Aerobic, combined, and high-intensity interval training were associated with lower 24-hour ambulatory blood pressure vs control conditions in adults with hypertension, but no exercise modality demonstrated clear superiority over another, according to a systematic review and Bayesian network meta-analysis published in Br J Sports Med.
The analysis included 31 randomized controlled trials, 67 intervention arms, and 1,345 participants. Twenty-nine trials contributed to the primary network meta-analysis of 24-hour systolic and diastolic ambulatory blood pressure. Researchers evaluated aerobic training, combined training, resistance training, high-intensity interval training, isometric training, Pilates, yoga, recreational sports, and control conditions.
Compared with control conditions, combined training was associated with a 6-mmHg reduction in 24-hour systolic ambulatory blood pressure, high-intensity interval training with a 6-mmHg reduction, and aerobic training with a 5-mmHg reduction. The credible intervals were wide for combined training and high-intensity interval training, with the high-intensity interval training estimate narrowly excluding the null. Aerobic training had the most consistent systolic signal, with its credible interval entirely beyond the researchers’ predefined minimum clinically important difference of 2 mmHg.
For 24-hour diastolic ambulatory blood pressure, high-intensity interval training was associated with a 5-mmHg reduction, Pilates with a 4-mmHg reduction, combined training with a 4-mmHg reduction, and aerobic training with a 3-mmHg reduction. However, no modality had a credible interval fully surpassing the 2-mmHg threshold for 24-hour diastolic ambulatory blood pressure.
The researchers noted that even a 2-mmHg reduction in ambulatory blood pressure is associated with reduced cardiovascular risk, underscoring the potential relevance of the 5- to 6-mmHg systolic reductions observed with aerobic, combined, and high-intensity interval training.
The researchers cautioned that treatment rankings should not be interpreted as definitive evidence of clinical superiority. For 24-hour systolic ambulatory blood pressure, the highest-ranking interventions by surface under the cumulative ranking curve were combined training, recreational sports, high-intensity interval training, and Pilates. However, recreational sports and Pilates did not show statistically significant reductions vs control conditions. For 24-hour diastolic ambulatory blood pressure, aerobic training ranked lower than several other modalities but was the only comparison rated above very low confidence.
The researchers rated all comparisons for 24-hour systolic ambulatory blood pressure as very low confidence. For 24-hour diastolic ambulatory blood pressure, only aerobic training vs control was rated low confidence; all other comparisons were rated very low confidence.
“Aerobic exercise training consistently reduced 24-hour, daytime and nighttime ambulatory blood pressure,” wrote lead study author Vinícius Mallmann Schneider, of the Postgraduate Program in Cardiology at Universidade Federal do Rio Grande do Sul and the Sports and Exercise Training Study Group at Hospital de Clínicas de Porto Alegre, and colleagues. “Combined training and high-intensity interval training were also associated with reductions in 24-hour ambulatory blood pressure, extending evidence beyond office-based measurements.”
Eligible trials enrolled adults aged 18 years and older with hypertension, defined as 24-hour systolic ambulatory blood pressure of at least 130 mmHg, 24-hour diastolic ambulatory blood pressure of at least 80 mmHg, or current antihypertensive medication use. Interventions had to include structured exercise lasting at least 4 weeks. Trials were excluded if they used crossover designs or combined exercise with other interventions likely to affect blood pressure, including dietary modification, supplementation, behavioral counseling, or medication changes.
Secondary analyses showed reductions in daytime systolic ambulatory blood pressure with combined training, aerobic training, and high-intensity interval training vs control conditions. High-intensity interval training and aerobic training were also associated with lower daytime diastolic ambulatory blood pressure. Nighttime systolic ambulatory blood pressure was reduced with aerobic training, combined training, and recreational sports, while nighttime diastolic ambulatory blood pressure was reduced with aerobic training, resistance training, and yoga. The findings for recreational sports, Pilates, and yoga were based on limited and imprecise evidence.
Aerobic training was the most frequently studied intervention, represented in 17 study arms. Combined training and isometric training each accounted for 6 arms, while resistance training accounted for 5 arms.
The findings differed from prior network meta-analyses based on office blood pressure measurements, which identified isometric exercise as a leading modality for blood pressure reduction. In the current ambulatory blood pressure analysis, isometric training was not associated with statistically significant reductions. The researchers noted that many office blood pressure studies used large-muscle protocols such as wall squats, whereas ambulatory blood pressure trials primarily evaluated short-term handgrip protocols.
Despite the low-confidence evidence base, the researchers stated that current data supported aerobic training, including continuous or interval training, and combined training as primary evidence-based exercise options for reducing 24-hour ambulatory blood pressure in adults with hypertension. They characterized dynamic and isometric resistance training as complementary rather than first-line strategies for ambulatory blood pressure reduction.
The analysis was prospectively registered and used a Bayesian network meta-analysis approach. Methodological quality was assessed with the Tool for the Evaluation of Study Quality and Reporting in Exercise, with included trials generally rated as moderate to high quality. Publication-bias testing did not suggest small-study effects for the primary outcomes.
The researchers cautioned that heterogeneity in exercise intensity, session structure, intervention volume, and follow-up duration may have influenced the estimates. Antihypertensive medication use was incompletely reported in several trials, adverse events and adherence were underreported, and adults younger than 40 years and older than 75 years were underrepresented.
Vinícius Mallmann Schneider and Dalva Muniz Pereira, PhD, received scholarships from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior. The researchers reported no competing interests and no specific grant funding for the study.