The comparative effectiveness of different exercise training modes on ambulatory blood pressure: a systematic review and network meta-analysis of randomized controlled trials.

Exercise training is an effective non-pharmacological strategy for reducing blood pressure; however, current guideline recommendations are largely derived from studies reporting resting clinic blood pressure rather than ambulatory blood pressure (ABP), which provides greater prognostic value. Comparative evidence on the effects of different exercise modalities on ABP remains limited. To compare the effects of major exercise modalities on 24-h systolic ABP using a Bayesian network meta-analysis, and to outline practical implications for antihypertensive exercise prescription. PubMed (MEDLINE) and the Cochrane Library were searched for randomized controlled trials published before January 2025 reporting changes in 24-h systolic ABP following an exercise intervention of at least 2 weeks' duration. Eligible studies included adults and compared aerobic exercise training (AET), resistance training (RT), high-intensity interval training (HIIT), combined training (CT), or isometric exercise training (IET), with a non-exercise control or another exercise modality. Bayesian network meta-analyses were conducted, with interventions ranked using surface under the cumulative ranking curve (SUCRA) values. Twenty-five studies (1096 participants) met inclusion criteria; 16 were included in the network meta-analysis. AET and HIIT reduced 24-h systolic ABP (-4.77 mmHg and -6.86 mmHg), with a smaller reduction following RT (-2.25 mmHg). Data were insufficient to analyse comparative effects for CT or IET. In the Bayesian network, rank order of effectiveness based on SUCRA values was HIIT (91.4%), AET (68.2%), and RT (35.4%). No statistically significant comparative differences were observed between exercise modalities. This Bayesian NMA demonstrates HIIT and AET as effective for reducing 24-h systolic ABP, supporting their role in hypertension management. However, the limited scale and connectivity of available trials restrict definitive comparisons between wider exercise modes. Larger, well-designed head-to-head trials incorporating ABP outcomes are needed to clarify the relative effectiveness of different exercise strategies and to better inform evidence-based exercise prescription for blood pressure management. Registration:PROSPERO: CRD420251177743.