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Walking Training Improves Ambulatory Blood Pressure Variability in Claudication

Background:

Walking training (WT) improves walking capacity and reduces clinic blood pressure (BP) in patients with peripheral artery disease (PAD), but its effects on ambulatory BP remains unknown.

Objective:

To investigate the effect of 12 weeks of WT on ambulatory BP and its variability in patients with PAD.

Methods:

Thirty-five male patients with PAD and claudication symptoms were randomly allocated into two groups: control (n = 16, 30 min of stretching) and WT (n = 19, 15 bouts of 2 min of walking at the heart rate of leg pain threshold interspersed by 2 min of upright rest). Before and after 12 weeks, 24-hour ambulatory BP was assessed. Ambulatory BP variability indices assessed at both time points included the 24-hour standard deviation (SD24), the awake and asleep weighted standard deviation (SDdn), and the 24-hour average real variability (ARV24). Data were analyzed by mixed two-way ANOVAs, considering P<0.05 as significant.

Results:

After 12 weeks, neither group had significant changes in 24-hour, awake and sleep BPs. The WT decreased systolic and mean BP variabilities (Systolic BP – 13.3±2.8 vs 11.8±2.3, 12.1±2.84 vs 10.7±2.5 and 9.4±2.3 vs 8.8±2.2 mmHg); Mean BP – 11.0±1.7 vs 10.4±1.9, 10.1±1.6 vs 9.1±1.7 and 8.0.±1.7 vs 7.2±1.5 mmHg) for SD24, SDdn and ARV24, respectively). Neither group had significant changes in diastolic BP variabilities after 12 weeks.

Conclusions:

The WT does not change ambulatory BP levels but decreases ambulatory BP variability in patients with PAD. This improvement may have a favorable impact on the cardiovascular risk of patients with symptomatic PAD. (Arq Bras Cardiol. 2021; 116(5):898-905)

Keywords:
Intermittent Claudication; Walking; Blood Pressure; Blood Pressure Monitoring Ambulatory; Muscle Weakness; Endurance Training


Resumo

Fundamento:

O treinamento de caminhada (TC) melhora a capacidade de caminhar e reduz a pressão arterial (PA) clínica em pacientes com doença arterial periférica (DAP), mas seus efeitos na PA ambulatorial permanecem desconhecidos.

Objetivo:

Investigar o efeito de 12 semanas de TC na PA ambulatorial e sua variabilidade em pacientes com DAP.

Métodos:

Trinta e cinco pacientes do sexo masculino com DAP e sintomas de claudicação foram alocados aleatoriamente em dois grupos: controle (n = 16, 30 min de alongamento) e TC (n = 19, 15 séries de 2 minutos de caminhada na frequência cardíaca em que ocorreu limiar de dor intercalados por 2 minutos de repouso em pé). Antes e depois de 12 semanas, a PA ambulatorial de 24 horas foi avaliada. Os índices de variabilidade da PA ambulatorial avaliados em ambos os momentos incluíram o desvio-padrão de 24 horas (DP24), o desvio-padrão ponderado de vigília e sono (DPvs) e a variabilidade real média de 24 horas (VRM24). Os dados foram analisados por ANOVAs mistas de dois fatores, considerando significativo P<0,05.

Resultados:

Após 12 semanas, nenhum dos grupos apresentou alterações na PA de 24 horas, vigília e sono. O TC diminuiu as variabilidades da PA sistólica e média (PA sistólica – 13,3 ± 2,8 vs 11,8 ± 2,3; 12,1 ± 2,84 vs 10,7 ± 2,5; e 9,4 ± 2,3 vs 8,8 ± 2,2 mmHg; PA média – 11,0 ± 1,7 vs 10,4 ± 1,9; 10,1 ± 1,6 vs 9,1 ± 1,7; e 8,0 ± 1,7 vs 7,2 ± 1,5 mmHg para DP24, DPvs e VRM24, respectivamente). Nenhum dos grupos apresentou mudanças significantesnos índices de variabilidade da PA diastólica após 12 semanas.

Conclusões:

O TC não altera os níveis ambulatoriais da PA, mas diminui a sua variabilidade em pacientes com DAP. Essa melhora pode ter um impacto favorável no risco cardiovascular de pacientes com DAP sintomática. (Arq Bras Cardiol. 2021; 116(5):898-905)

Palavras-chave:
Claudicação Intermitente; Caminhada; Pressão Arterial; Monitoração Ambulatorial da Pressão Arterial; Fraqueza Muscular; Treinamento Aeróbico

Introduction

Intermittent claudication, the most prevalent symptom of peripheral artery disease (PAD), impairs walking capacity, impacting on patient’s physical activity levels11. Gerage AM, Correia MA, Oliveira PML, Palmeira AC, Domingues WJR, Zeratti AE, et al. Physical Activity Levels in Peripheral Artery Disease Patients. Arq Bras Cardiol. 2019;113(3):410-6. and quality of life.22. Wu A, Coresh J, Selvin E, Tanaka H, Heiss G, Hirsch AT, et al. Lower Extremity Peripheral Artery Disease and Quality of Life Among Older Individuals in the Community. J Am Heart Assoc. 2017;6(1):e004519. In addition, this functional limitation is associated with increased rates of fatal and non-fatal cardiovascular events in this population.33. Ritti-Dias RM, Correia MA, Andrade-Lima A, Cucato GG. Exercise as a therapeutic approach to improve blood pressure in patients with peripheral arterial disease: current literature and future directions. Expert Rev Cardiovasc Ther. 2019;17(1):65-73.

Among cardiovascular diseases, arterial hypertension is a common comorbidity that affects more than 80% of the patients with PAD,44. Bhatt DL, Steg PG, Ohman EM, Hirsch AT, Ikeda Y, Mas JL, et al. International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA. 2006;295(2):180-9. who present higher clinic and specially higher ambulatory BP levels compared with healthy individuals.55. Svensson P, de Faire U, Niklasson U, Ostergren J. Office blood pressure underestimates ambulatory blood pressure in peripheral arterial disease in comparison to healthy controls. J Hum Hypertens. 2004;18(3):193-200. Interestingly, we recently demonstrated that walking capacity was negatively associated with ambulatory BP in PAD,66. Lima A, Chehuen M, Cucato GG, Soares AHG, Askew CD, Barbosa J, et al. Relationship between walking capacity and ambulatory blood pressure in patients with intermittent claudication. Blood Press Monit. 2017;22(3):115-21. indicating a poorer BP control in patients with greater functional impairment. Thus, therapeutic strategies that increase functional capacity, such as walking training, may improve cardiovascular outcomes and reduce cardiovascular risk in this group.

We have recently demonstrated that supervised walking training (WT) improves walking capacity in addition to reducing clinic BP in patients with symptomatic PAD,77. Chehuen M, Cucato GG, Carvalho CRF, Ritti-Dias RM, Wolosker N, Leicht AS, et al. Walking training at the heart rate of pain threshold improves cardiovascular function and autonomic regulation in intermittent claudication: A randomized controlled trial. J Sci Med Sport. 2017;20(10):886-92. however its effects on ambulatory BP remains unknown. This is a very important issue, since ambulatory BP is considered a stronger predictor of all-cause and cardiovascular mortality than clinic BP.88. Yang WY, Melgarejo JD, Thijs L, Zhang ZY, Boggia J, Wei FF, et al. Association of Office and Ambulatory Blood Pressure With Mortality and Cardiovascular Outcomes. JAMA. 2019;322(5):409-20. Additionally, a previous study reported no effect of resistance training on ambulatory BP levels, but an improvement in ambulatory BP variability,99. Gomes APF, Correia MA, Soares AHG, Cucato GG, Lima A, Cavalcante BR, et al. Effects of Resistance Training on Cardiovascular Function in Patients With Peripheral Artery Disease: A Randomized Controlled Trial. J Strength Cond Res. 2018;32(4):1072-80. a new and strong marker for target-organ damage, cardiovascular events, and mortality.1010. Mena LJ, Felix VG, Melgarejo JD, Maestre GE. 24-Hour Blood Pressure Variability Assessed by Average Real Variability: A Systematic Review and Meta-Analysis. J Am Heart Assoc. 2017;6(10):e006895. Given that aerobic training such as walking promotes considerable reduction on ambulatory BP levels compared to resistance training in normotensive and hypertensive populations,1111. Cardoso CG, Jr., Gomides RS, Queiroz AC, Pinto LG, da Silveira Lobo F, Tinucci T, et al. Acute and chronic effects of aerobic and resistance exercise on ambulatory blood pressure. Clinics (Sao Paulo). 2010;65(3):317-25. one may suppose that this mode of exercise can also improve ambulatory BP and its variability in patients with PAD, which needs to be checked. Thus, the aim of this study was to investigate the effects of WT on ambulatory BP and its variability in patients with symptomatic PAD.

Methods

Study Population

This is a complementary data from a previous study.77. Chehuen M, Cucato GG, Carvalho CRF, Ritti-Dias RM, Wolosker N, Leicht AS, et al. Walking training at the heart rate of pain threshold improves cardiovascular function and autonomic regulation in intermittent claudication: A randomized controlled trial. J Sci Med Sport. 2017;20(10):886-92. Patients were recruited from the Clinic Hospital’s Vascular Unit, University of Sao Paulo, Brazil. Male patients previously diagnosed with PAD and with symptoms of intermittent claudication were invited. Inclusion criteria were: (a) age ≥ 50 years; (b) ankle-brachial index (ABI) ≤ 0.90;1111. Cardoso CG, Jr., Gomides RS, Queiroz AC, Pinto LG, da Silveira Lobo F, Tinucci T, et al. Acute and chronic effects of aerobic and resistance exercise on ambulatory blood pressure. Clinics (Sao Paulo). 2010;65(3):317-25.,1212. Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017;69(11):e71-e126. c) Fontaine stage II of PAD;1313. Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. 2006;113(11):e463-654. (d) body mass index ≤ 35 kg/m2; (e) resting systolic BP ≤ 160 mmHg and diastolic BP ≤ 105 mmHg; (f) not taking β-blockers or non-dihydropyridine calcium channel blockers; (g) absence of cardiovascular autonomic neuropathy for diabetic patients;1414. Boulton AJ, Vinik AI, Arezzo JC, Bril V, Feldman EL, Freeman R, et al. Diabetic neuropathies: a statement by the American Diabetes Association. Diabetes Care. 2005;28(4):956-62. (h) ability to walk for at least 2 minutes at 3.2 km/h on a treadmill; (i) ability to undertake an incremental treadmill test limited by symptoms of intermittent claudication; (j) absence of myocardial ischemia or complex arrhythmias during a maximal treadmill test; (k) decrease of at least 15% in ABI after a maximal treadmill test; and (l) not engaged in any exercise program. In addition, patients were not included if they met at least one of the following criteria: 1) revascularization surgery or angioplasty less than one year earlier; 2) use of peripheral vasodilators, 3) lower limb amputation, and 4) orthopedic problems that contraindicate walking exercise. Subjects were excluded if they had their medications changed during the study. The study’s protocol was registered at the Brazilian Clinical Trials (RBR-7M3D8W) and approved by the Human Research Ethics Committee of the School of Physical Education and Sport of the University of Sao Paulo (process: 39-2008/55) and the Clinic Hospital (process:1179/09), being conducted in accordance with the Declaration of Helsinki. A written informed consent was obtained from all patients prior to participation.

Participant screening

Diagnosis of PAD was made based on clinical history and ABI measurement at rest and after a treadmill maximal test.1515. Guirguis-Blake JM, Evans CV, Redmond N, Lin JS. Screening for Peripheral Artery Disease Using the Ankle-Brachial Index: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2018;320(2):184-96. Arm systolic BP was measured using the auscultatory method, and ankle systolic BP of each leg was assessed with a Doppler ultrasound (Martec, DV 6000, Ribeirão Preto, Brazil). For each patient, the lowest ABI was recorded. Body mass and height were measured (Welmy, 110, São Paulo, Brazil), and body mass index was calculated. Resting brachial BP was measured in two visits, and the mean value was calculated and used for analysis. In each visit, after five minutes of seated rest, three auscultatory measurements were taken in each arm, and the highest mean value was recorded. Medication use and exercise habits were assessed via interview. In diabetic patients, the presence of cardiovascular autonomic neuropathy, was assessed according to the recommendations of the American Diabetes Association.1414. Boulton AJ, Vinik AI, Arezzo JC, Bril V, Feldman EL, Freeman R, et al. Diabetic neuropathies: a statement by the American Diabetes Association. Diabetes Care. 2005;28(4):956-62. Drug treatment was kept constant for all patients throughout the study.

Design

The experimental protocol is shown in Figure 1. The study had an initial pre-screening including a maximal treadmill test following Gardner’s protocol for assessing pain threshold.1616. Gardner AW, Skinner JS, Cantwell BW, Smith LK. Progressive vs single-stage treadmill tests for evaluation of claudication. Med Sci Sports Exerc. 1991;23(4):402-8. Then, subjects who met all the study criteria underwent 24-hour ambulatory BP monitoring at baseline and after 12-weeks of intervention. Patients were randomized using a specific online program (www.randomizer.org) into two groups: walking training (WTG) and control (CG).

Figure 1
Experimental design of the study.

For all the assessments, recommendations included no vigorous exercise in the previous 48 hours, a light meal 2 hours before, no ingestion of food with stimulant properties such as caffeine, no alcoholic beverages or smoking in the previous 12 hours. Clinic assessments were conducted in the morning in a temperature-controlled laboratory (20-22°C).

Measurements

Primary outcome: ambulatory blood pressure

Ambulatory BP monitoring was performed with a noninvasive oscillometric device (SpaceLabs Medical Inc, 90207, Washington, USA) placed on the non-dominant arm and programmed to perform measurements every 15 minutes for 24 hours. The accuracy of the device was confirmed by a mercury sphygmomanometer prior to use.

For the analysis, ambulatory systolic, diastolic and mean BP levels were calculated by the average of all BP measurements taken during the 24 hours as well as during the awake and asleep periods reported by the patient. In addition, ambulatory BP variability was calculated for systolic, diastolic and mean BP using three different indices:1717. Hansen TW, Thijs L, Li Y, Boggia J, Kikuya M, Björklund-Bodegård K, et al. Prognostic value of reading-to-reading blood pressure variability over 24 hours in 8938 subjects from 11 populations. Hypertension. 2010;55(4):1049-57. the 24-hour standard deviation (SD24); the awake and asleep weighted standard deviation (SDdn), and the 24-hour average real variability (ARV24). These indices were calculated as previously reported. Briefly, SD24 was calculated by the standard deviation (SD) over 24 hours weighted for the time interval between measures. SDdn was calculated by the mean of awake and asleep SD corrected for the number of hours of each of these periods [i.e SDdn = [(awake SD x awake hours) + (asleep SD x asleep hours)]/(wake + asleep hours)]. ARV24 was calculated by the average of absolute differences between consecutive measurements accounting for the order of measurement using following formula:

ARM=1wk=1n1w×|BPk+1BPk|

where k ranges from 1 to N−1, BP is the blood pressure and w is the time interval between BPk and BPk+1. N is the number of blood pressure readings.

Interventions

Details of the interventions have been previously reported.77. Chehuen M, Cucato GG, Carvalho CRF, Ritti-Dias RM, Wolosker N, Leicht AS, et al. Walking training at the heart rate of pain threshold improves cardiovascular function and autonomic regulation in intermittent claudication: A randomized controlled trial. J Sci Med Sport. 2017;20(10):886-92. Briefly, interventions were conducted twice a week for 12 weeks and supervised by one of the researchers. CG patients performed stretching exercises for 30 minutes. WTG patients performed 15 bouts of 2-minute walking on a treadmill intersected by 2 minutes of resting. During each walking bouts, speed was kept at 3.2 km/h and intensity was adjusted by setting the treadmill grade to maintain heart rate within 4 bpm of the heart rate obtained at the pain threshold assessed during maximal treadmill test1818. Cucato GG, Chehuen Mda R, Costa LA, Ritti-Dias RM, Wolosker N, Saxton JM, et al. Exercise prescription using the heart of claudication pain onset in patients with intermittent claudication. Clinics (Sao Paulo). 2013;68(7):974-8. (e.g., if the patient reported the pain threshold during maximal treadmill test at 100 bpm, the heart rate during each training session was kept between 96 to 104 bpm).

Statistical analysis

As previously described,77. Chehuen M, Cucato GG, Carvalho CRF, Ritti-Dias RM, Wolosker N, Leicht AS, et al. Walking training at the heart rate of pain threshold improves cardiovascular function and autonomic regulation in intermittent claudication: A randomized controlled trial. J Sci Med Sport. 2017;20(10):886-92. the sample size was estimated considering a power of 90%, alpha error of 5%, and standard deviation of 3 mmHg for systolic BP. The minimal sample size necessary to detect a difference of 4 mmHg was 7 subjects in each group.

Normality of data distribution and homogeneity of variance were evaluated using the Shapiro-Wilk and Levene tests, respectively. Skewed distributions were normalized using logarithmic transformations. At baseline, group differences were identified via chi-square test (comorbidities and drug therapy prevalence) or unpaired Student’s t-test (continuous variables). The effects of the interventions were assessed using a mixed two-way ANOVA (Statsoft, Statistic for Windows 4.3, Oklahoma, USA), the groups being the between factor, and the study phase (baseline and 12 weeks) being the within factor. Newman-Keuls post-hoc tests were used when necessary. P<0.05 was considered significant, and data were presented as mean ± SD.

Results

Patients flowchart is shown in Figure 2. Eighty-four patients were screened, but 35 were excluded for not meeting the eligibility criteria (n=7) or declining participation (n=28, not available to perform training sessions). The remaining 49 patients were randomly allocated in the CG (n=24) and the WTG (n=25). Fourteen patients withdrew due to circumstances unrelated to the the study. Thus, the final sample was composed of 35 patients (CG, n=16; WTG, n=19).

Figure 2
Participants flowchart. IC: Intermittent claudication, CG: Control group, WTG: Walking training group

These groups had similar initial characteristics regarding age, obesity level, clinic BP levels, disease limitations, comorbidities, and medication use (Table 1).

Table 1
Characteristics of the patients allocated in the control (CG) and the walking (WTG) training groups.

Ambulatory BP levels were similar between WTG and CG at baseline, and neither group presented any significant change in 24-hour, awake and asleep BPs after the 12 weeks of intervention (Table 2).

Table 2
Ambulatory blood pressure levels measured at baseline and after the 12-week intervention period for the walking training (WTG) and the control (CG) groups

BP variability indices assessed at baseline were similar between WTG and CG. There was a significant interaction between group and study phase for systolic and mean BP variability indices (all p<0,05), showing a reduction in SD24, SDdn, and AVR24 of systolic and mean BP in the WTG (Table 3, Figure 3). Neither group had any significant change in the indices of diastolic BP variability.

Table 3
Ambulatory blood pressure variability indices assessed at baseline and after the 12-week intervention period for the walking training (WTG) and the control (CG) groups
Figure 3
Absolute change (Δ) of ambulatory blood pressure variability for the control group (white bars) and walking training group (black bars). BP: blood pressure; SD24: standard deviation over 24 hours weighted for the time interval between consecutive readings; SDdn: the average of the daytime and nighttime SDs weighted for the duration of the daytime and nighttime interval; ARV24: the average real variability weighted for the time interval between consecutive readings in 24-hour ambulatory BP recordings. *p<0.05 vs control group.

Discussion

The main finding of this study was that 12 weeks of WT decreased systolic and mean BP variability indices without changing ambulatory BP levels.

In the present study, 12 weeks of WT did not alter ambulatory BP in patients with PAD, which contrasts with studies with normotensive subjects and hypertensive patients1919. Cornelissen VA, Buys R, Smart NA. Endurance exercise beneficially affects ambulatory blood pressure: a systematic review and meta-analysis. J Hypertens. 2013;31(4):639-48. that have consistently reported decreases around 3 mmHg for systolic and diastolic ambulatory BP after aerobic training. However, 12 weeks of resistance training have also not changed ambulatory BP in patients with PAD.99. Gomes APF, Correia MA, Soares AHG, Cucato GG, Lima A, Cavalcante BR, et al. Effects of Resistance Training on Cardiovascular Function in Patients With Peripheral Artery Disease: A Randomized Controlled Trial. J Strength Cond Res. 2018;32(4):1072-80. Thus, it has been hypothesized that the frequent episodes of ischemia during daily activities in patients with PAD produce claudication pain, oxidative stress and metabolic accumulation, increasing sympathetic nerve activity and, consequently, blunting any possible hypotensive effect of exercise training on ambulatory BP levels.2020. Muller MD, Drew RC, Blaha CA, Mast JL, Cui J, Reed AB, et al. Oxidative stress contributes to the augmented exercise pressor reflex in peripheral arterial disease patients. J Physiol. 2012;590(23):6237-46. Another potential explanation, however, can be the too short duration of the training program, since a previous study2121. Seals DR, Reiling MJ. Effect of regular exercise on 24-hour arterial pressure in older hypertensive humans. Hypertension. 1991;18(5):583-92. conducted with elderly hypertensive patients showed no change in ambulatory BP levels after 6 months of training, but a significant reduction after 12 months.

Despite the absence of change in ambulatory BP levels, reductions in ambulatory systolic and mean BP variabilities were observed for all variability indices: SD24, SDdn and ARV24. These results are in accordance with a previous study with resistance training in symptomatic PAD patients.99. Gomes APF, Correia MA, Soares AHG, Cucato GG, Lima A, Cavalcante BR, et al. Effects of Resistance Training on Cardiovascular Function in Patients With Peripheral Artery Disease: A Randomized Controlled Trial. J Strength Cond Res. 2018;32(4):1072-80. In addition, this result is coherent with the concept that changes in autonomic control precede alterations in BP levels, since BP variability mainly reflects autonomic control of BP.2222. Chaar LJ, Alves TP, Batista Junior AM, Michelini LC. Early Training-Induced Reduction of Angiotensinogen in Autonomic Areas-The Main Effect of Exercise on Brain Renin-Angiotensin System in Hypertensive Rats. PLoS One. 2015;10(9):e0137395.,2323. Masson GS, Costa TS, Yshii L, Fernandes DC, Soares PP, Laurindo FR, et al. Time-dependent effects of training on cardiovascular control in spontaneously hypertensive rats: role for brain oxidative stress and inflammation and baroreflex sensitivity. PLoS One. 2014;9(5):e94927. Additionally, these results are also in accordance with our previous clinic findings of improvements in cardiac autonomic modulation and baroreflex sensitivity, all markers of autonomic control, after WT in patients with PAD.77. Chehuen M, Cucato GG, Carvalho CRF, Ritti-Dias RM, Wolosker N, Leicht AS, et al. Walking training at the heart rate of pain threshold improves cardiovascular function and autonomic regulation in intermittent claudication: A randomized controlled trial. J Sci Med Sport. 2017;20(10):886-92. The absence of changes in diastolic ambulatory BP variability is also coherent with the absence of effects of walking training on calf vascular resistance, as previously described.77. Chehuen M, Cucato GG, Carvalho CRF, Ritti-Dias RM, Wolosker N, Leicht AS, et al. Walking training at the heart rate of pain threshold improves cardiovascular function and autonomic regulation in intermittent claudication: A randomized controlled trial. J Sci Med Sport. 2017;20(10):886-92.

Even without any changes in ambulatory BP levels, the decrease in ambulatory BP variability obtained with WT may have relevant clinical implications. BP variability has been associated with the presence and progression of subclinical organ damage as well as the incidence of hard endpoints such as cardiovascular events1010. Mena LJ, Felix VG, Melgarejo JD, Maestre GE. 24-Hour Blood Pressure Variability Assessed by Average Real Variability: A Systematic Review and Meta-Analysis. J Am Heart Assoc. 2017;6(10):e006895., leading to a worse cardiovascular prognosis.88. Yang WY, Melgarejo JD, Thijs L, Zhang ZY, Boggia J, Wei FF, et al. Association of Office and Ambulatory Blood Pressure With Mortality and Cardiovascular Outcomes. JAMA. 2019;322(5):409-20. Thus, the decrease induced by WT may have favorable impact on the cardiovascular risk of patients with PAD, reinforcing the recommendation of WT for these patients.

This study has some limitations that should be acknowledged. It was conducted only with men, and training-induced adaptations may differ between genders.2424. Correia MA, de Sousa ASA, Andrade-Lima A, Germano-Soares AH, Zerati AE, Puech-Leao P, et al. Functional and Cardiovascular Measurements in Patients With Peripheral Artery Disease: comparison between men and women. J Cardiopulm Rehabil Prev. 2020;40(1):24-8.,2525. Cucato GG, Ritti-Dias RM, Franco FG, de Mattos LD, Cendoroglo MS, Wolosker N, et al. Influence of peripheral arterial disease on daily living activities in elderly women. J Vasc Nurs. 2016;34(2):39-43. Thus, future studies should investigate the impact of WT on ambulatory BP and its variability also in women, especially the elderly, who may experience greater cardiovascular risk than men.2424. Correia MA, de Sousa ASA, Andrade-Lima A, Germano-Soares AH, Zerati AE, Puech-Leao P, et al. Functional and Cardiovascular Measurements in Patients With Peripheral Artery Disease: comparison between men and women. J Cardiopulm Rehabil Prev. 2020;40(1):24-8. The current study also only examined patients with claudication symptoms, and further studies should examine the effects of WT in other groups of patients, such as those who are asymptomatic (stage 1) and may also present a decrease in ambulatory BP levels after WT. Finally, the training program lasted 12 weeks, a length that improves functional capacity and clinic cardiovascular parameters in these patients,77. Chehuen M, Cucato GG, Carvalho CRF, Ritti-Dias RM, Wolosker N, Leicht AS, et al. Walking training at the heart rate of pain threshold improves cardiovascular function and autonomic regulation in intermittent claudication: A randomized controlled trial. J Sci Med Sport. 2017;20(10):886-92. but a longer training period may be necessary to decrease ambulatory BP levels.

Conclusion

In conclusion, 12 weeks of WT decreases ambulatory BP variability in men with symptomatic PAD.

  • Sources of Funding
    This study was partially funded by CNPQ (442507/2014-3; 304436/2018-6), FAPESP (2015/13800-0) and CAPES (0001).
  • Study Association
    This article is part of the thesis submitted by Marcel Chehuen, from Universidade de São Paulo.

Referências

  • 1
    Gerage AM, Correia MA, Oliveira PML, Palmeira AC, Domingues WJR, Zeratti AE, et al. Physical Activity Levels in Peripheral Artery Disease Patients. Arq Bras Cardiol. 2019;113(3):410-6.
  • 2
    Wu A, Coresh J, Selvin E, Tanaka H, Heiss G, Hirsch AT, et al. Lower Extremity Peripheral Artery Disease and Quality of Life Among Older Individuals in the Community. J Am Heart Assoc. 2017;6(1):e004519.
  • 3
    Ritti-Dias RM, Correia MA, Andrade-Lima A, Cucato GG. Exercise as a therapeutic approach to improve blood pressure in patients with peripheral arterial disease: current literature and future directions. Expert Rev Cardiovasc Ther. 2019;17(1):65-73.
  • 4
    Bhatt DL, Steg PG, Ohman EM, Hirsch AT, Ikeda Y, Mas JL, et al. International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA. 2006;295(2):180-9.
  • 5
    Svensson P, de Faire U, Niklasson U, Ostergren J. Office blood pressure underestimates ambulatory blood pressure in peripheral arterial disease in comparison to healthy controls. J Hum Hypertens. 2004;18(3):193-200.
  • 6
    Lima A, Chehuen M, Cucato GG, Soares AHG, Askew CD, Barbosa J, et al. Relationship between walking capacity and ambulatory blood pressure in patients with intermittent claudication. Blood Press Monit. 2017;22(3):115-21.
  • 7
    Chehuen M, Cucato GG, Carvalho CRF, Ritti-Dias RM, Wolosker N, Leicht AS, et al. Walking training at the heart rate of pain threshold improves cardiovascular function and autonomic regulation in intermittent claudication: A randomized controlled trial. J Sci Med Sport. 2017;20(10):886-92.
  • 8
    Yang WY, Melgarejo JD, Thijs L, Zhang ZY, Boggia J, Wei FF, et al. Association of Office and Ambulatory Blood Pressure With Mortality and Cardiovascular Outcomes. JAMA. 2019;322(5):409-20.
  • 9
    Gomes APF, Correia MA, Soares AHG, Cucato GG, Lima A, Cavalcante BR, et al. Effects of Resistance Training on Cardiovascular Function in Patients With Peripheral Artery Disease: A Randomized Controlled Trial. J Strength Cond Res. 2018;32(4):1072-80.
  • 10
    Mena LJ, Felix VG, Melgarejo JD, Maestre GE. 24-Hour Blood Pressure Variability Assessed by Average Real Variability: A Systematic Review and Meta-Analysis. J Am Heart Assoc. 2017;6(10):e006895.
  • 11
    Cardoso CG, Jr., Gomides RS, Queiroz AC, Pinto LG, da Silveira Lobo F, Tinucci T, et al. Acute and chronic effects of aerobic and resistance exercise on ambulatory blood pressure. Clinics (Sao Paulo). 2010;65(3):317-25.
  • 12
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Publication Dates

  • Publication in this collection
    17 May 2021
  • Date of issue
    May 2021

History

  • Received
    21 Nov 2019
  • Reviewed
    03 Feb 2020
  • Accepted
    16 Mar 2020
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