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Beta-Blockers Do Not Impair the Cardiovascular Benefits of Endurance Training in Hypertensives

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Beta-Blockers Do Not Impair the Cardiovascular Benefits of Endurance Training in Hypertensives Journal of Human Hypertension (2007) 21, 486–493 & 2007 Nature Publishing Group All rights reserved 0950-9240/07 $30.00 www.nature.com/jhh ORIGINAL ARTICLE Beta-blockers do not impair the cardiovascular benefits of endurance training in hypertensives TH Westhoff1,4, N Franke1,4, S Schmidt1, K Vallbracht-Israng2, W Zidek1, F Dimeo3,5 and M van der Giet1,5 1Medizinische Klinik IV – Nephrology, Charite´ – Campus Benjamin Franklin, Berlin, Germany; 2Department of Cardiology, Charite´ – Campus Virchow Klinikum, Berlin, Germany and 3Medizinische Klinik III – Section of Sports Medicine, Charite´ – Campus Benjamin Franklin, Berlin, Germany Aerobic physical exercise is broadly recommended as exertion (100 W) and increased endothelium-dependent a helpful adjunct to obtain blood pressure control in vasodilation (flow-mediated vasodilation, FMD) and hypertension. Beta-blockade interacts with heart rate, physical performance both in the presence and absence sympathetic tone, maximal workload and local lactate of beta-blockade (Po0.05 each). The extent of ABP production. In the present randomized-controlled study, reduction did not significantly differ in the presence we compared the cardiovascular effects of an endurance or absence of beta-blockade (D systolic ABP 10.6710.5 training programme in elderly hypertensives with or vs 10.678.8 mm Hg, D diastolic ABP 5.778.6 vs without beta-blockers and developed a first approach to 5.874.0 mm Hg). Mean training heart rate was signifi- determine a lactate-based training heart rate in presence cantly lower in the patients on beta-blockers (97.277.7 of beta-blockade. Fifty-two patients (23 with beta-block- vs 118.377.5/min, Po0.001). Lactate-based aerobic er, 29 without beta-blocker) X60 years with systolic 24-h endurance training evokes comparable cardiovascular ambulatory blood pressure (ABP) X140 mm Hg and/or benefits in the presence and absence of beta-blockade antihypertensive treatment were randomly assigned to including a marked improvement of endothelial func- sedentary activity or a heart-rate controlled 12-week tion. In the present study, target training heart rate with treadmill exercise programme (lactate 2.0 mmol/l). In the beta-blockers is about 18% lower than without. exercise group, the training significantly decreased Journal of Human Hypertension (2007) 21, 486–493. systolic and diastolic 24-h ABP, blood pressure on doi:10.1038/sj.jhh.1002173; published online 1 March 2007 Keywords: exercise; blood pressure; endothelial function; beta-blocker Introduction cardiovascular benefits, however, depends strictly on the concept of the endurance programme. Guide- Aerobic physical exercise is recommended as basic lines recommend modest levels of aerobic exercise lifestyle modification in the treatment of arterial 1,2 on a regular basis, such as walking, jogging or hypertension. Whereas cardiovascular training swimming for 30–45 min, 3–4 times a week.1,5,6 can induce systolic and diastolic blood pressure Training should be performed at 40–60% of maxi- reductions of approximately 3–4 mm Hg in normo- mum O uptake.7 Physical exercise beyond 60% of tensives, this phenomenon is even more pronoun- 2 3 maximal O2 consumption does not lead to further ced in hypertensives. Shear stress – as induced by reductions of blood pressure and might even physical exercise – is a potent stimulus on endo- increase blood pressure in hypertensives.8,9 The thelial cells for an increase in nitrous oxide (NO)- intensity of exercise is generally monitored by heart production leading to improved endothelial func- 4 rate. Adequate training heart rate can be assessed by tion and reduced vascular resistance. The extent of determination of the anaerobic threshold using ventilatory parameters or lactate.10,11 This proce- Correspondence: Dr TH Westhoff, Medizinische Klinik IV – dure, however, is too time-consuming and expen- Nephrology, Charite´ – Campus Benjamin Franklin, Hindenbur- sive to be used in general practice. Therefore, target gamm 30, 12200 Berlin, Germany. heart rates are usually determined on the basis of E-mail: [email protected] empirical experiences. The percentage of maximal Sources of financial support: None. heart rate is the most widely accepted parameter for 4These authors contributed equally to this work. 5These authors contributed equally to this work. the description of training intensities. The American Received 24 August 2006; revised 17 December 2006; accepted 20 College of Sports Medicine and the American January 2007; published online 1 March 2007 Heart Association recommend training intensities Endurance training and beta-blockade TH Westhoff et al 487 between 5512 and 65–85% of maximal heart rate.13 Methods As beta-blockers reduce heart rate both in rest and under exertion, target heart rates might differ from Study population general recommendations.14 Furthermore, acute Patients were recruited from the hypertension out- treatment with beta-blocking drugs modifies local patient clinic of our university hospital and by press muscular metabolic properties and impairs endur- announcement to assess cardiovascular benefits of ance exercise capacity resulting in an increase in exercise training on treated hypertensives. Inclusion perceived exertion, lower VO2max and lower work criteria for the current study were systolic ambula- rate, whereas the influence of chronical administra- tory blood pressure (ABP) X140 mm Hg and/or tion of beta-blockers is discussed controversially.15 It current antihypertensive treatment, age X60 years. has been shown that non-selective beta-blockers can Before the exercise programme, cardiac function increase lactate levels during exercise, for example, was examined by electrocardiogram (ECG) and 16 through b2-associated peripheral vasoconstriction. echocardiogram. Exclusion criteria were continuous Furthermore, metoprolol – as a selective b1-selective engagement in physical exercise training 460 min/ antagonist – induces a left-shift of both lactate and week in the past 12 weeks before inclusion in the ventilatory aerobic threshold.17 In a small study of study, symptomatic peripheral arterial occlusive 10 young healthy men, a small dose of bisoprolol disease, aortic insufficiency or stenosis 4stage I, given for 2 weeks reduced the percentage of hypertrophic obstructive cardiomyopathy (HOCM), maximal heart rate at the aerobic and anaerobic congestive heart failure (4NYHA II (New York threshold.18 Thus, it may be speculated that cardio- Heart Association, grade II)), uncontrolled cardiac vascular benefits of exercise at a defined heart rate arrhythmia with hemodynamic relevance, systolic differ in the absence and presence of beta-blockade. office BPX180 mm Hg, signs of acute ischemia in The aim of the present study is to determine the exercise electrocardiography, change of antihyper- differential effects of lactate-based exercise prescrip- tensive medication in the past 6 weeks before tion on hypertensives with or without chronic beta- inclusion or during the follow-up period. Further blockade. indication of hypertension-associated target-organ In the present study, we compared the cardio- damage was not regarded as exclusion criteria. vascular effects of a heart-rate controlled 12-week According to these criteria, 52 patients (26 male, endurance training programme between elderly 26 female) were enrolled to the study. Patients’ hypertensives with or without beta-blockers and characteristics including concomitant diseases are a sedentary control group. We developed a first presented in Table 1. All patients were treated with approach to determine a lactate-based training heart at least one antihypertensive drug. Irrespective of rate in the presence of beta-blockade. presence or absence of beta-blockade, patients were Table 1 Patients’ characteristics (age and number of antihypertensive drugs presented as mean7s.d.) Exercise Control All (n ¼ 25) Beta- No beta- All (n ¼ 27) Beta- No beta- blockade blockade blockade blockade (n ¼ 9) (n ¼ 16) (n ¼ 14) (n ¼ 13) Female 12 (48%) 6 (67%) 6 (38%) 14 (52%) 6 (43%) 8 (62%) Male 13 (52%) 3 (33%) 10 (63%) 13 (48%) 8 (57%) 5 (38%) Age (years) 67.874.7 66.473.4 68.575.2 68.975.2 68.975.2 69.075.3 Concomitant diseases Diabetes mellitus 4 (16%) 0 (0%) 4 (25%) 5 (19%) 4 (29%) 1 (8%) Hyperlipidemia 13 (52%) 5 (56%) 8 (50%) 11 (41%) 7 (50%) 4 (31%) Smoking 3 (12%) 3 (33%) 0 (0%) 2 (7%) 1 (7%) 1 (7%) Family history of 12 (48%) 6 (67%) 6 (38%) 13 (48%) 7 (50%) 6 (46%) cardiovascular disease Cardiac endorgan damage 14 (56%) 3 (33%) 9 (56%) 13 (48%) 6 (43%) 7 (54%) Antihypertensive medication Number of 2.471.4 2.971.4 2.171.3 3.271.4 3.971.0 2.271.2 antihypertensive drugs ACE inhibitors 8 (32%) 4 (44%) 4 (25%) 9 (33%) 5 (36%) 4 (31%) Angiotensin receptor 11 (44%) 4 (44%) 7 (44%) 12 (44%) 8 (57%) 4 (31%) blockers Calcium-channel blockers 11 (44%) 3 (33%) 8 (50%) 16 (59%) 11 (79%) 5 (38%) Diuretics 13 (52%) 6 (67%) 7 (44%) 17 (63%) 12 (86%) 5 (38%) Alpha blockers 2 (8%) 0 (0%) 2 (13%) 4 (15%) 2 (14%) 2 (15%) Clonidine 2 (8%) 1 (11%) 1 (6%) 1 (4%) 1 (7%) 0 (0%) Abbreviation: ACE, angiotensin-converting enzyme. Journal of Human Hypertension Endurance training and beta-blockade TH Westhoff et al 488 randomized to exercise or control group. Twenty- progressively increased to 30, 32 and 36 min and five patients were randomised to the exercise group, carried out without interruption. Training intensity 27 were randomized to the control group. Nine corresponded to the speed necessary to reach a patients in the exercise and 14 patients in the lactate concentration of 2.070.5 mmol/l in capillary control group were on beta-blockers. In the exercise blood. Heart rate during training was controlled by group, patients were on metoprolol, bisoprolol or a heart-rate monitor (Polar Sport Tester, Kempele, atenolol. In the control group, two patients were on Finland); blood pressure was measured according carvedilol, one patient on nebivolol and the other to Riva-Rocci every 5 min with the proband still patients were on metoprolol, bisoprolol and atenolol walking; lactate concentration was controlled every as well.
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