Canadian Journal of Cardiology
Clinical Research| Volume 34, ISSUE 12, P1641-1647, December 2018

Hypotensive Effect of Heated Water-Based Exercise Persists After 12-Week Cessation of Training in Patients With Resistant Hypertension

Published:October 05, 2018DOI:



      Heated water-based exercise (HEx) promotes a marked reduction of blood pressure (BP), but it is not entirely clear whether its effects on BP persist after cessation of HEx.


      We analyzed the effects of cessation of HEx on 24-hour ambulatory BP monitoring (ABPM) in patients with resistant hypertension (RH). Thirty-two patients (aged 53 ± 6 years) with RH (4 to 6 antihypertensive drugs) were randomly assigned to HEx (n = 16) or control (n = 16) groups. Antihypertensive therapy remained unchanged during the protocol. The HEx group participated in 36 sessions (60 minutes) in a heated pool (32oC [89.6°F]) for 12 weeks (training), followed by 12 weeks of cessation of training. The control group was evaluated during the same period and instructed to maintain their habitual activities.


      HEx and control groups had similar BP levels at baseline. HEx training reduced the 24-hour systolic (–19.5 ± 4.6 vs 3.0 ± 0.7 mm Hg, P = 0.001) and diastolic BP (–11.1 ± 2.4 vs 2.06 ± 0.9 mm Hg, P = 0.001) at week 12, compared with the control group. After 12 weeks of training cessation (week 24), 24-hour BP remained significantly lower in the HEx group than in the control group (–9.6 ± 3.8 vs 6.3 ± 3.5 mm Hg, P = 0.01 and –7.5±2.2 vs 2.2 ± 1.0 mm Hg, P = 0.009, for systolic and diastolic BP, respectively), although these differences were attenuated.


      BP remained lower after cessation of 12-week training among patients with RH who underwent HEx compared with the controls. The carryover effects of HEx on BP may help to overcome the challenging problem of exercise compliance in long-term follow-up.



      L’exercice en eau chaude (ExEC) favorise une réduction marquée de la pression artérielle (PA), mais il reste à déterminer si cet effet sur la PA persiste après la cessation de cette activité.


      Nous avons analysé les effets de la cessation de l’ExEC par une surveillance ambulatoire de la PA (SAPA) pendant 24 heures chez des patients souffrant d’hypertension résistante (HR). Trente-deux patients (âgés de 53 ± 6 ans) atteints d’HR (de 4 à 6 médicaments antihypertenseurs) ont été affectés au hasard au groupe ExEC (n = 16) ou au groupe témoin (n = 16). Le traitement antihypertenseur est demeuré inchangé pendant l’étude. Les participants du groupe ExEC ont pris part à 36 séances (d’une durée de 60 minutes) dans une piscine chauffée (à 32o C [89,6° F]) pendant une période de 12 semaines (entraînement), suivie d’une période de 12 semaines de cessation de l’entraînement. Les participants du groupe témoin, évalués durant la même période, avaient reçu la consigne de poursuivre leurs activités habituelles.


      Au début de l’étude, les valeurs de PA étaient similaires dans le groupe ExEC et dans le groupe témoin. Après 12 semaines, l’entraînement ExEC a entraîné une réduction de la PA systolique (-19,5 ± 4,6 vs 3,0 ± 0,7 mmHg, p = 0,001) et de la PA diastolique (-11,1 ± 2,4 vs 2,06 ± 0,9 mmHg, p = 0,001), mesurées pendant 24 heures, par rapport au groupe témoin. Après 12 semaines de cessation de l’entraînement (semaine 24), la PA est demeurée significativement plus basse dans le groupe ExEC que dans le groupe témoin (-9,6 ± 3,8 vs 6,3 ± 3,5 mmHg, p = 0,01 et -7,5 ± 2,2 vs 2,2 ± 1,0 mmHg, p = 0,009, pour la PA systolique et diastolique respectivement), même si les différences étaient moins marquées.


      La PA est demeurée plus basse chez les patients atteints d’HR du groupe ExEC après la cessation de leur entraînement pendant 12 semaines que dans le groupe témoin. Les effets rémanents de l’ExEC sur la PA pourraient aider à surmonter l’épineux problème de la fidélité à un programme d’activité physique dans le suivi à long terme.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Canadian Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • James P.A.
        • Oparil S.
        • Carter B.L.
        • et al.
        2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).
        JAMA. 2014; 311: 507-520
        • Calhoun D.A.
        • Jones D.
        • Textor S.
        • et al.
        Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research.
        Circulation. 2008; 117: e510-e526
        • Ciolac E.G.
        • Bocchi E.A.
        • Bortolotto L.A.
        • Carvalho V.O.
        • Greve J.M.D.
        • Guimãraes G.V.
        Effects of high-intensity aerobic interval training vs. moderate exercise on hemodynamic, metabolic and neuro-humoral abnormalities of young normotensive women at high familial risk for hypertension.
        Hypertens Res. 2010; 33: 836-843
        • Ciolac E.G.
        • Bocchi E.A.
        • Bortolotto L.A.
        • Carvalho V.O.
        • Greve J.M.
        • Guimãraes G.V.
        Haemodynamic, metabolic and neuro-humoral abnormalities in young normotensive women at high familial risk for hypertension.
        J Hum Hypertens. 2010; 24: 814-822
        • Ciolac E.G.
        • Bocchi E.A.
        • Greve J.M.
        • Guimãraes G.V.
        Heart rate response to exercise and cardiorespiratory fitness of young women at high familial risk for hypertension: effects of interval vs continuous training.
        Eur J Cardiovasc Prev Rehabil. 2011; 18: 824-830
        • Ciolac E.G.
        • Guimãraes G.V.
        • D'Avila V.M.
        • Bortolotto L.A.
        • Doria E.L.
        • Bocchi E.A.
        Acute effects of continuous and interval aerobic exercise on 24-h ambulatory blood pressure in long-term treated hypertensive patients.
        Int J Cardiol. 2009; 133: 381-387
        • Guimãraes G.V.
        • Ciolac E.G.
        • Carvalho V.O.
        • D'Avila V.M.
        • Bortolotto L.A.
        • Bocchi E.A.
        Effects of continuous vs. interval exercise training on blood pressure and arterial stiffness in treated hypertension.
        Hypertens Res. 2010; 33: 627-632
        • Garber C.E.
        • Blissmer B.
        • Deschenes M.R.
        • et al.
        American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise.
        Med Sci Sports Exerc. 2011; 43: 1334-1359
        • Graham I.
        • Atar D.
        • Borch-Johnsen K.
        • et al.
        European guidelines on cardiovascular disease prevention in clinical practice: full text. Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts).
        Eur J Cardiovasc Prev Rehabil. 2007; 14: S1-S113
        • Cornelissen V.A.
        • Smart N.A.
        Exercise training for blood pressure: a systematic review and meta-analysis.
        J Am Heart Assoc. 2013; 2e004473
        • Guimãraes G.V.
        • Cruz L.G.
        • Tavares A.C.
        • Dorea E.L.
        • Fernandes-Silva M.M.
        • Bocchi E.A.
        Effects of short-term heated water-based exercise training on systemic blood pressure in patients with resistant hypertension: a pilot study.
        Blood Press Monit. 2013; 18: 342-345
        • Guimãraes G.V.
        • de Barros Cruz L.G.
        • Fernandes-Silva M.M.
        • Dorea E.L.
        • Bocchi E.A.
        Heated water-based exercise training reduces 24-hour ambulatory blood pressure levels in resistant hypertensive patients: a randomized controlled trial (HEx trial).
        Int J Cardiol. 2014; 172: 434-441
        • Dimeo F.
        • Pagonas N.
        • Seibert F.
        • Arndt R.
        • Zidek W.
        • Westhoff T.H.
        Aerobic exercise reduces blood pressure in resistant hypertension.
        Hypertension. 2012; 60: 653-658
        • Cruz L.G.
        • Bocchi E.A.
        • Grassi G.
        • Guimaraes G.V.
        Neurohumoral and endothelial responses to heated water-based exercise in resistant hypertensive patients.
        Circ J. 2017; 81: 339-345
        • Mujika I.
        • Padilla S.
        Cardiorespiratory and metabolic characteristics of detraining in humans.
        Med Sci Sports Exerc. 2001; 33: 413-421
        • Toraman N.F.
        • Ayceman N.
        Effects of six weeks of detraining on retention of functional fitness of old people after nine weeks of multicomponent training.
        Br J Sports Med. 2005; 39 (discussion 568): 565-568
        • Vona M.
        • Rossi A.
        • Capodaglio P.
        • et al.
        Impact of physical training and detraining on endothelium-dependent vasodilation in patients with recent acute myocardial infarction.
        Am Heart J. 2004; 147: 1039-1046
        • Volaklis K.A.
        • Douda H.T.
        • Kokkinos P.F.
        • Tokmakidis S.P.
        Physiological alterations to detraining following prolonged combined strength and aerobic training in cardiac patients.
        Eur J Cardiovasc Prev Rehabil. 2006; 13: 375-380
        • Guimãraes G.V.
        • Ciolac E.G.
        Physical activity: practice this idea.
        Am J Cardiovasc Dis. 2014; 4: 31-33
        • Cornelissen V.A.
        • Buys R.
        • Smart N.A.
        Endurance exercise beneficially affects ambulatory blood pressure: a systematic review and meta-analysis.
        J Hypertens. 2013; 31: 639-648
        • Pascoalino L.N.
        • Ciolac E.G.
        • Tavares A.C.
        • et al.
        Exercise training improves ambulatory blood pressure but not arterial stiffness in heart transplant recipients.
        J Heart Lung Transplant. 2015; 34: 693-700
        • Tokmakidis S.P.
        • Spassis A.T.
        • Volaklis K.A.
        Training, detraining and retraining effects after a water-based exercise program in patients with coronary artery disease.
        Cardiology. 2008; 111: 257-264
        • Bocalini D.S.
        • Serra A.J.
        • Rica R.L.
        • Dos Santos L.
        Repercussions of training and detraining by water-based exercise on functional fitness and quality of life: a short-term follow-up in healthy older women.
        Clinics. 2010; 65: 1305-1309
        • Lovell D.I.
        • Cuneo R.
        • Gass G.C.
        The effect of strength training and short-term detraining on maximum force and the rate of force development of older men.
        Eur J Appl Physiol. 2010; 109: 429-435
        • Vona M.
        • Codeluppi G.M.
        • Iannino T.
        • Ferrari E.
        • Bogousslavsky J.
        • von Segesser L.K.
        Effects of different types of exercise training followed by detraining on endothelium-dependent dilation in patients with recent myocardial infarction.
        Circulation. 2009; 119: 1601-1608
        • Salles G.F.
        • Cardoso C.R.
        • Muxfeldt E.S.
        Prognostic influence of office and ambulatory blood pressures in resistant hypertension.
        Arch Intern Med. 2008; 168: 2340-2346
        • Fedecostante M.
        • Barbatelli P.
        • Guerra F.
        • Espinosa E.
        • Dessi-Fulgheri P.
        • Sarzani R.
        Summer does not always mean lower: seasonality of 24 h, daytime, and night-time blood pressure.
        J Hypertens. 2012; 30: 1392-1398
        • Torffvit O.
        The effect of achieving a systolic blood pressure of 140 mmHg: a prospective study of ambulatory measurements in type 2 diabetic patients with nephropathy.
        J Diabetes Complications. 2012; 26: 540-545
        • Fadel P.J.
        Arterial baroreflex control of the peripheral vasculature in humans: rest and exercise.
        Med Sci Sports Exerc. 2008; 40: 2055-2062
        • Castro R.E.
        • Guimãraes G.V.
        • Rodrigues da Silva J.M.
        • Bocchi E.A.
        • Ciolac E.G.
        Postexercise hypotension after heart transplant: water- versus land-based exercise.
        Med Sci Sports Exerc. 2016; 45: 804-810
        • Sosner P.
        • Gayda M.
        • Dupuy O.
        • et al.
        Ambulatory blood pressure reduction following high-intensity interval exercise performed in water or dryland condition.
        J Am Soc Hypertens. 2016; 10: 420-428
        • Lambert B.S.
        • Greene N.P.
        • Carradine A.T.
        • et al.
        Aquatic treadmill training reduces blood pressure reactivity to physical stress.
        Med Sci Sports Exerc. 2014; 46: 809-816
        • Tomas-Carus P.
        • Hakkinen A.
        • Gusi N.
        • Leal A.
        • Hakkinen K.
        • Ortega-Alonso A.
        Aquatic training and detraining on fitness and quality of life in fibromyalgia.
        Med Sci Sports Exerc. 2007; 39: 1044-1050
        • Becker B.E.
        • Hildebrand K.
        • Whitcomb R.K.
        • Sanders J.P.
        Biophysiologic effects of warm water immersion.
        IJARE. 2009; 3: 24-37
        • Suaya J.A.
        • Stason W.B.
        • Ades P.A.
        • Normand S.L.
        • Shepard D.S.
        Cardiac rehabilitation and survival in older coronary patients.
        J Am Coll Cardiol. 2009; 54: 25-33
        • Dibben G.O.
        • Dalal H.M.
        • Taylor R.S.
        • Doherty P.
        • Tang L.H.
        • Hillsdon M.
        Cardiac rehabilitation and physical activity: systematic review and meta-analysis.
        Heart. 2018; 104: 1394-1402
      1. Alter DA, Yu B, Bajaj RR, Oh PI. Relationship between cardiac rehabilitation participation and health service expenditures within a universal health care system [Epub ahead of print] Mayo Clin Proc, accessed November 14, 2018.

        • Cider A.
        • Schaufelberger M.
        • Sunnerhagen K.S.
        • Andersson B.
        Hydrotherapy: a new approach to improve function in the older patient with chronic heart failure.
        Eur J Heart Fail. 2003; 5: 527-535
        • Asa C.
        • Maria S.
        • Katharina S.S.
        • Bert A.
        Aquatic exercise is effective in improving exercise performance in patients with heart failure and type 2 diabetes mellitus.
        Evid Based Complement Alternat Med. 2012; 12: 349209
        • Osterberg L.
        • Blaschke T.
        Adherence to medication.
        N Engl J Med. 2005; 353: 487-497
        • Saneei P.
        • Salehi-Abargouei A.
        • Esmaillzadeh A.
        • Azadbakht L.
        Influence of dietary approaches to stop hypertension (DASH) diet on blood pressure: a systematic review and meta-analysis on randomized controlled trials.
        Nutr Metab Cardiovasc Dis. 2014; 24: 1253-1261