Effect of Exercise Training on Ambulatory BP in Resistant Hypertension

Quick Takes

  • This is an important study in which the magnitude of decrease in systolic blood pressure after 3 months of formal exercise training in resistant hypertension was safe, very meaningful, and at a level that has been shown to reduce cardiovascular events and mortality in hypertension trials.
  • There is no question that regular exercise and improved fitness are associated with longevity and lower risk of cardiovascular disease and cancer.
  • The major problems regarding exercise to prevent and treat hypertension, at least in the United States, are the lack of interest by patients with hypertension who would rather take medication, to what degree they would remain compliant over the long term, and what level of exercise is necessary to maintain improvement.

Study Questions:

Does aerobic exercise training intervention reduce ambulatory blood pressure (BP) among patients with resistant hypertension?


The EnRicH (Exercise Training in the Treatment of Resistant Hypertension) trial is a prospective, single-blinded, randomized clinical trial performed at two hospital centers in Portugal from March 2017–December 2019. Sixty patients aged 40–75 years were randomly assigned in a 1:1 ratio (strata into three age groups) to a 12-week moderate-intensity aerobic exercise training program (exercise group) or a usual care control group. The exercise group performed three 40-minute supervised sessions per week in addition to usual care. The powered primary efficacy measure was 24-hour ambulatory systolic BP (ASBP) change from baseline to 3 months. Secondary outcomes included changes in all other BP variables including office BP, and cardiorespiratory fitness. Major exclusion criteria in the 365 patients with resistant hypertension included secondary hypertension, evidence of target organ damage, heart failure, kidney failure, and change in hypertension treatment within the past 3 months.


From the total of 94 eligible patients, 53 of the 60 patients aged 40-75 years completed the study, including 26 in the exercise group and 27 in the control group. Twenty-four (45%) were women, and the mean age was 60.1 (standard deviation, 8.7) years. There were no between-group differences in mean number of antihypertensive drugs (4.6), ASBP (126 mm Hg), ambulatory diastolic BP (ADBP) (74 mm Hg), office BP (141/84 mm Hg), BMI (30 kg/m2), cardiovascular risk factors, baseline fitness (about 33 ml/kg/min), or atherosclerotic vascular disease. Attendance to exercise sessions was excellent. Compared with the control group, among those in the exercise group, ASBP was reduced by 7.1 mm Hg (95% CI, −12.8 to −1.4; p = 0.02). Additionally, ADBP (−5.1 mm Hg; 95% CI, −7.9 to −2.3; p = 0.001), daytime ASBP (−8.4 mm Hg; 95% CI, −14.3 to −2.5; p = 0.006), and daytime ADBP (−5.7 mm Hg; 95% CI, −9.0 to −2.4; p = 0.001) were reduced in the exercise group compared with the control group. Office SBP (−10.0 mm Hg; 95% CI, −17.6 to −2.5; p = 0.01) and cardiorespiratory fitness also improved in the exercise compared to the control group (between-group difference, 14%; 5.05 ml/kg/min of oxygen consumption; 95% CI, 3.5-6.6; p < 0.001). There were no between-group differences in body composition or biochemical parameters.


A 12-week aerobic exercise program reduced 24-hour and daytime ambulatory BP as well as office SBP in patients with resistant hypertension on optimized medical therapy. These findings provide clinicians with evidence to embrace moderate-intensity aerobic exercise as a standard coadjutant therapy targeting this patient population.


The definition of resistant hypertension included the following: mean ASBP of 130 mm Hg or greater and/or ASBP 135 mm Hg or greater during daytime hours while taking maximally tolerated doses of ≥3 antihypertensive agents, including a diuretic, or to have a controlled BP while taking ≥4 antihypertensive agents. This is the best among the very few controlled studies of exercise in resistant hypertension. The magnitude of differences in SBP is clinically meaningful and associated with lower risk of cardiovascular morbidity and mortality in adults with hypertension. However, other than hypertension, it is a low cardiovascular risk cohort without target organ damage and does not reflect the willingness of patients to participate in organized or leisure time exercise.

Clinical Topics: Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Prevention, Exercise, Hypertension

Keywords: Antihypertensive Agents, Blood Pressure, Blood Pressure Monitoring, Ambulatory, Body Mass Index, Diuretics, Exercise, Geriatrics, Hypertension, Leisure Activities, Maximum Tolerated Dose, Oxygen Consumption, Primary Prevention, Risk Factors

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