Exercise and Hypertension: What Works When We Measure Blood Pressure Over 24 Hours?

Posted on by bjsm

Key words: exercise training, ambulatory (24-h) blood pressure, hypertension

This blog provides a summary of a recent study published in BJSM (1). 

Why is this study important? 

High blood pressure is the leading modifiable risk factor for cardiovascular disease worldwide.  Exercise is a cornerstone non-pharmacological strategy for hypertension management. However,  current evidence and meta-analyses are predominantly based on office blood pressure, an isolated  measurement highly susceptible to measurement bias in exercise science. In contrast, 24-hour  ambulatory blood pressure monitoring (ABPM) provides a comprehensive physiological profile  by tracking blood pressure during daily activities and sleep, serving as a significantly stronger  predictor of cardiovascular events and mortality. Despite the clinical superiority of ABPM for  assessing true therapeutic efficacy, no previous study has performed a simultaneous head-to-head  comparison of diverse exercise modalities using ABPM as the primary outcome in adults with  systemic arterial hypertension. 

How did the study go about this? 

We conducted a systematic review and network meta-analysis, a statistical method that allows  multiple treatments to be compared at once, even when they have not been tested head-to-head.  We searched four major databases and identified 31 randomised controlled trials involving over  1,300 adults with hypertension. 

The included studies tested eight exercise modalities: aerobic training, combined aerobic and  resistance training, high-intensity interval training (HIIT), dynamic resistance training, isometric  training, Pilates, yoga, and recreational sports. All exercise modalities were compared with a  non-exercise control. We used Bayesian statistical models to estimate which modalities were  most effective for reducing 24-hour systolic and diastolic blood pressure. 

What did the study find? 

Three modalities significantly reduced 24-hour systolic blood pressure compared to control:  combined training (−6.2 mmHg), HIIT (−5.7 mmHg), and aerobic training (−4.7 mmHg). For  diastolic blood pressure, HIIT (−4.6 mmHg), Pilates (−4.2 mmHg), combined training (−3.9  mmHg), and aerobic training (−2.8 mmHg) showed significant reductions. In head-to-head  comparisons between exercise modalities, no single intervention demonstrated clear superiority,  as inter-group differences did not reach statistical significance. Aerobic training provided the  most robust and consistent evidence for blood pressure reduction across all ambulatory  parameters, including 24-hour, daytime, and nighttime periods  

Notably, despite having demonstrated efficacy in studies utilizing office blood pressure, dynamic  resistance training and isometric exercise did not yield statistically significant reductions in 24- hour ambulatory blood pressure, Non-conventional modalities such as Pilates, yoga, and 

recreational sports showed promising signals, but the evidence remains limited and imprecise  due to the small number of available trials.  

What are the key take-home points? 

  • Aerobic exercise remains the gold standard for reducing blood pressure across the  complete 24-hour cycle, providing the most robust and consistent evidence among all  modalities. 
  • Combined training and HIIT represent effective evidence-based alternatives, expanding  the therapeutic options for blood pressure management in clinical practice. 
  • The lack of a single superior modality in head-to-head comparisons suggests that exercise  prescription should prioritize patient preference to enhance long-term adherence. 
  • Office blood pressure improvements do not inherently translate to 24-hour ambulatory  benefits. 
  • Non-conventional modalities require further high-quality trials to confirm efficacy on  ABPM 

Author information 

Vinícius Mallmann Schneider, Patricia Klarmann Ziegelmann, Dalva Muniz Pereira,  Rodrigo Ferrari 

Universidade Federal do Rio Grande do Sul, Brazil 

Postgraduate Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande  do Sul; 

Postgraduate Program in Human Movement Sciences, School of Physical Education,  Universidade Federal do Rio Grande do Sul, Brazil 

Sports and Exercise Training Study Group (GET), Hospital de Clínicas de Porto Alegre, Brazil.

References

(1) Mallmann Schneider V, Klarmann Ziegelmann P, Muniz Pereira D, et alEffects of different exercise training modalities on 24-hour ambulatory blood pressure in adults with hypertension: a network meta-analysis of randomised controlled trialsBritish Journal of Sports Medicine 2026;60:983-990.

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