ABC | Volume 114, Nº5, May 2020

Arq Bras Cardiol. 2020; 114(5):943-987 Guidelines Brazilian Cardiovascular Rehabilitation Guideline – 2020 Table 4 – Indications for physical exercise in hypertension Indication Recommendation Level of evidence Aerobic exercise to prevent development of hypertension 110-112 I A Aerobic exercise in the treatment of hypertension 93,102,103,112 I A Dynamic muscle endurance training in the treatment of hypertension 103,112 I B Isometric training in the treatment of hypertension 105-108 IIa B Large randomized controlled trials and meta-analyses have confirmed that regular exercise can reduce BP levels. 102,112 In addition, the continuous practice of physical activities can be beneficial for both the prevention and the treatment of hypertension, further reducing cardiovascular morbidity and mortality. Demonstrating this, active individuals have up to a 30% lower risk of developing hypertension than sedentary ones, 111 and increasing daily physical activity significantly reduces BP. 113 Physical inactivity is one of the greatest public health issues of modern society, 114 as it is the most prevalent of the cardiovascular risk factors and one of the leading factors contributing to mortality worldwide. 115 Survival is lower among people who spend most of their time sitting than in those who spend little time in this position. 116 Television viewing time is directly associated with high BP levels and cardiovascular morbidity and mortality; 117 therefore, to reduce time spent in the seated position, standing for at least 5 minutes for every 30 minutes spent sitting is recommended as a valid preventive measure. Physical exercise is indicated for all patients with HTN (Table 4). 72,73,118 In addition to exercise, the treatment of HTN requires other lifestyle changes, such as proper diet, weight control, and cessation of risk factors such as smoking and excessive alcohol intake. In addition to the direct effect of exercise on HTN, another important component of CVR concerns the management of drug therapy, which can be optimized in the rehabilitation environment through disease education, advice on the need for treatment, and information on adverse effects and on the importance of adherence. 119 6.2.3. Pre-Exercise Evaluation Obviously, it is up to the patient’s primary physician to establish the diagnosis of HTN, search for other cardiovascular risk factors, and screen for target organ damage and other comorbidities in order to define the treatment strategy, which can be pharmacological and/or composed of one or more behavioral changes. 72 A CPET or TMET should be performed during pre-exercise evaluation, especially if there is suspicion of heart disease, target organ damage, or presence of three or more risk factors. 72 When CPET or TMET is used to support exercise prescription, it should ideally be performed with the patient on all of their usual medications, especially those with negative chronotropic effect, in order to mimic the actual conditions encountered during physical training. This will allow use of peak HR (TMET) or ventilatory thresholds (CPET) to determine the target training zone. 6.2.4. Special Considerations for the Prescription and Follow-Up of Physical Exercise Programs The exercise recommendation for hypertensive patients, is similar to that proposed for the general population: at least 150 minutes per week (five 30-minute sessions) of moderate- to-intense aerobic activity. In addition, two to three resistance training sessions per week are advisable. For greater benefit, absent any contraindications, patients may gradually increase their engagement towards a goal of 300 min/week of moderate aerobic exercise or 150 min/week of intense aerobic exercise. During training, it is important that BP be assessed at rest and in exertion. Patients with a resting BP higher than 160/100 mmHg or with target organ damage (left ventricular hypertrophy, retinopathy, nephropathy, etc.) are advised to optimize antihypertensive therapy for better BP control before starting or resuming exercise, 37 or to reduce training intensity until better BP control is achieved. In supervised CVR programs, these recommendations are flexible and can be adjusted individually at the discretion of the rehabilitation physician and according to the BP response observed during the stress test and exercise sessions. During exercise, it is recommended that BP remain below 220/105 mmHg. If BP exceeds this level, the session should be halted or the load reduced, and adjustment of drug therapy should be considered. 37 BP must be measured after each exercise session, and is commonly found to be lower than before the start of activities. In hypertensive patients, the acute antihypertensive effect of a single session tends to be greater with more intense levels of aerobic exercise. 120 This acute effect of physical training can cause symptomatic hypotension once the session ends, which usually improves with rest and hydration. Patients on alpha blockers, beta blockers, calcium channel blockers, and vasodilators may be at increased risk of post-exercise hypotension, and thus require special attention during the cooldown period. If post-exercise hypotension becomes recurrent, which usually results from an add-on antihypertensive effect of training, the need for dose adjustments or even discontinuation of medications must be considered. There is little data regarding the effect of exercise in patients with resistant hypertension, which is characterized by BP above target despite the use of three or more antihypertensive medications. In these patients, who require closer monitoring, a randomized, single-center clinical trial showed that exercising in warm water (30 to 32ºC) resulted in a pronounced reduction in BP (36/12 mmHg) after 3 months. 121 Although such effects need to be reproduced in further studies, exercise in warm water appears to be appropriate for patients with resistant hypertension. 956