AHA: Physical Activity Should First-line Therapy as BP, LDL Tick Upwards

The American Heart Association (AHA) is reminding physicians that lifestyle changes that involve upping the amount of physical activity should be the first line of attack when treating patients with mildly or moderately elevated blood pressure and cholesterol levels.

While physical activity is recommended for everybody, regardless of their CVD risk profile, those with slightly elevated blood pressure and LDL cholesterol are an important group to target because there is an opportunity to prevent or delay starting lifetime medical therapy, according to the AHA.  

“With this intermediate-risk group, the focus is on preventing, especially in younger people, the progression to [CVD] risk factors so that they’re not exposed to them early in life,” Bethany Barone Gibbs, PhD (University of Pittsburgh, PA), chair of the AHA scientific statement, told TCTMD. “It’s a critical moment. Their blood pressure or cholesterol is starting to increase and they don’t want to start medication. It’s a really important time to get people when they might be motivated and have a chance to stay off medication and to keep [their blood pressure or cholesterol] in a healthy range for longer.”

The document aims to encourage physicians to speak frequently with their  intermediate-risk patients about physical activity, in instances where lifestyle interventions can be an option. In the United States, roughly 21% of adults meet the criteria for lifestyle-only treatment of high blood pressure while nearly 30% of adults could start with a nonpharmacological, the AHA says, lifestyle-oriented approach to managing elevated LDL cholesterol levels.

Patients with “elevated blood pressure” and stage 1 hypertension, as defined by the 2017 American College of Cardiology/American Heart Association Hypertension Clinical Practice Guidelines, should be managed first with a lifestyle-only approach. This includes patients with systolic BP 120-129 mm Hg and diastolic BP less than 80 mm Hg (elevated BP) and patients at low atherosclerotic cardiovascular disease (ASCVD) risk with systolic BP 130-139 or diastolic BP 80-89 mm Hg (stage 1 hypertension).

Based on the 2018 cholesterol guidelines, a lifestyle-only treatment approach is an option after a shared decision-making discussion in low-risk patients aged 40 to 75 years with LDL > 70 mg/dL and a low ASCVD risk score (< 7.5%) and in patients with LDL > 70 mg/dL, intermediate ASCVD risk (7.5% to 20%), low coronary artery calcium score (< 100 Agatston units), and a low burden of other risk factors.

In the paper, published online today in Hypertension, the writing group describes the average effects physical activity can have on blood pressure and cholesterol levels. For example, aerobic physical activity reduces systolic BP by roughly 4 mm Hg and LDL cholesterol by 3 to 5 mg/dL. Aerobic activity also increases HDL cholesterol by 1 to 2 mg/dL and decreases triglycerides anywhere from 4 to 12 mg/dL. These effects are either comparable, superior, or complementary to other healthy lifestyle interventions, such as changes to diet and weight loss.

Gibbs said the 2018 Physical Activity Guidelines for Americans have hopefully made exercise a little less daunting for people. Patients are still advised to aim for 300 minutes of moderate-intensity physical activity each week—or 150 minutes of vigorous-intensity physical activity—but adults are now encouraged to move more and sit less throughout the day.

“These new physical activity guidelines really emphasize changing the way we think about physical activity,” said Gibbs. “A lot of people have this idea that if they didn’t run for 30 minutes, they didn’t exercise, [but] the evidence suggests that every little bit of physical activity counts. Even if you take the stairs a couple more times, that actually has measurable benefits. It would be better if you went for a 30-minute run, but it’s better to take the stairs if the alternative is to do nothing.” 

In the statement, the AHA writing committee also outlines how physicians can help patients adopt and maintain a physically active lifestyle. Gibbs noted that fitness trackers can objectively monitor physical activity in steps or distance and also alert people when they’ve been inactive for too long. “Tracking steps is such an easy way to look at all-day activity,” she said. “It’s easy for patients to understand, it’s easy for clinicians to understand. We know that even increasing your steps by 1,000 steps a day has benefits for long-term cardiovascular outcomes.”