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Table of Contents
                            Athletes with Systemic Hypertension
	Hypertension as a cardiovascular risk factor
	Classification of hypertension
	Assessment of the severity of hypertension and risk stratification
	Assessment of the risk associated with exercise
	Diagnostic evaluation
	Effects of exercise on blood pressure
		Dynamic exercise
		Static exercise
		General recommendations
		Choice of drugs
		Recommendations for leisure-time and competitive sports participation
Document Text Contents
Page 1


Cardiol Clin 25 (2007) 441–448
Athletes with Systemic Hypertension
Robert H. Fagard, MD, PhD

Hypertension and Cardiovascular Rehabilitation Unit, Department of Cardiovascular Diseases, University of Leuven,

KU Leuven, U.Z. Gasthuisberg – Hypertensie, Herestraat 49, B-3000 Leuven, Belgium

Blood pressure increases with age. Systolic
blood pressure continues to increase throughout

adult life, related to progressive arterial stiffening,
whereas diastolic blood pressure plateaus in the
sixth decade of life and decreases thereafter [1].

Blood pressure is lower in women than in men
below the age of about 50, rises more steeply in
women around menopause, and becomes higher

in women than in men thereafter.
In recent epidemiologic studies, hypertension is

defined as systolic blood pressure greater than or

equal to 140 mm Hg or diastolic blood pressure
greater than or equal to 90 mm Hg, or being on
antihypertensive treatment. The prevalence of
hypertension in the population amounts to about

25% and is expected to increase to up to about
29% in 2025 [2].

When broken down by age and gender, the

prevalence is approximately 15%, 30%, and 55%
in men aged 18 to 39, 40 to 59, and 60 and older,
respectively, and about 5%, 30%, and 65% in

women in these age groups. The prevalence of
isolated systolic hypertension is very low before
the age of 50, but increases sharply thereafter.
These epidemiologic data indicate that hyperten-

sion may already be present in the young athlete,
although rarely, but occurs more frequently in the
older sportsman.

Unless blood pressure is measured, hyperten-
sion may remain undetected because it usually
causes no symptoms. However, about 25% of

patients who have hypertension by conventional
measurements have a normal blood pressure on
24-hour ambulatory monitoring or on home

blood pressure measurements; this phenomenon

E-mail address: [email protected]
0733-8651/07/$ - see front matter � 2007 Elsevier Inc. All r
is the so-called ‘‘white-coat’’ or isolated clinic
hypertension [3,4]. Young athletes with clinic
hypertension often have normal blood pressure

on ambulatory monitoring [5]. On the other
hand, patients may have masked or isolated am-
bulatory hypertension, which is characterized by

a normal blood pressure in the office and an
elevated blood pressure out of the office [6].

Hypertension as a cardiovascular risk factor

Hypertension is associated with an increased
incidence of all-cause and cardiovascular mortal-

ity, sudden death, stroke, coronary heart disease,
heart failure, atrial fibrillation, peripheral arterial
disease, and renal insufficiency. In the population

at large, the relationship between cardiovascular
complications and blood pressure is linear [7]. The
prognosis of white-coat hypertension is better

than that of sustained ambulatory hypertension,
and studies suggest that it is even similar to that
of persons with true normal blood pressure,
whereas patients who have masked hypertension

appear to have a worse outcome than true normo-
tensives [3,4,6,8–10].

Despite conclusive evidence that antihyperten-

sive therapy reduces the complications of hyper-
tension [1,11], only about one half of all patients
who have hypertension are under treatment and

only a fraction of these have normal blood pres-
sure [12,13]. Systolic blood pressure appears to
be more difficult to control than diastolic blood

pressure, particularly in older patients.

Classification of hypertension

The classification of hypertension is based on

multiple conventional blood pressure measure-
ments taken on separate occasions, in the sitting
ights reserved.

mailto:[email protected]

Page 2


position, by use of a mercury sphygmomanometer
or another calibrated device. Table 1 summarizes
the definitions and classification of blood pressure

levels, according to the European Society of
Hypertension – European Society of Cardiology
guidelines for the management of arterial hyper-
tension [1,14]. The universally accepted blood pres-

sure threshold for hypertension is 140/90 mm Hg.
Twenty-four hour ambulatory blood pressure

monitoring should be considered in cases of

suspected white-coat hypertension, considerable
variability of office blood pressure, marked dis-
crepancy between blood pressure measured in the

office and at home, and in subjects with high office
blood pressure and low global cardiovascular risk.
The threshold for the definition of hypertension is
130/80 mm Hg for 24-hour blood pressure. The

threshold for daytime ambulatory blood pressure
and the self-measured blood pressure at home is
135/85 mm Hg. Patients above the threshold for

conventional blood pressure and below the
threshold for the out-of-office pressure are con-
sidered to have white-coat or isolated office

hypertension and the reverse is true for masked
or isolated ambulatory hypertension [1,15].

Approximately 95% of patients who have

hypertension have essential or primary hyperten-
sion, which results from an interaction between
genetic factors and lifestyle/environmental factors
that include being overweight, high salt intake,

excessive alcohol consumption, and physical in-
activity. The main causes of secondary hyperten-
sion involve renovascular, renal, and adrenal

abnormalities [1].
The role of ergogenic aids in increasing blood

pressure should be considered in the hypertensive

sportsman or athlete. Athletes may abuse

Table 1

Definitions and classification of clinic blood pressure

levels (mm Hg)

Category Systolic Diastolic

Optimal !120 and/or !80
Normal 120–129 and/or 80–84

High normal 130–139 and/or 85–89

Grade 1 hypertension 140–159 and/or 90–99

Grade 2 hypertension 160–179 and/or 100–109

Grade 3 hypertension R180 and/or R110
Isolated systolic


R140 and/or !90

Isolated systolic hypertension can also be graded

(grades 1, 2, 3) according to systolic blood pressure

values in the ranges indicated, provided diastolic values

are less than 90 mm Hg.
prohibited substances such as anabolic steroids,
erythropoietin, stimulants, and so forth. The un-
controlled use of these agents has been associated

with numerous side effects, including hypertension.
Also, the use of nonsteroidal anti-inflammatory
drugs should be specifically considered because
these compounds may increase blood pressure

and are commonly used in the athletic setting [16].

Assessment of the severity of hypertension

and risk stratification

The severity of hypertension depends not only
on the blood pressure level (see Table 1) but also

on the presence of other cardiovascular risk fac-
tors, target organ damage, and cardiovascular
and renal complications. Table 2 summarizes the
classification based on the overall cardiovascular

risk [1,14]. The terms low, moderate, high, and
very high added risk, in comparison with healthy
normotensives without risk factors, are calibrated

to indicate an approximate absolute 10-year risk
of cardiovascular disease of less than 15%, 15%
to 20%, 20% to 30% and greater than 30%,

respectively, according to the Framingham crite-
ria, or an approximate absolute risk of fatal
cardiovascular disease of less than 4%, 4% to

5%, 6% to 8% and more than 8%, according to
the European SCORE system [17].

The risk stratification is based on the accumu-
lated number of selected risk factors, the presence

of target organ damage, or cardiovascular or renal
disease, as outlined in Table 2. With regard to left
ventricular hypertrophy, it should be noted that

sports activity itself may induce hypertrophy; the
extent and distribution of hypertrophy and assess-
ment of diastolic left ventricular function may

help to distinguish between hypertensive heart
disease and athlete’s heart [18–21]. Athlete’s heart
typically shows normal diastolic filling and relax-

ation, and is considered a physiologic adaptation
to training, in contrast to the hypertrophy second-
ary to hypertension. Hypertensive patients usually
have concentric left ventricular hypertrophy (but

eccentric hypertrophy has also been described)
[22]; whether or not hypertension in an athlete
will accentuate the development and extent of

left ventricular hypertrophy, or whether athletic
conditioning in a hypertensive patient will worsen
the left ventricular hypertrophy, is not known.

The importance of the risk stratification is
that hypertensive patients at high or very high
added risk should be treated promptly with

Page 3


Table 2

Stratification of cardiovascular risk in four categories

Blood pressure (mm Hg)

Other risk

factors, target

organ damage,

or disease


(SBP 120–129

or DBP 80–84)

High normal

(SBP 130–139

or DBP 85–89)

Grade 1 HT

(SBP 140–159

or DBP 90–99)

Grade 2 HT

(SBP 160–179

or DBP 100–109)

Grade 3 HT

(SBPR180 or

No other

risk factors

Average risk Average risk Low added risk Moderate added


High added risk

1–2 risk


Low added risk Low added


Moderate added


Moderate added


Very high

added risk

3 or more

risk factors


MS or diabetes

Moderate added


High added


High added risk High added risk Very high

added risk

Established CV or renal


Very high

added risk

Very high

added risk

Very high

added risk

Very high

added risk

Very high

added risk

Low, moderate, high and very high added risk indicate an approximate 10-year risk of fatal or nonfatal cardiovas-

cular disease of less than 15%, 15% to 20%, 20% to 30%, and higher than 30%, respectively; or a risk of fatal cardio-

vascular disease of less than 4%, 4% to 5%, 5% to 8%, and higher than 8%, according to SCORE charts.

Abbreviations: CV, cardiovascular; DBP, diastolic blood pressure; HT, hypertension; SBP, systolic blood pressure;

MS, metabolic syndrome; TOD, target organ damage.
Risk factors used for stratification are blood pressure level; levels of pulse pressure (in the elderly); gender and age

(menO55 years; womenO65 years); smoking; dyslipidemia (total cholesterolO190 mg/dL or low-density lipoprotein
cholesterol O115 mg/dL, or high-density lipoprotein cholesterol !40 mg/dL in men and!46 mg/dL in women, or tri-
glyceridesO150 mg/dL); abdominal obesity (menR102 cm; womenR88 cm); first-degree family history of premature
cardiovascular disease (men!55 years; women!65 years); fasting plasma glucose (102–125 mg/dL); abnormal glucose
tolerance test.

Target organ damage includes hypertension-induced left ventricular hypertrophy; ultrasound evidence of arterial

wall thickening or atherosclerotic plaque; slight increase in plasma creatinine (men 1.3–1.5 mg/dL; women 1.2–1.4

mg/dL); estimated glomerular filtration rate!60 mL/min/1.73 m2); presence of microalbuminuria; carotid-femoral pulse
wave velocityO12 m/s; ankle/brachial blood pressure ratio!0.9.

Diseases include cerebrovascular disease (stroke; transient ischemic attack); ischemic heart disease (myocardial

infarction, angina, coronary revascularisation); heart failure; peripheral vascular disease; renal disease (diabetic ne-

phropathy; renal impairment; proteinuria); advanced retinopathy (hemorrhages; exudates; papiledema).
antihypertensive drugs, whereas patients at low or
moderate added risk are only treated when

hypertension persists despite lifestyle measures.
An alternative way to estimate risk in those who
are not at high or very high added risk according

to Table 2 is to use the European SCORE system

Assessment of the risk associated with exercise

Exercise-related sudden death at a younger age
is mainly attributed to hypertrophic cardiomyop-

athy, anomalies of the coronary arteries, or
arrhythmogenic right ventricular dysplasia
[21,23–25], and is unlikely to be related to hyper-

tension. On the other hand, coronary heart dis-
ease has been identified in approximately 75%
of victims of exercise-related sudden death above

the age of 35 [26]. Whether or not high blood pres-
sure is a cause of exercise-related sudden death on
its own is not known, but hypertension is certainly
a major risk factor for the development of coro-
nary artery disease. In addition, hypertension-in-

duced left ventricular hypertrophy may cause
life-threatening ventricular arrhythmias [27]. It is
likely that the risk associated with exercise can

be derived from the overall risk stratification
(see Table 2). Therefore, the general approach to
the hypertensive patient should also apply to the

exercising patient.

Diagnostic evaluation

Diagnostic procedures are aimed at

Establishing blood pressure levels
Identifying secondary causes of hypertension
Evaluating the overall cardiovascular risk by

searching for other risk factors, target organ
damage and concomitant diseases, or ac-
companying clinical conditions [1,14].

Page 4

Diagnostic procedures comprise a thorough
individual and family history; physical examina-

tion, including repeated blood pressure measure-

ments according to established recommendations;

and laboratory and instrumental investigations, of

which some should be considered part of the

routine approach in all subjects with high blood

pressure, some are recommended, and some are

indicated only when suggested by the core


Routine tests include hemoglobin and hemat-
ocrit; serum potassium, creatinine and uric acid;

estimated glomerular filtration rate; fasting

plasma glucose; serum total, low-density and

high-density lipoprotein cholesterol, and triglyc-

erides; urine analysis complemented by micro-

albuminuria dipstick test and sediment

examination; and standard electrocardiography.

In addition, in the competitive athlete with

hypertension, echocardiography and exercise test-

ing with electrocardiography and blood pressure

monitoring are indicated as routine tests [28,29].
Recommended tests include echocardiography;

carotid ultrasound; pulse wave velocity measure-

ment; ankle-brachial blood pressure ratio index;

fundoscopy; quantitative proteinuria (if dipstick

test positive); or glucose tolerance test (if fasting

plasma glucose O 100 mg/dL); and home and
24-hour blood pressure monitoring. Extended

evaluation may be necessary, based on the find-

ings from these investigations [1,14].

The indication for exercise testing depends on
the patient’s risk profile and on the amateur/

leisure-time sports characteristics (Table 3)

[29,30]. In patients who have hypertension and

are about to engage in intense (although amateur)

exercise training (ie, intensity R60% of maxi-
mum), a medically supervised peak or symptom-

Table 3

Indications for exercise testing for sports participation in

patients who have hypertension

Risk category

Demands of exercise

(static or dynamic)

Low or


High or

very high

Light (!40% of max) No No
Moderate (40%–59%

of max)

No Yes

High (R60% of max) Yes Yes

In case of an associated clinical condition, the

recommendations for the specific condition should be

limited exercise test with electrocardiography (or
cardiopulmonary testing) and blood pressure
monitoring is warranted. In asymptomatic men

or women with low or moderate added risk (see
Table 2) who engage in low-to-moderate leisure-
time physical activity (ie, intensity !60% of
maximum), further testing beyond the routine

evaluation is generally not needed. Asymptomatic
patients with high or very high added risk may
benefit from exercise testing before engaging in

moderate-intensity exercise (ie, 40%–60% of
maximum). Patients who have exertional dyspnea,
chest discomfort, or palpitations need further

examination, which includes exercise testing,
echocardiography, Holter monitoring, or combi-
nations thereof.

A major problem with exercise testing in

a population with a low probability of coronary
heart disease and in subjects with left ventricular
hypertrophy is that most positive tests on electro-

cardiography are falsely positive. Stress myocar-
dial scintigraphy or echocardiography, and,
ultimately, coronaroangiography, may be indi-

cated in cases of doubt. Evidence is inconclusive
that blood pressure response to exercise, in
addition to blood pressure at rest, should play

a role in the recommendations for exercise [31];
however, subjects with an excessive rise of blood
pressure during exercise are more prone to
develop hypertension and should be followed up

more closely [29]. Finally, physicians should be
aware that high blood pressure may impair
exercise tolerance [32].

Effects of exercise on blood pressure

Dynamic exercise

Blood pressure increases during acute dynamic
exercise in proportion to the intensity of the effort
[32]. During long-term, steady-state exercise,

blood pressure tends to decrease after an initial in-
crease of short duration. The increase is greater
for systolic than for diastolic blood pressure,
which increases only slightly or even remains un-

changed. For the same oxygen consumption, the
rise is more pronounced in older subjects and
when exercise is performed with smaller versus

larger muscle groups. The exercise is usually fol-
lowed by postexercise hypotension, which may
last for several hours and is generally more pro-

nounced and of longer duration in patients who
have hypertension than in normotensive subjects

Page 5


Cross-sectional and longitudinal epidemiologic
studies indicate that physical inactivity and low
fitness levels are associated with higher blood
pressure levels and increased incidence of hyper-

tension in the population [33]. Meta-analyses of
randomized, controlled intervention studies con-
cluded that regular dynamic endurance training

at moderate intensity significantly reduces blood
pressure [34–36].

A recent meta-analysis involved 72 trials and

105 study groups [36]. After weighting for the
number of participants, training was responsible
for a significant net reduction of resting and day-

time ambulatory blood pressure (3.0/2.4 mm Hg
and 3.3/3.5 mm Hg, respectively). The reduction
of resting blood pressure was more pronounced
in the 30 hypertensive study groups (�6.9/�4.9)
than in the others (�1.9/�1.6). Evidence was not
convincing that the degree of reduction in blood
pressure was related to the intensity of exercise

training, when this ranged between about 40%
and 80% of maximal aerobic power [34]. Systemic
vascular resistance decreased by 7.1%, plasma

norepinephrine by 29%, and plasma renin activ-
ity by 20%. Body weight decreased by 1.2 kg,
waist circumference by 2.8 cm, percent body fat

by 1.4%, and the homeostatic model assessment
(HOMA) index of insulin resistance by 0.31
units; high-density lipoprotein cholesterol in-
creased by 0.032 mg/dL. Therefore, aerobic en-

durance training decreases blood pressure
through a reduction of vascular resistance, in
which the sympathetic nervous system and the

renin-angiotensin system appear to be involved,
and favorably affects concomitant cardiovascular
risk factors.

Static exercise

Blood pressure increases during acute static

exercise and the increase is more pronounced than
with dynamic exercise, particularly with heavy
static exercise at an intensity of more than 40% to
50% of maximal voluntary contraction. In a recent

meta-analysis of randomized controlled trials,
‘‘resistance’’ training at moderate intensity was
found to decrease blood pressure by 3.5/3.2

mmHg [37]. The meta-analysis included nine stud-
ies designed to increase muscular strength and
power or endurance, and all but one study

involved dynamic, rather than purely static, exer-
cise. In fact, few sports are characterized by purely
static efforts. However, only three trials in the
meta-analysis reported on patients who had


General recommendations

Athletes with hypertension should be treated

according to the general guidelines for the man-
agement of hypertension [1,14]. Appropriate non-
pharmacologic measures should be considered in

all patients (ie, moderate salt restriction, increase
in fruit and vegetable intake, decrease in saturated
and total fat intake, limitation of alcohol consump-

tion to no more than 20 to 30 g ethanol/d for men
and no more than 10 to 20 g ethanol/d for women,
smoking cessation, and control of body weight).

Antihypertensive drug therapy should be started
promptly in patients at high or very high added
risk for cardiovascular complications (see Table 2).
In patients at low or moderate added risk, drug

treatment is only initiated when hypertension per-
sists after several weeks (moderate added risk) or
months (low added risk) despite appropriate life-

style changes. The goal of antihypertensive therapy
is to reduce blood pressure to at least below 140/90
mm Hg, and to lower values if tolerated, in all hy-

pertensive patients, and to below 130/80 mm Hg
in diabetics and other high- or very high-risk

Current evidence indicates that patients who
have white-coat hypertension do not have to be
treated with antihypertensive drugs, unless they
are at high or very high risk (see Table 2), but reg-

ular follow-up and nonpharmacologic measures
are recommended [1,14]. Also, subjects with nor-
mal blood pressure at rest but exaggerated blood

pressure response to exercise should be followed
up more closely.

Choice of drugs

Several drug classes can be considered for the
initiation of antihypertensive therapy: diuretics;
beta-blockers; calcium channel blockers; angio-
tensin-converting enzyme inhibitors, and angio-

tensin II receptor blockers [1,14]. However,
diuretics and beta-blockers are not recommended
for first-line treatment in patients engaged in com-

petitive or high-intensity endurance exercise [32].
Diuretics impair exercise performance and capac-
ity in the first weeks of treatment through a reduc-

tion in plasma volume, but exercise tolerance
appears to be restored during longer-term treat-

ment; nevertheless, diuretics may cause electrolyte

Page 6


and fluid disturbances, which are not desirable in
the endurance athlete. Beta-blockers reduce max-
imal aerobic power by 7% on average, as a result

of the reduction in maximal heart rate, which is
not fully compensated for by increases in maximal
stroke volume, peripheral oxygen extraction, or
both. Furthermore, the time that submaximal ex-

ercise can be sustained is reduced by about 20%
by cardioselective beta-blockers and by about
40% by nonselective beta-blockers, most likely

as a result of impaired lipolysis [32,38,39]. In addi-
tion, diuretics and beta-blockers are on the doping
list for some sports in which weight loss or control

of tremor are of paramount importance. Diuretics
are also banned because they may be used to con-
ceal the use of other doping agents, such as ana-
bolic steroids, by diluting the urine samples. The

hypertensive athlete who has to use a diuretic or
beta-blocker for therapeutic purposes should fol-
low the International Standard for Therapeutic

Use Exceptions of the World Anti-Doping

Calcium channel blockers and blockers of the

renin-angiotensin system are currently the drugs
of choice for the hypertensive endurance athlete
[32,40], and may be combined in case of insuffi-

cient blood pressure control. However, the combi-
nation of an angiotensin-converting enzyme
inhibitor and an angiotensin II receptor blocker
is currently not advocated for the treatment of

hypertension because the benefit of the combina-
tion for blood pressure control has not been
proved. If a third drug is required, a low-dose
thiazide-like diuretic, possibly in combination
with a potassium-sparing agent, is recommended.

Unequivocal evidence that antihypertensive
agents would impair performance in ‘‘resistance’’
sports does not exist.

Recommendations for leisure-time
and competitive sports participation

Recommendations to athletes with hyperten-
sion for participation in intense leisure-time and

competitive sports are based on the results of the
evaluation and on the risk stratification (see Table
2), with the understanding that the general recom-

mendations for the management of hypertension
as described earlier are observed, and provided
that the clinical condition is stable. Table 4 sum-
marizes recommendations with regard to compet-

itive sports participation [28,29].
The same recommendations may apply to

patients who aim to engage in hard or very hard

leisure-time sports activities to enhance perfor-
mance substantially. However, most recreational
physical activities are performed at low-to-mod-

erate intensity. Dynamic sports activities are
preferred, but also, low-to-moderate resistance
training may not be harmful and may even
contribute to blood pressure control [37]. In cases

of cardiovascular or renal complications, the
recommendations are based on the associated
clinical conditions. Finally, all patients should be
Table 4

Recommendation for intense leisure-time physical activity and competitive sports participation in athletes who have

systemic hypertension (and other risk factors) according to the cardiovascular risk profile

Risk category Evaluation Criteria for eligibility Recommendations Follow-up

Low added risk History, PE, ECG,

ET, Echo

Well-controlled BP All sports Yearly

Moderate added


History, PE, ECG,

ET, Echo

Well-controlled BP

and risk factors

All sports,

with exclusion of



sports (III C)


High added risk History, PE, ECG,

ET, Echo

Well-controlled BP

and risk factors

All sports,

with exclusion of


sports (III A–C)


Very high

added risk

History, PE, ECG,

ET, Echo

Well-controlled BP

and risk factors; no

associated clinical


Only low-

to moderate-dynamic,


sports (I A–B)

6 months

Abbreviations: BP, blood pressure; ECG, 12-lead electrocardiography; Echo, echocardiography at rest; ET, exercise

testing; PE, physical examination, including repeated blood pressure measurements according to guidelines.

Page 7


followed up at regular intervals, depending on the
severity of hypertension and the category of risk
(see Table 4). In addition, all exercising patients
should be advised on exercise-related warning

symptoms, such as chest pain or discomfort, ab-
normal dyspnea, and dizziness or malaise, which
would necessitate consulting a qualified physician.


Hypertension is rare in the young, but its
prevalence increases with aging. The overall risk
of the hypertensive patient depends not only on

blood pressure but also on the presence of other
cardiovascular risk factors, target organ damage,
and associated clinical conditions. The recom-

mendations for preparticipation screening, sports
participation, and follow-up depend on the car-
diovascular risk profile of the individual athlete.

When antihypertensive treatment is required,
calcium channel blockers and blockers of the
renin-angiotensin system are currently the drugs
of choice.


The authors gratefully acknowledge the secre-
tarial assistance of N. Ausseloos.


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