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Cuspidi C, Gherbesi E, Faggiano A, Sala C, Grassi G, Carugo S, Tadic M. Targeting Hypertensive Response to Exercise and the Association of Masked Hypertension With Subclinical Organ Damage: A Mini-Review and Meta-Analysis. Am J Hypertens 2024; 37:53-59. [PMID: 37195645 DOI: 10.1093/ajh/hpad049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 05/05/2023] [Accepted: 05/05/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Emerging evidence suggests that a hypertensive response to exercise (HRE) during dynamic or isometric stress tests assessing cardiac function is predictive of hypertension and cardiovascular events such coronary artery disease, heart failure and stroke. Whether HRE represents a marker of masked hypertension (MH) in individuals with no prior history of hypertension is still unclear. This is also the case for the association between MH and hypertension-mediated organ damage (HMOD) in the HRE setting. METHODS We addressed this issue through a review and a meta-analysis of studies providing data on this topic in normotensive individuals undergone both to dynamic or static exercise and to 24-h blood pressure monitoring (ABPM). A systematic search was performed using Pub-Med, OVID, EMBASE and Cochrane library databases from inception up to February 28th 2023. RESULTS Six studies including a total of 1,155 untreated clinically normotensive individuals were considered for the review. Data provided by the selected studies can be summarized as follows: (i) HRE is a BP phenotype linked to a high prevalence of MH (27.3% in the pooled population); (ii) MH is, in turn, associated with a greater, consistent likelihood of echocardiographic left ventricular hypertrophy (OR: 4.93, CI: 2.16-12.2, P < 0.0001) and vascular organ damage, as assessed by pulse wave velocity, (SMD: 0.34 ± 0.11, CI: 0.12-0.56, P = 0002). CONCLUSIONS On the basis of this, albeit limited, evidence, the diagnostic work-up in individuals with HRE should primarily be addressed to look for MH as well as for markers of HMOD, a highly prevalent alteration in MH.
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Affiliation(s)
- Cesare Cuspidi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Elisa Gherbesi
- Department of Cardio-Thoraco-Vascular Diseases, Foundation IRCCS Ca' Granda Ospedale Maggior Policlinico of Milano, Milano, Italy
| | - Andrea Faggiano
- Department of Clinical Sciences and Community Health, University of Milano, Milano, Italy
- Department of Cardio-Thoraco-Vascular Diseases, Foundation IRCCS Ca' Granda Ospedale Maggior Policlinico of Milano, Milano, Italy
| | - Carla Sala
- Department of Clinical Sciences and Community Health, University of Milano, Milano, Italy
| | - Guido Grassi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Stefano Carugo
- Department of Clinical Sciences and Community Health, University of Milano, Milano, Italy
- Department of Cardio-Thoraco-Vascular Diseases, Foundation IRCCS Ca' Granda Ospedale Maggior Policlinico of Milano, Milano, Italy
| | - Marijana Tadic
- Department of Cardiology, University Hospital "Dr. DragisaMisovic-Dedinje", Heroja Milana Tepica 1,11000 Belgrade, Serbia
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Moore MN, Blizzard CL, Dwyer T, Magnussen CG, Sharman JE, Venn AJ, Schultz MG. Exploring the direct and indirect effects of cardiovascular disease risk factors on exercise blood pressure. Scand J Med Sci Sports 2023; 33:2509-2515. [PMID: 37750022 DOI: 10.1111/sms.14480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 07/10/2023] [Accepted: 08/09/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVE Exaggerated exercise blood pressure (BP) is independently associated with cardiovascular disease (CVD) outcomes. However, it is unknown how individual CVD risk factors may interact with one another to influence exercise BP. The aim of this study was to quantify direct and indirect associations between CVD risk factors and exercise BP, to determine what CVD risk factor/s most-strongly relate to exercise BP. METHODS In a cross-sectional design, 660 participants (44 ± 2.6 years, 54% male) from the population-based Childhood Determinants of Adult Health Study had BP measured during low-intensity fixed-workload cycling. CVD risk factors were measured, including body composition, clinic (rest) BP, blood biomarkers, and cardiorespiratory fitness. Associations between CVD risk factors and exercise BP were assessed using linear regression, with direct and indirect pathways of association assessed via structural equation model. RESULTS Sex, waist-to-hip ratio, fitness, and clinic BP were independently associated with exercise systolic BP (SBP), and along with age, had direct associations with exercise SBP (p < 0.05 all). Most CVD risk factors were indirectly associated with exercise SBP via a relation with clinic BP (p < 0.05 all). Clinic BP, waist-to-hip ratio, and fitness were most-strongly associated (direct and indirect association) with exercise SBP (β[95% CI]: 9.35 [8.04, 10.67], 4.91 [2.56, 7.26], and -2.88 [-4.25, -1.51] mm Hg/SD, respectively). CONCLUSION Many CVD risk factors are associated with exercise BP, mostly with indirect effects via clinic BP. Clinic BP, body composition, and fitness were most-strongly associated with exercise BP. These results may elucidate how lifestyle modification could be a primary strategy to decrease exaggerated exercise BP-related CVD risk.
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Affiliation(s)
- Myles N Moore
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Australia
| | - Christopher L Blizzard
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Australia
| | - Terence Dwyer
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Australia
- George Institute for Global Health, Oxford Martin School and Nuffield Department of Obstetrics & Gynaecology, Oxford University, Oxford, UK
- Murdoch Children's Research Institute, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Costan G Magnussen
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Australia
- Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland
- Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - James E Sharman
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Australia
| | - Alison J Venn
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Australia
| | - Martin G Schultz
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Australia
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Masked Hypertension and Exaggerated Blood Pressure Response to Exercise: A Review and Meta-Analysis. Diagnostics (Basel) 2023; 13:diagnostics13061005. [PMID: 36980313 PMCID: PMC10047162 DOI: 10.3390/diagnostics13061005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/02/2023] [Accepted: 03/04/2023] [Indexed: 03/09/2023] Open
Abstract
Aim: Whether exaggerated blood pressure response (EBPR) to exercise represents a marker of masked hypertension (MH) in individuals with no prior history of hypertension is still unclear. We investigated this issue through a review and a meta-analysis of studies providing data on this association in normotensive individuals undergone both to dynamic or static exercise and to 24 h blood pressure monitoring (ABPM). Design: A systematic search was performed using Pub-Med, OVID, EMBASE, and Cochrane library databases from inception up to 31 December 2022. Studies were identified by using the following search terms: “masked hypertension”, “out-of-office hypertension”, “exercise blood pressure”, “exaggerated blood pressure exercise”, “exercise hypertension”. Results: Nine studies including a total of 387 participants with MH and 406 true normotensive controls were considered. Systolic BP (SBP) and diastolic BP (DBP) at rest were significantly higher in MH individuals than in sustained normotensives: 126.4 ± 1.4/78.5 ± 1.8 versus 124.0 ± 1.4/76.3 ± 1.3 mmHg (SMD: 0.21 ± 0.08, CI: 0.06–0.37, p = 0.007 for SBP; 0.24 ± 0.07, CI: 0.08–0.39, p = 0.002 for DBP). The same was true for BP values at peak exercise: 190.0 ± 9.5/96.8 ± 3.7 versus 173.3 ± 11.0/88.5 ± 1.8 mmHg (SMD 1.02 ± 0.32, CI: 0.39–1.65, p = 0.002 for SBP and 0.97 ± 0.25, CI: 0.47–1.96, p < 0.0001 for DBP). The likelihood of having an EBPR was significantly greater in MH than in their normotensive counterparts (OR: 3.33, CI: 1.83–6.03, p < 0.0001). Conclusions: Our meta-analysis suggests that EBPR reflects an increased risk of MH and that BP measurement during physical exercise aimed to assess cardiovascular health may unmask the presence of MH. This underscores the importance of BP measured in the medical setting at rest and in dynamic conditions in order to identify individuals at high cardiovascular risk due to unrecognized hypertension.
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Wand O, Gabbai D, Epstein Shochet G, Prokupetz A, Kats T, Ben-Ari O, Cohen-Hagai K, Gordon B. Negative impact of high-performance flights on aviators with mitral valve prolapse. J Cardiol 2023; 81:323-328. [PMID: 36372322 DOI: 10.1016/j.jjcc.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/18/2022] [Accepted: 10/24/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND While it appears not to affect healthy aviators' hearts, there are scarce data regarding the impact of high-performance flights on aviators with mitral valve prolapse (MVP). METHODS A retrospective, comparative cohort study of military aviators with MVP. Subjects were categorized to either high-performance (jet fighter) or low-performance (transport and helicopter) aviators. The primary outcomes were the rates of mitral interventions and of adverse cardiovascular events since being an aircrew candidate and up to the end of flying career. Additional outcomes were echocardiographic measurements and the cumulative proportion of mitral valve interventions over time. RESULTS Of 33 male aviators with MVP, 18 were high-performance aviators. On average, follow-up started at age 18.5 years and lasted 27.8 ± 10.1 years. Baseline characteristics were similar between the study groups. Aviators of high-performance aircraft had increased rates of mitral valve surgery (33 % vs. 0, p = 0.021), MVP-related complications (39 % vs. 6.7 %, p = 0.046), and a higher incidence of mitral valve repair over time (p = 0.02). High-performance flight was associated with increased intraventricular septum thickness (IVS, 9.7 mm vs 8.9 mm, p = 0.015) and IVS index (p = 0.026) at the last echocardiographic assessment. High-performance aviators tended to develop worsening severity of mitral regurgitation. CONCLUSIONS High-performance flight may be associated with an increased risk for valvular deterioration and need for mitral surgery in aviators with MVP.
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Affiliation(s)
- Ori Wand
- Israeli Defense Force Medical Corps, Tel Hashomer, Israel; Division of Pulmonary Medicine, Barzilai University Medical Center, Ashkelon, Israel; Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Daniel Gabbai
- Israeli Defense Force Medical Corps, Tel Hashomer, Israel
| | | | - Alex Prokupetz
- Israeli Defense Force Medical Corps, Tel Hashomer, Israel
| | - Tatiana Kats
- Israeli Defense Force Medical Corps, Tel Hashomer, Israel
| | - Oded Ben-Ari
- Israeli Defense Force Medical Corps, Tel Hashomer, Israel
| | - Keren Cohen-Hagai
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Nephrology and Hypertension, Meir Medical Center, Kfar-Saba, Israel
| | - Barak Gordon
- Israeli Defense Force Medical Corps, Tel Hashomer, Israel; The Faculty of Medicine, The Hebrew University, Jerusalem, Israel
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Schultz MG, Otahal P, Kovacevic AM, Roberts-Thomson P, Stanton T, Hamilton-Craig C, Wahi S, La Gerche A, Hare JL, Selvanayagam J, Maiorana A, Venn AJ, Marwick TH, Sharman JE. Type-2 Diabetes and the Clinical Importance of Exaggerated Exercise Blood Pressure. Hypertension 2022; 79:2346-2354. [PMID: 35938406 DOI: 10.1161/hypertensionaha.122.19420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Exaggerated exercise blood pressure (EEBP) during clinical exercise testing is associated with poor blood pressure (BP) control and cardiovascular disease (CVD). Type-2 diabetes (T2DM) is thought to be associated with increased prevalence of EEBP, but this has never been definitively determined and was the aim of this study. METHODS Clinical exercise test records were analyzed from 13 268 people (aged 53±13 years, 59% male) who completed the Bruce treadmill protocol (stages 1-4, and peak) at 4 Australian public hospitals. Records (including BP) were linked to administrative health datasets (hospital and emergency admissions) to define clinical characteristics and classify T2DM (n=1199) versus no T2DM (n=12 069). EEBP was defined as systolic BP ≥90th percentile at each test stage. Exercise BP was regressed on T2DM history and adjusted for CVD and risk factors. RESULTS Prevalence of EEBP (age, sex, preexercise BP, hypertension history, CVD history and aerobic capacity adjusted) was 12% to 51% greater in T2DM versus no T2DM (prevalence ratio [95% CI], stage 1, 1.12 [1.02-1.24]; stage 2, 1.51 [1.41-1.61]; stage 3, 1.25 [1.10-1.42]; peak, 1.18 [1.09-1.29]). At stages 1 to 3, 8.6% to 15.8% (4.8%-9.7% T2DM versus 3.5% to 6.1% no-T2DM) of people with 'normal' preexercise BP (<140/90 mm Hg) were identified with EEBP. Exercise systolic BP relative to aerobic capacity (stages 1-4 and peak) was higher in T2DM with adjustment for all CVD risk factors. CONCLUSIONS People with T2DM have higher prevalence of EEBP and exercise systolic BP independent of CVD and many of its known risk factors. Clinicians supervising exercise testing should be alerted to increased likelihood of EEBP and thus poor BP control warranting follow-up care in people with T2DM.
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Affiliation(s)
- Martin G Schultz
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.G.S., P.O., A.M.K., A.J.V., J.E.S.)
| | - Petr Otahal
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.G.S., P.O., A.M.K., A.J.V., J.E.S.)
| | - Ann-Marie Kovacevic
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.G.S., P.O., A.M.K., A.J.V., J.E.S.)
| | | | - Tony Stanton
- Sunshine Coast University Hospital, Birtinya, Australia (T.S.)
| | | | - Sudhir Wahi
- Princess Alexandra Hospital, Brisbane, Australia (S.W.)
| | - Andre La Gerche
- Baker Heart and Diabetes Institute, Melbourne, Australia (A.L.G., J.L.H., T.H.M.)
| | - James L Hare
- Baker Heart and Diabetes Institute, Melbourne, Australia (A.L.G., J.L.H., T.H.M.).,Department of Cardiology, The Alfred Hospital, Melbourne, Australia (J.L.H.)
| | - Joseph Selvanayagam
- Cardiac Imaging Research, Flinders University, Adelaide, Australia (J.S.).,South Australian Health and Medical Research Institute, Adelaide, Australia (J.S.)
| | - Andrew Maiorana
- Curtin School of Allied Health, Curtin University, Perth, Australia (A.M.).,Allied Health Department, Fiona Stanley Hospital, Perth, Australia (A.M.)
| | - Alison J Venn
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.G.S., P.O., A.M.K., A.J.V., J.E.S.)
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Australia (A.L.G., J.L.H., T.H.M.)
| | - James E Sharman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (M.G.S., P.O., A.M.K., A.J.V., J.E.S.)
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Cardiovascular risk stratification: how important is the hypertensive response to exercise? J Hypertens 2022; 40:27-29. [PMID: 34857702 DOI: 10.1097/hjh.0000000000003015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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