Ambulatory Blood Pressure Reduction Following 2 Weeks of High-Intensity

Archives of Cardiovascular Disease (2019) 112, 680—690

Available online at ScienceDirect www.sciencedirect.com

CLINICAL RESEARCH

Ambulatory blood pressure reduction

following 2 weeks of high-intensity interval

training on an immersed ergocycle

Réduction de la pression artérielle ambulatoire suivant 2 semaines

d’entraînement par intervalle à haute intensité sur cycloergomètre immergé

a,b,c,d,e,∗ e,f,g

Philippe Sosner , Mathieu Gayda ,

a,h e,f,i

Olivier Dupuy , Mauricio Garzon ,

j,k,l e

Vincent Gremeaux , Julie Lalongé ,

e e,f,g e,f,g

Douglas Hayami , Martin Juneau , Anil Nigam , a,h,i,m

Laurent Bosquet

Laboratoire MOVE (EA 6314), faculté des sciences du sport, université de Poitiers, 8, allée

Jean-Monnet, 86000 Poitiers, France

Service de cardiologie, CHU de Poitiers, 86000 Poitiers, France

Centre médico-sportif ‘‘Mon Stade’’, 75013 Paris, France

Centre de diagnostic et de thérapeutique, Hôtel-Dieu, AP—HP, 75004 Paris, France

Centre de prévention et de réhabilitation par l’activité physique (ÉPIC), H1T 1N6 Montréal,

QC, Canada

Centre de recherche, institut de cardiologie de Montréal, H1T 1C8 Montréal, QC, Canada

Département de médicine, université de Montréal, H3T 1J4 Montréal, QC, Canada

Faculté des sciences du sport, université de Poitiers, 86000 Poitiers, France

CEPSUM, département de kinésiologie, université de Montréal, H3T 1J4 Montréal, QC, Canada

Unité de médecine du sport, CHU Vaudois, 1011 Lausanne, Switzerland

Université de Lausanne, institut des sciences du sport, 1015 Lausanne, Switzerland

Département de réhabilitation, CHU Dijon Bourgogne, 21000 Dijon, France

Laboratoire LESCA, institut de gériatrie de Montréal, QC H3W 1W5 Montréal, QC, Canada

Received 31 January 2019; received in revised form 26 July 2019; accepted 29 July 2019

Available online 25 September 2019

Abbreviations: ABPM, Ambulatory Blood Pressure Monitoring; BP, Blood Pressure; d, Cohen’s d; DBP, Diastolic Blood Pressure; g, Hedges’

g; HIIT, High-Intensity Interval Training; MICT, Moderate-Intensity Continuous Training; PACES, Physical Activity Enjoyment Scale; POMS,

Proﬁle of Mood States; PPO, Peak Power Output; PWV, Pulse Wave Velocity; SBP, Systolic Blood Pressure.

∗

Corresponding author at: Laboratoire MOVE (EA 6314), faculté des sciences du sport, université de Poitiers, 8, allée Jean-Monnet, 86000

Poitiers, France.

E-mail address: [email protected] (P. Sosner).

https://doi.org/10.1016/j.acvd.2019.07.005

Ambulatory BP response to immersed interval training 681

KEYWORDS Summary

Ambulatory blood Background. — Hypertension guidelines recommend moderate-intensity continuous training

pressure monitoring; (MICT) for the primary or secondary prevention of hypertension. However, alternative modal-

Arterial stiffness; ities, such as high-intensity interval training (HIIT) on dry land or in water, have been studied

High-intensity less widely.

interval training; Aim. — To assess chronic blood pressure (BP) response to a 2-week training programme involving

Proﬁle of Mood six sessions of either MICT or HIIT performed on dry land or HIIT performed in an immersed

States; condition, in participants with baseline ofﬁce systolic/diastolic BP (SBP/DBP) ≥ 130/85 mmHg.

Water-based exercise Methods. — We randomly assigned 42 individuals (mean age 65 7 years; 52% men) with baseline

ofﬁce SBP/DBP ≥ 130/85 mmHg to perform six 24-minute sessions on an ergocycle (three times

a week for 2 weeks) of either MICT on dry land, HIIT on dry land or HIIT in a swimming pool,

and assessed BP responses using 24-hour ambulatory BP monitoring.

Results. — While 2-week MICT and HIIT on dry land modiﬁed none of the 24-hour average haemo-

dynamic variables signiﬁcantly, immersed HIIT induced a signiﬁcant decrease in 24-hour BP

(SBP −5.1 ± 7.3 [P = 0.02]; DBP −2.9 ± 4.1 mmHg [P = 0.02]) and daytime BP (SBP −6.2 ± 8.3

[P = 0.015]; DBP −3.4 ± 4.0 mmHg [P = 0.008]), and slightly improved 24-hour and daytime pulse

wave velocity (PWV) (24-hour PWV −0.17 ± 0.23 m/s [P = 0.015]; daytime PWV −0.18 ± 0.24 m/s

[P = 0.02]).

Conclusion. — HIIT on an immersed stationary ergocycle is an innovative method that should be

considered as an efﬁcient non-pharmacological treatment of hypertension. As such, it should

now be implemented in a larger cohort to study its long-term effects on the cardiovascular

system.

MOTS CLÉS Résumé

Mesure ambulatoire Contexte. — Les recommandations proposent la pratique d’une activité physique aérobie de

de pression type continu à intensité modérée (MICT) pour la prévention et le traitement de l’hypertension

artérielle ; artérielle. Cependant, d’autres modalités, telles que l’entraînement par intervalles à haute

Rigidité artérielle ; intensité (HIIT) sur terre ferme ou dans l’eau, ont été peu étudiées.

Entraînement par Objectifs. — Évaluer la réponse en termes de pression artérielle (PA) ambulatoire suivant un

intervalles de haute programme d’entraînement de 2 semaines comprenant 6 séances de MICT ou HIIT en gymnase,

intensité ; ou d’HIIT effectuées de fac¸on immergée en piscine, chez des personnes avec une PA clinique

≥

Proﬁl des états systolique ou diastolique (PAS/PAD) 130/85 mmHg.

émotionnels ; Méthodes. — Quarante-deux participants (âge moyen de 65 7 ans ; 52 % d’hommes) avec une

≥

Activité physique PAS/PAD clinique 130/85 mmHg ont été inclus, aﬁn d’effectuer 24 min d’exercice sur un ergo-

dans l’eau cycle stationnaire, 3 fois par semaine pendant 2 semaines (soit 6 séances). Ceux-ci ont été

randomisés en 3 groupes : MICT en gymnase, HIIT en gymnase, HIIT en piscine. Les réponses

tensionnelles ont été étudiées par mesure ambulatoire de PA (MAPA) des 24 h.

Résultats. — Bien que les 2 semaines de MICT et d’HIIT en gymnase n’aient pas modiﬁé de fac¸on

signiﬁcative les variables hémodynamiques sur les 24 h, l’HIIT en piscine a induit une diminution

signiﬁcative de PA des 24 h (PAS −5,1 ± 7,3 [p = 0,02] ; PAD −2,9 ± 4,1 mmHg [p = 0,02]) et diurne

(PAS −6,2 ± 8,3 [p = 0,015] ; PAD −3,4 ± 4,0 mmHg [p = 0,008]). Les vitesses de l’onde de pouls

(VOP) des 24 h et diurne ont été légèrement améliorées (VOP 24 h −0,17 ± 0,23 m/s [p = 0,015] ;

VOP diurne −0,18 ± 0,24 m/s [p = 0,02]).

Conclusion. — L’HIIT sur cycloergomètre stationnaire immergé en piscine est une méthode inno-

vante qui devrait être considérée comme un traitement non pharmacologique efﬁcace de

l’hypertension artérielle. À ce titre, il serait intéressant d’étudier ses effets cardiovasculaires

à plus long terme et plus grande échelle.

682 P. Sosner et al.

Background guidelines of the Tri-Council Policy Statement (TCPS), each

participant provided written informed consent, and the

High blood pressure (BP) is a common disease, with more research protocol was approved by the Research Ethics

than 1 billion cases worldwide; it is associated with and New Technology Development Committee (CÉRDNT) of

many cardiovascular complications, and is responsible for the Montreal Heart Institute (number registration MHI#12-

10.4 million deaths and 208.1 million disability-adjusted 1367).

life-years [1]. Non-drug measures, such as diet and phys-

ical activity, are the ﬁrst-line approach in guidelines for Experimental design

hypertension management [2,3]. The mechanisms of the

hypotensive beneﬁt of physical training are complex and On the ﬁrst visit, participants underwent a medical

are not fully understood. The ‘‘acute’’ BP drop follow- evaluation, with measurement of ofﬁce BP (automated

ing a bout of exercise contributes to the ‘‘chronic’’ oscillometric BP measuring device) and a resting electro-

antihypertensive effect of physical training [4]. In hyper- cardiogram. When inclusion criteria were fulﬁlled, they

tensive individuals, physical training induces both functional were allocated to one of the three groups (MICT, HIIT on

and structural adaptations, with many improvements to dry land [HIITdryland] or HIIT in up-to-the-chest immersed

capillary density and arteriolar wall-to-lumen ratio [5], condition [HIITimmersed]) using a stratiﬁed randomization in

renin-angiotensin-aldosterone system activity and arterial terms of both baseline ofﬁce BP level (mean arterial pres-

≥

stiffness [6], endothelial function [7] and cardiac autonomic sure < 107 or 107 mmHg, corresponding to a mean arterial

modulation [8]. pressure for SBP/DBP of 140/90 mmHg) and antihypertensive

In comparison with the classic mode of moderate- treatment (presence or absence). This stratiﬁed randomiza-

intensity continuous training (MICT) (45—65% of maximal tion in two levels was built by the statistical department,

oxygen consumption [VO2max] in a continuous way) [9] and results were placed inside individual sealed envelopes.

two or three times a week, the antihypertensive effect Then, participants underwent baseline 24-hour ABPM, which

of alternative exercise modalities, such as aerobic high- was followed the day after by a maximal continuous graded

intensity interval training (HIIT) performed on dry land or exercise test. After that, they performed six exercise ses-

in a swimming pool, have been studied less widely. Water sions on a stationary cycle (three times a week for 2 weeks)

immersion theoretically induces an additional antihyper- of either MICT, HIITdryland or HIITimmersed. The design of our

tensive effect compared with dry-land conditions, which study followed the CONSORT diagram illustrated in Fig. A.1.

is mainly explained by a more pronounced reduction in Seven individuals identiﬁed as eligible declined to partici-

peripheral vascular resistance, and also by speciﬁc adapta- pate because of their lack of availability for the six-session

tions to the autonomic control of the cardiovascular system 2-week training programme.

or the endocrine control of blood volume [10,11]. In a

preliminary report, we observed a greater acute antihyper- Maximal continuous graded exercise test

tensive effect of one session of HIIT compared with one

session of MICT, particularly when HIIT was performed in an The baseline maximal exercise test was performed on an

immersed condition [12]. Consequently, we aimed to assess electromagnetically braked cycle ergometer (Ergometrics

the chronic BP response to a 2-week training programme, 800, Ergoline, Blitz, Germany); initial power output was set

involving six sessions of either MICT or HIIT performed on at 30 W, and was increased by 15 W every minute until exer-

dry land or HIIT performed in immersed condition, in parti- cise cessation. Electrocardiographic activity was monitored

cipants with baseline ofﬁce systolic/diastolic BP (SBP/DBP) continuously using a 12-lead electrocardiogram (CASE

≥

130/85 mmHg. We hypothesized that HIIT would be more Marquette ; GE Healthcare, Chicago, IL, USA). Criteria for

effective than MICT in improving 24-hour ambulatory BP exercise cessation were volitional exhaustion, signiﬁcant

monitoring (ABPM) values, and that HIIT in immersed condi- electrocardiogram abnormalities or abnormal BP response.

tion would have an additional effect compared with dry-land The power of the last completed stage was considered as

conditions. the peak power output (PPO, in W) for use as the reference

for training intensity.

Methods Twenty-four-hour ABPM

Participants Twenty-four-hour ABPM was performed with a brachial

cuff-based oscillometric device (Mobil-O-Graph pulse wave

Forty-two participants (22 men, 20 women; mean age analysis monitor; IEM GmbH, Stolberg, Germany), pro-

65 ± 7 years, range 43—80 years) were recruited at grammed to measure BP every 20 min over 24 h [2]. Daytime

the Cardiovascular Prevention and Rehabilitation Cen- and night-time periods were adjusted individually according

tre (ÉPIC) of the Montreal Heart Institute. Inclusion to the times for bed and wake-up notiﬁed by each partici-

criteria were age > 18 years and ofﬁce SBP ≥ 130 mmHg pant. Patients were also asked to ﬁll out a diary indicating

and/or ofﬁce DBP ≥ 85 mmHg. Exclusion criteria were their activities over the 24-hour period. Data were anal-

ofﬁce SBP ≥ 180 mmHg and/or ofﬁce DBP ≥ 110 mmHg, any ysed as average 24-hour, daytime and night-time periods,

contraindications to high-intensity exercise, major car- for SBP/DBP (in mmHg) and heart rate (in bpm). The ﬁrst

diovascular event or procedure within the 12 months 24-hour ABPM was performed before the 2-week training

preceding enrolment, chronic atrial ﬁbrillation, night-time period, and the second one after the last training ses-

professional activity or pregnancy. Following the ethical sion.

Ambulatory BP response to immersed interval training 683

Arterial stiffness

Arterial stiffness was assessed using the same oscillomet-

ric device (Mobil-O-Graph pulse wave analysis monitor), at

rest with the patient in the supine position in a quiet atmo-

sphere for the ﬁrst measurement, and ambulatory every

20 min over the following 24 h. For each BP measurement,

captors in the cuff analysed pulse wave, and ARCSolver soft-

ware (AIT Austrian Institute of Technology, Vienna, Austria)

automatically calculated aortic central BP and pulse wave

velocity (PWV) [13]. This device had previously been val-

idated in a resting condition in comparison with standard

carotid-to-femoral PWV using tonometry [13]. Data were

analysed as resting and average 24-hour, daytime and night-

time periods, for central SBP/central DBP (in mmHg) and

PWV (in m/s).

Figure 1. Schematic illustration of the high-intensity interval

exercise (HIIE) mode. PPO: peak power output.

Subjective appreciation and mood state

The subjective appreciation of the training programme was recovery (Fig. 1). External power output was determined

assessed at the last visit using the ‘‘Physical Activity Enjoy- from pedalling cadence (in rpm) [21]. Each training session

ment Scale’’ (PACES) questionnaire [14]. The ‘‘Proﬁle Of was preceded by a 5-minute warm-up, consisting of ped-

Mood States’’ (POMS) test, which assesses six dimensions of alling at 40 rpm, and was followed by a 5-minute passive

mood (tension, depression, anger, vigour, fatigue and confu- recovery period in a sitting position.

sion) [15,16], was also applied at baseline and at the end of

the programme to assess changes in mood state. Statistical analysis

Training sessions Our study was an exploratory study. At the time of study

conception, we had no data assessing the difference in BP

Participants were asked to refrain from strenuous exercise change between HIIT and MICT programmes for a 2-week

the day before each session, and to arrive fully hydrated to duration and using the ambulatory method. We assumed a

the laboratory, at least 3 h after their last meal. No attempt higher response following 2-week HIIT than MICT, taking into

was made to control meal size or content. Exercise sessions account one study by Ciolac et al. [22] comparing the acute

were performed three times a week, on a stationary bicycle. effects between HIIE and MICE, and another by Molmen-

The MICT session was carried out on an electromagnet- Hansen et al. [23] comparing the chronic effects between

ically braked cycle ergometer (Ergometrics 800, Ergoline, HIIT and MICT for a 12-week programme. For the sample size

◦

Blitz, Germany) in a room at constant temperature (21 C) calculation, assuming a decrease in SBP of 3.5 mmHg in the

and humidity (45%). Each session was preceded by a 5- HIIT groups and of 1.5 mmHg in the MICT group ( = 2 mmHg),

minute warm-up, consisting of cycling at 50 W, followed by with a standard deviation of 4 mmHg reduced to 2.83 mmHg,

a 24-minute period of MICT. Exercise intensity was set at assuming an intraclass correlation at 0.75, for a bilateral

50% of PPO, which was in line with current recommenda- alpha of 0.05 and a power of 80% to demonstrate a signiﬁ-

tions [17]. Exercise duration was set at 24 min to match the cant difference between HIIT groups and MICT group in the

500—1000 METs/min/week recommended by the American SBP variable, the number of subjects required was 54 (18

College of Sports Medicine [9]. A 5-minute period of recovery per group). Unfortunately, the period of inclusion was closed

in a sitting position was proposed at the end of the workout. before we could reach this number of participants, because

The HIITdryland session was carried out on an electro- of logistical limitations.

magnetically braked cycle ergometer, and consisted of a Standard statistical methods were used for the calcu-

5-minute warm-up at 50% of PPO, followed by two 10-minute lation of means and standard deviations. Normal Gaussian

sets of exercise, composed of repeated phases of 15 s of distribution of the data was veriﬁed by the Shapiro-Wilk test.

cycling at 100% of PPO, interspersed by 15 s of passive recov- A two-way analysis of variance was performed to test the

ery. Four minutes of passive recovery were allowed between null hypothesis that dependent variables will not be affected

the two sets, as well as a 5-minute cool-down after the by exercise, whatever the group. Between-group compar-

last 15-second exercise phase, immediately followed by a isons were made with the Bonferroni post-hoc test. Pre-

5-minute period of passive recovery in a seated position versus post-training comparisons were made with Student’s

(Fig. 1) [18,19]. paired t test. The magnitude of the difference was assessed

HIITimmersed was performed on a mechanically braked by the Hedges’ g (g) to assess the effect of intervention,

cycle ergometer (HYDRORIDER , DIESSE, San Lazzaro di and by Cohen’s d (d) to assess the effect of sex. The scale

Savena, Italia) in an indoor swimming pool at constant proposed by Cohen was used for the interpretation of both

◦

temperature (30 C, which is considered thermoneutral for measures, as presented elsewhere [24]. The magnitude of

water exercise) [20]. The protocol was the same as on dry the difference was considered either small (0.2 < |g| ≤ 0.5),

land, with two 10-minute sets of repeated phases of 15 s moderate (0.5 < |g| ≤ 0.8), or large (|g| > 0.8). Calculations

of cycling at 100% of PPO, interspersed by 15 s of passive were carried out with StatView software, version 5.0 (SAS

684 P. Sosner et al.

Institute Inc., Cary, NC, USA). Statistical signiﬁcance was not uniform: 27 participants (64%) had a reduction in their

set at P < 0.05. 24-hour SBP after the training period (seven [50%] in the

MICT group, nine [64%] in the HIITdryland group and 11 [79%]

in the HIITimmersed group; Fig. 2). Regarding the effect of sex,

Results while we observed no difference between men and women

in main baseline characteristics (Table 1) and baseline ABPM

results (24-hour SBP for men 128.8 ± 10.4 and for women

Baseline characteristics of the 42 participants are pre-

128.0 ± 14.2 mmHg, d = 0.1 [P = 0.8]; 24-hour DBP for men

sented in Table 1. Regarding the cardiovascular risk factors,

78.0 8.2 and for women 76.7 ± 8.7 mmHg, d = 0.2 [P = 0.6];

23 (55%) participants had an antihypertensive treatment

24-hour heart rate for men 67.7 ± 11.7 and for women

(angiotensin-converting enzyme inhibitors or angiotensin II

70.5 7.0 bpm, d = −0.3 [P = 0.4]; 24-hour PWV for men

receptor blockers, 50%; thiazide diuretics, 24%; calcium

9.42 1.39 and for women 9.11 ± 1.12, d = 0.2 [P = 0.4]),

channel blockers, 10%; and beta-blockers, 17%), 19 (45%)

improvement in 24-hour SBP was similar in men and women

had a statin for dyslipidaemia, eight (19%) had diabetes

(−3.59 ± 7.58 in men and −3.45 ± 8.19 mmHg in women,

mellitus, three (7%) were current smokers and eight (19%)

d = −0.02 [P = 0.9]), and whatever the group (MICT: d = 0.4

had a personal history of cardiovascular disease. The mean

[P = 0.5]; HIITdryland: d = 0.1 [P = 0.9]; HIITimmersed: d = −0.9

waist circumference and percentage of fat mass were

[P = 0.2]).

98.7 12.6 cm and 39.0 ± 5.7%, respectively, in women, and

± Changes in central BP (Table 2) were similar to those

107.2 9.6 cm and 29.4 ± 4.9%, respectively, in men.

observed in peripheral BP (HIITimmersed: 24-hour central

The number of valid BP measurements taken over the

−

SBP 5.6 6.4 mmHg, g = −0.52 [P = 0.006]; 24-hour cen-

24-hour period, with a minimum of one per hour, was 61 ± 9

−

tral DBP 3.0 4.0 mmHg, g = −0.33 [P = 0.02]; daytime

(percentage of success 85 ± 13%) for baseline ABPM, 59 ± 11

−

± central SBP 5.6 7.0 mmHg, g = −0.49 [P = 0.01]; day-

(82 16%) for post-training ABPM and 61 ± 9 (85 ± 13%) for

−

time central DBP 3.4 ± 4.3 mmHg, g = −0.34 [P = 0.01]).

the last ABPM.

Central SBP also decreased after HIITimmersed during the

The average ABPM results at baseline and changes

night-time (−4.6 ± 7.8 mmHg, g = −0.41; P = 0.006). This

in ambulatory BP load after each condition of train-

exercise condition also resulted in small improvements in

ing are presented in Table 2. Despite the absence of

24-hour and daytime PWV (24-hour PWV −0.17 ± 0.23 m/s,

signiﬁcant difference in between-group analysis of vari-

g = −0.11 [P = 0.015]; daytime PWV −0.18 ± 0.24 m/s, g =

ance analysis, we observed a number of differences in

−

0.12 [P = 0.02]).

ABPM data at baseline versus after exercise. Haemody-

Regarding subjective appreciation of the training pro-

namic measures were not altered signiﬁcantly by MICT

gramme, the PACES score reached 18.9 ± 3.2 (minimum,

or HIITdryland, whatever the period (24-hour, daytime or

8/21; maximum, 21/21), which indicates good apprecia-

night-time). In contrast, HIITimmersed induced a decrease

tion, without signiﬁcant difference between groups (MICT:

in BP and heart rate over the 24-hour and daytime peri-

17.8 ± 4.4; HIITdryland: 18.9 ± 2.6; HIITimmersed: 20.1 ± 2.0).

ods (24-hour SBP −5.1 ± 7.3 mmHg, g = −0.42 [P = 0.02];

The POMS test results at baseline and after the 2-week

24-hour DBP −2.9 ± 4.1 mmHg, g = −0.35 [P = 0.02]; day-

training programme are presented in Table 3. Whereas

time SBP −6.2 ± 8.3 mmHg, g = −0.49 [P = 0.015]; daytime

MICT did not change any dimension of the question-

DBP −3.4 ± 4.0 mmHg, g = −0.35 [P = 0.008]; 24-hour heart

naire, HIITdryland moderately improved the perception of

rate −2.0 ± 2.6 bpm, g = −0.21 [P = 0.01]; daytime heart

fatigue (−4.25 ± 6.36, g = −0.32; P = 0.04) and the energy

rate—2.4 ± 3.9 bpm, g = −0.25 [P = 0.04]). Night/day SBP

index (+6.42 ± 8.11, g = 0.31; P = 0.02), while HIITimmersed

dipping was not modiﬁed by any of the training interven-

− ±

tions. resulted in a moderate decrease in anxiety ( 3.18 4.27,

g = −0.56; P = 0.04) and confusion (−2.66 ± 2.17, g = −0.58;

We did not ﬁnd any interaction between training condi-

P = 0.004).

tions. Furthermore, the BP response following training was

Table 1 Baseline characteristics.

Overall population Men Women MICT HIITdryland HIITimmersed

(n = 42) (n = 22) (n = 20) (n = 14) (n = 14) (n = 14)

Age (years) 65 ± 7 66 ± 8 64 ± 7 65 ± 6 65 ± 8 63 ± 9

Male sex 22 (52.4) — — 8 (57.1) 9 (64.3) 5 (35.7)

Body mass index (kg/m ) 29.7 ± 4.3 30.2 ± 4.0 29.2 ± 4.7 29.7 ± 4.5 30.7 ± 4.7 28.8 ± 3.9

SBP (mmHg) 143.1 ± 13.8 142.5 ± 14.1 143.9 ± 13.7 142.4 ± 11.4 144.2 ± 17.3 142.8 ± 12.9

DBP (mmHg) 85.1 ± 9.2 84.5 ± 10.3 85.7 ± 8.1 81.9 ± 6.2 87.6 ± 11.6 85.9 ± 8.8

a a

Heart rate (bpm) 71.7 ± 12.1 68.0 ± 10.7 75.9 ± 12.4 69.2 ± 11.3 73.6 ± 10.8 72.4 ± 14.3

PWV (m/s) 9.59 ± 1.29 9.65 ± 1.45 9.53 ± 1.25 9.52 ± 1.26 9.86 ± 1.39 9.40 ± 1.26

Data are expressed as mean ± standard deviation or number (%). DBP: diastolic blood pressure; HIITdryland: high-intensity interval

training on dry land; HIITimmersed: high-intensity interval training in immersed condition; MICT: moderate-intensity continuous training;

PWV: PWV, pulse wave velocity; SBP: systolic blood pressure.

P = 0.03 between sexes.

Ambulatory BP response to immersed interval training 685 a g

0.42 0.35 0.21 0.52 0.33 0.11 0.49 0.35 0.25 0.49 0.34 0.12 0.28 0.18 0.15 0.41 0.16 0.08 0.31 Hedge’s − − − − − − − − − − − − − − − − − − − high-intensity 14) b b

: =

b b b b b b b b b b b n ( 0.23 0.24 0.27 BP

7.3 4.1 2.6 6.4 4.0 8.3 4.0 3.9 7.0 4.3 8.2 5.3 3.7 7.8 5.3 4.5

± ± ±

immersed ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±

intervention.

HIIT 6.2 3.4 2.4 5.6 3.4 0.18 3.4 1.4 1.1 4.6 1.3 0.13 1.6 5.1 5.6 2.9 2.0 3.0 0.17

changes Post- training − − − − − − − − − − − − − − − − − − −

land;

training

12.1 10.6 12.7 11.3 12.1 11.2

dry 8.2 7.6 8.7 1.45 9.2 8.8 9.4 1.44 7.7 6.7 7.9 1.46 5.1

± ± ± ± ± ±

± ± ± ± ± ± ± ± ± ± ± ± ±

on immersed

2-week

Baseline 133.9 81.9 71.7 9.26 117.8 68.9 59.9 110.4 69.6 8.85 11.9 the 0.8). training

g |

velocity. g

(

after

interval wave

0.280.210.11 127.6 0.23 76.9 0.25 67.1 117.5 78.0 0.270.23 122.1 83.5 0.34 0.24 0.10 0.11 0.13 0.11 0.03 0.10 0.13 0.03 0.14 0.10 9.11

large

load Hedge’s − − − − − − − − − − − − − − − − − − −

14) HIIT pulse

0.28 0.31 0.23 BP

0.8) n

8.3 5.3 5.0 7.0 5.3 9.6 6.0 5.3 8.5 6.5 7.0 5.4 4.8 6.4 5.2 5.5

( ± ± ± ≤

PWV: | ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±

pressure g

| high-intensity

: 2.3 1.3 2.0 1.4 0.4 1.6 1.5 0.03 1.0 3.4 2.9 3.7 2.9 2.1 1.3 2.4 0.11 2.1 0.13 changes Post- training − − − − − − − − − − − − − − − − − − − (0.5

blood

dryland pressure;

12.2 12.2 11.1 11.2 14.2 14.4

HIIT 9.7 11.0 9.5 1.10 9.4 11.0 9.4 1.07 10.4 10.79 9.8 1.02

± ± ± ± ± ± 5.7

blood ± ± ± ± ± ± ± ± ± ± ± ±

dryland ± moderate

ambulatory Baseline 113.3 74.6 9.26 9.4

0.5), pressure;

systolic in

≤

a | g g |

SBP:

< blood

changes (0.2

0.150.210.06 130.6 0.24 78.7 0.21 72.6 118.7 80.1 0.160.220.06 135.1 0.24 81.8 0.29 77.6 122.1 83.5 0.010.110.02 122.5 0.24 73.5 64.4 0.26 0.03 9.48 0.07 9.61 0.02 − − − − − − − − − − − − − − − Hedge’s − − − training; and

diastolic

small

14) HIIT 0.33 0.46 0.27 BP

8.0 5.3 4.7 9.7 6.1 11.2 6.5 5.4 12.8 8.5 6.0 4.4 4.0 7.1 5.7 0.07 6.7 = DBP:

± ± ±

n ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± either

(

baseline, continuous

2.0 3.2 2.4 3.8 0.1 2.5 1.6 0.6 1.5 0.05 1.9 0.7 2.4 0.09 0.8 0.1 0.5 0.03 1.8 changes Post- training − − − − − − − − − − − − − − − − − − − at

pressure;

considered

12.9 10.6 14.2 14.3 10.5 13.4

7.5 9.9 7.5 1.35 7.9 11.9 7.7 1.31 6.9 8.7 6.5 1.38 5.0

blood results ± ± ± ± ± ±

are

± ± ± ± ± ± ± ± ± ± ± ± ±

BP:

comparison.

Baseline MICT moderate-intensity

Hedges’

monitoring

by MICT: deviation.

12.2 126.9 11.7 116.3 12.4 133.1 12.0 121.8 12.3 117.3 12.0 108.9 intragroup

8.359.7 76.4 8.5 67.3 1.27 76.7 9.24 8.710.7 80.8 8.7 71.8 1.26 82.6 9.46 8.58.9 69.9 8.4 60.9 1.285.3 68.9 9.00 11.7

± ± ± ± ± ±

± ± ± ± ± ± ± ± ± ± ± ± ±

42)

pressure =

assessed

standard

n condition; Overall population ( 11.0

pre-exercise blood

mean

difference as

immersed

versus

in (mmHg) 78.3 (mmHg) 83.2 (mmHg) 71.1 the (mmHg) 117.5 (mmHg) 122.0 (mmHg) 110.9

(bpm) 69.0 (bpm) 73.7 (bpm) 61.7

of period

post-

Ambulatory SBP DBP SBP DBP SBP DBP

in period rate rate rate

expressed period

(%)

training

(m/s) 9.28 (m/s) 9.45 (m/s) 9.04 time

(mmHg) 77.4 (mmHg) 81.5 (mmHg) 70.8

(mmHg) 128.4 (mmHg) 134.0 (mmHg) 119.2 2

− are 0.05

dip

SBP SBP SBP DBP Heart Central Central PWV DBP Heart Central Central PWV DBP Heart Central Central PWV Night-time/daytime P Magnitudes interval Table 24-hour Data a b SBP Daytime Night

686 P. Sosner et al.

Figure 2. Individual responses in terms of 24-hour systolic/diastolic blood pressure (SBP/DBP) values from baseline (T0) to after the

2-week training period (T1), for the three groups: moderate-intensity continuous training (MICT); high-intensity interval training on dry land

(HIITdryland,); and high-intensity interval training in immersed condition (HIITimmersed). ABPM: ambulatory blood pressure monitoring.

Discussion In a meta-analysis assessing the effects of aerobic train-

ing on ABPM results, baseline ofﬁce BP ≥ 130/85 mmHg was

The aim of this study was to assess chronic changes in ABPM associated with a greater BP improvement than baseline

results following a 2-week training programme involving six ofﬁce BP < 130/85 mmHg [26]. Following this tendency, the

sessions of either MICT on dry land or HIIT performed on recent North American guidelines proposed a threshold of

dry land or in immersed condition, in participants with a 130/80 mmHg (instead of 140/90 mmHg) for the diagnosis of

baseline ofﬁce SBP/DBP ≥ 130/85 mmHg. We hypothesized high BP [28].

that HIIT would be more effective than MICT at improving 24- Few studies have assessed the effect of the manipula-

hour BP load, and that the immersed condition would have tion of training modalities (MICT versus HIIT, dry land versus

an additional effect compared with the dryland condition. immersed condition) on 24-hour BP response. One random-

In accordance with this hypothesis, HIITimmersed resulted in ized study compared the effect of MICT versus HIIT on

a (small, moderate or large depending on the Hedge’s g) ABPM results; participants were 48 men and women with

decrease in BP load and PWV during the 24-hour and daytime hypertension (aged 52 8 years) who trained three times

periods. a week for 12 weeks [23]. The mean decrease in 24-hour

− −

Many studies have examined BP decrease following train- SBP/DBP load reached 12/ 8 mmHg following HIIT versus

− −

ing, and have consistently reported a greater BP drop in 4.5/ 3.5 mmHg following MICT. In our 2-week HIITimmersed

hypertensive than in normotensive participants [25]. The group, we observed a higher mean change in ABPM results

use of ABPM provides additional information — particularly than they observed following their 12-week MICT, thus sug-

regarding the sustained BP effect during the 24-hour period gesting a better cost-beneﬁt ratio for this exercise modality.

and the real improvement in BP load that is necessary to Regarding comparison of BP changes between aerobic

assess the chronic effect of an antihypertensive interven- training on dry land or in immersed condition, we did

tion. While the magnitude of BP decrease appeared lower not ﬁnd any studies using ABPM. However, we identiﬁed

in studies using ABPM than in those using ofﬁce BP, in a two studies describing the effect of training in a swim-

recent meta-analysis we reported a weighted mean SBP/DBP ming pool on ambulatory BP. The ﬁrst study reported an

− −

decrease reaching −4.1/−2.8 mmHg for the 24-hour period, SBP/DBP drop reaching 9.0/ 5.0 mmHg for daytime and

− −

3.8/ 2.7 mmHg for daytime and −2.4/−1.7 mmHg for 5.0/ 3.0 mmHg for night-time periods, in a group of

night-time [26]. Interestingly, in our study, the magnitude of 24 individuals (58 2 years) with prehypertension, who

decrease in ambulatory SBP/DBP following HIITimmersed was trained by swimming for 45 min three times a week for

larger than these reference values, despite a rather small 12 weeks [29]. The comparison with our study is complex

training volume. because of major differences observed previously in phys-

During the night-time period, we observed a signiﬁcant iological blood ﬂow response between upright practice of

decrease only in mean central SBP, and only in the HIITimmersed water exercise (such as cycling) and swimming practice

group. Night/day dipping, known for its prognostic value [30], and the training programme duration was longer than

for cardiovascular diseases [2], was not modiﬁed following in our study. The second study reported a much greater

− −

training programmes, whatever the group. decrease in SBP/DBP (24-hour: 17.0/ 9.0 mmHg; daytime:

− −

The BP threshold of 130/85 mmHg that we chose 18.0/ 10.0 mmHg; night-time: 15.0/ 8.0 mmHg) in 16

for an inclusion criterion could be questionable. This individuals younger than ours (mean age 55 6 years) [31].

threshold was highlighted by the SPRINT study [27], The explanation for their greater BP response partly relies

which included and treated individuals with ofﬁce SBP ≥ on a higher BP level at baseline, as previously suggested by

130 mmHg, with favourable results on non-fatal and fatal Sosner et al. [26] One study reported the BP change follow-

cardiovascular events and death from any cause in par- ing HIIT in a swimming pool: the intervention was swimming

ticipants undergoing the aggressive BP-lowering strategy. HIIT three times a week for 15 weeks compared with

Ambulatory BP response to immersed interval training 687 a g

MICT:

0.13 0.26 0.56 0.25 0.58 0.36 − − Hedge’s − − − 0.28 −

b b

10)

= condition;

n 4.27 3.18 2.17 3.98 5.15 11.36

( 5.74 8.25 0.22

± ± ± ± ± ±

± ±

3.18 0.97 1.12 1.75 8.10 2.66 immersed − − − − − Post- training changes − +2.43

5.64 3.88 4.33 8.44 7.78 5.31 21.32

15.31 +3.55

± ± ± ± ± ± ± training

immersed Baseline 44.84 51.88 9.02 interval 0.8).

| g

| (

0.370.130.43 46.23 40.94 0.280.35 44.24 15.50 0.32 42.85 a large − − − − − Hedge’s g − 0.31

programme.

or b b

high-intensity

: 12) HIIT

0.8) 9.55 8.17 6.26 6.36 6.58 19.98

9.07 0.21 8.11 =

≤

± ± ± ± ± ± n training

| ± ±

( g |

immersed <

3.11 1.32 2.73 4.25 2.00 9.58 HIIT − − − − − − Post- training changes

(0.5

2-week

land; the

5.55 7.69 6.48 7.8112.62 +2.17 6.78 21.62

17.94 +6.42 dry

± ± ± ± ± ± ±

moderate

dryland after on

0.5),

Baseline 47.40 and

≤

| g |

training

a g

(0.2 baseline

at interval

0.300.220.160.11 46.46 45.45 0.10 44.22 0.30 52.16 0.07 45.95 4.76 22.50 small

− − − − − − − Hedge’s test

either

11) HIIT 4.04 4.07 5.37 7.66 3.69 8.56 12.72

4.58 0.62

= States

± ± ± ± ± ± ±

± n

high-intensity (

: 1.63 1.22 0.93 1.10 0.30 3.28 0.91 Mood

− − − − − − − Post- training changes considered

dryland of

are

HIIT g

4.54 4.72 5.19 9.28 2.702.56 +2.17 8.18

comparison.

6.28 Proﬁle

± ± ± ± ± ± ±

the Hedges’

deviation. Baseline MICT of by

intragroup

5.285.93 43.47 5.38 42.46 8.67 42.73 9.45 57.64 5.51 38.16 15.43 40.95 19.48 18.97 4.45

standard assessed

training.

± ± ± ± ± ± ± ±

subscales ±

33)

pre-exercise the n

Overall population ( 45.39 43.09 43.91 42.94 43.76 14.36 mean

for as difference

continuous

versus

the

mood post- -scores

in expressed

index 10.96

score

are

0.05

disorder P Magnitudes moderate-intensity Table Anxiety Data a b Depression Energy Anger Confusion VigourFatigue 53.90 Total

688 P. Sosner et al.

swimming MICT, and the participants were 42 women with group), and some between-group differences could have

hypertension (mean age 45 2 years) [32]. The ofﬁce (not been revealed. We did not assess at baseline the partici-

ambulatory) SBP/DBP changes were higher following HIIT pants’ habits in terms of physical activity; nevertheless they

− −

( 6.0/ 2.0 mmHg) than following MICT (−4.0/0.0 mmHg). were non-athletes, and were asked to refrain from any other

Another study assessed the effects of 9 months of a com- physical activity for the duration of the study. This limitation

bined lifestyle programme, including HIIT on an ergocycle could be mitigated by the randomized nature of the inclu-

on dry land versus in immersed condition in obese individ- sions, which allows a theoretical homogeneous distribution

uals: resting ofﬁce BP improved similarly in the two groups of the participants’ characteristics. The post-training ABPM,

[33]. No previous study has assessed 24-hour ABPM results performed over the 24 h after the last training session, con-

following water-ergocycle training. A comparison between sequently included both an acute effect of the session and a

water-ergocycle and swimming training would be interest- chronic effect of the cumulative 2-week six-session training.

ing. Regarding arterial stiffness assessment, while the gold stan-

PWV is a marker of arterial stiffness, the reduction of dard method requires a tonometry device, we used another

which in the HIITimmersed group could have been driven by method, previously validated in resting condition [13].

changes during the day in peripheral sympathetic tone,

which also plays an important role in vascular stiffness reg-

ulation [34]. Interestingly, we also observed a decrease in Perspectives

mean heart rate that was signiﬁcant following HIITimmersed

(despite a non-signiﬁcantly lower value at baseline in this Water-based training and HIIT represent interesting

group). This could be the marker of improvement in car- prospects with good enjoyment levels that can promote

diac autonomic modulation [8], with an more pronounced patient adherence to physical training. The appreciable

increase in cardiac vagal tone following HIITimmersed. Further results we observed in the HIIT group cycling in a swimming

studies are needed to understand the mechanisms involved pool, led us to assess the beneﬁcial antihypertensive effects

in training-induced changes in BP following HIITimmersed, of such training programmes, which may be prescribed

including neurohormonal markers of plasma volume reg- for hypertensive individuals. To detail the mechanisms of

ulation (renin-angiotensin system or natriuretic peptide), the changes following HIIT in immersed condition, further

direct or indirect markers of cardiovascular autonomic con- multicentre studies should be performed, including a larger

trol (sympathetic nerve activity, baroreﬂex sensitivity or number of participants, with biological and physiological

PWV) and endothelial function. analysis, and extended to long-term follow-up. Endpoints of

Regarding the subjective perception of the training pro- such a follow-up should take into account the epidemiolog-

gramme, the score from the PACES questionnaire [14] ical transition of long-term consequences of hypertension,

favoured good appreciation, whatever the training modal- such as atrial ﬁbrillation and vascular dementia [37], which

ity. The changes in the POMS score were only signiﬁcant for could perhaps be prevented by varied physical training

the HIIT groups, not for the MICT group. After exclusion of programmes, including HIIT and immersed condition.

studies reporting mood proﬁling in sport or over-reaching

patterns of athletes, we found only two studies assess-

ing the impact of physical training on the POMS score in

non-athletes: In 33 individuals from the general population Conclusions

randomized to 10 weeks of MICT or control, the training pro-

≥

gramme led to greater reductions in the anxiety, confusion In individuals with a baseline ofﬁce BP of 130/85 mmHg,

and depression scores of the POMS test than the control the 24-hour and daytime BP loads, assessed by ABPM,

condition, and these effects were maintained at 3-month decreased signiﬁcantly following HIIT performed on a sta-

follow-up [35]; in 49 individuals who were positive for the tionary cycle in immersed condition. In addition, cycling in

human immunodeﬁciency virus randomized to 6 weeks of water was associated with an alleviation of 24-hour and day-

MICT and resistance training or control, the training pro- time average PWV and heart rate, and 2-week HIIT appeared

gramme led to a greater reduction in the depression score to be sufﬁcient to elicit an improvement in mood state,

of the POMS test than the control condition [36]. Hence, while MICT did not. This innovative method should be con-

our results reinforce the observation of favourable effects sidered as an efﬁcient non-pharmacological treatment of

on mood of exercise training programmes, and the hypothe- hypertension and, as such, should now be implemented in

sis that these effects could be proportional to the intensity a larger cohort to study its long-term effects on the cardio-

of the exercise. vascular system.

Study limitations

Our study was an exploratory study with sample size lim- Sources of funding

itation: the required number of subjects was not reached

This work was supported by the following institutions: ÉPIC

because of the logistical limitations of the inclusion period.

Centre and Montreal Heart Institute Foundations, Canada;

The impact of this methodological pitfall on our results

Bio-Health Doctoral School, ED No. 524, University of

could have been essentially a global lack of statistical power.

Poitiers, France; Laboratory MOVE (EA 6314), Faculty of

Thus, it can be assumed that the BP decrease following the

Sport Sciences, University of Poitiers, France; and University

training period observed in the HIITdryland group could have

Hospital of Poitiers, France.

been signiﬁcant (to a less extent than in the HIITimmersed

Ambulatory BP response to immersed interval training 689

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We wish to extend our thanks to all of the participants, to

[12] Sosner P, Gayda M, Dupuy O, et al. Ambulatory blood

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reviewed the English language.

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[13] Luzardo L, Lujambio I, Sottolano M, et al. 24-h ambulatory

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