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How does exercise treatment compare with antihypertensive medications? A network meta-analysis of 391 randomised controlled trials assessing exercise and medication effects on systolic blood pressure
  1. Huseyin Naci1,
  2. Maximilian Salcher-Konrad1,
  3. Sofia Dias2,3,
  4. Manuel R Blum4,5,6,
  5. Samali Anova Sahoo7,
  6. David Nunan8,
  7. John P A Ioannidis5,6,9
  1. 1 Department of Health Policy, London School of Economics and Political Science, London, UK
  2. 2 Bristol Medical School, University of Bristol, Bristol, UK
  3. 3 Centre for Reviews and Dissemination, University of York, York, UK
  4. 4 Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
  5. 5 Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California, USA
  6. 6 Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA
  7. 7 Department of Life Sciences and Management, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  8. 8 Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  9. 9 Stanford Prevention Center, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
  1. Correspondence to Dr Huseyin Naci, Department of Health Policy, London School of Economics and Political Science, London WC2A 2AE, UK; H.Naci{at}


Objective To compare the effect of exercise regimens and medications on systolic blood pressure (SBP).

Data sources Medline (via PubMed) and the Cochrane Library.

Eligibility criteria Randomised controlled trials (RCTs) of angiotensin-converting enzyme inhibitors (ACE-I), angiotensin-2 receptor blockers (ARBs), β-blockers, calcium channel blockers (CCBs) and diuretics were identified from existing Cochrane reviews. A previously published meta-analysis of exercise interventions was updated to identify recent RCTs that tested the SBP-lowering effects of endurance, dynamic resistance, isometric resistance, and combined endurance and resistance exercise interventions (up to September 2018).

Design Random-effects network meta-analysis.

Outcome Difference in mean change from baseline SBP between comparator treatments (change from baseline in one group minus that in the other group) and its 95% credible interval (95% CrI), measured in mmHg.

Results We included a total of 391 RCTs, 197 of which evaluated exercise interventions (10 461 participants) and 194 evaluated antihypertensive medications (29 281 participants). No RCTs compared directly exercise against medications. While all medication trials included hypertensive populations, only 56 exercise trials included hypertensive participants (≥140 mmHg), corresponding to 3508 individuals. In a 10% random sample, risk of bias was higher in exercise RCTs, primarily due to lack of blinding and incomplete outcome data. In analyses that combined all populations, antihypertensive medications achieved higher reductions in baseline SBP compared with exercise interventions (mean difference −3.96 mmHg, 95% CrI −5.02 to −2.91). Compared with control, all types of exercise (including combination of endurance and resistance) and all classes of antihypertensive medications were effective in lowering baseline SBP. Among hypertensive populations, there were no detectable differences in the SBP-lowering effects of ACE-I, ARB, β-blocker and diuretic medications when compared with endurance or dynamic resistance exercise. There was no detectable inconsistency between direct and indirect comparisons. Although there was evidence of small-study effects, this affected both medication and exercise trials.

Conclusions The effect of exercise interventions on SBP remains under-studied, especially among hypertensive populations. Our findings confirm modest but consistent reductions in SBP in many studied exercise interventions across all populations but individuals receiving medications generally achieved greater reductions than those following structured exercise regimens. Assuming equally reliable estimates, the SBP-lowering effect of exercise among hypertensive populations appears similar to that of commonly used antihypertensive medications. Generalisability of these findings to real-world clinical settings should be further evaluated.

  • exercise
  • evaluation

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Supplementary materials


  • Contributors HN and JPAI devised the paper. HN, MS-K, MRB, SAS identified studies and collected data. HN did all statistical analyses with input from SD and JPAI. HN developed the first draft of the paper and all authors contributed to subsequent versions. HN is the guarantor.

  • Funding HN is supported by the Higher Education Funding Council for England. SD is supported by the Medical Research Council, UK (MR/M005232/1). MRB is supported by a grant from the Swiss National Science Foundation (P2BEP3 175289).

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Data sharing statement Dataset is available from the authors upon request.

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