Heart rate recovery after physical exertion tests in elderly hypertensive patients undergoing resistance training

Abstract

Introduction:
Heart rate recovery after exercise is a valuable variable, associated with prognosis and it has been used as an indicator of cardiorespiratory fitness, especially in patients with heart disease, as hypertensive patients.

Objective:
This study aimed to analyze the response of heart rate recovery in elderly hypertensive patients undergoing a resistance training program. Methods: Sample was composed for 10 elderly women with a mean age of 70.7 ± 7.4 years. Exercise test and six-minute walk test were developed and we checked heart rate recovery in the 1st and 2nd minute post tests, before and after resistance training.

Results:
There was an increase in mean heart rate recovery in the analyzed minutes in both tests, but only in the 1st minute after six minutes walk test we found a significant increase (p = 0.02).

Conclusion:
The results suggest the efficacy of resistance training to improve cardiorespiratory fitness of elderly hypertensive patients.

Full text

Fisioter Mov. 2016 Jan/Mar;29(1):53-60
ISSN 0103-5150
Fisioter. Mov., Curitiba, v. 29, n. 1, p. 53-60, Jan./Mar. 2016
Licenciado sob uma Licença Creative Commons
DOI: http://dx.doi.org.10.1590/0103-5150.029.001.AO05
[T]
Heart rate recovery after physical exertion tests in elderly
hypertensive patients undergoing resistance training
[I]
Recuperação da frequência cardíaca após testes de esforço
em idosas hipertensas submetidas a treinamento resistido
[A]
Murillo Jales Lins de Lira, Ivan Daniel Bezerra Nogueira, Juliana Fernandes de Souza,
Flávio Emanoel Souza de Melo, Ingrid Guerra Azevedo, Patrícia Angélica de Miranda Silva Nogueira*
Universidade Federal do Rio Grande do Norte (UFRN), Natal, RN, Brazil
[R]
Abstract
Introduction: Heart rate recovery after exercise is a valuable variable, associated with prognosis and it has
-
sive patients. Objective: This study aimed to analyze the response of heart rate recovery in elderly hyperten-
sive patients undergoing a resistance training program. Methods: Sample was composed for 10 elderly women
with a mean age of 70.7 ± 7.4 years. Exercise test and six-minute walk test were developed and we checked
heart rate recovery in the 1st and 2nd minute post tests, before and after resistance training. Results: There
was an increase in mean heart rate recovery in the analyzed minutes in both tests, but only in the 1st minute
Conclusion: The results suggest the ef-

Keywords: Heart rate. Hypertension. Exercise. Elderly. Exercise test.[B]
* MJLL: grad, e-mail: murillojales@hotmail.com
IDBN: MSc, e-mail: idpa01@hotmail.com
JFS: MSc, e-mail: julianaferso@yahoo.com.br
 
IGA: MSc, e-mail: ingridguerra@outlook.com
PAMSN: PhD, e-mail: idpa02@hotmail.com

Fisioter Mov. 2016 Jan/Mar;29(1):53-60
De Lira MJL, Nogueira IDB, De Souza JF, Melo FES, Azevedo IG, Nogueira PAMS.
54
Resumo
Introdução: A recuperação da freqüência cardíaca após o exercício é uma variável valiosa que
está associada com o prognóstico e vem sendo utilizada como indicador do condicionamento cardiorrespi-
ratório, principalmente em pacientes cardiopatas, como é o caso dos hipertensos. Objetivo: O presente estu-
do objetivou analisar a resposta da recuperação da freqüência cardíaca em idosas hipertensas submetidas a
programa de treinamento resistido. Métodos: A Amostra foi composta de 10 idosas com média de idade de
70,7 ± 7,4 anos. Realizou-se o teste ergométrico, o teste de caminhada de seis minutos e verificou-se a recupe-
ração da freqüência cardíaca no 1° e 2° minutos após a realização dos testes pré e pós-treinamento resistido.
Resultados: Observou-se aumento na média da recuperação da freqüência cardíaca nos minutos analisados
em ambos os testes, porém apenas no 1° minuto após o teste de caminhada de seis minutos encontrou-se au-
mento significativo (p = 0,02). Conclusão: Os resultados sugerem eficácia do treinamento resistido para me-
lhorar o condicionamento cardiorrespiratório das pacientes.
[K]
Palavras-chave: Frequência cardíaca. Hipertensão. Exercício. Idoso. Teste de esforço.
Introduction
Systemic arterial hypertension (SAH) is a mul-
tifactorial disease with high prevalence in elderly,
especially in women, becoming a determining factor
in high morbidity and mortality rates of these indi-
viduals (1). Estimates suggest the high growth of this
disease in different countries, being one of the major
public health problems worldwide (2).
Among the main causes for establishment of HAS
we highlight the low level of physical activity and ex-
cessive body fat (3, 4). Thus, changes in lifestyle are
primordial to hypertension prevention, treatment and
control, being physical exercise an integral component
of this program (5). Some studies have shown the ef-
   
pressure levels in hypertensive individuals (6, 7).
Heart rate recovery (HRR) has a relationship
with cardiovascular function, where slower reduc-
tions are directly related to the worsening of cardio-
vascular mortality and function (8). Recent studies
have shown that the HRR decrease after exercise is
associated with less favorable prognosis in patients
monitoring (9). For this reason, studies have pointed
HRR post exercise as a prognostic tool (10).
In this context, HRR has been used in several stud-
ies (11-13) also as an indicator of cardiorespiratory

a reactivation function of parasympathetic activity
modulation and a reduction in sympathetic activity

seconds after exercise (9, 14).
     
several physical tests, such as six-minute walk test
(6MWT), as well as exercise test (ET) on a treadmill,
which are valuable tools for cardiac patients func-
tional performance assessment (15, 16).
Thus, considering the high prevalence of hyper-
tension in elderly, especially in women, and noticing
the lack of research on the analysis of HRR after RT
program in that population, this study aimed to ana-
lyze the HRR response in elderly hypertensive women
undergoing a RT program.
Materials and methods
Sample selection
Patients with controlled hypertension diagnosis
were recruited from the Program of Support and Care
for Hypertension (PSCH), linked to a high complexity
in cardiology hospital.
Females, aged 60 years or higher, with clinical
stability, medical agreement based on clinical as-
sessment and previous ET were considered eligible
for this study. The study excluded patients who had
inappropriate response of blood pressure (BP) and
heart rate (HR) during the ET, ET-induced ventricu-
lar arrhythmias, severe pulmonary hypertension or

Fisioter Mov. 2016 Jan/Mar;29(1):53-60
Heart Rate Recovery After physical exertion tests in Elderly Hypertensive Patients Undergoing Resistance Training 55
other serious lung disease, consumption of alcohol
and / or tobacco, use of tranquilizers or sedatives,
confusion or dementia, orthopedic limitation and/
or cognitive impairment that could hinder the tests
execution, pain or inability to perform the protocol
established by the research and changes in medica-
tion during the study period. Besides, it was excluded
patients who were absent in more than 15% of the
proposed period for training or three consecutive
absences, in order to diminish bias in the evaluation
at the end of training, being held for all participants
the conditioning obtained with RT program.
Previously, patients were informed about the
study's purpose and it was asked to consent by sign-
ing a consent form approved by the Ethics Committee
of the institution, under the number 223/08.
Study Dynamics
In this longitudinal study of quasi-experimental
type, selected patients underwent a clinical evalua-
tion for entry into the RT protocol, including resting
electrocardiogram analysis, ET and 6MWT.
-
tion to personal data, anthropometric measurements,
such as weight and height, as well as information on
pathological history. For body composition analysis,
the volunteer’s body weight was measured, through
a Filizola
®
mechanical scale. Height was measured
through a stadiometer and we calculated body mass
index (BMI).
BP measurement was performed by indirect
auscultation method using a BD
®
stethoscope and
BD
®
sphygmomanometer. Procedures for BP mea-
surements were based on VI Brazilian Guidelines on
Hypertension (17).
Exercise testing
A Micromed
®
treadmill was used for exercise test-
ing (Centurion 200 model). Ramp protocol was used,
in which the load increase was given by a continuous
and gradual manner during the entire duration of
effort. The reason that the load was increased was
  
sex, age and physical condition. So, we had a good
approximation of the individual maximum oxygen
uptake (VO2max). From this, the protocol suggested
the percentage of slope and speed, which would be
necessary to take the patient to a maximal effort at
a desired time, usually between 8 - 12 minutes (18).
Six minutes walk test
The 6MWT was performed on a 30 meters cor-
ridor, marked meter by meter, by a single examiner,
following the American Thoracic Society (ATS) pro-
tocol (19).
Patients were instructed to walk as fast as possible
without running, according to their exercise tolerance
in the 6-minutes period. Before starting each test,
respiratory rate and heart rate were obtained, mea-
sured by a pulse oximeter (Nonin
®
brand - Onyx-9500
model), and blood pressure was measured by a BD®
sphygmomanometer and a Littman
®
stethoscope. The
perceived exertion was measured using Borg Scale
(20). At the end of each test, these parameters were
recorded again, as well as the total distance walked
in meters for the period of 6 minutes.
HRR measurement
HR was measured in supine position during every
minute of the two stress tests developed, at peak ex-
ercise and on 1
st
and 2
nd
minutes of recovery after the


the fall of HR during this time interval (10).
Resistance training program
Before RT, volunteers underwent an adaptation
period of exercise, lasting two weeks, to learn the
correct techniques of movements execution.
After this adaptation process, tests of eight maxi-
mum repetitions (8-MR) were developed to the muscle
groups to be trained. The 8-MR test corresponded to
the maximum load that can be lifted by the participant
throughout the normal range of motion, while maintain-
ing the proper technique, in eight successive repetitions.
RT lasted eight weeks, with a weekly frequency
of three times, every other day, held in two sets of
eight repetitions, always in the afternoon. Training
intensity was progressively increased throughout the
training program, i.e., in the end of each week the

Fisioter Mov. 2016 Jan/Mar;29(1):53-60
De Lira MJL, Nogueira IDB, De Souza JF, Melo FES, Azevedo IG, Nogueira PAMS.
56
examination. Regarding the execution of ET, we did
not found arrhythmias or other symptoms that could
avert the realization of RT protocol.
patient was oriented to do two more repetitions of
each exercise, and if possible, the current load was
increased by 5% (21, 22).
The adopted training method was the alternate
segments with exercises performed sequentially in
the following order: leg press, bench press, leg exten-
sion, frontal pull chair, leg curl knee, shoulder abduc-
tion with dumbbells, hip abduction and barbell curl.
The execution speed used was 2: 2 and a 2 - minute
rest interval between each series (5).
During the movements execution, the patients
were instructed to breathe properly and continuously
during each exercise repetition, exhaling during the
concentric contraction and inspiring during the ec-
centric contraction, and thus, reducing the chance of
performing Valsalva maneuver.
Before RT, patients developed a 5 minutes heat-
ing, through a light walk, followed by self-stretching
the major muscles used, which had been previously
oriented. After each training session, self-stretching
exercises were repeated.
Statistical analysis
Data were analyzed using the statistical software
Statistical Package for Social Sciences version 17.0
(SPSS Inc., Chicago, IL, USA). Descriptive analysis
was presented as mean and standard deviation (SD).
Normality test for the studied variables indicated
data normal distribution using Kolmogorov-Smirnov
test, which allowed the use of paired Student t test


Results
15 volunteers were eligible for the study. However,
-
sons, among them: cataract surgery, unfeasible
driving until the training camp and family commit-
ments. Thus, the sample consisted of 10 hypertensive
patients, mean age 70 years and BMI > 25 kg / m2.
Among the comorbidities observed, it was evidenced
hypercholesterolemia (80%), arthritis (50%) and
obesity (50%). The patients’ clinical characteristics
are summarized in Table 1.
All patients in the study were able to com-
plete 6MWT without stopping or interrupting the
Table 1 - General characteristics of the study population
Age (years)70.7 ± 7.4
Weight (Kg)61.6 ± 9.04
Height (m)1.55 ± 0.09
BMI (Kg/m2)25.14 ± 3.34
Hemodynamic variables (rest)
SBP (mmHg) 150 ± 15.63
DBP (mmHg) 94 ± 8.43
HR (bpm) 78 ± 18.67
Comorbidities
Diabetes Mellitus 1 (10%)
Hypercholesterolemia 8 (80%)
Osteoporosis 1 (25%)
Arthritis 5 (50%)
Obesity 5 (50%)
Medications in use
Beta-blocker 4 (40%)
ACE Inhibitor 6 (60%)
Diuretic 1 (10%)
Calcium channel blocker 4 (40%)
Note: BMI: Body mass index; ACE: Angiotensin-converting enzyme;
SBP: Systolic blood pressure; DBP: Diastolic blood pressure; HR:
Heart rate.
Regarding HRR behavior after 6MWT, there was a
 
obtained in the 1
st
minute of recovery when comparing
the moments before and after RT program. However, in
the 2nd minute after the test, despite increase in mean


These values are described in detail in Table 2.
There was an increase in HRR mean values after
ET when comparing the moments before and after
RT program. However, this difference observed in 1
st
minute and 2nd

Discussion
The sample consisted of elderly hypertensive wom-
en, who presented obesity and hypercholesterolemia

Fisioter Mov. 2016 Jan/Mar;29(1):53-60
Heart Rate Recovery After physical exertion tests in Elderly Hypertensive Patients Undergoing Resistance Training 57
Table 2 - Average values, standard deviation and p val-
ue of HRR in the 6-minute walk test, developed
in 10 patients diagnosed with hypertension.
6MWT Pre RT Post RT p value
Heart rate recovery (bpm)
1º minute 25.5 ± 8.8 31.6 ± 10.0 0.02*
2º minute 29.4 ± 12.7 34.3 ± 9.8 0.17
Note: 6 MWT: 6 - minute walk test, HR: heart rate, RT: resistance
training; *signicant difference (p < 0.05).
as main comorbidities. It is known that females are
associated with more rapid HRR (9) and that factors
such as increasing age (9, 23), high BMI levels (BMI >
25kg/m
2
) (24), increased abdominal girth, hypercho-
lesterolemia and high systolic pressure (23, 25) are
independently associated with attenuated response
of HRR post exercise.
Recent studies (23, 25, 26) indicate that both
individuals with prehypertension as those with
hypertension may have delayed HRR when com-
pared to healthy subjects, suggesting that this pa-
thology is associated with autonomic dysfunction
    
in hypertensive patients, especially when there are
co-morbidities associated.
HRR evaluation, besides permitting infer a cardiovas-
cular autonomic regulation dysfunction, as evidenced
by a slow decline in the 1
st
and 2
nd
minutes after a stress
test (27), can be considered a risk factor for cardiovas-
cular disease and furthermore, shows correlation with
mortality from all causes (28 - 30). There is also direct
correlation of HRR with maximum oxygen uptake, so
it is believed that patients with an attenuated response
have lower exercise capacity (31, 32).
Table 3 - Average values, standard deviation and p
value of HRR in exercise testing, developed in
10 patients diagnosed with hypertension.
Exercise
Testing
Pre RT Post RT p value
Heart rate recovery (bpm)
1º minute 27.0 ± 16.3 34.6 ± 11.8 0.16
2º minute 38.5 ± 11.9 42.5 ± 10.2 0.30
Note: HR: heart rate, RT: resistance training; * signicant difference
(p < 0.05).
In this regard, it was noted that HRR values in 1st
minute pre-intervention in this study (25 to 27 bpm, de-
pending on the used test) corroborate with those found
in the literature. Aneni et al. (26), evaluating individuals
with hypertension, found a HRR in the 1st minute of 24

in healthy individuals. However, in general, a decrease
of 20 to 45 bpm in the 1st minute of recovery, as found
in this study, is related to a good cardiovascular health
and a favorable clinical outcome (28).
When observing HRR in the 2nd pre-intervention
minute, the results of this research (29 and 39 bpm,
depending on the assessment) show values that are
still lower than those found by Aneni et al. (26), which
also evaluated patients with hypertension and found
a slower HRR in the 2
nd
minute post exercise (54 bpm)
compared to normotensive subjects (65 bpm).
Among the results of this study, it is possible to
highlight the increased speed of HRR found in pa-
tients after their participation in an eight-week re-
sistance training program. This improvement was

st
minute post 6MWT, as well as an increase, although

in the 2nd minute after both tests, although also not

training program.
It is necessary to resume the concept that heart
rate after exercise has a slow and a fast phase re
-
covery (11). It is suggested that a high drop in HR
at 1st minute (fast phase) not necessarily result in a
steepest HR in the following minutes (slow phase)

difference in the 1st minute and has not occurred in
the 2nd minute for any of the tests.
It is well established that aerobic exercise train-
ing can increase the delta between HR at the end of
exercise and in early stages of recovery (34 - 36),
  

exercise (34). However, when compared to aerobic,
little is known about the autonomic control post RT
(37 - 40), especially in clinical populations of elderly
hypertensive patients.
In the present study, it is supposed that the HRR


-
rectly related to HRR, for example, improvements in


Fisioter Mov. 2016 Jan/Mar;29(1):53-60
De Lira MJL, Nogueira IDB, De Souza JF, Melo FES, Azevedo IG, Nogueira PAMS.
58
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of the improved HRR, found through the 6MWT after
a RT program, in this study.
Therefore, it is suggested that the HRR evaluation
should be considered in a RT program for elderly

health risks, and possibly could be used for RT pre-
scription and monitoring (38, 39).
Some limitations can be found in this study: 1) a
small sample size, which may be one of the reasons

tests in the 2nd minutes recovery; 2) although the
HRR is a simple method to evaluate parasympathetic
tone, the use of heart rate variability would provide a
more sensitive and accurate assessment of autonomic
nervous system function; 3) once the sample was
composed only of women, there may be limitations
to extrapolate the results for hypertensive men; 4)
There was no control group.
However, these limitations do not invalidate this re-
search results because, despite several studies about
HRR post physical tests are found in the literature, there
is still lack of researches in order to verify, through that
variable, the effects of RT for elderly hypertensive popu-
lation, since this group is leaning to develop cardiovas-
cular diseases, showing a less favorable prognosis.
Conclusion

st
minute post 6MWT, and an increase, although not sig-


of the cardiac post-exercise autonomic control, due to a
RT program. In addition, it may mean, despite not hav-
ing been this study focus, reduced risk of cardiovascular
complications for elderly hypertensive patients.
It is suggested that HRR should be observed in
future researches, especially involving clinical popu-
lations; other studies will also be needed to clarify
mechanisms of increased parasympathetic activity
in these patients after their participation in the RT
program proposed, as well as the risk of cardiovas-
cular events related to this autonomic modulation.
Potential Conict of Interest


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