High Intensity Interval Training and Arterial Hypertension: Quality of Reporting

Abstract

The benefits of exercise have been well described for the treatment of hypertension. Poor reporting quality impairs quality appraisal and replicability. High intensity interval training (HIIT) has been shown to be an effective alternative to traditional aerobic exercise in patients with hypertension. We evaluated the completeness of reporting of randomized controlled trials (RCTs) with HIIT for hypertension and to compare both exercise modes in reporting quality. RCTs of HIIT with a minimum duration of 6 weeks in adults with at least high normal blood pressure (≥130 mmHg/≥85 mmHg) were evaluated using the Consensus on Exercise Reporting Template (CERT). Nine RCTs conducting HIIT in hypertensive patients (N=718; 51.8 years) were evaluated. A mean of 62.6% of items were sufficiently described, compared with 49.2% in moderate intensity training interventions. Exercise dose was adequately reported in 8 out of 9 studies. Only one study reported information on adverse events. In a small sample of RCTs with HIIT in patients with hypertension we found a better reporting quality than in moderate intensity training interventions. However, reporting completeness is not optimal for a good replicability in clinical practice. The lack of reporting of adverse events in interventions using high intensities is particularly unfavourable.

Keywords

reporting quality - clinical practice - CERT checklist - interval training - high blood pressure

Introduction

Hypertension is a major public health problem that affects millions of people worldwide. This can lead to a variety of serious health problems, including heart disease, stroke, and kidney disease [1]. Risk factors for hypertension include obesity, lack of physical activity, high salt intake, smoking, and high alcohol consumption. In addition, genetic factors and age can also play a role in the development of hypertension [2] [3] [4].

Hypertension is treated with lifestyle changes such as diet, exercise, and weight management, as well as medication. While medications can effectively lower blood pressure [5], they come with a risk of side effects [6]. Lifestyle changes, on the other hand, can not only lower blood pressure but also improve overall health [7] [8] [9].

Physical exercise, including regular exercise, is known to be one of the most effective lifestyle interventions for the management of hypertension. Exercise, particularly aerobic exercise, has been shown to be effective in reducing both systolic and diastolic blood pressure [10] [11]. The American Heart Association (ACC/AHA) and other professional societies recommend regular moderate-intensity aerobic exercise, such as brisk walking or cycling, for at least 150 minutes per week, or 30 minutes per day, five days a week, as a strategy for preventing hypertension and controlling blood pressure in those with hypertension [12] [13] [14] [15].

More recently, research has begun to focus on the effects of other exercise modes such as high-intensity interval training (HIIT) on hypertension. HIIT in a variety of forms, involves repeated short to long bouts of rather high intensity exercise interspersed with active or passive recovery periods [16]. HIIT has recently generated research interest as it is more time-efficient while showing similar blood pressure reducing effects than traditional endurance training in the general and hypertensive population [17] [18] [19]. Surprisingly, HIIT is not included in most routine exercise programs for hypertension, and even the latest guideline recommendations of the European Society of Cardiology [13] and the European Society of Hypertension as well as the ACC/AHA [12] are largely based on older data without mentioning high-intensity training protocols for patients with hypertension.

A distinctive feature of interval training is the possibility to manipulate the different training variables making this training approach infinitely variable. Thus, studies using HIIT as a novel exercise mode should be very precise in describing the intervention. The primary objective of this study is to assess the quality of studies on HIIT for hypertensive treatment.

Notably, compared with similar trials of medicines, the reporting of interventions in exercise trials is often poor [20]. Only high-quality reporting will ensure replicability in clinical practice and reduction of possible risks of the HIIT intervention [21] [22] [23]. As HIIT can have potential side effects in individuals with cardiovascular disease, it is particularly crucial to provide clear and detailed reports of the exercise intervention for individuals with hypertension. Previous research by our group and other authors has revealed a lack of quality in reporting exercise interventions for hypertension [24] and other trials in health and disease [25] [26] [27] [28].

Therefore, the present study aimed to investigate the reporting quality of HIIT on hypertension. It was hypothesized that shortcomings of the quality of reporting HIIT interventions might be similar to moderate endurance interventions previously demonstrated by our group [24].

Material and Methods

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines [29].

Eligibility criteria

We included individually randomised parallel group-controlled trials. We excluded cluster-randomised studies due to the risk of contamination and we did not include cross-over trials due to possible carry-over effects of the intervention. All randomised controlled trials involving adults (18 years of age) with a blood pressure that was at least high normal according to ESH guideline (systolic blood pressure [SBP]≥130 mmHg and/or diastolic blood pressure [DBP]≥85 mmHg [15]) treated with HIIT. Exercise therapy interventions were defined as those involving any HIIT intervention with a minimum duration intervention of 6 weeks.

The comparison was non-exercising or non-intervention controls or other exercise interventions. Only studies with data on the long-term effect on systolic and diastolic blood pressure measured by any standard devices were included. Studies showing information in the acute post-intervention blood pressure only were excluded. Studies published in languages other than English or German were not eligible for study inclusion.

Search strategy

The studies included in this analysis were retrieved by a systematic search strategy as shown in [Fig. 1]. In contrast to previous studies investigating the quality of reporting of exercise interventions, we did not use meta-analyses found in the guidelines of the hypertension or cardiology societies as a data source because currently here are no uniform recommendations for HIIT in hypertension. Thus, we looked for newer studies using HIIT in patients with hypertension. We searched PubMed up to July 2022, using the search terms “hypertension AND high intensity interval training”. Intentionally, we did not restrict the study search by year of publication, publication status, or language.

Fig. 1 Flow chart of study selection.

We checked the bibliographies of included studies and any relevant systematic reviews identified for further references to relevant trials. Where necessary, we contacted authors of key papers and abstracts to request additional information about their trials.

Data extraction

Primary studies with hypertensive patients were evaluated using the Consensus on Exercise Reporting Template (CERT) [26]. The CERT template was used to investigate the quality of reporting of HIIT interventions in the selected studies as this checklist was specifically designed to improve the reporting of exercise interventions. The completeness of reporting is expressed as the percentage of studies that reported each item in sufficient detail. CERT was published in 2016 as an extension of the Template for Intervention Description and Replication (TIDieR) [30] to give guidance to authors for structured and detailed reporting of exercise-based interventions. This will lead to subsequently facilitate research replication and increase the clinical uptake of an intervention, which turned out to be effective in research. In addition, authors, editors, and reviewers can use both templates to ensure completeness and quality of exercise intervention description.

The CERT template was applied to the selected studies by checking every item (Supplemental Table 1). Completely described items were marked with “1” and incomplete or missing descriptions were marked with “0”, while not applicable items were “NA”. The assessment of every item was performed by two different experienced researchers (blinded for peer review). In case of a discrepancy, differences were discussed based on the explanation and elaboration statements of the CERT guideline [31]. The checklists items for every RCT were extracted into Excel and results were analysed descriptively.

Data analyses

Individual study ratings were described as counts and proportions and the sum of “1” assessments as means and SD or 95% confidence intervals (95% CI). Analyses were based on the number of “1” assessments compared with “0”. “Not applicable” was treated as a given item. The following study details were extracted: author, year, journal, country, population, intervention and control data, blood pressure inclusion criteria.

Results

At the time of the literature search (July 2022), we found 92 studies at the initial screening. Studies without an intervention were excluded (n=11). Animal studies were not included in the present review (n=15). Two studies had to be eliminated because they were not published either in English or German and one study had to be excluded as no full-text article was found (n=1). Studies not using HIIT were omitted (n=6) as were papers originally excluding hypertensive as well as including normotensive subjects or underage persons (n=27). Investigations with no information on the long-term effect on blood pressure or only data on the acute effect post training session were excluded (n=9). The minimum duration intervention was defined at 6 weeks (9 studies excluded). Interestingly, two of the remaining 10 studies were identical with the same dataset but only one study reported pre- and post-test blood pressure data. Therefore, one of the duplicates or double publications was excluded [32].

Finally, we assessed HIIT intervention reporting of nine RCTs [33] [34] [35] [36] [37] [38] [39] [40] [41] comprising 718 patients (HIIT intervention group: 334, control group: 384; mean age 51.84 years). The nine trials were published between 2010 and 2020 and reported data from six countries. In total, 19 interventions were performed, whereas 12 were HIIT protocols (n=334) and 7 were moderate intensity endurance training protocols (n=194). All studies except one had a non-exercising control group (n=190). On average, interventions ranged from 6 weeks to 16 weeks, involved two to three sessions per week, lasting 15–80 minutes per session. CERT ratings of the included studies are presented in Supplementary Table 1 and a detailed exercise dose description with blood pressure inclusion criteria of each trial is shown in Supplementary Table 2.

The quality of description of the HIIT interventions is shown in [Fig. 2]. Completeness of CERT item reporting ranged from 42.1 to 73.7% among the studies. On average, 12 items out of 19 items of the CERT template were described in detail in every study, resulting in an average reporting quality of 62.6% (95% CI: 55.4–69.7). Following the CERT checklist, the type of exercise equipment (item 1, 89%) and description of each exercise (item 8, 89%) as well as the mode of delivery (item 4, 100%) and intended method of exercise tailoring/progression (item 14a and 14b, 100%) were also addressed in almost all studies. The least reported items belong to motivation strategies und instructor’s adherence (none of the studies). Only one study reported information on adverse events.

Fig. 2 Percentage of studies which adequately reported the CERT item (n=9).

However, there was a good quality of reporting of item 13 – exercise dosage (reported in 8 (89%) of the studies). A complete description of the essential components of the exercise dose intervention could be found for type, time and frequency, whereas the intensity of exercise prescribed was missing in one study (Supplementary Table 2).

Discussion

The goal of the present study was to evaluate for the first time the quality of intervention reporting of HIIT studies for arterial hypertension. Our study provides evidence that there is still an urgent need of improvement in the reporting quality of HIIT interventions for patients with hypertension. Overall, maintaining a good quality of reporting is important in order to promote clinical translation, evidence synthesis, and study appraisal. Only explicit reported interventions can be replicated for research and, more importantly, for clinical practice [22] [23]. Poor reporting of interventions is a general issue across a range of medical interventions [42], but exercise interventions were found to be less well described [20]. We did not find a single intervention with all items of CERT completely described. However, the overall quality of reporting is better in HIIT interventions than in moderate endurance training interventions for hypertension (62% vs. 49%) as previously described by our group [24]. Particularly, the reporting of the exercise dose is remarkably better than the description for aerobic endurance training intervention [24] or other health conditions (e. g. cardiovascular, musculoskeletal, neurological) [27].

To date, aerobic (endurance) interventions of moderate intensity were generally recommended in hypertension [43]. There still is a widespread perception that HIIT may be associated with greater safety concerns than moderate intensity exercises [18]. This might trigger doubts about using HIIT for clinical practice. However, according to the blood pressure reduction effects that could be demonstrated in recent studies by Edwards et al. [17] and Li et al. [18], exercise of higher intensity and in intervals lower blood pressure in hypertensive subjects to a very similar degree compared with moderate endurance training or other exercise training modes. In addition, HIIT might have other advantages over low intensities. It is more time-efficient and more effective in improving associated risk factors and physical fitness, which is an important protective factor in cardiovascular disease [44] [45] [46]. However, the shortcomings of the reporting quality especially found for items of delivery mode, progression, adherence, and adverse events in the present study are a further problem for a general prescription of HIIT interventions in common recommendations despite their importance. As a result, clinicians may not be able to replicate and recommend HIIT programs for their hypertension patients. Our findings should therefore be considered in future exercise recommendations for the prevention and treatment of arterial hypertension using HIIT protocols as replicability is limited to a certain extent.

An item that is also indispensable for the replicability not only of exercise studies in hypertension is certainly the reporting of adverse events. HIIT is associated with greater safety concerns than traditional moderate intensity endurance training; however, no significant adverse events were found in HIIT versus moderate endurance training [47]. In our analysis, adverse events (item 11) were sufficiently reported in only one out of nine studies. In clinical practice, hypertensive patients might have concomitant diseases such as coronary artery disease or heart failure. Although these conditions are not always contraindications for HIIT, there is a need to closely monitor adverse events. The lack of reporting of adverse events or the absence of adverse effects in almost all studies might seriously prevent the use of HIIT in clinical practice. Only one study reported a myocardial infarction at home in the comparator moderate intensity group but stated that the numbers of patients was too small to estimate the issue of safety. While we rated this description as adequate, we did not consider it sufficient to report that the intervention was well tolerated. Since HIIT is a popular alternative for patients with hypertension, a detailed description of possible adverse events would be all the more important.

Despite the clinical utility of exercise modes with high intensities [48], recent studies have demonstrated greater ratings of perceived enjoyment than moderate endurance exercise interventions [49] but revealed conflicting results regarding completion rates and attendance at exercise training sessions [47] [50]. There was only insufficient information in the studies on adherence parameters (56%), which is in line with the quality of adherence reporting for moderate intensity exercise interventions [24]. We are convinced that in the majority of interventions, motivation strategies are used to reduce dropout rates and increase adherence. Again, there was no detailed information on if and how such strategies were used in the interventions. By contrast, we found a good quality of reporting (89%) of items that are crucial for the dosage of HIIT for hypertension. This finding is even better than the quality of reporting of dosage information in moderate intensity training interventions for hypertension (78%) [24]. However, it should be noted that a low level of reporting of details about an exercise intervention may not reflect a low quality of the intervention per se. Abell et al. contacted authors of interventions about unreported details and found that many aspects were considered in the exercise protocols but not adequately reported [51]. Moreover, although journals with higher impact factors are more likely to endorse and enforce reporting quality guidelines [52] [53] [54], we demonstrated no correlation between the quality of exercise reporting and the impact factor of the journals in which the studies were published [24] [25]. One could have hypothesized finding a much better and more complete description of the exercise programs, as HIIT is an innovative tool and investigated in more recent studies. In this study, the oldest study from 2010 has the lowest quality of reporting (47%) [33]. However, despite the advent of checklists, research show that the quality of reporting of exercise interventions does not appear to have improved over time [27]. Full compliance with reporting guidelines can be difficult given the strict word limits of many journals. We therefore suggest authors provide all relevant information required for CERT as supplemental material. Notably, no single study reported to follow the Consolidated Standards of Reporting Trials (CONSORT) guideline [55], which is used worldwide to improve the reporting and transparency of trials. Journals should encourage and require submission of a completed CERT checklist when exercise interventions are submitted. Based on the findings of this study, if HIIT is comparable to traditional moderate intensity training modes with regard to blood pressure reduction, then how it is prescribed and delivered is mainly unclear, potentially limiting its translation from research to practice. In a previous publication, we proposed the CORE-CERT template with the most important items necessary for the replicability of exercise interventions in clinical practice [26]. In addition, disease-specific checklists would further improve the intervention description of exercise studies for hypertension including blood pressure values during HIIT. For hypertension interventions, items relating to patients’ antihypertensive medication directly before and during the intervention or monitoring time and method could usefully be integrated into such “CERT plus” hypertension-specific checklist.

Strength and limitations

This study revealed the quality of reporting of RCTs with HIIT in patients with at least high normal blood pressure. However, this study has several limitations. In previous studies investigating reporting quality we used the best available evidence according to meta-analyses quoted by the most recent recommendations of international scientific societies. The RCTs in these meta-analyses were presumed to the most relevant evidence. In the case of HIIT for hypertension, there is no widespread recommendation by national and international hypertension societies. Thus, we did a study search on our own and found a low number of RCTs with small sample sizes as compared to our previous analysis of moderate intensity endurance exercise and hypertension. Although, the number of RCTs on the subject is ever increasing of late, we have no indication that the studies used in our study have a lower quality than more recent publications. Additionally, we have included and analysed far fewer primary studies than those of a recent meta-analysis by Li et al. [18] on HIIT for hypertension. In contrast to our study, this meta-analysis included studies of any intervention duration and with adult patients diagnosed at least with prehypertension (SBP≥120 mmHg / DBP≥80 mmHg) according to Chinese guidelines. Different international guidelines classify certain blood pressure levels differently, with some categorizing a blood pressure of≥130/85 mmHg as primary hypertension. However, in our study, we followed the ESH guidelines, which classify a blood pressure of SBP≥130/ DBP≥85 mmHg as ‘high normal’.

Although the CERT template is increasingly being used to assess the reporting quality of exercise interventions, it paid little attention to the question on what is essential for simple replication of study setting as proposed in a recent study by our group [26]. A greater focus on key components could produce findings that account more for the ability to perform and replicate an exercise therapy intervention in practice and therefore are prerequisite for subsequent physical exercise recommendations. Therefore, we basically refined the original CERT tool as a future step in the initiative to improve the quality of reporting and developed the CORE-CERT checklist as a more focused version of a guideline to report key items of exercise studies, which are necessary for study replication. Although we propose the use of the CORE-CERT checklist as a reporting tool across all types of exercise interventions and conditions, we used the original CERT version here in order to compare our results with our previous findings on endurance exercise intervention for hypertension. In the future, researchers, journal editors, and reviewers should insist on the use of reporting guidelines if exercise interventions are described.

Practical Implications

Numerous analyses have stressed the importance of good reporting quality in studies on exercise and different diseases. Recently, a comparable pressure-lowering effect of HIIT with common exercise training modes was shown; however, the low quality of reporting in studies of HIIT interventions for high blood pressure is a disappointing result. Given the high variability of HIIT protocols, it would be very difficult to replicate the interventions to reduce blood pressure in clinical practice. To improve quality appraisal, evidence synthesis, replication and translation of exercise interventions in practice, reporting of exercise interventions must improve. In particular, the absence of references to adverse effects is not suited to create confidence in clinicians considering the use of HIIT in patients with hypertension. Therefore, we propose that authors be strongly encouraged to use CORE-CERT for planning, carrying out, and publishing exercise interventions. This would help to capture elements of the intervention that are thought influential in determining effectiveness.

Conflict of Interest

The authors declare that they have no conflict of interest.

Acknowledgement

We acknowledge financial support by Land Schleswig-Holstein within the funding programme Open Access Publikationsfonds.

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Publication History

Received: 11 September 2024
Received: 04 November 2024

Accepted: 10 November 2024

Article published online:
12 February 2025