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Acute Effect of Interval vs. Continuous Exercise on Blood Pressure: Systematic Review and Meta-Analysis

Abstract

Background

Continuous aerobic exercise (CE) is one of the main non-pharmacological recommendations for hypertension prevention and treatment. CE is safe and effective to reduce blood pressure chronically, as well as in the first few hours after its performance, a phenomenon known as post-exercise hypotension (PEH). Interval exercise (IE) also results in PEH.

Objective

This systematic review and meta-analysis sought to compare the magnitude of PEH between CE and IE in adults.

Methods

A systematic review of studies published in journals indexed in the PubMed, Web of Knowledge, Scopus and CENTRAL databases was performed until March 2020, which compared the magnitude of PEH between CE and IE. PEH was defined as between 45-60 minutes post-exercise. The differences between groups on blood pressure were analyzed using the random effects model. Data were reported as weighted mean difference (WMD) and 95% confidence interval (CI). A p-value <0.05 was considered statistically significant. The TESTEX scale (0-15) was used to verify the methodological quality of the studies.

Results

The IE showed a higher magnitude of PEH on systolic blood pressure (WMD: -2.93 mmHg [95% CI: -4.96, -0.90], p = 0.005, I2 = 50%) and diastolic blood pressure (WMD: -1,73 mmHg [IC95%: 2,94, -0,51], p= 0.005, I2= 0%) when compared to CE (12 studies, 196 participants). The scores of the studies on the TEXTEX scale varied from 10 to 11 points.

Conclusions

The IE resulted in a higher magnitude of PEH when compared to CE between 45 and 60 minutes post-exercise. The absence of adverse event data during IE and CE in the studies prevents comparisons of the safety of these strategies. (Arq Bras Cardiol. 2020; 115(1):5-14)

Hypertension; Blood Pressure; Post-Exercise Hypotension; Exercise Therapy; Exercise; Review

Resumo

Fundamento

O exercício aeróbio contínuo (EC) é uma das principais recomendações não farmacológicas para prevenção e tratamento da hipertensão arterial sistêmica. O EC é seguro e eficaz para reduzir a pressão arterial cronicamente, assim como nas primeiras horas após sua realização, fenômeno conhecido por hipotensão pós-exercício (HPE). O exercício intervalado (EI) também gera HPE.

Objetivo

Essa revisão sistemática e metanálise buscou comparar a magnitude da HPE entre o EC e EI em adultos.

Métodos

Realizou-se uma revisão sistemática de estudos publicados em revistas indexadas nas bases PubMed, Web of Knowledge, Scopus e CENTRAL até março de 2020 que compararam a magnitude da HPE entre o EC versus EI. Foi definida HPE entre 45 e 60 minutos pós-exercício. As diferenças entre grupos sobre a pressão arterial foram analisadas por meio do modelo de efeito aleatório. Os dados foram reportados como diferença média ponderada (WMD) e 95% de intervalo de confiança (IC). Valor p menor que 0,05 foi considerado estatisticamente significativo. A escala TESTEX (0 a 15) foi usada para verificação da qualidade metodológica dos estudos.

Resultados

O EI apresentou HPE de maior magnitude sobre a pressão arterial sistólica (WMD: -2,93 mmHg [IC95%: -4,96, -0,90], p = 0,005, I2 = 50%) e pressão arterial diastólica (WMD: -1,73 mmHg [IC95%: -2,94, -0,51], p = 0,005, I2 = 0%) quando comparado ao EC (12 estudos; 196 participantes). A pontuação dos estudos na escala TEXTEX variou entre 10 e 11 pontos.

Conclusões

O EI gerou HPE de maior magnitude quando comparado ao EC entre 45 e 60 minutos pós-exercício. A ausência de dados sobre eventos adversos durante o EI e EC nos estudos impede comparações sobre a segurança dessas estratégias. (Arq Bras Cardiol. 2020; 115(1):5-14)

Hipertensão; Pressão Arterial; Hipotensão Pós Exercício; Terapia por Exercício; Exercício; Revisão

Introduction

Hypertension affects between 30 and 40% of the world’s population.11. Mahajan R. Joint National Committee 8 report: how it differ from JNC 7. Int J Appl Basic Med Res. 2014;4(2):61-2. , 22. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021-104. In Brazil, its prevalence varies from 22.3 to 43.9%, affecting more than 60% of the elderly.33. Malachias MVB, Souza WKSB, Plavnik FL, Rodrigues CIS, Brandão AA, Neves MFT, et al. 7aDiretriz Brasileira De Hipertensão Arterial. Arq Bras Cardiol. 2016;107(3 Suppl 3):1-83. , 44. Picon RV, Fuchs FD, Moreira LB, Fuchs SC. Prevalence of hypertension among elderly persons in urban Brazil: a systematic review with meta-analysis. Am J Hypertens. 2013;26(4):541-8. Hypertension is directly associated with the incidence of heart and cerebrovascular diseases,33. Malachias MVB, Souza WKSB, Plavnik FL, Rodrigues CIS, Brandão AA, Neves MFT, et al. 7aDiretriz Brasileira De Hipertensão Arterial. Arq Bras Cardiol. 2016;107(3 Suppl 3):1-83. responsible for approximately 20% of deaths in individuals over 30 years of age,55. Mansur AP, Favarato D. Mortality due to cardiovascular diseases in Brazil and in the metropolitan region of São Paulo: a 2011 update. Arq Bras Cardiol. 2012;99(2):755-61. in addition to generating costs of around R$ 30.8 billion reais per year.66. Azambuja MIR, Foppa M, Maranhão MF, Achutti AC. Economic burden of severe cardiovascular diseases in Brazil : an estimate based on secondary data. Arq Bras Cardiol. 2008;91(3):148-55. Changes in lifestyle, including physical activity, healthy eating habits, weight reduction and smoking cessation have been strongly recommended for the prevention and treatment of hypertension.11. Mahajan R. Joint National Committee 8 report: how it differ from JNC 7. Int J Appl Basic Med Res. 2014;4(2):61-2. , 33. Malachias MVB, Souza WKSB, Plavnik FL, Rodrigues CIS, Brandão AA, Neves MFT, et al. 7aDiretriz Brasileira De Hipertensão Arterial. Arq Bras Cardiol. 2016;107(3 Suppl 3):1-83. In fact, changes in lifestyle result in reductions in blood pressure (BP) levels, which reduce the risk of cardiovascular events.33. Malachias MVB, Souza WKSB, Plavnik FL, Rodrigues CIS, Brandão AA, Neves MFT, et al. 7aDiretriz Brasileira De Hipertensão Arterial. Arq Bras Cardiol. 2016;107(3 Suppl 3):1-83. , 77. 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 Sport Exerc. 2004;36(3):533-53. , 88. Pescatello LS, MacDonald HV, Lamberti L, Johnson BT. Exercise for hypertension: a prescription update integrating existing recommendations with emerging research. Curr Hypertens Rep. 2015;17(11):87.

Regarding physical exercises, the guidelines for the prevention and treatment of hypertension recommend aerobic exercises performed continuously (CE), mainly of moderate intensity, as they are safe and effective for reducing BP levels, improving the cardiovascular and metabolic risk profile, in addition to increasing cardiorespiratory fitness.33. Malachias MVB, Souza WKSB, Plavnik FL, Rodrigues CIS, Brandão AA, Neves MFT, et al. 7aDiretriz Brasileira De Hipertensão Arterial. Arq Bras Cardiol. 2016;107(3 Suppl 3):1-83. , 99. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71(19):e127-248. The antihypertensive effects of CE can occur acutely,1010. Casonatto J, Polito MD. Post-exercise hypotension : a systematic review. Rev Bras Med Esporte. 2009;15(2):151-7. , 1111. Carpio-Rivera E, Moncada-Jiménez J, Salazar-Rojas W, Solera-Herrera A. Acute effects of exercise on blood pressure: a meta-analytic investigation. Arq Bras Cardiol. 2016;106(5):422-33. a phenomenon known as post-exercise hypotension (PEH), or chronically, after several sessions of physical exercise over weeks or months.1212. Eches EHP, Ribeiro AS, Gerage AM, Tomeleri CM, Souza MF, Nascimento MA, et al. Twenty minutes of post-exercise hypotension are enough to predict chronic blood pressure reduction induced by resistance training in older women. Motriz. 2018;24(1):1-7. , 1313. Cardoso Jr CG, Gomides RS, Queiroz ACC, Pinto LG, Lobo FS, Tinucci T, et al. Acute and chronic effects of aerobic and resistance exercise on ambulatory blood pressure. Clinics. 2010;65(3):317-25. In recent years, special attention has been given to exercises that can enhance the magnitude and duration of PEH, considering that this effect would reduce cardiovascular overload in the hours after the exercise session, thus decreasing the risk of cardiovascular events.1414. Bundy JD, Li C, Stuchlik P, Bu X, Kelly TN, Mills KT, et al. Systolic blood pressure reduction and risk of cardiovascular disease and mortality a systematic review and network meta-analysis. JAMA Cardiol. 2017;2(7):775-81. , 1515. Whelton PK, He J, Appel LJ, Cutler JA, Havas S, Kotchen TA, et al. Primary prevention of hypertension: clinical and public health advisory from The National High Blood Pressure Education Program. JAMA. 2002;288(15):1882-8. Additionally, more recent studies have shown that individuals with greater PEH after an exercise session, tend to have a greater reduction in resting BP after weeks of training (i.e., greater chronic effect).1616. Brito LC, Fecchio RY, Peçanha T, Andrade-Lima A, Halliwill JR, Forjaz CLM, et al. Post-exercise hypotension as a clinical tool: a ‘“single brick”’ in the wall. J Am Hypertens. 2018;12(12):e59-64. Therefore, the magnitude of PEH seems to predict the magnitude of the chronic antihypertensive effect, which represents an important practical applicability.

PEH can occur with different “doses” of physical exercise, both aerobic and strength.1616. Brito LC, Fecchio RY, Peçanha T, Andrade-Lima A, Halliwill JR, Forjaz CLM, et al. Post-exercise hypotension as a clinical tool: a ‘“single brick”’ in the wall. J Am Hypertens. 2018;12(12):e59-64. In relation to aerobic exercises, a systematic review and previous meta-analysis1111. Carpio-Rivera E, Moncada-Jiménez J, Salazar-Rojas W, Solera-Herrera A. Acute effects of exercise on blood pressure: a meta-analytic investigation. Arq Bras Cardiol. 2016;106(5):422-33. showed that PEH occurs after performing CE and IE, despite being documented mainly after CE, which is the basis for hypertension prevention and treatment recommendations.33. Malachias MVB, Souza WKSB, Plavnik FL, Rodrigues CIS, Brandão AA, Neves MFT, et al. 7aDiretriz Brasileira De Hipertensão Arterial. Arq Bras Cardiol. 2016;107(3 Suppl 3):1-83. , 99. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71(19):e127-248. However, in recent years, IE, whether at vigorous or maximum intensity (“all out”), has been considered an alternative to CE for the improvement of several cardiovascular parameters, such as cardiorespiratory capacity,1717. Milanović Z, Sporiš G, Weston M. Effectiveness of High-Intensity Interval Training (HIT) and Continuous Endurance Training for VO2max improvements: a systematic review and meta-analysis of controlled trials. Sports Med. 2015;45(10):1469-81. vascular function1818. Ramos JS, Dalleck LC, Tjonna AE, Beetham KS, Coombes JS. The Impact of high-intensity interval training versus moderate-intensity continuous training on vascular function : a systematic review and meta-analysis. Sports Med. 2015;45(5):679-92. and clinical BP.1919. Costa EC, Hay JL, Kehler DS, Boreskie KF, Arora RC, Umpierre D, et al. Effects of high-intensity interval training versus moderate- intensity continuous training on blood pressure in adults with pre- to established hypertension : a systematic review and meta-analysis of randomized trials. Sports Med. 2018;48(9):2127-42.

However, it is important to highlight that no direct comparisons were made on the acute effects of CE and IE on BP. Thus, it is not clear whether there is a superiority of the acute antihypertensive effect between exercises, which is an important knowledge gap, as it can help professionals in both hypertension prevention and treatment. Therefore, the aim of this systematic review and meta-analysis was to compare the magnitude of PEH between CE and IE in adults.

Methods

Literature search strategy

The systematic review was carried out following the guidelines of the ‘Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA)’.2020. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions : explanation and elaboration. PLoS Med. 2009;6(7):e1000100. The search for the articles was carried out in PubMed, Web of Knowledge, Scopus and CENTRAL electronic databases. The search strategy used the following descriptors and free terms: “high intensity interval training” [MeSH Terms] OR “high intensity interval exercise” [TIAB] OR “aerobic interval training” [TIAB] OR “aerobic interval exercise” [TIAB] OR “sprint training” [TIAB] OR “sprint” [TIAB] OR “sprint exercise” [TIAB] OR “sprint interval exercise” [TIAB] AND “blood pressure” [MeSH Terms] OR “post-exercise hypotension” [Mesh Terms] OR “post-exercise hypotension” [Mesh Terms] OR “hypotension” [Mesh Terms]. All processes for article search, selection and evaluation were carried out in duplicate and independently.

Eligibility criteria

The eligibility criteria were established according to the PICOS (Population, Intervention, Comparator, Outcomes and Study Design) question.

Population

This review included studies involving adults (18 years or older) of both genders, with no restriction regarding the level of physical activity and BP classification (normotensive, pre-hypertensive and hypertensive). Mean pre-exercise systolic and diastolic BP values were used to classify individuals regarding BP, following the same procedures as other systematic reviews1919. Costa EC, Hay JL, Kehler DS, Boreskie KF, Arora RC, Umpierre D, et al. Effects of high-intensity interval training versus moderate- intensity continuous training on blood pressure in adults with pre- to established hypertension : a systematic review and meta-analysis of randomized trials. Sports Med. 2018;48(9):2127-42. , 2121. Cornelissen VA, Smart NA. Exercise training for blood pressure: a systematic review and meta-analysis. J Am Heart Assoc. 2013;2(1):e004473. and the 7thBrazilian Guidelines on Hypertension.33. Malachias MVB, Souza WKSB, Plavnik FL, Rodrigues CIS, Brandão AA, Neves MFT, et al. 7aDiretriz Brasileira De Hipertensão Arterial. Arq Bras Cardiol. 2016;107(3 Suppl 3):1-83.

Intervention

The classification system for IE proposed by Weston et al.2222. Weston KS, Wisloff U, Coombes JS. High-intensity interval training in patients with lifestyle-induced cardiometabolic disease: a systematic review and meta-analysis. Br J Sports Med. 2014;48(16):1227-34. was used to define the eligibility criteria for this intervention. According to this proposal, repeated stimuli at vigorous intensity (80-100% of peak heart rate - HRpeak) interspersed with periods of recovery (active or passive) are classified as high-intensity interval training, and maximum stimuli (“all out”; or above the peak oxygen consumption load -VO2peak) interspersed with recovery periods (active or passive) are classified as sprint interval exercise. Studies that used the percentage of VO2peak, VO2reserve or rating of perceived exertion (RPE) equivalent to 80-100% of HRpeak according to the American College of Sports Medicine,2323. Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise.. Med Sci Sports Exerc. 2011;43(7):1334-59. were considered eligible, as well as the “all out” protocols. Studies that showed interventions associated with IE, such as another form of exercise (e.g., strength exercises) or nutritional strategy, were not considered for inclusion.

Comparator

The CE was considered as a comparator of the IE. Studies that used the percentage of VO2peak, VO2reserve or RPE equivalent to moderate intensity (i.e., 64-76% of HRpeak) or vigorous intensity (i.e. 77-95% of HRpeak) were considered eligible. Studies that showed interventions associated with CE, such as another type of exercise or nutritional strategy, were not considered for inclusion.

Outcomes

The primary outcome of this review was clinical BP, measured between 45 and 60 minutes post-exercise. This post-exercise time was defined considering that most studies that investigated the effects of CE and IE included measures within that period. Therefore, even though the study analyzed BP beyond 60 minutes post-exercise, this measure was not considered for the meta-analysis.

Study Design

Crossover studies were considered, involving a session of CE and IE, randomized performance order, in English or Portuguese. The search was carried out without a date limit and ended in March 2020.

Data extraction

An electronic spreadsheet was used to extract data from the included articles, according to the eligibility criteria, in duplicate and independently. In case of disagreement, a meeting was held, and a consensus was established between the researchers. The characteristics of the study participants (age, gender, body mass index, level of physical activity, BP classification), characteristics of the exercise sessions (modality, environments, duration, intensity and time spent in the training session), method of BP measurement and post-exercise BP measurement period were extracted and recorded. Absent data in the texts were requested directly from the authors.

Evaluation of study methodological quality

The ‘Tool for the assEssment of Study qualiTy and reporting in Exercise (TESTEX)’ scale was used to assess the methodological quality of the included studies,2424. Smart NA, Waldron M, Ismail H et al. Validation of a new tool for the assessment of study quality and reporting in exercise training studies: TESTEX. Int J Evid Based Healthc. 2015;13(1):9-18. also in duplicate and independently. In case of disagreement, a meeting was held, and consensus was established between the researchers.

Quantitative synthesis

The changes (post and pre-intervention) in clinical BP were extracted from each study and expressed as mean ± standard deviation. The data were reported as weighted mean differences (WMD) and 95% confidence interval (95%CI). The heterogeneity (I2) between the studies was calculated. Values > 75% and p <0.10 were used to indicate high heterogeneity.2525. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557-60. The random-effects model was adopted in the presence of low or high statistical heterogeneity. Publication bias was assessed using the funnel plot ( Figure 3 ). The meta-analysis was performed using the Review Manager software (RevMan 5.3, Nordic Cochrane, Denmark). Two studies did not report the standard deviation values in the pre- and post-intervention moments.2626. Rossow L, Yan H, Fahs CA, Ranadive SM, Agiovlasitis S, Wilund KR, et al. Postexercise hypotension in an endurance-trained population of men and women following high-intensity interval and steady-state cycling. Am J Hypertens. 2010;23(4):358-67. , 2727. Angadi SS, Bhammar DM, Gaesser GA. Postexercise hypotension after continuous, aerobic interval, and sprint interval exercise. J Strength Cond Res. 2015;29(10):2888-93. In this case, the values were estimated based on the recommendations of Follman et al.2828. Follmann D, Elliot P, Suh I, Cutler J. Variance imputation for overviews of clinical trials with continuous response. J Clin Epidemiol. 1992;45(7):769-73. For this purpose, the study by Costa et al.2929. Costa EC, Dantas TC, Farias-Junior LF, Frazão DT, Prestes J, Moreira SR, et al. Inter- and intra-individual analysis of post-exercise hypotension following a single bout of high-intensity interval exercise and continuous exercise: a pilot study. Int J Sports Med. 2016;37(13):1038-43. was adopted as the basis. In all analyses, the level of significance adopted was 5%.

Figure 3
Funnel plot of the comparison of interval exercise (IE) vs. continuous exercise (CE) on blood pressure (BP)

Results

Included studies

The search strategy identified 3,252 articles for the initial analysis. After screening the titles, abstracts and excluding duplicate results, 84 studies were selected for full-text analysis. Of these, 72 did not meet the eligibility criteria for inclusion in the study. Additionally, an unpublished study was included in the analyses.3030. Costa EC, Kent DE, Boreskie KF .Acute effect of high-intensity interval vs. moderate-intensity continuous exercise on blood pressure and arterial compliance in hypertensive women with arterial stiffness. Journal Strengh and Conditioning Research. 2020 [ahead print]Figure 1 shows the flowchart of the research results.

Figure 1
PRISMA flowchart of selected studies. BP: blood pressure; CE: aerobic exercises performed continuously; IE: interval exercise; PEH: post-exercise hypotension.

Characteristics of participants

The 12 articles included in the study analyzed clinical BP as the main outcome and none of them reported adverse effects (n = 196; age between 20-75 years; BMI between 21.2-33.0 kg/m2).2626. Rossow L, Yan H, Fahs CA, Ranadive SM, Agiovlasitis S, Wilund KR, et al. Postexercise hypotension in an endurance-trained population of men and women following high-intensity interval and steady-state cycling. Am J Hypertens. 2010;23(4):358-67. , 2727. Angadi SS, Bhammar DM, Gaesser GA. Postexercise hypotension after continuous, aerobic interval, and sprint interval exercise. J Strength Cond Res. 2015;29(10):2888-93. , 2929. Costa EC, Dantas TC, Farias-Junior LF, Frazão DT, Prestes J, Moreira SR, et al. Inter- and intra-individual analysis of post-exercise hypotension following a single bout of high-intensity interval exercise and continuous exercise: a pilot study. Int J Sports Med. 2016;37(13):1038-43.

30. Costa EC, Kent DE, Boreskie KF .Acute effect of high-intensity interval vs. moderate-intensity continuous exercise on blood pressure and arterial compliance in hypertensive women with arterial stiffness. Journal Strengh and Conditioning Research. 2020 [ahead print]

31. Mourot L, Bouhaddi M, Tordi N, Rouillon JD, Regnard J. Short- and long-term effects of a single bout of exercise on heart rate variability: Comparison between constant and interval training exercises. Eur J Appl Physiol. 2004;92(4-5):508-17.

32. Lacombe SP, Goodman JM, Spragg CM, Liu S, Thomas SG. Interval and continuous exercise elicit equivalent postexercise hypotension in prehypertensive men, despite differences in regulation. Appl Physiol Nutr Metab. 2011;36(6):881-91.

33. Graham MJ, Lucas SJ, Francois ME, Stavrianeas S, Parr EB, Thomas KN, et al. Low-volume intense exercise elicits post-exercise hypotension and subsequent hypervolemia, irrespective of which limbs are exercised. Front Physiol. 2016 May 31;7:199.

34. Morales-Palomo F, Ramirez-Jimenez M, Ortega JF et al. Acute hypotension after high-Intensity interval exercise in metabolic syndrome patients. Int J Sports Med. 2017;38(7):560-7.

35. Santos JM, Gouveia MC, Souza Jr FA, Silva Rodrigues CE, Santos JM, Oliveira AJS, et al. Effect of a high-intensity interval training session on post-exercise hypotension and autonomic cardiac activity in hypertensive elderly subjects. J Exerc Physiol. 2018;21(3):58-70.

36. Maya ATD, Assunção MJ, Brito CJ, Vieira E, Rosa TS, Pereira FB, et al. High-intensity interval aerobic exercise induced a longer hypotensive effect when compared to continuous moderate. Sport Sci Health. 2018;14(2):379-85.

37. Boeno FP, Ramis TR, Farinha JB, Moritz C, Santos VP, Oliveira AR, et al. Hypotensive response to continuous aerobic and high-intensity interval exercise matched by volume in sedentary subjects. Int J Cardiovasc Sci. 2019;32(1):48-54.
- 3838. Pimenta FC, Montrezol FT, Dourado VZ, Silva LFM, Borba GA, Oliveira Vieira W, et al. High-intensity interval exercise promotes post-exercise hypotension of greater magnitude compared to moderate-intensity continuous exercise. Eur J Appl Physiol. 2019;119(5):1235-43. Of these, three studies involved 46 normotensive individuals (n = 23 women),2626. Rossow L, Yan H, Fahs CA, Ranadive SM, Agiovlasitis S, Wilund KR, et al. Postexercise hypotension in an endurance-trained population of men and women following high-intensity interval and steady-state cycling. Am J Hypertens. 2010;23(4):358-67. , 2929. Costa EC, Dantas TC, Farias-Junior LF, Frazão DT, Prestes J, Moreira SR, et al. Inter- and intra-individual analysis of post-exercise hypotension following a single bout of high-intensity interval exercise and continuous exercise: a pilot study. Int J Sports Med. 2016;37(13):1038-43. , 3434. Morales-Palomo F, Ramirez-Jimenez M, Ortega JF et al. Acute hypotension after high-Intensity interval exercise in metabolic syndrome patients. Int J Sports Med. 2017;38(7):560-7. with a mean age of 32.67 years, and mean BMI of 24.52 km/m2. The mean systolic and diastolic BP at rest was 118/65.46 mmHg in IE and 117.27 / 64.73 mmHg in CE. Six studies involved 89 pre-hypertensive patients (n = 1 woman),2727. Angadi SS, Bhammar DM, Gaesser GA. Postexercise hypotension after continuous, aerobic interval, and sprint interval exercise. J Strength Cond Res. 2015;29(10):2888-93. , 3131. Mourot L, Bouhaddi M, Tordi N, Rouillon JD, Regnard J. Short- and long-term effects of a single bout of exercise on heart rate variability: Comparison between constant and interval training exercises. Eur J Appl Physiol. 2004;92(4-5):508-17.

32. Lacombe SP, Goodman JM, Spragg CM, Liu S, Thomas SG. Interval and continuous exercise elicit equivalent postexercise hypotension in prehypertensive men, despite differences in regulation. Appl Physiol Nutr Metab. 2011;36(6):881-91.
- 3333. Graham MJ, Lucas SJ, Francois ME, Stavrianeas S, Parr EB, Thomas KN, et al. Low-volume intense exercise elicits post-exercise hypotension and subsequent hypervolemia, irrespective of which limbs are exercised. Front Physiol. 2016 May 31;7:199. , 3636. Maya ATD, Assunção MJ, Brito CJ, Vieira E, Rosa TS, Pereira FB, et al. High-intensity interval aerobic exercise induced a longer hypotensive effect when compared to continuous moderate. Sport Sci Health. 2018;14(2):379-85. , 3737. Boeno FP, Ramis TR, Farinha JB, Moritz C, Santos VP, Oliveira AR, et al. Hypotensive response to continuous aerobic and high-intensity interval exercise matched by volume in sedentary subjects. Int J Cardiovasc Sci. 2019;32(1):48-54. with a mean age of 29.15 years, and mean BMI of 24.68 km/m2. Mean systolic and diastolic BP at rest was 127.22 / 73.12 mmHg in IE and 126.72 / 73.22 mmHg in CE. Four studies involved 61 hypertensive patients (n = 34 women),3030. Costa EC, Kent DE, Boreskie KF .Acute effect of high-intensity interval vs. moderate-intensity continuous exercise on blood pressure and arterial compliance in hypertensive women with arterial stiffness. Journal Strengh and Conditioning Research. 2020 [ahead print] , 3434. Morales-Palomo F, Ramirez-Jimenez M, Ortega JF et al. Acute hypotension after high-Intensity interval exercise in metabolic syndrome patients. Int J Sports Med. 2017;38(7):560-7. , 3535. Santos JM, Gouveia MC, Souza Jr FA, Silva Rodrigues CE, Santos JM, Oliveira AJS, et al. Effect of a high-intensity interval training session on post-exercise hypotension and autonomic cardiac activity in hypertensive elderly subjects. J Exerc Physiol. 2018;21(3):58-70. , 3838. Pimenta FC, Montrezol FT, Dourado VZ, Silva LFM, Borba GA, Oliveira Vieira W, et al. High-intensity interval exercise promotes post-exercise hypotension of greater magnitude compared to moderate-intensity continuous exercise. Eur J Appl Physiol. 2019;119(5):1235-43. mean age of 60,67 years, and mean BMI of 29,97 km/m2and all used antihypertensive medication.

Regarding the BP measurement, of the 12 included studies, four used the auscultatory method (~ 33%), while the others used the oscillometric method in an automatic equipment. All studies used inferential statistics, adopting a value of p ≤ 0.05. Table 1 and 2 shows additional information on the characteristics of the studies and interventions.

Table 1
Characteristics of participants included in the studies

Table 2
Characteristics of the CE and IE sessions of the included studies

Characteristics of interventions

Of the 12 studies included, seven (~ 58%) used a cycle ergometer,2626. Rossow L, Yan H, Fahs CA, Ranadive SM, Agiovlasitis S, Wilund KR, et al. Postexercise hypotension in an endurance-trained population of men and women following high-intensity interval and steady-state cycling. Am J Hypertens. 2010;23(4):358-67. , 2727. Angadi SS, Bhammar DM, Gaesser GA. Postexercise hypotension after continuous, aerobic interval, and sprint interval exercise. J Strength Cond Res. 2015;29(10):2888-93. , 3131. Mourot L, Bouhaddi M, Tordi N, Rouillon JD, Regnard J. Short- and long-term effects of a single bout of exercise on heart rate variability: Comparison between constant and interval training exercises. Eur J Appl Physiol. 2004;92(4-5):508-17.

32. Lacombe SP, Goodman JM, Spragg CM, Liu S, Thomas SG. Interval and continuous exercise elicit equivalent postexercise hypotension in prehypertensive men, despite differences in regulation. Appl Physiol Nutr Metab. 2011;36(6):881-91.

33. Graham MJ, Lucas SJ, Francois ME, Stavrianeas S, Parr EB, Thomas KN, et al. Low-volume intense exercise elicits post-exercise hypotension and subsequent hypervolemia, irrespective of which limbs are exercised. Front Physiol. 2016 May 31;7:199.

34. Morales-Palomo F, Ramirez-Jimenez M, Ortega JF et al. Acute hypotension after high-Intensity interval exercise in metabolic syndrome patients. Int J Sports Med. 2017;38(7):560-7.
- 3535. Santos JM, Gouveia MC, Souza Jr FA, Silva Rodrigues CE, Santos JM, Oliveira AJS, et al. Effect of a high-intensity interval training session on post-exercise hypotension and autonomic cardiac activity in hypertensive elderly subjects. J Exerc Physiol. 2018;21(3):58-70. and five used a treadmill2929. Costa EC, Dantas TC, Farias-Junior LF, Frazão DT, Prestes J, Moreira SR, et al. Inter- and intra-individual analysis of post-exercise hypotension following a single bout of high-intensity interval exercise and continuous exercise: a pilot study. Int J Sports Med. 2016;37(13):1038-43. , 3030. Costa EC, Kent DE, Boreskie KF .Acute effect of high-intensity interval vs. moderate-intensity continuous exercise on blood pressure and arterial compliance in hypertensive women with arterial stiffness. Journal Strengh and Conditioning Research. 2020 [ahead print] , 3636. Maya ATD, Assunção MJ, Brito CJ, Vieira E, Rosa TS, Pereira FB, et al. High-intensity interval aerobic exercise induced a longer hypotensive effect when compared to continuous moderate. Sport Sci Health. 2018;14(2):379-85.

37. Boeno FP, Ramis TR, Farinha JB, Moritz C, Santos VP, Oliveira AR, et al. Hypotensive response to continuous aerobic and high-intensity interval exercise matched by volume in sedentary subjects. Int J Cardiovasc Sci. 2019;32(1):48-54.
- 3838. Pimenta FC, Montrezol FT, Dourado VZ, Silva LFM, Borba GA, Oliveira Vieira W, et al. High-intensity interval exercise promotes post-exercise hypotension of greater magnitude compared to moderate-intensity continuous exercise. Eur J Appl Physiol. 2019;119(5):1235-43. in the exercise sessions. When the IE session was performed on the treadmill, reductions in systolic and diastolic BP of ~ 9.8 and 4.4 mmHg were observed, respectively. When the IE session was performed on a cycle ergometer, the reduction in systolic and diastolic BP was ~ 7.6 and 3.7 mmHg, respectively. The reduction in systolic and diastolic BP after the CE session on the treadmill was ~ 6.2 and 2.5 mmHg, respectively, and the reduction in systolic and diastolic BP in the cycle ergometer was ~ 4.5 and 2.6 mmHg, respectively. The most frequently used IE protocol consisted of 4 minutes at high intensity, followed by 3 minutes,2727. Angadi SS, Bhammar DM, Gaesser GA. Postexercise hypotension after continuous, aerobic interval, and sprint interval exercise. J Strength Cond Res. 2015;29(10):2888-93. , 3434. Morales-Palomo F, Ramirez-Jimenez M, Ortega JF et al. Acute hypotension after high-Intensity interval exercise in metabolic syndrome patients. Int J Sports Med. 2017;38(7):560-7. 2 minutes3535. Santos JM, Gouveia MC, Souza Jr FA, Silva Rodrigues CE, Santos JM, Oliveira AJS, et al. Effect of a high-intensity interval training session on post-exercise hypotension and autonomic cardiac activity in hypertensive elderly subjects. J Exerc Physiol. 2018;21(3):58-70. or 1 minute3131. Mourot L, Bouhaddi M, Tordi N, Rouillon JD, Regnard J. Short- and long-term effects of a single bout of exercise on heart rate variability: Comparison between constant and interval training exercises. Eur J Appl Physiol. 2004;92(4-5):508-17. of active recovery. The other protocols used shorter periods (30 seconds to 3 minutes) at high intensity. The CE protocols, on the other hand, had a constant stimulus, lasting between 30 and 70 minutes.

Table 3 shows the qualitative assessment of the included studies. According to the TESTEX scale (0-15 points), all studies had scores > 10 points. The weakest points in the studies were: lack of allocation concealment (92%),2626. Rossow L, Yan H, Fahs CA, Ranadive SM, Agiovlasitis S, Wilund KR, et al. Postexercise hypotension in an endurance-trained population of men and women following high-intensity interval and steady-state cycling. Am J Hypertens. 2010;23(4):358-67.

27. Angadi SS, Bhammar DM, Gaesser GA. Postexercise hypotension after continuous, aerobic interval, and sprint interval exercise. J Strength Cond Res. 2015;29(10):2888-93.

28. Follmann D, Elliot P, Suh I, Cutler J. Variance imputation for overviews of clinical trials with continuous response. J Clin Epidemiol. 1992;45(7):769-73.
- 2929. Costa EC, Dantas TC, Farias-Junior LF, Frazão DT, Prestes J, Moreira SR, et al. Inter- and intra-individual analysis of post-exercise hypotension following a single bout of high-intensity interval exercise and continuous exercise: a pilot study. Int J Sports Med. 2016;37(13):1038-43. , 3131. Mourot L, Bouhaddi M, Tordi N, Rouillon JD, Regnard J. Short- and long-term effects of a single bout of exercise on heart rate variability: Comparison between constant and interval training exercises. Eur J Appl Physiol. 2004;92(4-5):508-17.

32. Lacombe SP, Goodman JM, Spragg CM, Liu S, Thomas SG. Interval and continuous exercise elicit equivalent postexercise hypotension in prehypertensive men, despite differences in regulation. Appl Physiol Nutr Metab. 2011;36(6):881-91.

33. Graham MJ, Lucas SJ, Francois ME, Stavrianeas S, Parr EB, Thomas KN, et al. Low-volume intense exercise elicits post-exercise hypotension and subsequent hypervolemia, irrespective of which limbs are exercised. Front Physiol. 2016 May 31;7:199.

34. Morales-Palomo F, Ramirez-Jimenez M, Ortega JF et al. Acute hypotension after high-Intensity interval exercise in metabolic syndrome patients. Int J Sports Med. 2017;38(7):560-7.

35. Santos JM, Gouveia MC, Souza Jr FA, Silva Rodrigues CE, Santos JM, Oliveira AJS, et al. Effect of a high-intensity interval training session on post-exercise hypotension and autonomic cardiac activity in hypertensive elderly subjects. J Exerc Physiol. 2018;21(3):58-70.

36. Maya ATD, Assunção MJ, Brito CJ, Vieira E, Rosa TS, Pereira FB, et al. High-intensity interval aerobic exercise induced a longer hypotensive effect when compared to continuous moderate. Sport Sci Health. 2018;14(2):379-85.
- 3737. Boeno FP, Ramis TR, Farinha JB, Moritz C, Santos VP, Oliveira AR, et al. Hypotensive response to continuous aerobic and high-intensity interval exercise matched by volume in sedentary subjects. Int J Cardiovasc Sci. 2019;32(1):48-54. blinding of the evaluator to evaluate the outcome (100%)2626. Rossow L, Yan H, Fahs CA, Ranadive SM, Agiovlasitis S, Wilund KR, et al. Postexercise hypotension in an endurance-trained population of men and women following high-intensity interval and steady-state cycling. Am J Hypertens. 2010;23(4):358-67. , 2727. Angadi SS, Bhammar DM, Gaesser GA. Postexercise hypotension after continuous, aerobic interval, and sprint interval exercise. J Strength Cond Res. 2015;29(10):2888-93. , 2929. Costa EC, Dantas TC, Farias-Junior LF, Frazão DT, Prestes J, Moreira SR, et al. Inter- and intra-individual analysis of post-exercise hypotension following a single bout of high-intensity interval exercise and continuous exercise: a pilot study. Int J Sports Med. 2016;37(13):1038-43. and absence of the reporting of adverse events (75%).2626. Rossow L, Yan H, Fahs CA, Ranadive SM, Agiovlasitis S, Wilund KR, et al. Postexercise hypotension in an endurance-trained population of men and women following high-intensity interval and steady-state cycling. Am J Hypertens. 2010;23(4):358-67. , 2929. Costa EC, Dantas TC, Farias-Junior LF, Frazão DT, Prestes J, Moreira SR, et al. Inter- and intra-individual analysis of post-exercise hypotension following a single bout of high-intensity interval exercise and continuous exercise: a pilot study. Int J Sports Med. 2016;37(13):1038-43.

30. Costa EC, Kent DE, Boreskie KF .Acute effect of high-intensity interval vs. moderate-intensity continuous exercise on blood pressure and arterial compliance in hypertensive women with arterial stiffness. Journal Strengh and Conditioning Research. 2020 [ahead print]
- 3131. Mourot L, Bouhaddi M, Tordi N, Rouillon JD, Regnard J. Short- and long-term effects of a single bout of exercise on heart rate variability: Comparison between constant and interval training exercises. Eur J Appl Physiol. 2004;92(4-5):508-17. , 3333. Graham MJ, Lucas SJ, Francois ME, Stavrianeas S, Parr EB, Thomas KN, et al. Low-volume intense exercise elicits post-exercise hypotension and subsequent hypervolemia, irrespective of which limbs are exercised. Front Physiol. 2016 May 31;7:199.

34. Morales-Palomo F, Ramirez-Jimenez M, Ortega JF et al. Acute hypotension after high-Intensity interval exercise in metabolic syndrome patients. Int J Sports Med. 2017;38(7):560-7.

35. Santos JM, Gouveia MC, Souza Jr FA, Silva Rodrigues CE, Santos JM, Oliveira AJS, et al. Effect of a high-intensity interval training session on post-exercise hypotension and autonomic cardiac activity in hypertensive elderly subjects. J Exerc Physiol. 2018;21(3):58-70.

36. Maya ATD, Assunção MJ, Brito CJ, Vieira E, Rosa TS, Pereira FB, et al. High-intensity interval aerobic exercise induced a longer hypotensive effect when compared to continuous moderate. Sport Sci Health. 2018;14(2):379-85.
- 3737. Boeno FP, Ramis TR, Farinha JB, Moritz C, Santos VP, Oliveira AR, et al. Hypotensive response to continuous aerobic and high-intensity interval exercise matched by volume in sedentary subjects. Int J Cardiovasc Sci. 2019;32(1):48-54.

Table 3
Methodological quality analysis of the included studies

Effect of IE versus CE on clinical BP

Figure 2 (panel A) shows the direct comparison between the effects of IE and CE on systolic BP. The meta-analysis showed a significant difference in favor of IE (WMD: -2.93 mmHg [95% CI: -4.96, -0.90], p = 0.005). Moderate heterogeneity was found for this analysis (I2= 50%; p = 0.01).

Figure 2
Forest plot of the comparison of the effects of interval exercise (IE) vs. continuous exercise (CE) on systolic (panel A) and diastolic (panel B) blood pressure (BP). Results are expressed in delta change (post-exercise blood pressure values - pre-exercise blood pressure values).

A sensitivity analysis showed that the effect in favor of IE on PEH persisted after the removal of each of the included studies.

The direct comparison between the effects of IE and CE on diastolic BP showed a significant difference in favor of IE (WMD: -1.73 mmHg [95% CI: -2.94, -0.51], p = 0.005). Low heterogeneity was found for this analysis (I2= 0%; p = 0.49), as shown in Figure 2 (panel B). In the sensitivity analysis, all studies (one by one) were removed and it was found that only the removal of the study by Maya et al.3636. Maya ATD, Assunção MJ, Brito CJ, Vieira E, Rosa TS, Pereira FB, et al. High-intensity interval aerobic exercise induced a longer hypotensive effect when compared to continuous moderate. Sport Sci Health. 2018;14(2):379-85. from the analysis made the positive result in favor of IE disappear (WMD: -0.99 mmHg [95% CI: -2.30, 0.32], p = 0.14; I2= 0%; p = 0.97).

Discussion

To the best of our knowledge, this is the first systematic review and meta-analysis that directly compared the magnitude of PEH after a session of CE and IE in adults. The main finding of this study is that the IE shows a reduction in systolic and diastolic BP of ~ 3 and 1.3 mmHg, respectively, more than the CE (between 45-60 minutes post-exercise). However, it is important to highlight that this result on diastolic BP has considerable influence of a single study.3636. Maya ATD, Assunção MJ, Brito CJ, Vieira E, Rosa TS, Pereira FB, et al. High-intensity interval aerobic exercise induced a longer hypotensive effect when compared to continuous moderate. Sport Sci Health. 2018;14(2):379-85.

Overall, the present study observed that IE showed a reduction of ~ 8 and 4 mmHg for systolic and diastolic BP, respectively, between 45-60 minutes post-exercise. The reduction observed after CE, however, was ~ 5 and 2.6 mmHg for systolic and diastolic BP, respectively, in the same post-exercise analyzed period. Therefore, a direct comparison (head-to-head) of the effects of these interventions confirmed the superiority of IE over CE in terms of the magnitude of systolic and diastolic PEH between 45-60 minutes. These data are similar to those found in a previous meta-analysis,1111. Carpio-Rivera E, Moncada-Jiménez J, Salazar-Rojas W, Solera-Herrera A. Acute effects of exercise on blood pressure: a meta-analytic investigation. Arq Bras Cardiol. 2016;106(5):422-33. which observed a reduction in systolic BP of 7.1 and 4.0 mmHg and a reduction in diastolic BP of 2.5 and 3.2 mmHg, respectively, for interval and continuous exercise. However, it is important to highlight that not only the interval versus continuous nature was compared in the present meta-analysis, but interventions that specifically involved IE (at vigorous intensity and “all out”) versus CE (at moderate and vigorous intensity), which was not performed in the previous study.1111. Carpio-Rivera E, Moncada-Jiménez J, Salazar-Rojas W, Solera-Herrera A. Acute effects of exercise on blood pressure: a meta-analytic investigation. Arq Bras Cardiol. 2016;106(5):422-33.

Studies have shown that the magnitude of PEH can be related both to the intensity reached during the exercise session,1010. Casonatto J, Polito MD. Post-exercise hypotension : a systematic review. Rev Bras Med Esporte. 2009;15(2):151-7. , 1111. Carpio-Rivera E, Moncada-Jiménez J, Salazar-Rojas W, Solera-Herrera A. Acute effects of exercise on blood pressure: a meta-analytic investigation. Arq Bras Cardiol. 2016;106(5):422-33. , 3939. Forjaz CL, Cardoso CG Jr, Rezk CC, Santaella DF, Tinucci T. Postexercise hypotension and hemodinamics: the role of exercise intensity. J Sports Med Phys Fitness. 2004;44(1):54-62. and to the exercise volume.1111. Carpio-Rivera E, Moncada-Jiménez J, Salazar-Rojas W, Solera-Herrera A. Acute effects of exercise on blood pressure: a meta-analytic investigation. Arq Bras Cardiol. 2016;106(5):422-33. , 4040. MacDonald JR, MacDougall JD, Hogben CD. The effects of exercise duration on post-exercise hypotension. J Hum Hypertens. 2000;14(2):125-9. In the present meta-analysis, most of the included studies ( ~ 66%; n = 8)2929. Costa EC, Dantas TC, Farias-Junior LF, Frazão DT, Prestes J, Moreira SR, et al. Inter- and intra-individual analysis of post-exercise hypotension following a single bout of high-intensity interval exercise and continuous exercise: a pilot study. Int J Sports Med. 2016;37(13):1038-43. equalized the volume, and / or average intensity, and / or total energy expenditure of IE with CE sessions, which can facilitate the understanding of the impact of the exercise nature (interval vs . continuous) and intensity of stimuli on the PEH magnitude. This aspect is important because studies show that when volume and/or mean intensity are equalized, PEH is similar between IE and CE.4141. Cunha GA, Rios ACS, Moreno JR, Braga PL, Campbell CSG, Simões HG, et al. Post-exercise hypotension in hypertensive individuals submitted to aerobic exercises of alternated intensities and constant intensity-exercise. Rev Bras Med Esporte. 2006;12(6):313-7. , 4242. Jones H, George K, Edwards B, Atkinson G. Is the magnitude of acute post-exercise hypotension mediated by exercise intensity or total work done? Eur J Appl Physiol. 2007;102(1):33-40. However, of the studies included in this systematic review, those that showed volume, and / or mean intensity, and / or total energy expenditure equalized between the exercise protocols, mean reductions of -9.7 and -5 mmHg were observed in systolic BP and -4.3 and -2.2 mmHg in diastolic BP, for IE and CE, respectively. The IE protocols that showed lower volume, and/or mean intensity and/or energy expenditure,2626. Rossow L, Yan H, Fahs CA, Ranadive SM, Agiovlasitis S, Wilund KR, et al. Postexercise hypotension in an endurance-trained population of men and women following high-intensity interval and steady-state cycling. Am J Hypertens. 2010;23(4):358-67. , 2727. Angadi SS, Bhammar DM, Gaesser GA. Postexercise hypotension after continuous, aerobic interval, and sprint interval exercise. J Strength Cond Res. 2015;29(10):2888-93. , 3333. Graham MJ, Lucas SJ, Francois ME, Stavrianeas S, Parr EB, Thomas KN, et al. Low-volume intense exercise elicits post-exercise hypotension and subsequent hypervolemia, irrespective of which limbs are exercised. Front Physiol. 2016 May 31;7:199. , 3535. Santos JM, Gouveia MC, Souza Jr FA, Silva Rodrigues CE, Santos JM, Oliveira AJS, et al. Effect of a high-intensity interval training session on post-exercise hypotension and autonomic cardiac activity in hypertensive elderly subjects. J Exerc Physiol. 2018;21(3):58-70. showed mean reductions of -6.2 and -3.4 mmHg in systolic and diastolic BP, respectively, which was slightly higher than the mean reductions in systolic and diastolic BP observed in CE (-4.9 and -3.2 mmHg, respectively). Therefore, high-intensity stimuli seem to have a role in the magnitude of PEH, regardless of whether or not there was volume, and/or mean intensity and / or total energy expenditure equalization.

The mechanisms through which PEH occurs after a CE session are well documented.1313. Cardoso Jr CG, Gomides RS, Queiroz ACC, Pinto LG, Lobo FS, Tinucci T, et al. Acute and chronic effects of aerobic and resistance exercise on ambulatory blood pressure. Clinics. 2010;65(3):317-25. , 1616. Brito LC, Fecchio RY, Peçanha T, Andrade-Lima A, Halliwill JR, Forjaz CLM, et al. Post-exercise hypotension as a clinical tool: a ‘“single brick”’ in the wall. J Am Hypertens. 2018;12(12):e59-64. , 4343. Halliwill JR, Buck TM, Lacewell AN, Romero SA. Postexercise hypotension and sustained postexercise vasodilatation: what happens after we exercise? Exp Physiol. 2013;98(1):7-18. , 4444. Brito LC de, Rezende RA, Silva Jr ND, Tinucci T, Casarini DE, Cipolla-Neto J, et al. Post-exercise hypotension and its mechanisms differ after morning and evening exercise: a randomized crossover study. PLoS One. 2015;10(7):e0132458. The reduction in peripheral vascular resistance has often been attributed as one of the main mechanisms of acute post-exercise BP reduction,4545. Chen CY, Bonham AC. Postexercise hypotension : central mechanisms. Exerc Sport Sci Rev. 2010;38(3):122-7. which is aided by the reduction of sympathetic activity in the vessel due to baroreflex control, which generates prolonged vasodilation.4646. Halliwill JR, Dinenno FA, Dietz NM. Alpha-adrenergic vascular responsiveness during postexercise hypotension in humans. J Physiol. 2003;550(Pt 1):279-86. , 4747. Floras JS, Sinkey CA, Aylward PE, Seals DR, Thoren PN, Mark AL. Postexercise hypotension and sympathoinhibition in borderline hypertensive men. Hypertension. 1989;14(1):28-35. Additionally, local vasodilators, such as prostaglandins and nitric oxide, also play an important role in the occurrence of PEH.4848. Santana HA, Moreira SR, Asano RY, Sales MM, Córdova C, Campbell CS, et al. Exercise intensity modulates nitric oxide and blood pressure responses in hypertensive older women. Aging Clin Exp Res. 2013;25(1):43-8. , 4949. Halliwill JR, Minson CT, Joyner MJ. Effect of systemic nitric oxide synthase inhibition on postexercise hypotension in humans. J Appl Physiol. 2000;89(5):1830-6. In patients with vascular disorders (e.g., the elderly, peripheral arterial disease, and obese individuals), PEH occurs by reducing the stroke volume, due to a decreased preload, which is not compensated by increased heart rate.2626. Rossow L, Yan H, Fahs CA, Ranadive SM, Agiovlasitis S, Wilund KR, et al. Postexercise hypotension in an endurance-trained population of men and women following high-intensity interval and steady-state cycling. Am J Hypertens. 2010;23(4):358-67. , 4545. Chen CY, Bonham AC. Postexercise hypotension : central mechanisms. Exerc Sport Sci Rev. 2010;38(3):122-7. , 5050. Brito LC, Queiroz AC, Forjaz CL. Influence of population and exercise protocol characteristics on hemodynamic determinants of post-aerobic exercise hypotension. Braz J Med Biol Res. 2014;47(8):626-36. The studies that directly compared the acute effects of CE and IE on BP showed that the mechanisms related to PEH between these exercise models seem to be different.2626. Rossow L, Yan H, Fahs CA, Ranadive SM, Agiovlasitis S, Wilund KR, et al. Postexercise hypotension in an endurance-trained population of men and women following high-intensity interval and steady-state cycling. Am J Hypertens. 2010;23(4):358-67. , 3030. Costa EC, Kent DE, Boreskie KF .Acute effect of high-intensity interval vs. moderate-intensity continuous exercise on blood pressure and arterial compliance in hypertensive women with arterial stiffness. Journal Strengh and Conditioning Research. 2020 [ahead print] , 3232. Lacombe SP, Goodman JM, Spragg CM, Liu S, Thomas SG. Interval and continuous exercise elicit equivalent postexercise hypotension in prehypertensive men, despite differences in regulation. Appl Physiol Nutr Metab. 2011;36(6):881-91. , 3434. Morales-Palomo F, Ramirez-Jimenez M, Ortega JF et al. Acute hypotension after high-Intensity interval exercise in metabolic syndrome patients. Int J Sports Med. 2017;38(7):560-7.

In normotensive individuals, Rossow et al.2626. Rossow L, Yan H, Fahs CA, Ranadive SM, Agiovlasitis S, Wilund KR, et al. Postexercise hypotension in an endurance-trained population of men and women following high-intensity interval and steady-state cycling. Am J Hypertens. 2010;23(4):358-67. observed a greater reduction in peripheral vascular resistance and an increase in cardiac output (mediated by an increase in heart rate) after the IE protocol, when compared to the CE. In pre-hypertensive men, Lacombe et al.3232. Lacombe SP, Goodman JM, Spragg CM, Liu S, Thomas SG. Interval and continuous exercise elicit equivalent postexercise hypotension in prehypertensive men, despite differences in regulation. Appl Physiol Nutr Metab. 2011;36(6):881-91. demonstrated that IE resulted in greater changes in baroreflex sensitivity and heart rate variability than CE in the post-exercise period. Morales-Palomo et al.3434. Morales-Palomo F, Ramirez-Jimenez M, Ortega JF et al. Acute hypotension after high-Intensity interval exercise in metabolic syndrome patients. Int J Sports Med. 2017;38(7):560-7. observed, in individuals with metabolic syndrome (normotensive and hypertensive), greater reductions in stroke volume, peripheral vascular resistance, skin vascular resistance, higher blood flow in the skin and greater increases in heart rate after IE, when compared to CE. In middle-aged and elderly hypertensive women, Costa et al.3030. Costa EC, Kent DE, Boreskie KF .Acute effect of high-intensity interval vs. moderate-intensity continuous exercise on blood pressure and arterial compliance in hypertensive women with arterial stiffness. Journal Strengh and Conditioning Research. 2020 [ahead print] found that there was a reduction in peripheral vascular resistance 60 minutes after IE, when compared to the control session, which did not occur after CE. Considered together, IE seems to induce a greater reduction in peripheral vascular resistance post-exercise, when compared to CE. It is important to emphasize that the studies that compared the hemodynamic determinants of PEH between IE and CE are few and involve different populations, which makes it difficult to understand the possible differences between these protocols.

From a clinical point of view, a chronic reduction of 2 mmHg in systolic BP reduces the risk of mortality from stroke by 6% and coronary artery disease by 4%, while a reduction of 5 mmHg decreases 14% and 9% of the risk, respectively.1515. Whelton PK, He J, Appel LJ, Cutler JA, Havas S, Kotchen TA, et al. Primary prevention of hypertension: clinical and public health advisory from The National High Blood Pressure Education Program. JAMA. 2002;288(15):1882-8. A meta-analysis showed that the chronic antihypertensive effect of IE and CE is similar in individuals with prehypertension and hypertension, both on systolic (-6.3 vs . -5.8 mmHg) and diastolic BP (-3.8 vs . -3.5 mmHg) at rest.1919. Costa EC, Hay JL, Kehler DS, Boreskie KF, Arora RC, Umpierre D, et al. Effects of high-intensity interval training versus moderate- intensity continuous training on blood pressure in adults with pre- to established hypertension : a systematic review and meta-analysis of randomized trials. Sports Med. 2018;48(9):2127-42. Regarding the acute antihypertensive effect of exercise, the present review suggests the superiority of IE over CE for both systolic (~ 3 mmHg) and diastolic (~ 1.3 mmHg) BP. However, it is important to note that this effect was observed between 45-60 minutes after the exercise. Therefore, physical exercise must be performed regularly so that the chronic benefits can be attained.

The findings of this study demonstrated that a single session of aerobic exercise is capable of promoting PEH in adults, regardless of the performed stimulus (CE or IE). The magnitude of the PEH was associated to the intensity and interval nature of the exercise, so that the IE generated a greater PEH. However, it is important to emphasize that there are different forms of IE prescription, which makes it impossible to determine a protocol that maximizes PEH.

Despite the new and interesting results, this systematic review has some limitations: i) only four databases were searched for study inclusion; ii) few studies were included in this review; iii) the included studies involved a small number of participants (between 10 and 30 individuals); iv) different BP measurement methods were used in the studies; v) food and water intake control, level of physical activity and other confounding factors were seldom reported in the studies; vi) short post-exercise BP monitoring time, which makes it difficult to understand the duration of PEH between protocols.

Conclusions

This systematic review and meta-analysis of crossover studies suggests that IE induces a PEH of greater magnitude compared to CE, between 45-60 minutes post-exercise in adults, both in systolic (~3 mmHg) and diastolic BP (~1.3 mmHg). However, the clinical importance of these findings should be considered with caution. Future studies comparing the acute effect of IE and CE on ambulatorial BP are required in order to clarify whether, in fact, the difference between these types of exercises has clinical importance regarding acute BP control, both in wakefulness and in sleep.

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  • Study Association
    This article is part of the doctoral dissertation by Raphael José Perrier Melo from Universidade de Pernambuco - UPE
  • Ethics approval and consent to participate
    This article does not contain any studies with human participants or animals performed by any of the authors.
  • Sources of Funding
    There were no external funding sources for this study.

Publication Dates

  • Publication in this collection
    07 Aug 2020
  • Date of issue
    July 2020

History

  • Received
    25 Feb 2019
  • Reviewed
    14 May 2019
  • Accepted
    23 June 2019
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