High Blood Pressure in Athletes: Causes and the Link with Pharmacology
Regular exercise is one of the most effective ways to lower blood pressure, so a high reading in a fit, active person can come as a surprise. Yet hypertension is far from rare among athletes, particularly in strength sports and in older competitors. Our editorial team looks at why it happens, how medications and performance-enhancing substances contribute, and how to get an accurate diagnosis.
How common is hypertension in sport?
Hypertension is the most common cardiovascular condition seen in athletes, according to the European Society of Cardiology's sports cardiology guidelines (Pelliccia et al., 2021). Its prevalence is lower than in the general population overall, but it is far from negligible, especially among masters athletes and those in power disciplines.
Several factors explain why fitness does not guarantee normal blood pressure. Genetics play a strong role, body mass in heavier athletes adds load, and lifestyle factors such as diet, alcohol and sleep remain relevant regardless of training volume.
In England, NICE guidance (NG136) defines hypertension as a clinic reading of 140/90 mmHg or higher, confirmed by ambulatory or home monitoring averaging 135/85 mmHg or higher. A single high reading — particularly one taken just after exercise, coffee or a stressful journey — is not a diagnosis.
Undetected hypertension matters because it damages arteries, the heart, kidneys and brain silently over years. In athletes, it can also contribute to left ventricular hypertrophy beyond the normal "athlete's heart" adaptation.
Non-drug causes in active people
Before looking at pharmacology, it is important to rule out ordinary contributors. Many of them are common in sport.
- Family history and ageing: blood pressure tends to rise with age, even in trained people.
- High salt intake: processed foods, sports foods and large restaurant meals can deliver more sodium than most people realise.
- Obstructive sleep apnoea: more frequent in heavier athletes with large neck circumference, such as rugby forwards and strength athletes.
- Alcohol: regular heavy drinking raises blood pressure.
- Kidney disease and hormonal disorders: less common, but relevant in young people with high readings.
- "White-coat" effect: anxiety during medical checks can push readings up temporarily.
Heavy resistance training causes very large but short-lived rises in blood pressure during the lift itself. This is a normal acute response and does not by itself cause chronic hypertension, although people with existing uncontrolled hypertension should take medical advice about very heavy lifting.
Secondary causes — those with an identifiable underlying disease — are more likely in young athletes with markedly raised blood pressure. Doctors may therefore check kidney function, electrolytes and hormones in this group.
Medicines and supplements that raise blood pressure
A number of commonly used, perfectly legal substances can raise blood pressure. Athletes are often heavy users of several of them.
| Substance | How it can raise blood pressure | Practical note |
|---|---|---|
| NSAIDs (e.g. ibuprofen, naproxen) | Sodium and fluid retention; reduced effect of BP medicines | Frequent use for aches is common in sport |
| Decongestants (pseudoephedrine, phenylephrine) | Constriction of blood vessels | Found in cold and flu remedies |
| Caffeine and pre-workout products | Acute rise, especially in non-habitual users | High-stimulant products can contain several sources |
| Liquorice (glycyrrhizin) | Mimics aldosterone, causing salt retention | Large amounts of sweets or herbal teas |
| Some antidepressants and ADHD medicines | Sympathetic stimulation | Monitoring advised by prescriber |
| Combined oral contraceptives | Modest rise in some women | BP checks before and during use |
Non-steroidal anti-inflammatories deserve emphasis. Many athletes take them almost daily for minor pain, which may raise blood pressure and, combined with dehydration in endurance events, can also harm the kidneys.
"Fat burner" and pre-workout products may contain multiple stimulants, and some products sold online have been found to contain undeclared drugs. These can provoke sharp increases in blood pressure and heart rhythm disturbances.
Anabolic steroids and other doping agents
Anabolic-androgenic steroids (AAS) are among the most significant pharmacological causes of hypertension in gym users. An American Heart Association scientific statement (Baggish et al., 2017) described AAS-related increases in blood pressure, adverse lipid changes, cardiomyopathy and accelerated coronary disease.
Rasmussen and colleagues (2018) found higher blood pressure and greater aortic stiffness in men using AAS compared with non-using controls, with some changes persisting after use had stopped. The Endocrine Society's scientific statement (Pope et al., 2014) also lists hypertension among recognised harms.
Other substances add to the risk. Erythropoietin and related agents increase red cell mass and blood viscosity; growth hormone can cause fluid retention; stimulants such as amphetamines and clenbuterol raise heart rate and blood pressure. Combining several substances compounds these effects.
These are prescription-only or prohibited drugs, and their non-medical use carries serious cardiovascular risks beyond blood pressure. Anyone who has used them should tell their GP, who can arrange appropriate checks without judgement.
Diagnosis, monitoring and management
An accurate diagnosis starts with correct measurement: seated for five minutes, with an appropriately sized cuff — standard cuffs can overestimate readings in muscular arms — and no caffeine, smoking or exercise for at least 30 minutes beforehand.
NICE recommends confirming high clinic readings with ambulatory blood pressure monitoring over 24 hours, or with home monitoring if ambulatory monitoring is not suitable. Further assessment usually includes blood tests, a urine test for protein and an ECG; athletes may also be offered an echocardiogram.
Lifestyle measures remain the foundation: reducing salt, limiting alcohol, treating sleep apnoea and stopping substances that raise blood pressure. Regular aerobic exercise continues to be beneficial.
When medication is needed, the choice may take sport into account. European guidelines (Williams et al., 2018) and sports cardiology recommendations note that some drugs, such as beta-blockers, can reduce exercise capacity and are prohibited in certain sports, so ACE inhibitors, angiotensin receptor blockers or calcium channel blockers are often preferred for athletes. Diuretics are on the WADA prohibited list and require a Therapeutic Use Exemption in tested sport.
Conclusions of the editorial team
Being fit lowers the risk of hypertension but does not eliminate it. Genetics, age, salt, sleep apnoea and alcohol all play a role in athletes too.
Pharmacology is an often overlooked contributor: everyday painkillers, decongestants and stimulants can raise blood pressure, while anabolic steroids and other doping agents carry well-documented cardiovascular harm.
Correct measurement, confirmation with ambulatory or home monitoring and an honest conversation with a doctor about all substances used are the keys to sensible management.
We suggest our related articles on haematocrit in strength athletes, on the cardiovascular risks of anabolic steroids and on choosing safe pre-workout products.
References
- Pelliccia A, Sharma S, Gati S, et al. 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease. Eur Heart J. 2021;42(1):17–96.
- Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021–3104.
- Baggish AL, Weiner RB, Kanayama G, et al. Cardiovascular toxicity of illicit anabolic-androgenic steroid use. Circulation. 2017;135(21):1991–2002.
- Rasmussen JJ, Schou M, Madsen PL, et al. Increased blood pressure and aortic stiffness among abusers of anabolic androgenic steroids: potential effect of suppressed natriuretic peptides in plasma? J Hypertens. 2018;36(2):277–285.
- Pope HG Jr, Wood RI, Rogol A, et al. Adverse health consequences of performance-enhancing drugs: an Endocrine Society scientific statement. Endocr Rev. 2014;35(3):341–375.
- National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management (NG136). London: NICE; 2019.
