Objective To perform a large-scale pairwise and network meta-analysis on the effects of all relevant exercise training modes on resting blood pressure to establish optimal antihypertensive exercise prescription practices. Design Systematic review and network meta-analysis. Data sources PubMed (Medline), the Cochrane library and Web of Science were systematically searched. Eligibility criteria Randomised controlled trials published between 1990 and February 2023. All relevant work reporting reductions in systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) following an exercise intervention of ≥2 weeks, with an eligible non-intervention control group, were included. Results 270 randomised controlled trials were ultimately included in the final analysis, with a pooled sample size of 15 827 participants. Pairwise analyses demonstrated significant reductions in resting SBP and DBP following aerobic exercise training (−4.49/–2.53 mm Hg, p<0.001), dynamic resistance training (–4.55/–3.04 mm Hg, p<0.001), combined training (–6.04/–2.54 mm Hg, p<0.001), high-intensity interval training (–4.08/–2.50 mm Hg, p<0.001) and isometric exercise training (–8.24/–4.00 mm Hg, p<0.001). As shown in the network meta-analysis, the rank order of effectiveness based on the surface under the cumulative ranking curve (SUCRA) values for SBP were isometric exercise training (SUCRA: 98.3%), combined training (75.7%), dynamic resistance training (46.1%), aerobic exercise training (40.5%) and high-intensity interval training (39.4%). Secondary network meta-analyses revealed isometric wall squat and running as the most effective submodes for reducing SBP (90.4%) and DBP (91.3%), respectively. Conclusion Various exercise training modes improve resting blood pressure, particularly isometric exercise. The results of this analysis should inform future exercise guideline recommendations for the prevention and treatment of arterial hypertension.

It is well known that physical activity and exercise is associated with a lower risk of a range of morbidities and all-cause mortality. Further, it appears that risk reductions are greater when physical activity and/or exercise is performed at a higher intensity of effort. Why this may be the case is perhaps explained by the accumulating evidence linking physical fitness and performance outcomes (e.g. cardiorespiratory fitness, strength, and muscle mass) also to morbidity and mortality risk. Current guidelines about the performance of moderate/vigorous physical activity using aerobic exercise modes focuses upon the accumulation of a minimum volume of physical activity and/or exercise, and have thus far produced disappointing outcomes. As such there has been increased interest in the use of higher effort physical activity and exercise as being potentially more efficacious. Though there is currently debate as to the effectiveness of public health prescription based around higher effort physical activity and exercise, most discussion around this has focused upon modes considered to be traditionally ‘aerobic’ (e.g. running, cycling, rowing, swimming etc.). A mode customarily performed to a relatively high intensity of effort that we believe has been overlooked is resistance training. Current guidelines do include recommendations to engage in ‘muscle strengthening activities’ though there has been very little emphasis upon these modes in either research or public health effort. As such the purpose of this debate article is to discuss the emerging higher effort paradigm in physical activity and exercise for public health and to make a case for why there should be a greater emphasis placed upon resistance training as a mode in this paradigm shift.

Hypertension is recognised as a leading attributable risk factor for cardiovascular disease and premature mortality. Global initiatives towards the prevention and treatment of arterial hypertension are centred around non-pharmacological lifestyle modification. Exercise recommendations differ between professional and scientific organisations, but are generally unanimous on the primary role of traditional aerobic and dynamic resistance exercise. In recent years, isometric exercise training (IET) has emerged as an effective novel exercise intervention with consistent evidence of reductions in blood pressure (BP) superior to that reported from traditional guideline-recommended exercise modes. Despite a wealth of emerging new data and endorsement by select governing bodies, IET remains underutilised and is not widely prescribed in clinical practice. This expert-informed review critically examines the role of IET as a potential adjuvant tool in the future clinical management of BP. We explore the efficacy, prescription protocols, evidence quality and certainty, acute cardiovascular stimulus, and physiological mechanisms underpinning its anti-hypertensive effects. We end the review with take-home suggestions regarding the direction of future IET research.

Objective: Hypertension remains the leading modifiable risk factor for cardiovascular disease. Isometric exercise training (IET) has been shown to be a useful nonpharmacological intervention for reducing resting blood pressure (BP). This study aimed to measure alterations in office BP, ambulatory BP, cardiac autonomic modulation and inflammatory and vascular biomarkers following a programme of IET in unmedicated hypertensive patients. Methods: Twenty-four unmedicated stage 1 hypertensive patients (age 43.8 ± 7.3 years; height, 178.1 ± 7 cm; weight 89.7 ± 12.8 kg) were randomly assigned in a cross-over study design, to 4-weeks of home-based IET and control period, separated by a 3-week washout period. Office and ambulatory BP, cardiac autonomic modulation, and inflammatory and vascular biomarkers were recorded pre and post-IET and control periods. Results: Clinic and 24-h ambulatory BP significantly reduced following IET by 12.4/6.2 and 11.8/5.6 mmHg in SBP/DBP, respectively (P < 0.001 for both), compared with the control. The BP adaptations were associated with a significant (P = 0.018) reduction in the average real variability of 24-h ambulatory BP following IET, compared with control. Cardiac autonomic modulation improved by 11% (P < 0.001), baroreceptor reflex sensitivity improved by 47% (P < 0.001), and IL-6 and asymmetric dimethylarginine reduced by 10% (P = 0.022) and 19% (P = 0.023), respectively, which differed significantly to the control period. Conclusion: This is the first evidence of durable BP reduction and wider cardiovascular disease risk benefits of IET in a relevant patient population. Our findings support the role of IET as a safe and viable therapeutic and preventive intervention in the treatment of hypertension.

We hypothesized that reflex autonomic cardiovascular control is an important mediator in reducing BP. To test our hypothesis, we investigated continuous cardiac autonomic modulation and baroreceptor reflex sensitivity (BRS) in response to IE. Methods Twenty-five prehypertensive participants performed a single IE wall squat training session. Total power spectral density (PSD) of HR variability (HRV) and associated low-frequency (LF) and high-frequency (HF) power spectral components were recorded in absolute (ms2) and normalized units (nu) before, during, and after an IE session. HR was recorded via electrocardiography and BRS via the sequence method. Continuous BP was recorded via the vascular unloading technique and stroke volume via impedance cardiography. Total peripheral resistance was calculated according to Ohm's law. Results During IE, there were significant reductions in HRV (P < 0.05) and BRS (P < 0.05) and significant increases in HR (P < 0.001), systolic, diastolic, and mean BP (all P < 0.001). In recovery from IE, HRV (P < 0.001), HFnu (P < 0.001), and BRS (P < 0.001) significantly increased with a significant decrease in LFnu (P < 0.001) and LF:HF ratio (P < 0.001), indicative of predominant parasympathetic over sympathetic activity. This autonomic response was associated with a significant reduction in systolic (23.2 ± 18.1 mm Hg, P < 0.001), diastolic (18.7 ± 16.9 mm Hg, P < 0.001), and mean (15.8 ± 15.5 mm Hg, P < 0.001) BP, below baseline and a significant reduction in total peripheral resistance (P < 0.001). Conclusions A single IE session is associated with improved cardiac autonomic modulation and hemodynamic cardiovascular control in prehypertensive males. These acute responses may be mechanistically linked to the chronic reductions in resting BP reported after IE training interventions....