342 Brief report
Effects of short-term heated water-based exercise training
on systemic blood pressure in patients with resistant
hypertension: a pilot study
Guilherme V. Guimarãesa, Lais G.B. Cruza, Aline C. Tavaresa, Egidio L. Doreab,
Miguel M. Fernandes-Silvaa and Edimar A. Bocchia
High blood pressure (BP) increases the risk
of cardiovascular diseases, and its control is a clinical
challenge. Regular exercise lowers BP in patients
with mild-to-moderate hypertension. No data are available
on the effects of heated water-based exercise in
hypertensive patients. Our objective was to evaluate the
effects of heated water-based exercise on BP in patients
with resistant hypertension. We tested the effects of 60-min
heated water-based exercise training three times per week
c 2013 Wolters
in 16 patients with resistant hypertension (age 55±6
years). The protocol included walking and callisthenic
exercises. All patients underwent 24-h ambulatory blood
pressure monitoring (ABPM) before and after a 2-week
exercise program in a heated pool. Systolic office BP was
reduced from 162 to 144 mmHg (P < 0.004) after heated-
water training. After the heated-water exercise training
during 24-h ABPM, systolic BP decreased from 135 to
123 mmHg (P = 0.02), diastolic BP decreased from 83 to
74 mmHg (P = 0.001), daytime systolic BP decreased from
141 to 125 mmHg (P = 0.02), diastolic BP decreased
from 87 to 77 mmHg (P = 0.009), night-time systolic
BP decreased from 128 to 118 mmHg (P = 0.06),
Introduction
Systemic hypertension is a highly prevalent disease,
affecting almost 20% of the population worldwide, and
is one of the major risk factors for cardiovascular
morbidity and mortality [1]. Resistant hypertension (RH)
is prevalent in 10–30% of all hypertensive patients, and
control is a recognized clinical challenge [2].
Regular physical exercise reduces systemic blood pressure
(BP) and is broadly recommended by current hyperten-
sion guidelines [3–8]. However, a recent study showed
that conventional exercise has only modest effects on BP
in patients with RH [9].
The correlation between temperature and BP has been
documented, with higher values in winter and lower values
in warm seasons [10,11]. One study showed that exercise
and saunas have discreet effects on BP in patients with
untreated hypertension [12], but there is a lack of evidence
of heat as a treatment for hypertension. Heated water-
based exercise training (HEx) has been studied in patients
with coronary arterial disease, heart failure, and other
pathologies, and it seems to have greater advantages
1359-5237
c 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
and diastolic BP decreased from 77 to 69 mmHg (P = 0.01).
In addition, BP cardiovascular load was reduced
significantly during the 24-h daytime and night-time period
after the heated water-based exercise. Heated water-
based exercise reduced office BP and 24-h daytime and
night-time ABPM levels. These effects suggest that heated
water-based exercise may have a potential as a new
therapeutic approach to resistant hypertensive
patients. Blood Press Monit 18:342–345
Kluwer Health | Lippincott Williams & Wilkins.
Blood Pressure Monitoring 2013, 18:342–345
Keywords: blood pressure, blood pressure monitoring, exercise,
hypertension, water-based
a
Heart Institute (InCor), Clinics Hospital and bUniversity Hospital, University of
São Paulo Medical School, São Paulo, Brazil
Correspondence to Guilherme V. Guimarães, PhD, Heart Institute, Hospital Das
Clinicas Da Faculdade De Medicina Da Universidade De São Paulo,
Rua Dr. Baeta Neves, 98, São Paulo 05444-050, Brazil
Tel: + 55 112 661 5419; fax: + 55 112 661 5502;
e-mail: gvguima@usp.br
Received 21 June 2013 Revised 6 August 2013
Accepted 11 September 2013
compared with land-based exercise [13–16]. Data on this
mode of exercise in RH do not exist.
Our objective was to test the effects of 2-week HEx on
systemic BP in patients with RH.
Methods
Population
We studied 16 patients diagnosed with RH, who in the
previous 6 months had unchanged or regular use of three
classes of antihypertensive drugs, with an office systolic
BP of at least 140 mmHg and diastolic BP of at least
90 mmHg. Baseline characteristics of the study popula-
tion are shown in Table 1.
Study design
All patients were recruited from a hypertension out-
patient clinic at the University Hospital of the University
of São Paulo in May 2011. Medical history from patient
records was used to exclude patients with secondary
hypertension because of other diseases. Patients with
heart failure, any previous cardiovascular event, renal
failure, chronic obstructive pulmonary disease, insulin
DOI: 10.1097/MBP.0000000000000000

Table 1 Baseline characteristics of the resistant hypertensive
patients
Sex (female/male)
Age (years)
BMI (kg/m2)
Etiology W/B
Abdominal circumference (cm)
Neck circumference (cm)
SBP office (mmHg)
DBP office (mmHg)
Peak VO2 (ml/kg/min)
Maximum heart rate (bpm)
Number of antihypertensive drugs
Diuretic
ACE inhibitor
b-Blocker
a-Adrenergic inhibitor
ARB
Vasodilator
CCB
Statin
Acetylsalicylic acid
Hypoglycemic drug
ACE, angiotensin-converting-enzyme inhibitor; ARB, angiotensin II receptor
blocker; B, black; CCB, calcium channel blocker; SBP and DBP, systolic and
diastolic blood pressure at office; W, white.
dependent diabetes, biomechanical limitations to physi-
cal activity, smokers, or those participating in regular
physical activity were excluded. All patients underwent a
cardiopulmonary treadmill exercise test before training.
Ambulatory blood pressure monitoring (ABPM) was
performed before and 72 h after the last HEx session.
All patients were instructed to maintain the same
antihypertensive treatment during the entire study
period. The local ethics committee approved all proce-
dures. The volunteers read a detailed description of the
protocol and provided written informed consent.
Cardiopulmonary exercise test
Cardiopulmonary exercise testing was performed before
exercise training to exclude the presence of coronary
artery disease and to determine physical exercise work-
load. The cardiopulmonary exercise testing was performed
according to a previous study [17].
Blood pressure measurements
Office BP was measured three times using the auscultatory
method (mercury sphygmomanometer; Heidji, São Paulo,
Brazil) with the patient in a sitting position. It was taken at
intervals of 1 min, at baseline, and on the last day of the
exercise training, between 9 a.m. and 2 p.m., by a profes-
sional staff person who was blinded to the study data.
ABPM was performed before and 72 h after the last
session in the heated pool. Both measurements were
initiated at the same time of the day (between 1:00 and
2:00 p.m.) using a Spacelabs model 90207 ABP monitor
(Spacelabs Medical Inc., Redmond, Washington, USA).
The BP cuff was worn on the nondominant arm with a
proper cuff size. Participants were instructed to perform
their habitual daily activities and not to exercise during
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Heated water-based exercise Guimarães et al. 343
the recording interval for daytime ABPM. For analysis,
ABPM data were classified by mean, 24 h, daytime, and
8/8 night-time periods for systolic and diastolic BP, separately.
54.9±5.7
29.4±3.6
The daytime and night-time periods were based on the
6/12 time patients got out of and into bed, respectively. The
100.3±10.0 monitor was programmed to measure BP every 15 min
39.4±4.0
163.2±20.6 during the daytime and every 20 min during night-time
89.7±8.3 periods. BP load was defined as the percentage of BP
25.1±4.7
149.8±21.5
measurements of at least 130/80 mmHg in the 24-h
4 (3–6) period, 135/85 mmHg during daytime, and 120/70 mmHg
100% during night-time. Data were accepted only if at least
68%
62%
75% of the measurements were taken successfully.
31%
25%
68% Exercise training protocol
68% The exercise sessions took place in the afternoon
43%
31%
(1:30–2:30 p.m.) and were performed in a controlled
43% temperature (30–321C) swimming pool. Patients were
immersed in warm water up to the xiphoid process level,
and the sessions were performed three times a week, for 2
weeks. All patients were instructed to not add any
leisure-time exercise during the study period. Patients
were either unused to or had no previous experience with
water or swimming. The exercise sessions were per-
formed for 60 min: 5 min of warming up, 20 min of
calisthenics (upper and lower limbs), 30 min of walking
(HR between the anaerobic threshold and respiratory
compensation point, 68–85%, respectively, and Borg scale
between 11 and 13), and 5 min of cooling down and
stretching [18]. All patients exercised using a heart rate
monitoring device (Polar Beat; Polar Electro Inc.,
Kempele, Finland) during every training session to ensure
that they were training at their training heart rate.
Statistical analysis
Descriptive statistics were used to describe the character-
istics of the patients. Data are presented as mean±SD.
The Shapiro–Wilk test was applied to ensure a Gaussian
distribution of the data. Paired t-test was used to compare
the baseline and second week of training office BP
evaluation, at baseline and after training ABPM data. For
the percentage of patients with target ABPM data,
the level of significance was set at P less than 0.05. The
statistical program SPSS 20.0 for Windows (SPSS Inc.,
Chicago, Illinois, USA) was used to carry out the statistical
analyses.
Results and discussion
The exercises were well tolerated and safe for RH
patients.
Office systolic BP decreased significantly after 2 weeks
of the heated-water immersion aerobic exercise by
17.4±12.5 mmHg (P = 0.004).
Figure 1 shows the significant decrease in systolic
and diastolic ABPM, respectively, in the 24-h period
(– 11.6/ – 8.4 mmHg), daytime (– 11.6/ – 6.4 mmHg), and
344 Blood Pressure Monitoring 2013, Vol 18 No 6
Fig. 1
180
P = 0.02 P = 0.03
P = 0.06
160
140
120
P = 0.002 P = 0.009
mmHg
100
80
60
40
20
0
SBP DBP SBP DBP SBP
24 h 24 h daytime daytime night-time night-time
Baseline After training
Average of 24-h period daytime and night-time ambulatory blood
pressure monitoring at baseline and after 2 weeks of the exercise
training in heated water immersion.
(– 9.6/ – 7.4 mmHg). The systolic and diastolic BP loads
decreased significantly, respectively, at 24 h from 86.4/
72.9 to 51.0/44.2%, daytime from 81.2/73.8 to 50.9/44.0%,
and night-time from 95.2/76.3 to 74.1/53.9% after the
HEx.
To the best of our knowledge, this is a pioneering study
showing the beneficial effects of HEx in patients with
RH. The main finding of this study is that short-term
HEx leads to a significant reduction in 24-h BP in RH
patients. A few studies have analyzed the effects of HEx
on BP [12–14], but they did not include patients with
hypertension.
Our data are in agreement with published results of
beneficial effects of land-based exercise training on BP in
RH patients [9]. However, our results showed a more
pronounced reduction in 24-h systolic and diastolic BPs,
respectively (11.6/8.4 vs. 5.4/2.8 mmHg). Once the BP in
both studies was similar at baseline, this distinctive effect
suggests that immersion in heated water has, indeed, an
additional advantage to the positive effect of exercise
training on systolic and diastolic BP. Interestingly, we have
shown that this benefit did not result from the acute effects
of heat or exercise, as the ABPM was performed 72 h after
the last session. However, studies directly comparing these
two strategies, land-based and heated water-based exercise,
should be carried out to confirm this hypothesis.
Multiple mechanisms can explain our results, but are still
speculative. Exercise training has been shown to decrease
sympathetic and increase vagal nervous activity, and
improve baroreceptor reflex sensitivity after exercise
training [13]. Additional effects attributed to exercise
being performed specifically in heated water are arterial
vasodilatation and reduction in volemia [14,16]. These
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
effects could result in decreased concentrations of renin,
angiotensin II, aldosterone, reduction in renal sympa-
thetic outflow, and increase in nitric oxide and atrial
natriuretic peptide release, which have been observed
previously in healthy individuals and in patients with
heart failure [13,16,19]. However, changes in neurohor-
P = 0.01
monal secretion, peripheral resistance, and diuresis
reported as the result of heated water-based exercise
were not associated with reduction in BP in healthy
individuals and patients with heart failure [13,14,19].
Future training studies with heated pools are needed to
evaluate these hypotheses.
DBP Important limitations of this study are that it has a small
number of individuals and is not a randomized clinical
trial. However, the study has shown that ABPM has a high
reproducibility when repeated in a short-term period [20],
and probably the reduction in BP we found would not
occur in a control group.
This study reinforces the value of exercise training
associated with antihypertensive therapy in hypertensive
patients. HEx induced beneficial effects on BP in patients
with RH, and there were no signs of adverse reactions.
These positive effects of HEx may have a potential as a new
therapeutic approach in resistant hypertensive patients.
However, research involving a large number of patients,
long-term training, randomized clinical trials comparing it
with no exercise, and exercise on land and pool water at
different temperatures would be required in the future.
Acknowledgements
This work was supported by Fundação de Amparo à Pesquisa
do Estado de São Paulo (Fapesp) and Conselho Nacional de
Desenvolvimento Cientı́fico e Tecnológico (CNPq).
Conflicts of interest
There are no conflicts of interest.
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