High blood pressure (hypertension) is redefined for the first time in 14 years by the American College of Cardiology and American Heart Association Task Force on Clinical Practice Guidelines. The new threshold for high blood pressure is 130or 80 mmHg versus the old standard of 140 or 90 mmHg, as was defined by the Joint National Committee Seven on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)1. The change means 46 percent of adults in the United States now have hypertension, compared with 32 percent according to the old JNC 7 definition. Furthermore, the JNC 7 term prehypertension, defined as a resting systolic blood pressure from 120 to 139 mmHg or diastolic blood pressure from 80 to 89 mmHg, has been eliminated, and the new term elevated blood pressure, defined as resting systolic blood pressure from 120 to 129 mmHg and diastolic blood pressure < 80 mmHg, has been added. See the figure below for the new blood pressure classification scheme and other Highlights from the new 2017 Guideline for the Prevention, Treatment, Evaluation and Management of High Blood Pressure in Adults2.
What do the new guidelines mean for your patients and clients with high blood pressure?
According to Dr. Paul Thompson, Chief of Cardiology at Hartford Hospital, and 42nd President of the American College of Sports Medicine,
If you had come into my office in the past in that 130-to-140 mmHg range, I might have left you alone, maybe told you to keep an eye on it, improve your diet or exercise more. Even though the new guidelines recommend not prescribing medications for most patients* until they reach 140/90 mmHg, I think many doctors will. Keep in mind these are guidelines, not rules, so it will be up to the doctor to decide. This is also a lifestyle alert. The lower hypertension definition gives people a better chance to address their high blood pressure with exercise, weight loss, better diet, less sodium, and moderate alcohol use.
What do the new guidelines mean for you, the exercise professional?
The good news, as Dr. Thompson indicates, is the new guidelines are a lifestyle alert. Indeed, they state, “Even though more people will be classified as having hypertension . . . nearly all of these new patients can treat their hypertension with lifestyle changes instead of medications . . . with the biggest impacts being changes to diet and exercise.” In the report, physical activity was rated among the best nonpharmacologic interventions for the prevention and treatment of hypertension as it lowers blood pressure 5 to 8 mmHg among adults with hypertension3. The blood pressure lowering effects of exercise occur from lower to higher intensity, when exercise is continuous or accumulated in shorter bouts, and after both aerobic and resistance exercise. Dr. Thompson also likes to emphasize to his patients that you do not have to “get in shape” to get the blood pressure benefits from exercise since blood pressure is lowered immediately following a single session of exercise for up to 24 hours. In other words, 30 minutes a day of exercise, might help keep the medicines away. Nonetheless, the immediate blood pressure lowering effects of exercise, termed postexercise hypotension, were not addressed in thereport.
The new guidelines recommend 90 to 150 minutes per week of moderate-to-vigorous intensity, aerobic and resistance exercise training which is a bit of a departure from the American College of Sports Medicine (ACSM) recommendations regarding intensity and modality4,5. However, since the publication of the ACSM position stand on exercise and hypertension over a decade ago, accumulating evidence indicates the importance of higher exercise intensity6, and dynamic resistance7 and concurrent (i.e., aerobic and resistance combined)8 exercise in addition to aerobic exercise to lower blood pressure among adults with hypertension. The ACSM is in the process of revising its 2004 position stand on exercise and hypertension as a systematic review and meta-analysis of this newer evidence. Stay tuned!
*Those with known cardiovascular disease, diabetes melllitus, or chronic kidney disease or an atherosclerotic cardiovascular disease risk score >10%, the new guideline recommends both lifestyle and pharmacological treatment for those with a systolic blood pressure >130 mmHg or diastolic blood pressure >80 mmHg. If the atherosclerotic cardiovascular risk score is <10%, lifestyle modification is recommended for those in these blood pressure ranges. For those with a systolic blood pressure >140 mmHg or diastolic blood pressure >90 mmHg, lifestyle and pharmacological treatment are recommended. Learn more here.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL,Jr, Jones DW, Materson BJ, Oparil S, Wright JT,Jr, Roccella EJ, Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung,and Blood Institute, National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003; 42(6):1206-52.
The American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines released the 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults [Hypertension, 2017].
Cornelissen, VA, Smart, NA. Exercise training for blood pressure: a systematic review and meta-analysis. J Am Heart Assoc. 2013b. 2(1):e004473
Pescatello LS, Franklin BA, Fagard R, Farquhar WB, Kelley GA, Ray CA, et al. American College of Sports Medicine position stand: Exercise and hypertension. Med Sci Sports Exerc. 2004;36:533-53.
ACSMs Guidelines for Exercise Testing and Prescription 10thEdition. Riebe, D (senior ed.) and Ehrman, JK, Liguori, G, and Magal, M (assoc. eds.). Philadelphia, PA: Wolters Kluwer Health, 2018.
Pescatello LS, MacDonald HV, Ash GI, Lamberti LM, Farquhar WB, Arena R, Johnson BT. Assessing the existing professional exercise recommendations for hypertension: A review and recommendations for future research priorities. Mayo Clin Proc [Internet]. 2015 Jun;90(6):801-12.
MacDonald, HV, Johnson, BT, Huedo-Medina, TB, et al. Dynamic Resistance Training as Stand-Alone Antihypertensive Lifestyle Therapy: A Meta-Analysis. J Am Heart Assoc. 2016. 5(10):#pages#
Corso, LM, Macdonald, HV, Johnson, BT, et al. Is Concurrent Training Efficacious Antihypertensive Therapy? A Meta-analysis. Med Sci Sports Exerc. 2016. 48(12):2398-2406
Linda Pescatello, PhD, FACSM, is a Distinguished Professor of Kinesiology at the University of Connecticut. Her research on topics including exercise and hypertension, physical activity interventions and exercise genomics (among other topics) has been widely published. She was the recipient of an ACSM Citation Award in 2011, and served as the Senior Editor for ACSM's Guidelines for Exercise Prescription and Testing, 9th edition.
Dr. Paul Thompson, M.D., FACSM is the Chief of Cardiology at Hartford HealthCare Heart and Vascular Institute in Hartford, CT. His research in the area of heart disease and cardiac function have been widely published. He served as the 42nd President of the American College of Sports Medicine 1998-1999.