
 Aerobic training reduces blood pressure but its effect on BPV has not Too old to benefit from sports? The cardiovascular effects of exercise training in
been studied. elderly subjects treated for isolated systolic hypertension. Kidney Blood Press Res
2007; 30(4): 240–247.
What this study adds 16 Westhoff TH, Franke N, Schmidt S, Vallbracht-Israng K, Zidek W, Dimeo F et al.
 Exercise had no effect on the intraindividual systolic and diastolic Beta-blockers do not impair the cardiovascular benefits of endurance training in
variability of blood pressure at daytime and night-time despite the hypertensives. J Hum Hypertens 2007; 21(6): 486–493.
significant reduction of the systolic and diastolic blood pressure. 17 Dimeo F, Pagonas N, Seibert F, Arndt R, Zidek W, Westhoff TH. Aerobic exercise
 The BPV on exertion remained also unchanged after the exercise reduces blood pressure in resistant hypertension. Hypertension 2012; 60(3):
training. 653–658.
18 Guidelines for exercise testing and prescription. Lea & Feibiger: Philadelphia, PA,
USA, 1995.
19 Kindermann W, Simon G, Keul J. The significance of the aerobic-anaerobic tran-
sition for the determination of work load intensities during endurance training.
CONFLICT OF INTEREST Eur J Appl Physiol Occup Physiol 1979; 42(1): 25–34.
20 Dahlof B, Sever PS, Poulter NR, Wedel H, Beevers DG, Caulfield M et al. Prevention
The authors declare no conflict of interest.
of cardiovascular events with an antihypertensive regimen of amlodipine adding
perindopril as required versus atenolol adding bendroflumethiazide as required,
in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm
ACKNOWLEDGEMENTS
(ASCOT-BPLA): a multicentre randomised controlled trial. Lancet 2005; 366(9489):
The study was supported by the Gertrud und Hugo Adler Stiftung, Georgensgmünd, 895–906.
Germany. 21 Webb AJ, Rothwell PM. Effect of dose and combination of antihypertensives on
interindividual blood pressure variability: a systematic review. Strok 2011; 42(10):
2860–2865.
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