Any training advice for training a hypertensive client?

Hi Craig,

My first question is, is the medication working? I have many patients on multiple blood pressure medications and still have resting blood pressure values hovering around 150/90ish. Per my policies, I hold exercise if pre-exercise, resting systolic BP is >/=170 or if diastolic BP is >/=100 and send my patients to their doc for evaluation to determine if medication adjustments are warranted.

I think that it was a really good idea to get him cleared by his doc before starting exercise. Does your client have any other comorbidities? Any history of heart disease? Diabetes? You’ll definitely want to take these into consideration as well when determining how to approach his exercise program. If the doc decides to order an exercise stress test, and does it with your client’s medications on board, I would be very interested in his BP response to exercise.

When we exercise, our blood pressure increases, it’s a normal and appropriate physiologic response to the additional stress placed on the body. Aerobic, or cardiovascular exercise normally results in an increase in systolic BP and either no change or a decrease in diastolic BP caused by the arteries in the periphery dilating. Someone with hypertension is at risk for an exaggerated exercise blood pressure response – I prefer that my patients’ exercise BP’s not get beyond 200/100. Weight training also results in an increase in BP, but there is a different physiologic mechanism involved. It is important to emphasize proper breathing techniques and avoiding the Valsalva maneuver, that is holding your breath, while lifting a heavy weight. I would also avoid excessively heavy weight lifting with someone whose resting BP trends tend to be high and/or who has an exaggerated BP response to exercise (i.e. greater than ~ 200/100 during submaximal exercise or 220/110 during a maximal stress test).
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If your patient’s BP is well controlled with medications and he doesn’t have any other medical conditions, and is cleared by his doc to start exercise, then you can treat him like any other client and he should respond appropriately. However, if he has other medical conditions, or if his BP even with medications still runs high, I recommend starting slow and allowing for some training adaptations to occur before progressing him, you should start to see drops in BP in a week or two. If he has an exaggerated exercise BP response, then you really need to let his exercise BP during your training sessions dictate his exercise progression.

The good news is that aerobic exercise is fantastic treatment for lowering blood pressure. The additional blood flow being pumped through the heart during cardiovascular exercise results in the heart muscle becoming stronger and a more efficient pump and over time your client’s blood pressure should drop. In my diabetic, hypertensive patients, most with a history of heart disease, we’ve observed drops in blood pressure of 30 mm Hg over 10-12 weeks of moderate intensity exercise training, 3 days/week.

I hope this was helpful!

Thanks Lauren,

Well he has something wrong with his shoulder and knee (he didn't seem too sure what) and does have a history of heart attack before the age of 55.

I don't know how I can measure his exercise BP, but should I measure his BP before every session to ensure its not over 170/100?

What would you recommend I should do with him training-wise if his doc limits him to moderate intensity exercise? Bearing in mind I'm a home PT not a gym PT. I think circuit training is always a good beginner workout to target all the body etc but it's always high intensity when I do it? Any advice here?

Finally, do you recommend I train him separate to his wife seeing as his wife has no health problems?

Hi Craig,

Forgive my long-windedness with these answers, but it is my hope that I can give you some helpful advice when embarking on a higher risk client and there are some important concepts to keep in mind with this situation. Since your client seems to have a history of coronary heart disease (CAD) his cardiologist should order a stress test prior to him starting exercise. Actually, most cardiologists ask that their patients have a stress test annually since they’re a really good way of determining if there is disease progression. To protect yourself, I would not exercise him until he has been cleared for exercise and you have a written OK from his doc to do so.

I’ve got a couple of questions for you:
-You mentioned a heart attack before 55; how old is he now? Did your client participate in a cardiac rehab program after he was discharged from the hospital? Is he doing any exercise now? Heart patients are almost always instructed to walk regularly; although not everyone follows their cardiologist’s instructions.
-Is your client familiar with his angina symptoms? That is, what someone feels when their heart muscle is not receiving adequate oxygen. Not everyone has the typical chest pain/pressure, left arm pain, jaw pain. Diabetics and women often state that they experienced chest pressure, became incredibly fatigued or have no symptoms at all. I suggest asking your client how did he know that something was wrong when he was having his heart attack? What was he feeling? Someone’s angina symptoms will also present similarly and your patient MUST let you know if he experiences any similar symptoms, even if they’re not as intense as they were during his heart attack. And if he does experience angina, STOP exercise immediately and have him follow up with his cardiologist. Most importantly, does your client experience any angina now?
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Most people with heart disease and histories of heart attacks tend to have very well controlled blood pressures, may have automated BP cuffs at home, and they SHOULD be familiar with their BP trends. Often individuals with CAD are so well controlled that their BP tends to be lower than what is seen with “normal” people and they can become orthostatic (i.e. dizzy when changing from a seated or lying position to a standing one because of blood pooling in the legs and not making it up to the brain). I would inquire with your client if he ever becomes dizzy when rising from a chair or getting out of bed. If this is happening, avoid any quick up and down motions with him.

If your client is familiar with his BP trends and they trend pretty normally and in this case, I’d say less than around 140/90, I would not be terribly concerned about his pre-exercise BP’s. If the stress test was normal and the person running the stress test determined that the BP response to exercise was normal and appropriate, I would not worry about trying to hone your exercise BP skills.

When I worked in a cardiac rehab program and was exercising heart failure patients I would encourage them to find a workout buddy upon being discharged from my care to help them stay motivated and exercise regularly. So I think that it would be OK for you to work with him and his wife together; especially if they tend to have approximately the same fitness level. Because aerobic exercise provides such a great cardiovascular benefit and has been demonstrated over and over again to reduce risk of secondary cardiac events, cardiac patients are encouraged to regularly engage in aerobic exercise and moderate resistance training. Can you get your clients to walk outside, weather permitting? Maybe encourage them to go for brisk walks, include some hills for additional cardiovascular conditioning? Now that I think about it, because I work in a hospital, maybe it would be easier if you could give me an idea what you normally plan for your clients and then we could work together to find some modifications?

How else can I be helpful?

Oh there's been a confusion here! When I said he has a history of heart attack before the age of 55 I meant his father died of one before 55, my fault sorry! He's never had one but has high blood pressure and meds to control it. He has just passed the same age that his father died of a heart attack, but his wife is adamant he start exercising to make sure he lives much longer and doesn't suffer the same fate as his father. If his doctor clears him to enter into vigorous exercise then all is good. However if he is cleared only for moderate intensity exercise then I don't know how to keep it moderate really.

I had already planned to get them both walking more anyway, I bought them pedometers so they can compete with each other each week :) but as for the actual sessions when I'm with them, I want to keep it interesting for both of them. I can always play around with the intensities for both of them, but he's the competitive type and I just know he won't be happy if he has to do moderate exercise while I'm getting his wife doing more vigorous work!

I'm just wondering really, should I just do a whole body resistance training routine, few sets of 8-12 reps in a circuit fashion, but making sure they take small breaks in between exercises to keep HR lower than normal circuit training (whereby you do each exercises in succession)? And then encourage the walking each day for the aerobic benefits? They live near countryside anyway so they have plenty of hills etc to challenge the walking. That way I could focus on resistance training in the sessions and later on introduce little bits of aerobic work progressively?

Thanks for your advice Lauren! Really appreciate it as I've never dealt with someone that has high blood pressure, I don't want anything bad happening!

Hi Craig!

Oh! OK! Well just having a family history of heart disease is a whole lot easier than working with someone who’s actually had a heart attack! :-) So here’s the deal, if all that’s going on is that his blood pressure trends are high, but are controlled with medication, and his doctor cleared him, you should be fine and should not be at a high risk of something happening. You can consider him to be “normal” and not fragile. If his BP trends remain high with medications, then you’ll want to keep things at a slightly lower intensity, especially initially, until the body adapts to the exercise and then just progress him a little bit more slowly than usual.

I’m a big advocate of it’s better to err on the side of caution and gradually work someone up to a higher intensity workout over an exercise session or two rather than start with an intense workout immediately. It builds self-efficacy and helps prevent muscle soreness. A resistance circuit that works large muscle groups should be fine. Again, you might want to start slow, see how they respond, maybe give longer rest breaks or decrease the number of reps or sets initially, but it should not present any health concerns.

Something to keep in mind is that HR and blood pressure are physiologically two different animals. And so while they can influence each other, someone can have a normal resting HR but a high blood pressure and vice versa. In short, HR is controlled by the electrical system in the heart; and blood pressure is part of the plumbing system. If someone has high blood pressure, the HR response to exercise may not be reflective of the BP, especially considering that many blood pressure medications can affect and attenuate the HR response to exercise.

I LOVE your idea of the pedometers! Guidelines recommend accumulating at least 10,000 steps/day. There was new research that was published this summer that found that 7,500 steps/day prevented cardiac events. So I would see if you can get them up to at least 7,500 steps/day.

I work at the veterans hospital here in Washington, DC and have had my fair share of salty vets who still think that they can do now, at 65 what they did when they were 18 and in the military so I understand sometimes needing to rein in a competitive personality. I remind my vets of a couple of things – first, just because you CAN do something, does not necessarily mean that you SHOULD! Second, I remind my patients that we all need to focus on what our own bodies can do and not compare ourselves to others. I’m 5 foot tall (I was measured at 5'1" once and sitll cling on to that once inch! :) ), there is absolutely no way that I will ever be a competitive basketball or volleyball player; so there’s no point in trying to dunk a basketball, I’m just not ever going to be successful!

If you have any other questions, please let me know! And do keep me updated on how things go!

I'm so glad that I can help!

I'm going to list some resources in order from shortest length to longest:
- http://www.exerciseismedicine.org/
Exercise Is Medicine is a joint effort between ACSM and American Medical Assn. and has some really good resources and one pagers for clients and fitness professionals.

- ACSM has a position stand regarding exercise and hypertension. The abstract can be found at http://www.ncbi.nlm.nih.gov/pubmed/15076798. If you cannot access the full text, I'll be happy to email you a pdf copy.

- My colleague, Peter Kokkinos, wrote a book, Physical Activity and Cardiovascular Disease Prevention. Now granted, I am a little biased here because I was consulted often while the book was being written, and my stress test data, albeit a few years old now, is in the book, but I really like the book and refer to it regularly. It's very clearly written and covers all of the basic exercise and heart disease concepts that are important to be aware of when working with individuals with CVD or at risk for developing disease. I found it on amazon.com http://www.amazon.com/Physical-Activity-Cardiovascular-Disease-Prevention/dp/0763756121

If I can be of any additional help, please let me know! Your clients are very lucky to have someone as conscientious as you are working with them!