Should Resistance Training Also Be Considered a Mandatory Component?Keywords
Endurance Training; Resistance Training; Arterial Pressure
Palavras-chave
Treino Aeróbico; Treinamento Resistido; Pressão Arterial
Keywords
Endurance Training; Resistance Training; Arterial Pressure
Palavras-chave
Treino Aeróbico; Treinamento Resistido; Pressão Arterial
I have read with interest the Brazilian Guidelines for Hypertension 2025, specifically Chapter 6: Nonpharmacological Measures (Physical Activity and Exercise). Although the current guideline1 has interesting practical applications for endurance training, some methodological issues might be of interest to readers, especially regarding the practice of resistance training (RT) for hypertensive patients.
The guideline1 states that aerobic training is a mandatory component, whereas RT is considered only complementary. However, this approach underestimates the clinical relevance of RT. Recent international guidelines2–5 recommend a structured exercise program that includes both aerobic exercise and/or RT. Notably, the Japanese Society of Hypertension4 highlights that regular aerobic and RT are equally effective in lowering blood pressure, and both are therefore strongly recommended.
The 2025 American Heart Association Scientific Statement2 recommends RT at moderate-to-high intensities (50–80% of 1RM, 6 exercises, 3 sets/exercise, 10 repetitions/set, 90-150 min/wk). RT has been shown to reduce resting blood pressure in individuals both without hypertension (−2 to −5 mmHg systolic) and with hypertension (−2 to −7 mmHg systolic), supported by vascular mechanisms3 including improvements in endothelial function, vasodilatory capacity, and vascular conductance.
A meta-analysis6 of randomized controlled trials (5065 hypertensive patients) showed that all exercise (aerobic, dynamic RT, isometric RT, and combined) significantly reduced systolic and diastolic blood pressure compared to non-exercise. In addition, the results demonstrated that dynamic RT has a similar antihypertensive effect to aerobic exercise in hypertensive patients, and both are strongly recommended.
Epidemiological evidence indicates that muscle-strengthening activities are associated with a reduced risk of all-cause mortality and cardiovascular disease (CVD) morbidity and mortality.7,8 Adults who participate in RT have ≈15% lower risk of all-cause mortality and 17% lower risk of CVD, compared with adults who report no RT.2 Previous studies7–9 have reported that muscle strength has cardioprotective properties and that higher levels of muscle strength are associated with lower mortality rates in both the general population8 and hypertensive people.10 Furthermore, RT contributes to improvements in glycemic control, lipid profile, body composition, and physical function.3 Outcomes that directly impact cardiovascular risk and long-term adherence in real-world practice.
Hypertension is the most common cardiovascular disease in older adults. More than 60% of older present hypertension, characterized by a high prevalence and low rate of blood pressure control.1 The aging process is associated with increased arterial stiffness,1 as well as progressive declines in muscle mass, strength, power, and bone mineral density. All of these morphofunctional changes can be attenuated or minimized through RT. Therefore, RT should not be regarded as merely complementary,2–6 but rather as a co-primary strategy alongside aerobic exercise in the treatment and control of hypertension.
In light of this evidence, dynamic RT should not be viewed as merely complementary but rather as a co-primary strategy, alongside aerobic training, for the treatment and control of hypertension. Moreover, RT is a valuable option for individuals with low tolerance to aerobic exercise (physical incapacity) and osteomuscular limitations.3 The central purpose of this comment is not to diminish the well-established benefits of aerobic exercise, but to emphasise that dynamic RT must also be considered a mandatory component to maximize the cardiovascular and cardiometabolic benefits. Adopting such an approach would bring the Brazilian Guidelines into closer alignment with global recommendations and maximize their applicability in diverse clinical settings.
References
-
1 Brandão AA, Rodrigues CIS, Bortolotto LA, Armstrong ADC, Mulinari RA, Feitosa ADM, et al. Brazilian Guidelines of Hypertension - 2025. Arq Bras Cardiol. 2025;122(9):e20250624. doi: 10.36660/abc.20250624.
» https://doi.org/10.36660/abc.20250624 -
2 Jones DW, Ferdinand KC, Taler SJ, Johnson HM, Shimbo D, Abdalla M, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2025;152(11):e114-e218. doi: 10.1161/CIR.0000000000001356.
» https://doi.org/10.1161/CIR.0000000000001356 -
3 Paluch AE, Boyer WR, Franklin BA, Laddu D, Lobelo F, Lee DC, et al. Resistance Exercise Training in Individuals with and without Cardiovascular Disease: 2023 Update: A Scientific Statement from the American Heart Association. Circulation. 2024;149(3):e217-e231. doi: 10.1161/CIR.0000000000001189.
» https://doi.org/10.1161/CIR.0000000000001189 -
4 Ohya Y, Sakima A, Arima H, Fukami A, Furuhashi M, Ishida M, et al. Key Highlights of the Japanese Society of Hypertension Guidelines for the Management of Elevated Blood Pressure and Hypertension 2025 (JSH2025). Hypertens Res. 2025;48(10):2500-11. doi: 10.1038/s41440-025-02331-8.
» https://doi.org/10.1038/s41440-025-02331-8 -
5 Gulati M, Moore MM, Cibotti-Sun M. 2025 High Blood Pressure Guideline-at-a-Glance. J Am Coll Cardiol. 2025;86(18):1560-6. doi: 10.1016/j.jacc.2025.07.010.
» https://doi.org/10.1016/j.jacc.2025.07.010 -
6 Morita H, Abe M, Suematsu Y, Uehara Y, Koyoshi R, Fujimi K, et al. Resistance Exercise has an Antihypertensive Effect Comparable to that of Aerobic Exercise in Hypertensive Patients: A Meta-Analysis of Randomized Controlled Trials. Hypertens Res. 2025;48(2):733-43. doi: 10.1038/s41440-024-01998-9.
» https://doi.org/10.1038/s41440-024-01998-9 -
7 Momma H, Kawakami R, Honda T, Sawada SS. Muscle-Strengthening Activities are Associated with Lower Risk and Mortality in Major Non-Communicable Diseases: A Systematic Review and Meta-Analysis of Cohort Studies. Br J Sports Med. 2022;56(13):755-63. doi: 10.1136/bjsports-2021-105061.
» https://doi.org/10.1136/bjsports-2021-105061 -
8 García-Hermoso A, Cavero-Redondo I, Ramírez-Vélez R, Ruiz JR, Ortega FB, Lee DC, et al. Muscular Strength as a Predictor of All-Cause Mortality in an Apparently Healthy Population: A Systematic Review and Meta-Analysis of Data from Approximately 2 Million Men and Women. Arch Phys Med Rehabil. 2018;99(10):2100-2113.e5. doi: 10.1016/j.apmr.2018.01.008.
» https://doi.org/10.1016/j.apmr.2018.01.008 -
9 Shailendra P, Baldock KL, Li LSK, Bennie JA, Boyle T. Resistance Training and Mortality Risk: A Systematic Review and Meta-Analysis. Am J Prev Med. 2022;63(2):277-85. doi: 10.1016/j.amepre.2022.03.020.
» https://doi.org/10.1016/j.amepre.2022.03.020 -
10 Artero EG, Lee DC, Ruiz JR, Sui X, Ortega FB, Church TS, et al. A Prospective Study of Muscular Strength and All-Cause Mortality in Men with Hypertension. J Am Coll Cardiol. 2011;57(18):1831-7. doi: 10.1016/j.jacc.2010.12.025.
» https://doi.org/10.1016/j.jacc.2010.12.025
