For people with hypertension, an exercise program may lower blood pressure (BP) almost as effectively as antihypertensive medications, conclude the authors of a meta-analysis of randomized controlled trials (RCTs).

In an analysis of studies that included almost 40,000 patients, evidence-based medical therapy was associated with a greater drop in systolic BP compared to interventions that consisted of exercises for endurance, dynamic resistance, isometric resistance, or both endurance and resistance. But the difference in average BP change was only 3.96 mmHg.

There was no significant difference in the extent to which BP was reduced in an analysis limited to persons with a baseline systolic BP ≥140 mmHg. The study by Huseyin Naci, PhD, London School of Economics and Political Science, United Kingdom, and colleagues was published online December 18 in the British Journal of Sports Medicine.

“These findings could be used to examine and improve the evidence base supporting exercise recommendations,” particularly in light of the fact that recommendations “are primarily based on observational evidence and highly variable across different settings,” the group writes.

On the other hand, the authors highlight the wide variation in sample sizes and methods used in the exercise RCTs. These variations “highlight the need for a more standardized approach to the design, conduct, analysis and reporting of exercise trials,” the investigators state.

Their meta-analysis included 194 studies of the impact of exercise interventions on systolic BP and 197 antihypertensive drug trials reported from 2012 to 2018.

“We need to be cautious about what types of data we’re looking at here,” especially inasmuch as not one RCT compared exercise and medications directly, Naci told theheart.org | Medscape Cardiology.

“We’re just starting to scratch the surface by providing this piece of information,” he said. “We may want to think about nondrug interventions as potential alternatives to drugs in some cases, and blood-pressure lowering seems to be a good start.”

Naci pointed out that recent guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) lower the threshold for stage 1 hypertension from 140 mmHg to 130 mmHg, which “may result in more people being prescribed antihypertensive medication.”

It’s possible, he said, “that some of those individuals may be indicated instead for exercise interventions. But this is very much something that patients should discuss with their doctors, one on one, thinking about all the constraints, as well as their preferences and values and what they want to achieve with their therapies.”

The researchers stress that “it would be very important to evaluate the comparative systolic BP-lowering effects of exercise and medication interventions.”

Guidelines such as those from the AHA/ACC underline the importance of exercise and other lifestyle interventions in managing and treating hypertension, but they tend to consider pharmacologic and nonpharmacologic interventions separately.

The analysis covered 10,461 individuals in exercise-intervention RCTs and 29,281 patients in trials that evaluated BP-lowering medications. All medication trials included people with hypertension, defined as having a systolic BP ≥140 mmHg. People with hypertension were included in some of the exercise trials, which combined accounted for 3508 individuals.

Both forms of intervention reduced systolic BP levels from baseline in comparison with control interventions. Mean reductions were 8.80 mmHg for antihypertensive drugs and 4.84 mmHg for exercise.

Overall, medications achieved greater average reductions in systolic BP than the exercise interventions. The mean reduction difference was 3.96 mmHg.

The different forms of exercise intervention were associated with similar reductions in systolic BP, although endurance and resistance training combined were more effective in reducing systolic BP than dynamic resistance alone (mean reduction difference, 2.96 mmHg).

All classes of antihypertensive drugs were associated with similar reductions in systolic BP. Interestingly, the group notes, most classes of such medications yielded results that were not significantly different from those seen with isometric resistance and with the combination of endurance and dynamic resistance training.

Also of note, exercise interventions were associated with an average 8.96 mmHg greater reduction from baseline compared with the control intervention solely among persons who had hypertension at the start of the trials.

In that higher-risk group, there was no significant difference in reduction in systolic BP between the exercise interventions and medications (mean difference, 0.18 mmHg).

Further analysis indicated that the benefit of exercise interventions on systolic BP in people with hypertension was driven by endurance training, dynamic resistance, and their combination.