This systematic review evaluated how different types and intensities of exercise compared against different classes and doses of antihypertensive medications in lowering systolic blood pressure levels. The review included randomised controlled trials that were conducted in adults with or without hypertension but no cardiovascular disease, cerebrovascular disease, diabetes or other chronic condition such as cancer. Any form of structured exercise and antihypertensive medication was considered to be included as the experimental intervention. Interventions were compared against usual practice (no exercise), other exercise regimens, or medications. Risk of bias was evaluated with the Cochrane risk of bias tool. A network meta-analysis was performed to compare the multiple interventions simultaneously.

The review included 197 trials of exercise (n = 10,461 participants) and 194 trials testing antihypertensive drugs (n = 29,281), totalling 391 trials included in the analysis (n = 39,742). No trials directly compared exercise and antihypertensive drugs. The average systolic blood pressure at baseline was 132 mmHg for participants in trials of exercise interventions, whereas in trials of antihypertensive medications it was consistently over 150 mmHg. The majority of trials tested endurance interventions (n = 135), such as walking, running, cycling or aquatic exercise.

Across all populations, both exercise interventions (mean difference -5 mmHg, 95% confidence interval -6 to -4) and antihypertensive medications (-9 mmHg, -10 to -8) were effective in lowering systolic blood pressure compared with control. Populations receiving medications achieved greater reductions in systolic blood pressure compared with those participating in exercise interventions (-4 mmHg, -5 to -3). All types of exercise lowered blood pressure in a similar fashion, with exception of the combination of endurance and resistance training which was more effective than dynamic resistance exercise alone (-3 mmHg, -5 to -1). A dose-response effect was observed for medications, but there was substantial uncertainty for effects of different intensities of exercise.

This review showed that the effect of exercise on lowering systolic blood pressure appears to be similar to that of commonly used antihypertensive medications across diverse populations and settings. The possibility of confounding due by the observed differences in trial populations and characteristics cannot be ruled out.

Network meta-analysis is explained in a PEDro blog from 2018.

Naci H, et al. 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. Br J Sports Med 2019;53(14):859-69

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