What exercise regimen is recommended for an adult with hypertension (resting blood pressure ≥180/110 mm Hg)?

Exercise Recommendations for High Blood Pressure (≥180/110 mm Hg)

For adults with severe hypertension (≥180/110 mm Hg), blood pressure must first be controlled with medication before initiating any intensive exercise program; once controlled, the primary recommendation is at least 150 minutes per week of moderate-intensity aerobic exercise (such as brisk walking) on most days of the week, supplemented with low-to-moderate intensity resistance training 2-3 days per week. 1, 2

Critical Safety Precaution for Severe Hypertension

• Do not begin intensive exercise until blood pressure is medically controlled below 180/110 mm Hg, as severe hypertension significantly increases the risk of cardiovascular events during exertion. 2
• Once BP is controlled with medication, exercise can be gradually introduced with careful monitoring. 2

Primary Exercise Prescription: Aerobic Training

Frequency

• 5-7 days per week is optimal for blood pressure control, as the post-exercise hypotensive effect lasts approximately 24 hours. 1, 3, 4
• Minimum of 3-4 days per week if daily exercise is not feasible. 4

Duration

• At least 30 minutes per session, working toward 30-60 minutes. 1, 4
• Total weekly volume of ≥150 minutes (can reach 75 minutes if vigorous intensity). 1, 4
• Sessions can be split into multiple 10-minute bouts throughout the day with comparable BP-lowering effects. 1, 4

Intensity

• Moderate-intensity (50-70% maximum heart rate, Borg RPE 11-13) is the primary recommendation. 1, 3, 4
• This equates to brisk walking that noticeably accelerates heart rate but still allows conversation. 5, 6
• Avoid vigorous-intensity exercise initially in severe hypertension due to increased transient cardiovascular risk. 1, 4

Type

• Brisk walking, jogging, cycling, or swimming using large muscle groups. 1, 2, 4
• Walking is particularly recommended as it requires no equipment, is safe, and has low injury risk. 7

Expected Blood Pressure Reduction

• Aerobic exercise reduces systolic BP by 7-8 mm Hg and diastolic BP by 4-5 mm Hg in hypertensive patients. 4
• Some sources report reductions of 5-10 mm Hg systolic and 2-8 mm Hg diastolic. 4

Supplementary Exercise: Resistance Training

When to Add

• After 4-6 weeks of aerobic exercise without symptoms, add resistance training. 3
• Resistance training should supplement, not replace, aerobic exercise. 2, 4

Prescription

• Frequency: 2-3 days per week. 1, 2, 4
• Intensity: Low-to-moderate (40-60% of 1-repetition maximum). 3
• Volume: 2-3 sets of 10-15 repetitions targeting large muscle groups (squats, push-ups, sit-ups). 1, 3
• Expected additional BP reduction: approximately 4 mm Hg systolic and 2 mm Hg diastolic. 2

Types of Resistance Exercise

• Dynamic resistance training: weight-lifting, circuit training with 8-10 different exercises. 2
• Isometric resistance training: low-to-moderate intensity exercises like hand-grip, plank, wall sit (3 sets of 1-2 minutes contraction). 1

Critical Monitoring and Safety

Medication Considerations

• Beta-blockers blunt heart rate response to exercise; adjust intensity targets accordingly using perceived exertion rather than heart rate. 3, 4
• Perform gradual cool-down after exercise to prevent hypotension, especially when taking antihypertensive medications. 3

Warning Signs to Stop Exercise

• Chest pain, unusual shortness of breath, dizziness, or persistent fatigue lasting >1 hour after exercise. 3
• Avoid Valsalva maneuvers and maximal isometric efforts that acutely spike blood pressure. 3, 4

Monitoring Schedule

• Check blood pressure weekly for the first month after starting the exercise program. 3
• Re-evaluate if symptoms develop or BP remains uncontrolled. 3

Essential Lifestyle Integration

Dietary Sodium Restriction

• Limit sodium intake to approximately 2 grams per day (equivalent to 5 grams or one teaspoon of salt). 1, 3
• This includes both added salt and sodium already in processed foods. 1

Potassium Intake

• Increase dietary potassium in patients with high sodium intake (>5 g/day), as the lower sodium-to-potassium ratio enhances BP reduction. 1
• Avoid excessive supplementation in advanced chronic kidney disease. 1

Weight Management

• Target BMI of 20-25 kg/m² if overweight. 3
• Combine exercise with caloric deficit of 300-500 kcal/day. 3

Common Pitfalls to Avoid

• Starting too intensely: Begin with low-to-moderate intensity and progress gradually over weeks. 3
• Exercising with uncontrolled severe hypertension: Always achieve medical control first. 2
• Relying solely on resistance training: Aerobic exercise must be the foundation. 1, 4
• Inconsistent frequency: Daily or near-daily exercise is significantly more effective than 3 days per week. 3, 4
• Ignoring medication interactions: Adjust exercise prescription based on antihypertensive regimen. 3, 4

Evidence Quality Note

The 2024 European Society of Cardiology guidelines provide the most current and comprehensive exercise recommendations for hypertension, giving Class I evidence for aerobic exercise. 1 However, the evidence base has methodological limitations, with many studies not specifically enrolling patients with established hypertension. 1 Despite these limitations, the consensus across all major guidelines strongly supports the recommendations outlined above. 1, 4