Resistance / Weight training for Beginners with Hypertension

Cardiovascular disease (CVD) is a broad, umbrella term which can include many aberrant conditions involving any part of the cardiovascular system. Common pathology included in CVD is atherosclerosis, endothelial dysfunction, cardiac disease, previous myocardial infarct, hypertensive disorders, history of stroke, cardiac arrhythmia, cardiac failure, or cardiac valvular disorder. For the sake of this article, let’s discuss how hypertension (HTN) disorders can improve when performing regular resistance (RT) or weight training since incorporating consistent RT is acknowledged internationally as a valid means to help HTN. Also, since HTN is considered a main risk factor for other CVD’s and HTN has an astonishing prevalence estimate approximately 40% of the world’s population age 25+ years old (Lopes et al., 2018). Great news about RT and HTN by the recent American Heart Association (AHA) is individuals with HTN can expect to see reductions of up to 6mmHg of systolic BP and 5mmHg of diastolic BP (Paluch et al., 2023). We will discuss precautions and guidelines to get started with a RT program. Lastly, a sample weekly routine will be laid out with how to progress and vary the training sessions over the next few months to help you safely and effectively improve your hypertension and general fitness and well-being.

HTN can occur from a variety of dysfunctional mechanisms of the kidneys (mineral/ electrolyte imbalances), autonomic system, endocrine system, collagen/ soft tissue, inflammation, etc. A main concern with chronic hypertension is added strain to the heart, vessels, and other organs which is why we want to use exercise as a fun, safe, and drug-free way to reduce or eliminate HTN. For those with HTN, it might have been advised to you at some point by some medical professional that weight training can be harmful if you have HTN since elevation in systolic blood pressure occurs during those training sessions (Jacobs, 2018). While transient increases in systolic blood pressure does occur, here is why and when you should not be concerned about it. Research studies recommend that if systolic pressure is not getting above 220 or diastolic pressure above 105 during the training then your training intensity and type of exercise is just fine to continue.

However, if you have HTN greater than 180/110 it is not advised to begin RT training until below this threshold (RT (Paluch et al., 2023). Instead of RT, aerobic exercise could be recommended because it only moderately increases systolic BP during exercise and usually no changes in diastolic BP (Smith & Fernhall, 2023). Also, systematic review of 27 randomized control trial (RCT) by Borjesson et al. (2016) determined the average reduction in systolic BP to be 10.8mmHg with 40-60min aerobic sessions done 3+ times per week for greater than 4 weeks with moderate to high-intensity training providing the best reductions in systolic BP. An added health bonus is the hours following aerobic training can reduce resting BP for at least 5 hours (Lopez et al., 2018) which is a big win!

Here are some general guidelines from the NSCA textbook for beginning RT if you have HTN (Jacobs, 2018):

FREQUENCY	2-3 days/ week; non-consecutive days
INTENSITY	60-80% of 1RM (can begin at 40%)
REPITITIONS	8-15reps; stop set with 2-5 RIR
SETS	1-3
REST PERIODS	30-60s
EXERCISES	8-12 multi-joint compound
PROGRESSION	Increase weight 2-5lbs per week until at 80% then begin new cycle at 60%

A side note regarding the tempo of the repetitions. Tempo is talking about the time it takes to lift the weight, hold it at the contraction, and time to return the weight back to the start position. Why is this worth mentioning especially since many exercise program prescriptions don’t discuss it? For one, it is a means to vary the intensity of RT without having to adjust the weight or load. The tempo and HTN relationship matter because when you hold a muscular contraction for a longer period of time, it dramatically increases peripheral resistance since the intra-muscular forces are at their highest which begins to occlude the vessels (Smith & Fernhall, 2023). Hence, we would prefer to minimize the max contracted isometric pause to just 1-3 seconds and avoid prolonged (i.e. 30+ seconds of isometrics) with muscles in their contracted state.

Also, BP is increased during both the eccentric and concentric phase while resting in lockout allows BP to reduce. Thus, a general starting tempo could be 2-1-2-1 (contraction 2 seconds, pause 1 second, 2 seconds lowering, pause 1 second). Secondly, we understand that peak systolic blood pressures are increased with maximal straining with the relative effort (perceived effort) and thought to be the most probable contributor (Smith & Fernhall, 2023) which is why we do not need to push sets to failure. Plus, we don’t have to take sets to failure to elicit the fitness and health benefits. Hence, I recommend not going past an 8-9 RPE (rate of perceived exertion); meaning you should stop your set when you think you have 2-5 reps left in you (also known as reps-in-reserve/ RIR).

Regarding absolute loads, meaning what percentage of your 1-rep maximum (1RM) there is precaution for those with HTN to “max-out” and lift weights 80-90%+ of 1RM especially in the lower body since peak blood pressures are up to 1.75 times greater compared to loads at 65% (Smith & Fernhall, 2023). Regarding exercise volume, it is recommended to try to perform at least 8 different exercises per session since about a 3-fold greater effect of reducing systolic BP is observed in those who do 8+ exercises per session (Lopez et al., 2018). According to research data, this means that you may only see an average of 1.7mmHg reduction in systolic BP if doing less than 8 exercises, but 4.4mmHg reduction if doing 8+ exercises per session. So, exercise variety is a key component to evoking beneficial changes to BP. One timesaving (and very fun way to some) is to perform your weight training sessions in a circuit. Meaning if you have 8 exercises to do that day, do exercise A, then B, then C, and so on until all have been done. When alternating body parts/ regions it means that resting 15-30 seconds between exercises is enough for recovery and saves time versus waiting 1-2 minutes between sets. Beginning with 2 rounds (i.e. 2 sets total of each exercise) is a reasonable starting place for the first few weeks (Paluch et al., 2023).

The AHA guidelines for implementation and progression of RT is similar to the NSCA guidelines. The AHA recommends increasing the intensity by gradually increasing volume (# of sets), weight/ resistance, or increased frequency (Paluch et al., 2023). An easy rule-of-thumb for know when you can increase the weight/ resistance is following the “2-for-2” guidelines. This means that if you can perform 2 or more reps for at least 2 consecutive sets better than the last training session, you can increase the load 2%-10% more (Paluch et al., 2023). Translating to simpler terms, let’s look at an example below:

Exercise: Reverse dumbbell lunges

• Week 1

  • Set 1: 50lbs, 10 reps

  • Set 2: 50lbs, 9 reps

  • Set 3: 50lbs, 8 reps

• Week 2

  • Set 1: 50lbs, 12 reps

  • Set 2: 50lbs, 12 reps

  • Set 3: 50lbs, 10 reps

• Week 3 = progress load to 55lbs

Now, for addressing concerns and reasons why not to partake in resistance training. According to the AHA’s 2023 statement on resistance training in those with CVD with the following conditions are contraindicated should not participate in RT (Paluch et al., 2023):

Absolute contraindications:

o   Uncontrolled hypertension (>180/110mmHg)

o   Uncontrolled atrial and/ or ventricular arrhythmias

o   Severe and symptomatic aortic stenosis

o   Aortic dissection

o   Diabetic retinopathy

o   Unstable coronary heart disease

Relative contraindication (warranting evaluation and clearance from physician):

o   Defibrillator or pacemaker

o   History of stroke

o   Low functional capacity (<4 METs)

o   Controlled hypertension

For warm-up and cool down, research suggests about 10 min for both a warm-up and cool down, especially performing relaxation and/or breathwork as part of the cool-down (Ramirez-Velez et al., 2020). Let’s finish by putting all the pieces together for a sample workout which can be performed 3x/week.

Warm-up

o   5-10 minutes of easy aerobic activity at about 50-60% max HR.

o   3-5 minutes of joint mobility or dynamic stretching if desire

RT circuit (2 rounds)

o   Perform 2 rounds (rest 15-30 seconds between exercises; rest 1-3 min between rounds). Estimated total time 30-40 minutes. Perform 10-15 repetitions of each exercise with 3-5 RIR or about 7 of 10 RPE.

  1) Goblet squats

  2) Dumbbell curls

  3) Pushups

  4) TRX ring body rows

  5) Back squats/ leg press

  6) seated dumbbell press

  7) stiff leg deadlift

  8) Cable triceps pushdown

Cool-down

o   3-5min of easy aerobic walking or elliptical.

o   3-5min of relaxion breathing techniques.

Have fun!

References:

Börjesson M, Onerup A, Lundqvist S, Dahlöf B. Physical activity and exercise lower blood pressure in individuals with hypertension: narrative review of 27 RCTs. Br J Sports Med. 2016;50(6):356–361.

Jacobs, P. L., & National Strength & Conditioning Association, issuing body. (2018). NSCA’s essentials of training special populations (P. L. Jacobs, Ed.). Human Kinetics.

Lopes, S., Mesquita-Bastos, J., Alves, A. J., & Ribeiro, F. (2018). Exercise as a tool for hypertension and resistant hypertension management: current insights. Integrated blood pressure control, 11, 65–71. https://doi.org/10.2147/IBPC.S136028

Paluch, A. E., Boyer, W. R., Franklin, B. A., Laddu, D., Lobelo, F., Lee, D. C., McDermott, M. M., Swift, D. L., Webel, A. R., Lane, A., & on behalf the American Heart Association Council on Lifestyle and Cardiometabolic Health; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Epidemiology and Prevention; and Council on Peripheral Vascular Disease (2024). Resistance Exercise Training in Individuals With and Without Cardiovascular Disease: 2023 Update: A Scientific Statement From the American Heart Association. Circulation, 149(3), e217–e231. https://doi.org/10.1161/CIR.0000000000001189

Ramírez-Vélez, R., Castro-Astudillo, K., Correa-Bautista, J. E., González-Ruíz, K., Izquierdo, M., García-Hermoso, A., Álvarez, C., Ramírez-Campillo, R., & Correa-Rodríguez, M. (2020). The Effect of 12 Weeks of Different Exercise Training Modalities or Nutritional Guidance on Cardiometabolic Risk Factors, Vascular Parameters, and Physical Fitness in Overweight Adults: Cardiometabolic High-Intensity Interval Training-Resistance Training Randomized Controlled Study. Journal of strength and conditioning research, 34(8), 2178–2188. https://doi.org/10.1519/JSC.0000000000003533

Smith, D. L., & Fernhall, B. (2023). Advanced cardiovascular exercise physiology (Second edition.). Human Kinetics.