The effectiveness of aerobic exercise for hypertensive population: A systematic review and meta‐analysis

Abstract

The study aims to evaluate the effectiveness of different durations of aerobic exercise on hypertensive patients. Four electronic databases (PubMed, Embase, Cochrane Library, and Web of Science) were searched from their inception until July 2018. English publications and randomized controlled trials involving aerobic exercise treatment for hypertensive population were included. Two reviewers independently extracted the data. The Cochrane's Risk of Bias tool was used to assess the quality of included studies. In this systematic review, a total of 14 articles were included, involving 860 participants. The quality of the included studies ranged from moderate to high. The results of the meta‐analysis showed that compared with the control group, significant effects of aerobic exercise were observed on reducing systolic blood pressure (SBP) (mean difference [MD] = −12.26 mm Hg, 95% confidence interval [CI] = −15.17 to −9.34, P < 0.05), diastolic blood pressure (DBP; MD = −6.12 mm Hg, 95% CI = −7.76 to −4.48, P < 0.05), and heart rate (MD = −4.96 bpm, 95% CI = −6.46 to −3.43, P < 0.05). In addition, significant reductions were observed in ambulatory DBP (MD = −4.90 mm Hg, 95% CI = −8.55 to −1.25, P < 0.05) and ambulatory SBP (MD = −8.77mm Hg, 95% CI = −13.97 to −3.57, P < 0.05). Therefore, aerobic exercise might be an effective treatment for blood pressure improvement in hypertensive patients. However, the effectiveness between the duration of different treatment needs to be well‐designed and rigorous studies will be required to verify the dataset.

Full text

J Clin Hypertens. 2019;00:1–9. wileyonlinelibrary.com/journal/jch 
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1
©2019 Wiley Periodicals, Inc.
Received:21Februa ry2019
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Revised:27A pril2019
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Accepted:9May2019
DOI : 10.1111/j ch.1358 3
REVIEW PAPER
The effectiveness of aerobic exercise for hypertensive
population: A systematic review and meta‐analysis
Liujiao Cao MM1,2,3 | Xiuxia Li PhD1,2,3 | Peijing Yan MM4 | Xiaoqin Wang PhD2,3 |
Meixuan Li MM1,2,3 | Rui Li MM1,2,3 | Xiue Shi MB5 | Xingrong Liu PhD1 |
Kehu Yang PhD1,2,3,4,5
1SchoolofPublicHealth,Evidence-Based
SocialScienceRe searchCenter,Lanzhou
University,Lan zhou,China
2KeyLaborator yofEvidenceBased
MedicineandKnowledgeTranslationof
GansuProvince,L anzhou,China
3EvidenceB asedMedicineCenter,Scho olof
BasicMedicalSciences,LanzhouUniversit y,
Lanzhou,China
4Instit uteofClinicalResearchandEviden ce
BasedMe dicine ,TheGan suProvin cial
Hospit al,Lanzhou,C hina
5Instit uteforEvid enceBasedRehabilitation
MedicineofGansuP rovince ,Lanzh ou,China
Correspondence
KehuYangandXi ngrongL iu,Evide nce-
BasedMe dicineC enter,Lan zhouUni versit y,
199Dongga ngWestRoa d,Lanzhou
730000,China.
Emails:kehuyangebm20 06@126.co m;
liuxingrong2019@163.com
Funding information
Suppor tedbytheFundam entalResearch
FundsfortheCentr alUnive rsities
(16LZUJBWTD013,18L ZUJBWZX006,
lzujbk y-2018-14):Evidence-bas edSocial
Science sResearch.Chi naMedicalBoard
OpenPro jectFun ding(CMB#17-279):
TrackingandEvaluati ngQuality(T EQ)of
RuralHe althServicesinNWChina:Tool
kitsforruralclinicqualitymanagementand
capacitybuilding.S pecialFundforSof t
Sciencei nGansuProvince(18CX1ZA0 43):
StudyontheMeasu restoImp rovethe
Qualit yofRuralHealthServicesinGa nsu
Province
Abstract
The study aimsto evaluate the effectiveness ofdifferent durations of aerobic ex-
ercise on hypertensive patients. Four electronic databases (PubMed, Embase,
CochraneLibrary,andWebofScience)weresearchedfromtheirinceptionuntilJuly
2018.Englishpublicationsandrandomizedcontrolledtrialsinvolvingaerobicexercise
treatmentforhypertensivepopulationwereincluded.Tworeviewersindependently
extractedthedata.TheCochrane'sRiskofBiastoolwasusedtoassessthequalityof
includedstudies.Inthissystematicreview,atotalof14articleswereincluded,involv-
ing860 participants. Thequality of the included studies ranged from moderate to
high.Theresultsofthemeta-analysisshowedthatcomparedwiththecontrolgroup,
significant effects of aerobic exercise were observed on reducing systolic blood
pressure (SB P)(me an difference [MD] = −12.26 mm Hg, 95% confidence inte rval
[CI]=−15.17to−9.34,P<0.05),diastolicbloodpressure(DBP;MD=−6.12mmHg,
95%CI=−7.76to−4.48,P<0.05),andheartrate(MD=−4.96bpm,95%CI=−6.46
to−3.43,P<0.05).Inaddition,significantreductionswereobserved inambulator y
DBP(MD= −4.90mmHg,95%CI =−8.55to−1.25,P<0.05)andambulatorySBP
(MD=−8.77mmHg,95%CI=−13.97to−3.57,P<0.05).Therefore,aerobicexercise
might be an ef fective treatment for blo od pressure improveme nt in hypertensive
patients.However,theeffectiveness between the durationof differenttreatment
needstobewell-designedandrigorousstudieswillberequiredtoverifythedataset.
1 | INTRODUCTION
Hypertension isamajor worldwide public health concern because
of its high p revalence and co ncomitant risk of c ardiovascula r and
kidney dis ease. In addition , hypertensio n is frequently ass ociated
withdiabetesmellitus,dyslipidemia,andobesity,whichleadtoneg-
ativeoutcomes,such as stroke,myocardialinfarction, renalfailure,
atherosclerosis,andheartfailure.1,2In2015,roughly1.13billionin-
dividualswereaffectedbyhypertensionworldwide,3andi thasbeen
estimatedthatin2025,~1.56 billionindividualswillbeaf fectedby
Liujia oCaoan dXiuxiaL iareco-f irstau thor s.

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hypertension.4Ithaspreviouslybeenshownbymajorpharmaco-
logical trialsthatitisa challenge forsingle-drug therapytocontrol
and maintain the blood pressure of hypertensive patient s within
the normalrange, and in only 25%-62%ofpatientspropercontrol
isachieved.5Inordertocontr olthebl oo dp ressure,m anyin dividuals
require treatment with more than one antihypertensivedrug, how-
ever,suchpracticeincreasesthefinancialburdenandmaygenerate
sideeffects.6 Therefore, inexpensive, safe, and strategies that can
beeasilyimplementedareofutmostimpor tancefortheprevention
ofhypertension.
Aerobic exercise(AE)hasproventobe an effective nonphar-
macological method to treat and prevent coronar y artery dis-
ease,7 cardiovascular disease,8type2diabetesmellitus,
9,10 a nd
hypertension. Moreover, it has been widely recommended by
both European and American hypertension guidelines that AE
can be use d as an adjunct to th e treatment of hype rtension.11
Inpreviousstudies, it hasbeen demonstrated thatAE produces
thepositiveeffectsonsystolicbloodpressure(SBP)anddiastolic
bloodpressure (DBP).12-16 Furthermore, increasing evidence has
indicated that AE has favorable effec ts on cardiovascular risk
factors,cardiacautonomic function, andendothelialpathophys-
iology inindividualswithhypertension.17,1 8Jointguidelinesfrom
the American Heart Association(AHA)and American College of
SportsMedicine(ACSM)haverecommendedmoderate-intensity
AEforaminimumof30minutesperday,5daysaweekorvigor-
ous-intensit y AE for a minimum of 20 minutes per day, 3 days a
week.19 However,the duration of different exercises has differ-
enteffectsonthetreatmentoutcomeofhypertensionpatients.20
Therefore,itisofimport ancetofurtherdiscusswhichtypeofex-
erciseandwhichdurationcanproduceoptimaltreatmentef fect s
inhypertensionpatients.
Considering the potential benefits of AE on health out-
comes, su ch as blood pres sure and hear t rate, we per formed a
comprehensivesystematic review to evaluatethe effectiveness
ofAE in hypertensivepatients andanalyzed the relationshipbe-
tween ch anges in blood pr essure and the dur ation of exercise,
so as to provid e reliable clinic al evidence for the t reatment of
hypertension.
2 | METHODS AND MATERIALS
2.1 | Search strategy
PubMed,Embase,CochraneLibrar y,andWebofSciencedatabases
were searched from inception until July 2018.Our searchwasnot
restri cted based on t he basis of public ation typ e, or year of pub-
lishing.Thesearchtermsandbasicsearchstrategywereasfollows:
(hyper tension OR “high bloo d pressure” OR “hype rtensive”) AND
(“aerobicexercise”OR“aerobicsport”OR“aerobicspor ts”OR“aero-
bic exercis es” OR “enduran ce exercise” OR “end urance exerci ses”)
AND random*.In addition, to ensure a comprehensivedata collec-
tion,re fe re nc esofr el ev an treviewsw er esea rc he dmanuallytoid en -
tifyadditionaleligiblestudies.
2.2 | Study selection
Twore viewers (CL J and LR) indep endently re viewed the tit le and
abstracts of initially selected studies. The full text s of articles
wereretrieved ifthere wasanydoubtabout inclusionof the study.
Disagreements were resolved through discussion or by consulting
a third revi ewer (LXX ). Studies wer e included if th e following cri-
teria were m et: (a) randomi zed controlle d trials (RCT ); (b) enrolle d
participantsbetweentheagesof30and85years, who werediag-
nosed wit h hypertensio n based on clinic al and laborato ry studies
(SBP≥140mmHgandDBP≥90mmHg),notaccompaniedbyother
metabolicorcardiovasculardiseases,noalcoholuseandnonsmok-
ing,able to voluntary join exercise;(c)theexercise grouponlyper-
formed regular AEand thecontrol group did notreceive anytype
exercise,andparticipant sinneithergroupreceivedanytypeofspe-
cialintervention,suchasanimproveddietorachangeinlifestyle;(d)
the study included at least onetype ofquantitative outcome data
(blood p ressure, hea rt rate, ambu latory pres sure blood, o r quality
oflife).Theexclusioncriteriawereasfollows:(a)thestudyincluded
toolit tleinformationordatacouldnotbe obtained,suchasreview
articles,editorials,comments,andprotocols;(b)duplicaterepor tsof
thesamestudy.
2.3 | Data extraction and quality assessment
After se lecting stu dies based on the in clusion and exclusi on cri-
teria,two reviewers(LMX and CLJ) independentlyconductedthe
data extractionbyusingaself-developeddata extractionform. In
caseof anydisagreementbetweenthetworeviewers,afinaldeci-
sionwas obtained by consensusafter discussionandconsultation
with a thir d reviewer (YPJ). Gen eral informat ion about the s tudy
includedthe following:(a)basiccharacterof theincludedresearch
obje ct(a uth or, pu blica tionyea r,s tu dycou nt r y,t hepar ticip antn um-
bersintheaerobicgroupandcontrolgroup,durationoffollow-up);
(b) generaldemographic characteristics (gender ratio, heart rate,
body mas s index [BMI], an d SBP and DBP at b aseline and at t he
endofstudy); (c)inter ventiongroupandcontrolgroupoftimeand
intensit y of exercise. If t he informatio n present was u nclear or if
info rma tio nw asm is sin g,t hecor res pon din ga uth o ro ft hes tud ywa s
contactedviaemail.
Tworeviewers(LRandCLJ)independentlyassessedthequality
of include d studies . Risk of bias was as sessed for e ach study, and
include d using the Coc hrane Risk of B ias Tool for RCT,21,22 which
evaluatedsevensourcesofbias,includingrandomization,allocation
concealment, blinding of participants and personnel, blinding of
outcomeassessment,completenessofoutcomedata,selectiveout-
comereporting,andotherpotentialbias.Eachstudy wasexamined
basedontheabovesevenaspectsandsubsequentlyjudgedasbeing
lowrisk, high risk,or unclear risk.Studies that were scoredashigh
riskofbiasformorethan one keydomain were considered as high
riskof bias.In addition,studiesthatwerescoredaslow risk ofbias
forallkeydomains were considered as lowrisk ofbias. In all other
cases,studieswereconsideredtohaveanunclearriskofbias.23

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2.4 | Statistical analyses
Blood pr essure (SBP, DBP) and hear t rate were cons idered prima ry
outcomes of t he study, and ambu latory blood p ressure and qua lity
oflife were considered secondar youtcomes. Statisticalanalysis was
performed by Cochrane Review Manager (RevMan 5.3) software
(Cochrane).Forcontinuousoutcomes,themeandifference(MDs)and
95%confidenceintervals (CIs)werecalculated.P<0.05wasconsid-
eredstatistically significant. Heterogeneity between studieswas as-
sessedusingtheHigginsI2testandPvalues.IfP < 0.05 and I2>50%,
the rand om effect s model was se lected to cal culate the pool ed ef-
fecti ve size. In other case s, the fixed-ef fects mo del was employed .
Pot en tialmoder at ingf act or so fS BP/DB Pwer eevalu at ed bysubgro up 
analysis,andpublicationbiaswastestedbyfunnelplotanalysis.
3 | RESULTS
3.1 | Literature selection
Basedonthesearchstrategy,atotalof16553studieswereselected
fromtheinitialdatabasesearch.Ofthosestudies,5356studieswere
excluded because of duplication, therefore 11 192 studies were
selec ted for furt her analysis. B y screening of ti tles and abst racts,
10751studieswereexcluded. Afterreading the full textofthere-
maining 4 46 studies , another 433 we re excluded, wh ich included
reviewarticlesandguidelines(n=45),nonrandomizedtrials(n=31),
other intervention studies (n = 136), studies with no mention of
subjectswith hypertension(n = 131),otheroutcomes(n = 79),and
studiesfromwhichobtainrelateddatacouldnotbeobtained(n=5).
Finally, a total of 14 studies were included in the meta-analysis.
The detailed flowchart showing screening process is presented in
Figure1.
3.2 | Study characteristics
Table1showsthemaincharacteristicsofallincludeds tudies.The
14includedstudies involved atotalof860 hypertensivepatients
wereenrolled,andthesamplesizeoftheincludedstudiesranged
from16to217,including444casesintheaerobicsgroupand416
cases in t he control group. T he included fo urteen stu dies were
publishedbetween1985and2018.Inonestudy,onlyfemalepar-
ticipantswereenrolled,inonestudyonlymaleparticipantswere
enrolled,andinsevenstudies,bothmaleandfemaleparticipants
were enrolled. The mean age of the subjects ranged between
39.67and83.4yearsofage.In13studygroups,thebaselineBMI
wasrepor ted, whichrangedfrom 22.48to29.6kg /m2,12study
groups reportedSBP and DBP at baseline, andthe SBP atbase-
linerangedfrom130.3to170.45mmHgandtheDBPatbaseline
ranged fr om 67.5 to 95.2 mm Hg. Th e duration of inter vention
ranged fr om 40 minute s to 6 months. Re garding nat ionality, pa-
ti e n t sin c l uded i nbot h theA E gro u p andc o ntro l gro u p wer e m ain l y
fromGermany,Iran,Taiwan,Ibadan,Japan,andNigeria.Mostpar-
ticipant sinthecontrolgroupswereinstructednottocha ngetheir
usuallifestyle,includingphysicalactivity.Thedurationofexercise
trainin g in the 13 studie s was <8, 8-12, and >12we eks. Amon g
them,3studieshadanexercisedurationof≤8weeks,in8studies,
FIGURE 1 Flowdiagramregarding
thearticleselectionforthemet a-analysis
Records idenfied through
database searching
(
n =16553
)
gnineercS
dedulcnI
ytilibigilE
noitacifitnedI
Addional records idenfied
through other sources
(
n =0
)
Recordsaer duplicates removed
(n =11192 )
RecordsscreenedExcluded based on
screening of tles or abstracts
(n=10751)
Full-text arcles assessed for
eligibility
(n = 446)
Full-text arcles excluded, with
reasons(n =446)
Non-randomised trials :( n=31)
No subjects in
hypertension :( n=131)
Review; Guidelines :( n=45)
No intervenon of sole aerobic
exercise in exercise group (n=112)
No match’s outcomes: (n=79)
Data incompleteness: (n=5)
Included other intervenon in
control group: (n=24)
Arcles included in the
meta-analysis
(n =14)

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CAO et Al.
theexercise durationwasbetween 8-12weeks,andintwostud-
ies,theexercisedurationwasmorethan12weeks.Nosignificant
differencesinbaselineageandBMIwereobservedbetweenthe
aerobicsgroupandthecontrolgroup.
3.3 | Risk of bias
Figure2presents thesummar yoftheriskof biasforeachincluded
study. For the i tem of “random s equence gen eration ,”fi ve studies
usedthemethodsofpropergenerationwithalowriskofbias,three
includedstudieswerescoredasunclearriskofselectionbias,andin
sevenstudies,onlyrandomizationwasmentionedwithoutanyclari-
ficationoftheprocedures performed.Concealmentofallocationto
groupwasunclear in12studies.For outcomeblinding, five studies
adopted a si ngle-blind m ethod to eval uate the inter vention mea s-
ures. Because of objective outcome measures, outcome data were
consideredlowriskin13studies.
3.4 | Meta‐analysis
3.4.1 | Blood pressure analysis
Inatotal of 13 studies (757samples)blood pressure of partici-
pa ntsw asr e por t e d.T h er e sul t s of t hem eta- ana l ysi ssh owe dtha t ,
comp ar edwitht he co nt rolgrou p, SB PandDBP we re si gnifi cantl y
reducedintheAEgroup,andthepooledMDwas−12.26mmHg
(95%C I: −15.17 to −9.34, P<0.05)and−6.12mmHg(95%CI:
–7.76 to −4.48, P < 0.05), respectively. Subgroup analysis of
the SBP sh owed that accord ing to the exercis e duration of t he
AE group using the random effects model (Figure 3), signifi-
cant dif ferences were obse rved between groups at ≤8 wee ks,
8-12 weeks, and more than 12 weeks, the pooled MD was
−16.66mmHg(95%CI:−18.55to−14.76,P<0.05) ,−11.74mmHg
(95%CI: −15.94to −7.54, P<0.05),and−8.84mmHg(95%CI:
−13.52to−4.15,P<0.05),respectively.Subgroupanalysisofthe
TABLE 1 Characteristicsofstudiesincludedinthemeta-analysis
Study name Year Country Group Age
Number of sub‐
jects (AE/C) BMI, kg/m2Follow‐up
Farahani,A.V.40 2010 Iran AE 48.33±10.74 (12/28) 27.44±4. 27 10wk
Control 46.96±11.58 28 .06±3.51
Molmen-Hansen,H.E.26 2012 Norway AE 52.50±7.40 (25/25) 26.8±4.10 12wk
Control 51.30 ± 9.20 28.80±3.7
Maruf.F.A.a28 2013 NA AE 50.80 ± 8.31 (53/50) 27.40±4.96 12wk
Control 54.75±8. 56 25.39±4.61
Maruf,.F.A.b15 2014 Nigeria AE 50. 80 ± 8.31 (45/4 3) 27.45±4.99 12wk
Control 54.75±8. 56 25.41±4.70
Tsai,J.C.12 2004 China AE 4 8.80±6.3 (52/50) 23.6±1.8 10wk
Control 49.30±7.2 23.8 ± 2.2
He,L.25 2018 China AE 58.0 ± 2.0 (20/22) 27.41±2.11 12wk
Control 57.0±2.0 27.65±2.61
Masroor,S.16 2018 India AE 39.67±4.10 (15/13) 29.6±4.4 4wk
Control 41.54 ± 4. 25
Dimeo,F.13 2012 Germany AE 62.80±8 .1 (22/25) 28.9 ± 4.4 8-12wk
Control 67.90±6.2 29.9±4.7
Westhoff,T.H.14 2008 Germany AE 66.10±4.4 (12/12) 28.6±4.4 12wk
Control 68.40±9.1 26.5±3.0
Lima,L .G.41 20 17 Brazil AE 67.80±4.3 (15/14) 28.9 ± 3.5 10wk
control 69.90±5.5 27.6±3.4
Sikiru,L.42 2014 Nigeria AE 58.63±7.22 (112/105) 22.4 8 ± 2.89 8wk
Control 58. 27±6.24 24.16±4.91
Oliveira,J.27 2016 Portugal AE 83.40 ± 3.2 (9/9 ) 28.5 ± 2 .0 40 min
Control 82.70±2. 5 28.0 ± 2. 5
Tsuda,K.43 2003 Japan AE 46.2±1.4 (8/8) 25.2 ± 0.8 6mo
Control 49.0 ± 5.1 24.9 ± 1.1
Duncan,J.24 1985 American AE 21-37(mean:
30.4)
56 NA 16wk
Abbreviations:AE/C:aerobicexercise/controlgroups;AE:aerobicexercise;BMI:bodymassindex.

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CAO et Al .
DBP was performed according to the duration of the AE group
using the random effectsmodel (Figure 4). The pooled MD was
−6.43 mm Hg(95%CI: −7.83 to −5.03,P<0.05),−5.44mmHg
(95% CI: −8.22 to −2.66, P<0.05),and−7.52mmHg(95%CI:
−12.42to−2.62,P<0.05),respectively.
3.4.2 | Heart rate
Insevenstudies12,14,16 ,24-27(316samples),dataforheartrateasso-
ciated wit h each inter vention was sp ecific ally repor ted. The h eart
rate of the AEgroup wassignificantlyreduced compared with the
controlgroup(MD:−4.94,95%CI:–6.46to−3.43,P=0.78,I2=0%)
(Figure5).
3.4.3 | Ambulatory blood pressure
In two st udies,13,26 t he ambulator y blood pre ssure was addr essed
as a specif ic outcome. The met a-analysis of 97 participants indi-
cated tha t AE reduced am bulator y SBP and amb ulatory DB P with
apooledMD−8.77mmHg(95%CI=−13.97to−3.57,P<0.05)and
−4.90mmHg(95%CI=−8.55to−1.25,P<0.05),respectively,when
comparedwithindividualswhodidnotreceiveexerciseinter vention
(Figure6).
3.4.4 | Quality of life
Inonlyonestudy,28specificdataforthequalit yoflifewasrepor ted,
which showed thatsignificantimprovements were observed in the
AEgroupinalldomainsofWHOQoL-BREF(physicalhealth:+23.33,
P<0.05;psychologicalhealth:+18.17,P<0.05;socialrelationships:
+14 .51,  P< 0 .05; environm ent: +11.51,P < 0. 05). However, in the
WHOQoL-BREFscale,thecontrolgrouponlyshowedimprovements
intheareasofphysicalhealth(15.42;P<0.05),psychologicalhealth
(9.70 ; P<0.05),andsocialrelationshipsdomains(9.55;P<0.05).
3.5 | Publication bias
In a total of 13 studies, AE interve ntion with baselin e treatment
alone was performed and the effect of AE on bloodpressure was
evaluated . In this syste matic review, a funne l plot was created t o
check for p ublicati on bias. Neit her changes i n SBP nor chan ges in
DBPrevealedpotentialpublicationbias(Figure7).
4 | DISCUSSION
Inthissystematic review andmeta-analysis, thedatafrom14stud-
ieswerepooledandanalyzed,therebyevaluatingthe effects ofAE
traininginterventionsonbloodpressure,hear trate,andambulator y
blood pressurein atotalof860hypertensivesubjects.Overall,the
result s of the meta-analysi s showed that the bloo d pressure and
heart r ate were improved b y AE training. S ubsequent ly,su bgroup
analyseswereperformedtoevaluatetheinfluenceoftrainingdura-
tionontheefficacyofAE.Subgroupanalysisindicatedthatthe de-
greeofblood pressurereductiondidnotsignificantlydif fer among
trialsinwhichadifferentdurationofAEwasused.
Theef fect ofAE onbloodpressurehasbeenshowninprevious
meta-analyses,2 0, 29, 3 0whichsuggestedthattheAEinterventionde-
creased theriskofincidenthypertension orhadan effectonblood
pressurereduction.Thesefindings wereinaccordance withourre-
sults,showingthatAEcansignificantlyreducebloodpressure(both
SBPandDBP)inhypertensivepatients.Moreover,inthisreview,we
showed tha t the degree of bloo d pressure reduc tion signific antly
differsamongstudiesforalldurationsofexercise(lessthan8weeks,
8-12weeks,and more than12weeks), and AE thatlasts for about
8 weeks may hav e a better ant ihyperte nsive effec t. However, the
small num ber of included s tudies and the h igh risk of bias of the
FIGURE 2 Riskofbiassummary

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CAO et Al.
FIGURE 3 Aerobicexerciseonsystolicbloodpressureinhypertensivepatient s
FIGURE 4 Aerobicexerciseondiastolicbloodpressureinhypertensivepatients

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CAO et Al .
original s tudies may have impa cted this conclusi on. Furthermo re,
insomestudies,31,3 2itwaspointedoutthatseveralimportantvari-
ables,includingdifferencesinAEintensity,frequency,ethnicity,and
hypertensive status, might have someinevitable influenceson the
benefits ofAE in individuals withhypertension.Therefore, consid-
ering the abovefactors,additional studies with largersamplesizes
tocomparethose factors shouldbeconsidered tohelp understand
thesefindings.
It is wort h noting that th e pooled SBP af ter AE showe d a sig-
nificantheterogeneity.The sensitivity analysisshoweda relatively
stable result for SBP after excluding two individual studies,24, 25
whic hindicatedarelativel yhigherhea rtrate,longerdur ationofaer-
obic tra ining or a younge r age. The stu dy present ed by He et al25
demonstrated thatarelativelyhighheartrate with a long-termAE
(12weeks)mightinduceamoresignificantreductiononSBP,which
wassignificantlydifferentfromthatofotherstudies,thereforethis
study wa s removed from t he dataset , which dram atically ch anged
theresults.Hypertensionis achronicage-relateddisease,33 and in
astudybyDuncanetal,24theoverallageofstudyparticipant swas
significantlyyoungercomparedtothatinotherstudies,whichmight
beacontributingfactortothechangeinresults.
Wealsoobservedthat AE inter ventionplayed an activerole in
reducin g heart rate . These eff ects have be en discussed i n several
reviews34 and clinical reports, and similar results were obtained.
Kingsley et al35 concluded that postexercise hear t rate recovery
was influenced by parasympathetic reactivation and sympathetic
recover y to resting le vels, there by reducing th e resting he art rate
by increasing parasympathetic tone improvement in autonomic
modulationwithexercise.InanotherreportbyCornelissenandcol-
leagues,32 it was s tated that the e ffect s on heart rat e were more
pronouncedafterhigherintensityAE.Takentogether,theseabove
reportsshowedevidencethatsupportedourfindings.Sinceonlysix
studies(316participants) havebeen included,which is a relatively
smallsamplesize,therefore,thereliabilityoftheresultsisrelatively
small. Toconfirm these effects, additional trials will berequiredin
thefuture.
RegardingthedesignofRCTsinvolvingAEforhypertension,high
risk of bias ex isted in ran dom sequen ce generation and allo cation
concealment,whichmayhaveresultedinpotentialselectionbias.In
the designandrepor ting of included RCTs,allocationconcealment
was ar gu ab lythewe akes tlinkan dm ayp ot entiallya ffectthere li abil-
ityofthestudyresults.36, 37Inaddition,ourjudgmentonthequality
ofinclusionstudies wasprimarilybasedontheirrepor ts, therefore,
futurestudieswillberequiredtoimprovethequalityoftheoriginal
study researchandavoidtheoccurrenceofvariousbiases,thereby
suggestingthatisstrictlyreferredtotheCONSORTstatement .38,39
FIGURE 5 Effectsofaerobictrainingonhear trateinhypertension
FIGURE 6 Effectsofaerobictrainingonambulatorybloodpressureinhypertension

8
|
CAO et Al.
Comparedwith previous meta-analysespresentedby Montero
etal20andWenetal,29inthecurrentstudy,strictinclusionandex-
clusion criteriawere employed, includinga comprehensive search
strateg y,whichtakesintoaccountawiderrangeofoutcomeindica-
tors(bloodpressure,heartrate,ambulatoryblood pressure,quality
oflife).Inaddition,thecurrentstudyfocusedonthedurationofAE
andsubgroup analysiswasperformed, in which dif ferent durations
ofAE were used to assess the blood pressure of hypertensive pa-
tients.Thus,ourresultsmightbeofgreatvalueforproviding refer-
encesforthecontrolofbloodpressureandheartrateviaAE.
This stu dy has several limi tations. Fir stly, although a com pre-
hensive searchstrategy was conducted, thecurrent studyonly in-
cludedstudiesthatwerewritteni nth eEnglishorChineselang uage.
Therefore,itislikelythatrelevantpublishedorunpublishedstudies
weremissed, however the representativeness of included studies
wasnotaffected.Secondly,because not all included trialswereof
high quali ty, the estimates of t herapeuti c effects m ay have been
impacted.Furthermore,withtheemergenceofnewlyrelatedstud-
ies,theexistingresult smay changes.Whensuchnovel andrelated
newstudiesappear af ter July 2018,thissystematic reviewwillbe
updated.
5 | CONCLUSIONS
The results of this meta-analysisshowed thatAEhas favorable ef-
fectsonblood pressure,heart rate, and ambulatory bloodpressure
ofhypertensivepatients.However,theeffectivenessbetweenthe
duratio n of different t reatments is s till not clear. Our f inding was
based on a small number of studies with evidence of consider-
able st atistical a nd clinical he terogeneit y,and t here is insuf ficient
evidenceofhigh-qualitystudies.Furthermore, high-qualityoriginal
studiesare alsowarranted to confirm themagnitude of the effect
ofdifferentdurationsofAEonchangesinbloodpressureandheart
rateamonghypertensiveindividuals.
ACKNOWLEDGMENTS
The authors would like to thank Jinhui Tian and all members of
Evidence-BasedMedicineCenter,LanzhouUniversity,fortheirhelp
withthisstudy.
CONFLICT OF INTEREST
Wedeclarethatwehavenoconflictofinterest.
AUTHOR'S CONTRIBUTION
LJCaoandXXLi:projectdevelopment,datacollection,analysisand
interpretation, manuscript writing, article revised. PJ Yan:projec t
development, analysis and interpretation, manuscriptwriting, arti-
cle revise d. XQ Wang: data co llection , analysis an d interpret ation,
manuscriptwriting. MX Li: datacollection, analysis and interpreta-
tion. R Li:data analysis and interpretation. XE Shi: data collection,
articlerevised.KHYangandXRLiu:academic oversightandedited
alldraf ts.Allautho rsc rit icallyrev ise dthear ticleforimport antinte l-
lectualcontentandapprovedthefinalversionofthemanuscript.
ORCID
Kehu Yang https://orcid.org/0000-0001-7864-3012
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How to cite this article:CaoL,LiX,YanP,etal.The
effectivenessofaerobicexerciseforhypertensive
population:Asystematicreviewandmet a-analysis.J Clin
Hypertens. 2019;00:1–9. htt ps://doi .o rg /10.1111/j ch .135 83