High blood pressure (BP) or hypertension is the most common costly but modifiable major risk factor for the development of cardiovascular disease and premature mortality, affecting nearly half (47%) of the U.S. adult population. A recent scientific statement from the American Heart Association (AHA) reinforces physical activity as a critical component of first-line treatment for individuals with mild- to moderate-risk BP. In addition, individuals with elevated BP are encouraged to self-measure BP in the home to (a) confirm a diagnosis of hypertension, (b) rule out white-coat hypertension and (c) evaluate the treatment response of interventions such as exercise. Just the act of BP self-monitoring is associated with improved BP control, but when performed in conjunction with co-interventions (e.g., education, clinician involvement, lifestyle modification) translates to superior BP reductions than self-monitoring alone.
This all sounds great on paper, but putting these guidelines into practice can be challenging. The default care model offers few resources or tools to support patients who are going from 0 to 1. In addition, providers have diminishing bandwidth and incentive to provide initial and/or ongoing behavioral counseling for interventions like exercise or BP self-monitoring. The result is often a very overwhelmed patient who has just been told they have 12 weeks to lower their BP on their own but with no clue where to begin. How much exercise is enough? What BP monitor should I buy? How often should I take my BP? Should I be recording all this data somewhere?
After 12 weeks, the same patient returns for a follow-up visit clutching a crumpled piece of paper with a few BP values scribbled on it, with no corresponding date or documentation of physical activity, rendering this data difficult to make any sense of. Lifestyle intervention never stood a chance!
How can we do better to make sure our most vulnerable patients aren’t “left to their own devices”? Currently, there are few resources for the co-implementation of a structured BP self-monitoring and exercise program. However, exercise professionals are well positioned to serve as a trusted partner in care to unlock the value of patient-generated data into actionable insights that facilitate guideline-directed care. As such, it’s imperative that our field is prepared to support commonly experienced scenarios encountered when working with individuals with hypertension embarking on a behavior-change journey. Table 1 presents an overview of evidence-based best practices (when available) and common sense recommendations derived from clinical and research experience. Note that these guidelines are geared toward exercise professionals but may be useful for any qualified health care professional coordinating a multi-component, condition-specific lifestyle intervention for adults with hypertension.
Table 1. Key Clinical Levers to Support Individuals Initiating an Exercise-Based, Hypertension Self-Management Program
| Key Touchpoints | Recommendations | Quick Resources |
| BP device selection | Patients should be encouraged to select a validated, automated BP device (oscillometric method preferred) intended for home use and that measures BP from the upper arm (if possible). | Patients can be referred to the U.S. Blood Pressure Validated Device Listing as a trusted and non-biased resource to support device selection. |
| BP device training and education | Recommendations for self-measured BP emphasize the importance of ensuring proper BP measurement technique. | Target:BPTM, an AHA/AMA initiative, hosts a suite of educational and practical resources to support patient education, including a Patient Training Checklist tool. |
| BP self-measurement protocol | Guidelines recommend a self-measured BP monitoring of 2 measurements taken at least 1 min apart in the morning and evening (i.e., 4 readings per day) optimally for 7 days (i.e., 28 readings total) with a minimum of 3 days (i.e., 12 readings total). Encourage patients to record time of day, exercise, medication use and other factors that may be useful for interpretation. | Target:BP™ tools such as the SMBP Recording Log can be used to support a standardized protocol to reference in the home. |
| Establish baseline and target goal BP | After baseline home BP is established, ensure all members of care team are aligned with goal BP and exercise intervention (e.g., intensity, the need for pre-participation screening, special considerations) | 2017 Clinical Practice Guidelines for Hypertension |
| Establish ExRx for hypertension | Individuals with hypertension are encouraged to engage in ≥20 – 30 min of low, moderate, or vigorous intensity exercise on most, preferably all, days of the week to total ≥90 to 150+ min per week of continuous or accumulated exercise of any duration. Special emphasis should be placed on a) moderate intensity and b) aerobic or resistance exercise (alone or combined) in addition to neuromotor and flexibility depending on personal preference. | ACSM member resource provided by Pescatello LS summarizes new ExRx for individuals with hypertension. Note that emphasis is no longer placed on aerobic exercise alone and patients should be encouraged to engage in any multi-modal exercise that they enjoy. |
| Provide ongoing high-touch support | In the initial phase of BP self-monitoring, patients may seek technical support. As task self-efficacy and comfort increase, patients will likely shift to require more clinical support (e.g., interpretating BP values).When possible, facilitating BP self-monitoring in a fitness or medical facility gives additional opportunities for training, feedback, education and habit formation. | ACSM Guidelines for Exercise Testing and Prescription, 11th Edition |
| Integrate BP self-monitoring with exercise intervention | In addition to daily BP assessment, patients can be encouraged to measure BP before and after an exercise session. Self-monitoring of BP before and after an exercise session has the potential to provide immediate feedback that BP is lower following exercise (and for some time after), allowing a patient to link their exercise behavior with the positive health outcome of lower BP as a result of exercise. | Methods previously reported by Zaleski et al. PMID: 31058797 |
| Outcomes-based evaluation | Support proper documentation of self-monitoring and exercise interventions, inclusive of daily/weekly averages for exercise characteristics (e.g., frequency, intensity, time, type); BP values; % exercise adherence; and other relevant patient-level measures. | Methods previously reported by Zaleski et al. PMID: 31058797 |
To Summarize
Exercise professionals have an opportunity to contribute tremendous value to a patient-centered, multidisciplinary care team through the provision of (a) upfront education and counseling on the benefits of BP self-monitoring and exercise for prevention, treatment, and control of hypertension; (b) high-touch support in the initial phases of BP self-monitoring; (c) serving as a trusted resource to “quarterback” care, interpret and appraise the BP response to exercise, and escalate to the provider (when necessary); and (d) proper documentation of a structured lifestyle intervention that directly informs and enables guideline-directed care decisions. Whenever possible, an interdisciplinary, collaborative approach involving the patient, health care provider(s) and other members of the care team will largely improve lifestyle and pharmaceutical adherence, translating to greater BP control and overall health, which is the ultimate goal in the treatment of hypertension.
Amanda Zaleski, Ph.D., ACSM-CEP, is a senior scientist in the Department of Preventive Cardiology at Hartford Hospital with clinical and research expertise in the blood pressure response to exercise, digital health interventions, statin-associated muscle symptoms and mechanisms underlying blood clot risk in athletes. Dr. Zaleski was a contributing author for ACSM’s Guidelines for Exercise Testing and Prescription, 11th Edition, and ACSM’s Exercise Testing and Prescription, Seventh Edition; an ACSM Credentialed Evidence Analyst; a project manager for the Hypertension Position Stand Update; and most recently, a proud member of the inaugural editorial group for ACSM’s newest journal, Exercise, Sport, and Movement.
