Additional blood-pressure-lowering effect of exercise in adults on stable antihypertensive medication: a systematic review and meta-analysis of randomised controlled trials.

Physical exercise and antihypertensive medications are routinely co-prescribed for treating hypertension. Contemporary international guidelines separately establish the expected effects of pharmacological and exercise interventions. However, meta-analytical evidence assessing the additional effect of exercise on antihypertensive medication is lacking. We conducted a systematic review and meta-analysis of randomised controlled trials evaluating the effects of exercise interventions in adults receiving stable antihypertensive medication. The outcomes included blood pressure parameters, body composition, lipid profiles, glycaemic markers, and cardiorespiratory fitness. Mean differences (MDs) with 95% CIs were pooled using random-effects models, and the risk of bias of the studies was assessed using the RoB2 tool. This systematic review with meta-analysis was registered in PROSPERO (CRD420261277175). Forty-eight studies (2085 participants across 57 publications) fulfilled the inclusion criteria. Compared with usual care on a background of stable medication, exercise reduced office SBP (MD -7.9 mmHg; 95% CI -10.3 to -5.6; I² = 78%) and office DBP (-4.4; -5.8 to -3.1; I² = 64%). The magnitude of these reductions is comparable to that expected from adding a further antihypertensive agent, although the certainty of evidence was low and the prediction intervals were wide. Beyond these effects, significant improvements were observed across multiple outcomes, including office mean blood pressure (MAP), 24 h ambulatory DBP, daytime DBP, nighttime ambulatory blood pressure, body weight, BMI, HDL-c, triglycerides, fasting glucose, and cardiorespiratory fitness. In contrast, no significant between-group differences were observed for changes in 24 h ambulatory SBP, daytime SBP, 24 h MAP, daytime MAP, body fat percentage, waist circumference, total cholesterol, LDL-c, and HbA1c levels. Evidence quality ranged from low to very low for ambulatory SBP, whereas it was moderate for diastolic and nocturnal measurements. No exercise modality (aerobic, resistance, combined, high-intensity interval, or isometric training) was significantly superior to another for any outcome. Adding structured exercise to stable antihypertensive therapy was associated with further reductions in office blood pressure and several ambulatory blood-pressure indices, and with improvements in cardiovascular risk factors; however, given the heterogeneity and risk of bias, the certainty was low to moderate for most estimates, and trials testing exercise-guided medication adjustment are warranted.