Am J Hypertens. 2013 Aug;26(8):1005-10.

The joint association of physical activity, blood-pressure control, and pharmacologic treatment of hypertension for all-cause mortality risk.

Brown RE, Riddell MC, Macpherson AK, Canning KL, Kuk JL.

School of Kinesiology and Health Science, York University, 4700 Keele Street, Toronto, ON, Canada, M3J 1P3.

 

Abstract

BACKGROUND:

We conducted a study to determine the joint association of physical activity, pharmacologic treatment for hypertension, and the control of blood pressure (BP) on all-cause mortality risk.

METHODS:

The study subjects were 10,665 adults from the Third National Health and Nutrition Examination Survey (NHANES III) and the Continuous NHANES survey (1999-2000 and 2000-2001). Cox proportional hazards analyses were used to estimate differences in mortality risk according to physical activity, pharmacologic treatment for hypertension, and BP control, with physically active, treated, and controlled as the referent category.

RESULTS:

The average follow-up time in the study was 8.6±4.8 years. The main effect of physical activity was significant independently of pharmacologic treatment and BP control (P < 0.001). Physically inactive adults with hypertension had a higher risk of mortality than did physically active adults with treated and controlled hypertension (inactive, treated and controlled hypertension: HR, 1.42; 95% CI, 1.17-1.72; P < 0.01; inactive, treated, and uncontrolled hypertension: HR, 1.55; 95% CI, 1.30-1.84; P < 0.01; inactive, untreated, and uncontrolled hypertension: HR, 1.27; 95% CI, 1.07-1.52, P < 0.01). However, the risk of mortality for physically active adults with hypertension did not differ significantly with or without treatment for hypertension if their hypertension remained uncontrolled (active, treated and uncontrolled hypertension: HR, 1.17; 95% CI 0.98-1.40; P = 0.08; active, untreated and uncontrolled hypertension: HR, 0.90; 95% CI, 0.76-1.08; P = 0.25). Physically active, normotensive individuals had a lower all-cause mortality risk than did the referent group of physically active individuals being treated with antihypertensive medication and who had controlled hypertension (HR, 0.72; 95% CI, 0.60-0.86; P < 0.01), whereas physically inactive, normotensive individuals had a risk of mortality similar to that of the referent group (HR, 1.08; 95% CI, 0.90-1.30; P = 0.42).

CONCLUSION:

Physical activity may be as or even more important than pharmacotherapy for reducing the risk of mortality in adults with hypertension. However, the risk of mortality remained higher for physically active adults with treated and controlled hypertension than did the risk of mortality for physically active normotensive populations. Prevention of hypertension is therefore imperative for reducing the all-cause risk of premature mortality in adults.

KEYWORDS:

NHANES, antihypertensive agent, blood pressure, hypertension, leisure activities, mortality.

PMID: 23690165

 

Supplements:

Hypertension, or high blood pressure, affects about 30% of the U.S. adult population.  Hypertension is a major risk factor for heart attack, heart disease, and stroke, and is associated with early mortality.  Of the individuals who have hypertension, over three quarters are treated with antihypertensive medication.  However, only about half of individuals are able to achieve controlled blood pressure (<140/90 mmHg).  Regular physical activity is recommended for people with hypertension as it has been shown to significantly reduce resting blood pressure, and reduce mortality risk in populations with hypertension.

Although the goal of hypertension management is to achieve normal blood pressure, past research shows mixed results as to whether or not obtaining normal blood pressure actually helps lower risk of premature mortality.  It is also not known if individuals with hypertension who obtain normal blood pressure can achieve a similar mortality risk as individuals without hypertension.

The purpose of this study was to determine the joint association between physical activity, pharmacotherapy, and blood pressure control on mortality risk in adults with and without hypertension.  Our hypothesis was that adults with hypertension who were physically active, treated, and controlled (goal situation), would have a lower mortality risk than all other adults with hypertension, and a similar mortality risk as adults without hypertension.

We used data from 10 665 adults from the Third National Health and Nutrition Examination Survey (NHANES III), and from NHANES continuous 1999-2002 surveys.  Blood pressure was measured during a physical exam and medication use was self-reported.  Physical activity was assessed with a questionnaire.  Because there is evidence that participating in physical activity even once a week is associated with lower mortality risk, we defined individuals as physically active if they participated in moderate or vigorous physical activity at least once a week. Blood pressure was considered to be controlled when blood pressure was <140/90 mmHg (<130/90 mmHg for individuals with type 2 diabetes).

Participants were divided into 8 groups:  2 groups who did not have hypertension and who were either physically active or inactive, and 6 groups who had hypertension and differed by physical activity, medication use, and blood pressure control status.  Cox proportional hazards analyses were used to determine differences in the risk of all-cause mortality between the groups, with hypertensive adults who were physically active, pharmacologically treated, and controlled (goal situation), as the referent group.  Analyses were adjusted for age, sex, education, ethnicity, smoking status, type 2 diabetes, high cholesterol, cardiovascular disease, and body mass index.

Compared to adults with hypertension who were physically active, treated, and controlled, other adults with hypertension who were physically inactive had a higher mortality risk, regardless of treatment or control status (Figure 1).  Surprisingly, adults with hypertension who were physically active had a similar mortality risk regardless of their treatment or control status.  Compared to adults with hypertension who were physically active, treated, and controlled, adults without hypertension who were physically active had a 28% lower mortality risk, and had a similar mortality risk as adults without hypertension who were physically inactive .

The major finding of this study was that in hypertensive populations, physical activity was associated with a dramatically lower mortality risk regardless if individuals were treated with medication, or if they attained blood pressure control.  This suggests that physical activity may be critical for individuals with hypertension, especially for those who do not have their blood pressure controlled with medication.   However, we also found that adults without hypertension who were physically active still had a 28% lower mortality risk compared to adults with hypertension who were physically active, treated, and controlled (goal for hypertension).  Therefore, prevention of hypertension is critical and for populations with hypertension physical activity is very important to prevent premature mortality risk.

Ruth Brown-1

Figure 1.  Mortality risk by physical activity, medication use, and blood control in adults with and without hypertension.  * = significantly different mortality risk compared to adults with hypertension who were physically active, treated, and had controlled blood pressure (goal situation) (P<0.05).

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