Comparative efficacy of exercise and anti-hypertensive pharmacological interventions in reducing blood pressure in people with hypertension: A network meta-analysis

Problem

Hypertension is the leading preventable causes of premature morbidity and mortality globally. Recently updated European guidelines are circumspect regarding the perceived efficacy of exercise. This may be because the evidence base underpinning the efficacy of anti-hypertensive medications is well-established with a perceived relative lack of evidence for exercise. We therefore aimed to determine the comparative efficacy of anti-hypertensive medication and exercise interventions on blood pressure reduction in people with hypertension.

Approach

A systematic review was conducted focusing on randomised controlled trials of exercise interventions and first-line anti-hypertensive pharmacotherapy interventions where BP reduction was the primary outcome in those with hypertension. Network meta-analyses were conducted to generate estimates of comparative efficacy of each intervention class in terms of reduction of the primary outcomes: systolic and diastolic BP.

Findings

We identified 93 RCTs with a total of 32,404 participants which compared placebo or usual care to first-line antihypertensive interventions and exercise interventions. Of these, there were 81 (87%) trials related to anti-hypertensive medication with 31, 347 (97%) participants and 12 (13%) trials related to exercise with 1, 057 (3%) participants. The mean age of the study participants ranged from 39 to 69.9 years. The mean SBP ranged from 125 mmhg to 193 mmhg, while the mean DBP ranged from 72.8 mmhg to 166 mmhg. The studies formed a connected and consistent network of evidence. For both SBP and DBP, there was not sufficient evidence to suggest that first-line pharmacotherapy interventions significantly reduced BP to a greater extent than did the exercise interventions.

Consequences

The current limited evidence base with a bias towards medication research justifies, perhaps, the circumspection of the European guidelines regarding the efficacy of exercise. In the meantime individual clinicians may justifiably consider trials of exercise for low risk patients who confirm their interest in such an approach.