Hypertension Unit， University of Leuven (KU Leuven)， Leuven-BELGIUM

International Circulation: There has been a lot of discussion about pharmacotherapy， and we know that hypertension involves a lot of factors in addition to pharmacotherapy. Therefore， in your opinion， what’s the influence of exercise on blood pressure and cardiovascular risk factors?

Prof. Fagard: We can look at this in two ways. Firstly， we can look as the epidemiological data – when we look as cross-sectional epidemiological data it is obvious that there is a relationship between the amount of exercise， physical activity and blood pressure. So， the higher the physical activity， the lower the blood pressure， and there are even prospective studies where the amount of physical activity is prospected for the development of hypertension. But， of course， with epidemiological cross-sectional studies there are the usual problems for adjustment and things that have not been measured， etcetera， etcetera， so I think intervention studies are much more important than the cross-sectional data.So， we did some interventional studies where we applied moderate exercise in people with hypertension and people without hypertension and we looked at the response of blood pressure in a well-controlled manner， and in addition to that we did a large meta-analysis where we looked at all the data available in literature – but only randomized control trials. In that overall meta-analysis published in Hypertension a few years ago we saw that there is a decrease in blood pressure of on average 3mm of mercury， which is highly significant.But then， if you look at normal-tensive studies and hypertensive studies， it is somewhat less that the normal-tensive studies but， still， it is significant. However， if you look at the hypertensive studies – studies performed on patients with hypertension – you find a decrease 7 to 8mm of mercury， which is a nice， substantial decrease， and these are from really well controlled studies. In that meta-analysis， in contrast to previous meta-analyses， we also looked at all other risk factors that have been studies in these trials and， for example， we observed that HDL cholesterol increased， that glucose intolerance improved， that endothelial function improved， so exercise is not only good for blood pressure， it is also good for the other risk factors involved.

国际循环：对高血压的药物治疗谈论很多，我们都知道高血压的管理除了药物治疗还应该包括很多内容。那么您认为锻炼对血压和心血管危险因素有什么影响？

Fagard教授：我们可以从两个方面来看这个问题，首先从流行病学数据来看，横断面流行病学数据显示体育锻炼，运动量和血压之间具有相关性。一般来讲，锻炼越多，血压越低。另外前瞻性观察研究显示运动量与高血压病的进展呈负相关。但是当然，流行病学横断面研究通常存在不完全调整和未测量变量等问题。所以干预性研究数据比横断面研究数据更为重要。我们做了一些干预性研究，分别让有高血压和无高血压的患者进行适量的运动，以对照的方式观察锻炼对血压的影响。此外，最近我们还做了一个大型的荟萃分析，对所有随机对照研究的文献中可用的数据进行分析。在这项荟萃分析中包括了2005年发表在高血压杂志上的文献，我们观察到动态有氧训练可以产生平均血压3mmHg的显著下降。但是如果分别观察正常血压组和高血压组，会发现正常血压组的血压降幅较少，但结果仍有显著差异。然而，在高血压组中会发现血压有7/5mmHg的下降。同前面的荟萃分析结果相反，我们通过已经进行关于其它所有危险因素的研究得到的结论，例如，通过锻炼可以是腹围下降、HDL胆固醇增加、胰岛素抵抗和内皮功能得到改善。所以，锻炼不仅对血压有好处，对其他有关的危险因素也有好处。

International Circulation: You mentioned interventional studies and perhaps in many Western countries when the transition was happening from a very active， more physical-centred lifestyle， to this more sedentary lifestyle， it was earlier on and perhaps some of the studies had not conducted. How about， for example， in a country like China， which is now developing and the lifestyle is changing. Do you think perhaps that there is a real opportunity to do studies like this as this transition is taking place?

Prof. Fagard: I think these studies should be performed， because when I think back to all the randomized control trials， so the really good trials， that we reviewed as part of our meta-analysis， I do not remember there being any from China， so I think it would be very worthwhile to conduct such studies to see if what we found in other populations is also true in China. Particularly if obesity is increasing， physical exercise will be very important.

国际循环：您刚才提到了干预试验，可能在西方国家，生活方式已经从一种以体力活动为主的方式转变为一种以久坐为主的生活方式，由于这些试验开始的比较早，可能研究没有这样指导。比如中国这样的发展中国家，生活方式也正在发生改变，您认为这是否是一个研究这种生活方式变化发生的好时机？

Fagard教授：我认为这些研究应该进行，因为当为我们的荟萃分析回顾一些随机对照试验时，发现它们确实是很好的试验，但是没有一项结果是来自中国的，尽管有几项是来自日本的。因此我认为，这样的研究非常值得花时间去做，这样我们就能发现是否在其他人群中得到的结果在中国也成立。尤其是，当肥胖的发生越来越多，锻炼就显得更加重要。

International Circulation: With regards to these endpoints， does the influence of exercise vary? For example， in China， data suggest stroke is more common than myocardial infarction， so does exercise affect these end points differently – perhaps a greater reduction in stroke than in MI， or vice-versa?

Prof. Fagard: The problem is that we do not have intervention studies in that regard. We do have intervention studies in cardiac rehabilitation， so there are some well controlled studies in cardiac rehabilitation and they have shown that mortality reduces by 25% in multi-disciplinary rehabilitation and that cardiovascular and total mortality reduce by about 25%， but there is no further distinction between stroke and myocardial infarction， so we cannot really answer that question. Of course， there are follow-up epidemiological studies which investigates whether mortality and cardiovascular events are related to physical activity at baseline， and to the best of my knowledge there are improvements in all types of score-specific cardiovascular events.

国际循环：考虑这些终点，是否是收到锻炼不同的影响而产生的呢？比如在中国，数据显示在高血压患者中卒中比心梗更常见，那么是否锻炼对不同终点事件有不同的影响？是否锻炼能减少卒中的发生多于减少心梗的发生？或者是否锻炼能减少心梗的发生多于卒中的发生？

Fagard教授：问题是我们没有在这些人群或高血压人群中做过关于锻炼的干预性研究。然而，我们在心脏病患者中做过相关研究，所以在心脏康复方面有一些对照试验的荟萃分析中，显示康复组的患者的全因死亡率和心血管死亡率较对照组减少了25%，然而在卒中和心梗之间没有进一步的差别。所以我们不能真正回答这个问题。另外一方面，一些关于基线水平锻炼和死亡率及心血管事件之间关系的流行病学随访研究，我所知道的是，所有类型的心血管事件都得到了改善。

International Circulation: In primary care settings in Spain， it was found that office BP was adequately controlled in only 23.6% of their patients. In contrast， daytime ambulatory BP was adequately controlled in 51.6% of patients. But in another comparable survey in primary care settings in Japan， it was found that， compared with office BP， morning home BP was rather poorly controlled. So， in your opinion is out-of-the-office blood pressure useful in primary care?

Prof. Fagard: Well， I think we have to see what has been shown with out-of-the-office blood pressure in primary care in terms of prognosis. There are three studies in primary care – one study by Dr. De Corte from our group in his pr