Pathophysiological mechanisms underlying the beneficial effects of physical activity in hypertension

Abstract

Prevention and management of hypertension represent a global public health challenge. Therefore, the identification of new therapeutic strategies is of growing interest. The American Heart Association defines as "alternative approaches," the non-pharmacological treatments able to lower blood pressure, classifying them into three main categories: behavioral therapies, non-invasive procedures, and exercise-based regimens.1 In the last decades, several studies have revealed that exercise and fitness produce beneficial effects in the general population, reducing the relative risk of death by 20%-35%,2, 3 particularly death caused by cardiovascular disease.4, 5 The definition of "exercise" given by the American College of Sports Medicine reads "Any and all activity involving generation of force by the activated muscle(s) that results in disruption of a homeostatic state." Behind this general definition, different categories of exercise are recognized, which differ for type, intensity, and duration. As the success of pharmacological therapies is linked to the optimal dose, also for "exercise" the potential therapeutic effect strongly depends on the "dose," resulting from optimal intensity and duration. This critical point has opened an extensive research aimed at considering exercise training in therapeutic plans for the management of systemic disorders like diabetes and hypertension. Substantial evidence in literature supports the efficacy of fitness on hypertension, suggesting that physical activity lowers blood pressure, thereby preventing the development and progression of hypertension. In this issue of the Journal, Wellman and colleagues have shown in an elegant study performed in adolescents that engaging in physical activity is associated with lower odds of having blood pressure in the hypertensive range.6 The exact molecular basis of the beneficial effects that physical activity produces on blood pressure is not completely understood, probably because the regulation of blood pressure is complex and multifactorial, including neuro-hormonal, hemodynamic, and metabolic mechanisms. Starting from this multifaceted substrate, exercise training can affect blood pressure acting on different processes (Figure 1), only in part known. A foremost mechanism by which physical exercise can affect blood pressure is the regulation of endothelial function. Indeed, vascular homeostasis depends on the activity of the endothelium, which is a fundamental regulator of the vasomotor responses, modulating the health and resistance of the vessels. Nitric oxide (NO) is a key mediator of endothelial function, and both clinical and preclinical studies have confirmed the ability of exercise to improve NO-dependent endothelial vasodilation.7-12 Physiologically, high NO production occurs in response to increased blood flow to compensate the shear stress by vasodilation.13-15 Exercise training results in repeated exposure to shear stress, thus improving the bioavailability of NO.16 In rats, a 2- to 4-week exercise training not only stimulates the NO production in the arterioles of the skeletal muscle, but also markedly improves the vasodilator response to acetylcholine.17 A regular aerobic exercise can improve endothelial function also in aged population, in which the endothelium is compromised. Indeed, exercise training has been shown to attenuate endothelial dysfunction during aging,18 probably increasing NO synthesis to counteract ROS generation.19 A direct evidence of the improvement of endothelial function as a pivotal mechanism underlying the antihypertensive effect of physical exercise comes from the SEFRET study (Study of endothelial function response to exercise training in hypertensive individuals).20 In this report, the authors unveil two crucial points: (a) physical activity ameliorates the endothelium-dependent vasodilation in a hypertensive population; and (b) the magnitude of the improvement of endothelial function depends on the type of exercise training (aerobic, resistance, or concurrent training). This evidence strengthens the concept that the prescription of a specific exercise program is fundamental in the therapeutic approach of hypertensive patients. Hypertension is characterized by microvascular rarefaction caused by impaired angiogenesis.21 Constant physical exercise has been shown to induce vessel adaptation, augmenting blood flow reserves.22 These morphological changes in the vascular tree result from exercise-induced angiogenesis, which increases the size and number of blood vessels.23 The formation of new microvessels and the increase of vessel networks are processes regulated by vascular endothelial growth factor (VEGF) and other mediators; released in response to exercise training, VEGF produces a mitotic effect on endothelial cells, induces endothelial cell migration, and promotes chemotaxis.24 Other factors able to regulate angiogenesis are released in response to exercise, including angiopoietins and met