In this network meta-analysis of randomized controlled studies, all modes of exercise were effective for reducing systolic and diastolic blood pressure, but isometric exercise seemed to be superior to other types of exercise.

The effect of different modes of exercise on systolic blood pressure (SBP) and diastolic blood pressure (DBP).

A total of 15,827 participants.

A meta-analysis was conducted on 270 randomized controlled exercise-training studies.

The exercise protocols were categorized into one of several primary modes: aerobic exercise training, dynamic resistance training, combined (aerobic + resistance) training,high-intensity interval training (HIIT), and isometric exercise training.

Submodes of exercise were defined within each category:

• Aerobic exercise: walking, running, and cycling
• HIIT: sprint interval training and aerobic interval training
• Isometric exercise: handgrip exercise, leg extension, and wall squats

The main analysis was designed to investigate the effect of each mode (and submode) of exercise on blood pressure. Furthermore, the researchers conducted a network meta-analysis to compare the different exercise modes. Additional analyses stratified participants by their baseline blood pressure as normal (<130/85 mmHg), prehypertension (130–139/85–89 mmHg), or hypertension (>140/90 mmHg).

SBP was reduced after aerobic exercise (−5 mmHg), resistance training (−5 mmHg), combined training (−6 mmHg), HIIT (−4 mmHg), and isometric exercise (−8 mmHg).

Effects of exercise on systolic blood pressure

SBP was reduced in the exercise subgroups as well, including walking (−3 mmHg), cycling (−7 mmHg), running (−7 mmHg), sprint interval training (−5 mmHg), handgrip exercise (−7 mmHg), leg extension (−10 mmHg), and wall squats (−10 mmHg).

DBP was reduced after aerobic exercise (−3 mmHg), resistance training (−3 mmHg), combined training (−3 mmHg), HIIT (−3 mmHg), and isometric exercise (−4 mmHg).

Effects of exercise on diastolic blood pressure

DBP was reduced in the exercise subgroups as well, including walking (−1 mmHg), cycling (−3 mmHg), running (−6 mmHg), sprint interval training (−3 mmHg), handgrip exercise (−3 mmHg), leg extension (−4 mmHg), and wall squats (−5 mmHg).

All modes of exercise reduced blood pressure in people with normal blood pressure, but the effects were larger in people with hypertension. When exercise modes were ranked for their effectiveness in reducing SBP and DBP, isometric exercise was the most effective.

Exercise is one of the best nonpharmacological strategies for reducing blood pressure. Two other large-scale meta-analyses have confirmed the blood-pressure-lowering effects of exercise.

A meta-analysis published in 2012^[1] included 93 randomized controlled trials that investigated the effects of endurance, resistance, combined, and isometric exercise on blood pressure. With the exception of combined training for DBP, all modes of exercise were effective for reducing SBP and DBP. However — and aligning with findings from the summarized study — isometric exercise produced the largest reductions in SBP (−10 mmHg) and DBP (−6 mmHg) compared to the other modes of exercise, for which reductions ranged from 1 to 4 mmHg.

Another network meta-analysis published in 2018^[2] included 391 randomized controlled trials, about half of which compared exercise interventions (i.e., endurance, dynamic resistance, combined, and isometric exercise) to a control intervention. The second half of the trials compared antihypertensive medications (i.e., angiotensin-converting enzyme inhibitors, angiotensin-2 receptor blockers, beta-blockers, calcium channel blockers, and diuretics) to control interventions for the management of blood pressure.

Antihypertensive medications outperformed exercise by approximately 4 mmHg, though both exercise and medications were effective for reducing blood pressure. However, among people with hypertension, there were no differences found between most medications and endurance or dynamic resistance exercise for blood pressure. So while more research needs to be done directly comparing exercise and medication, exercise generally has comparable blood-pressure-lowering effects to medication, which is why exercise is included in the guidelines of many major societies as a first-line strategy to prevent/treat hypertension.^[3][4]

This was the first network meta-analysis to compare the effects of different exercise modes and submodes on blood pressure, and it revealed the distinct effects of each type of exercise.

When exercise modes were ranked for their effectiveness in reducing SBP, isometric exercise was the most effective, followed by combined training, resistance training, aerobic exercise training, and HIIT. Subgroup rankings were as follows: wall squats, leg extension, handgrip exercise, cycling, running, combined training, sprint interval training, resistance training, aerobic interval training, and walking.

When exercise modes were ranked for their effectiveness in reducing DBP, isometric exercise was also the most effective, followed by resistance training, HIIT, combined training, and aerobic exercise training. Subgroup rankings were as follows: running, wall squats, handgrip exercise, leg extension, cycling, sprint interval training, resistance training, aerobic interval training, combined training, and walking.

One novelty of this meta-analysis compared to previous ones was the addition of HIIT as an exercise mode. Although it is often considered to be aerobic exercise, HIIT is shorter and more intense and may have effects that are unique from those of traditional endurance training. In this study, HIIT led to clinically relevant reductions in SBP and DBP, though it was least effective among the interventions. The benefits of HIIT were driven primarily by sprint interval training (“all out” efforts), while aerobic interval training interventions weren’t effective. Along with the superior benefits of running and cycling compared to walking, this finding seems to indicate that higher-intensity aerobic exercise may be necessary to elicit the greatest blood pressure reductions.

It’s somewhat surprising that isometric exercise ranked the best among all interventions because this type of exercise is often given less attention than aerobic and resistance training. However, there are mechanisms to support its benefits. During isometric exercise, prolonged muscle contraction temporarily cuts off blood flow through the vasculature. When the exercise is over, blood flow returns with a high magnitude in a process called reactive hyperemia, leading to a large release of nitric oxide and the relaxation of blood vessels. Over time, this process improves the health and function of blood vessels and reduces blood pressure.^[7]

Performing isometric exercise with a larger muscle — wall squats or leg extension, for example — would have an even greater effect by causing more postexercise reactive hyperemia. This is likely why wall squats were ranked as the most effective submode of exercise for reducing blood pressure.

Although it’s nice to know which exercise is “best” for improving blood pressure, this study is a welcome reminder that any and all types of exercise are beneficial. If you enjoy running, then run. If you enjoy lifting weights, then do that. Better yet, do a bit of both.

Although the quality of this network meta-analysis was high and the methods were strong, it still only offers an indirect comparison of exercise modes from individual trials. As such, the findings on comparative effectiveness should be interpreted with caution, especially given the relative lack of studies on isometric exercise (24) compared to aerobic exercise (182), resistance training (57), combined training (46), and HIIT (49).