Long-term risk of stroke and myocardial infarction in middle-aged men with a hypertensive response to exercise: a 44-year follow-up study

Exaggerated Systolic Blood Pressure Increase with Exercise and Myocardial Ischemia on Exercise Stress Echocardiography

BACKGROUND

Central Illustration : Exaggerated Systolic Blood Pressure Increase with Exercise and Myocardial Ischemia on Exercise Stress Echocardiography ESBPRE: exaggerated systolic blood pressure response to exercise; HR: heart rate; SBP: systolic blood pressure.

BACKGROUND

The association between exaggerated systolic blood pressure response to exercise (ESBPRE) and myocardial ischemia is controversial and little studied in patients with established or suspected chronic coronary syndrome.

OBJECTIVE

To verify the relationship between myocardial ischemia and ESBPRE in patients undergoing exercise stress echocardiography (ESE).

METHODS

This is a cross-sectional study with 14,367 patients undergoing ESE, from January 2000 to January 2022, divided into the following 2 groups: G1, composed of patients whose peak systolic pressure increased ≥ 90 mmHg (value corresponding to the 95th percentile of the study population), and G2, patients who did not demonstrate an exaggerated hypertensive response. The groups were compared using Student's t and chi-square tests. P values < 0.05 were considered significant. Logistic regression was also performed to identify independent risk factors for myocardial ischemia, ESBPRE, complaints of typical chest pain prior to the exam, and angina during the test.

RESULTS

Of the 14,367 patients, 1,500 (10.4%) developed ESBPRE, and 7,471 (52.0%) were female. The percentages of previous complaints of typical chest pain, angina during the test, and myocardial ischemia in patients with ESBPRE were 5.8%, 2.4% and 18.1%, compared to 7.4%, 3.9%, and 24.2%, in patients without ESBPRE, respectively (p = 0.021,p = 0.004, p < 0.001). In multivariate analysis, ESBPRE was independently associated with a lower probability of myocardial ischemia (odds ratio: 0.73; 95% confidence interval: 0.58 to 0.93; p = 0.009).

CONCLUSION

Exaggerated increase in systolic blood pressure during ESE may be a marker for excluding myocardial ischemia.

Clinical and Prognostic Value of Exaggerated Blood Pressure Response to Exercise

The hypertensive response to exercise testing, defined as exaggerated blood pressure response (EBPR), has been documented to be independently associated with unhealthy conditions, carrying an increased risk of future hypertension, cardiovascular (CV) morbidity and mortality. In treated hypertensives, EBPR is a marker of uncontrolled hypertension, a condition previously undetected by office blood pressure (BP) measurements at rest; EBPR may also detect masked hypertension, a phenotype characterized by normal BP values in the medical environment but elevated home or ambulatory BP monitoring (ABPM). The aim of the present review is to provide a comprehensive and up-dated information on the clinical importance of EBPR targeting the following issues: (I) definition and prevalence; (II) underlying mechanisms; (III) clinical correlates and association with subclinical organ damage; (IV) predictive value; (V) clinical decision making.

Maximum ambulatory daytime blood pressure and risk of stroke in individuals with higher ambulatory arterial stiffness index: the JAMP study

The aim of this study was to determine whether a high daytime maximum blood pressure (BP) assessed by ambulatory BP monitoring (ABPM) constitutes a risk for atherosclerotic cardiovascular disease (ASCVD) events, especially in those with increased arterial stiffness, because BP variability is linked to arterial stiffness. A total of 6294 participants (mean age, 68.6 ± 11.7 years; 78% treated hypertensive patients), who had at least 1 cardiovascular risk factor, were followed for 4.5 years. Daytime maximum BP was calculated as the highest 1-hour moving average of 2 consecutive systolic BP (SBP) readings during the daytime. The ambulatory arterial stiffness index (AASI) was calculated as 1 minus the slope of the linear regression line between SBP and diastolic BP during 24-hour BP. During the follow-up, there were 217 ASCVD events (119 stroke and 98 coronary artery disease [CAD]). In the higher-AASI group (≥0.5783), subjects in the top quartile of daytime maximum SBP (≥179.4 mmHg) had a greater risk of stroke events compared to those in other quartiles (adjusted hazard ratio [HR], 1.89; 95% confidence interval [CI], 1.13-3.15). In the higher-AASI group, participants with 24-hour SBP of 130 mmHg or more and in the top quartile of daytime maximum SBP had an adjusted HR (95%CI) of 2.55 (1.32-4.95) compared to those without. The analysis did not suggest that daytime maximum SBP posed a risk for CAD events and in the lower-AASI group. Daytime maximum SBP did pose a risk of stroke events, especially for those with higher arterial stiffness represented as AASI.

Cardiorespiratory Fitness in the Prevention and Management of Cardiovascular Disease

Cardiovascular disease (CVD) is the leading cause of death among adults in the U.S. and elsewhere. Variation in the presence, severity, and control of major modifiable risk factors accounts for much of the variation in CVD rates worldwide. Cardiorespiratory fitness (CRF) reflects the integration of ventilation, circulation, and metabolism for the delivery and utilization of oxygen in support of dynamic aerobic physical activity. The gold standard measure of CRF is maximal oxygen uptake. Because the primary factor underlying differences in this measure between individuals is maximal cardiac output, it can serve as a clinical indicator of cardiac function. Higher CRF is associated with favorable levels of major CVD risk factors, lower prevalence and severity of subclinical atherosclerosis, and lower risks of developing both primary and secondary clinical CVD events. The beneficial associations between CRF and CVD are seen in women and men, older and younger adults, in those with multiple coexisting risk factors or prior diagnosis of CVD. Exercise training and regular physical activity of at least moderate intensities and volumes improves CRF in adults, and improvements in CRF are associated with lower risks of subsequent CVD and mortality. Routine assessment of CRF in primary care settings could enhance individual-level CVD risk assessment and thereby guide implementation of appropriate measures to prevent future clinical events.

Blood pressure response during treadmill exercise testing and the risk for future cardiovascular events and new-onset hypertension

OBJECTIVE

The physiologic response to exercise may provide valuable prognostic information. We investigated the association of blood pressure (BP) measurements during exercise stress testing (EST) with long-term risk of myocardial infarction, stroke or death (major adverse cardiovascular event, MACE), as well as the development of new-onset hypertension.

METHODS

A retrospective analysis of treadmill ESTs (years 2005-2019) performed by the Bruce protocol in patients aged 35-75 years without a history of cardiovascular disease (n = 14 792; 48% women). BP was documented at rest, submaximal exercise (Bruce stage-2), peak exercise and recovery (2 min). Association of SBP measures with study outcomes during median follow-up of 6.5 years was investigated.

RESULTS

Highest vs. lowest SBP quartile at rest (≥140 vs. <120 mmHg), submaximal-exercise (≥170 vs. <130 mmHg), peak-exercise (≥180 vs. ≤145 mmHg) and recovery (≥160 vs. <130 mmHg) was associated with an increase in the adjusted hazard ratio and 95% confidence interval (CI) for MACE: 1.53 (1.23-1.88), 1.33 (1.01-1.76), 1.30 (1.05-1.61), 1.35 (1.09-1.68), respectively. The association between SBP at submaximal exercise and recovery with MACE displayed a J-shaped pattern. Among nonhypertensive patients (n = 8529), excessive SBP response to peak exercise (≥190 mmHg in women and ≥210 mmHg in men) was an independent predictor of hypertension [hazard ratio (95% CI)]: 1.87 (1.41-2.48), as were SBPs during submaximal exercise [>160 vs. ≤130 mmHg: 2.44 (1.97-3.03)] and recovery [≥140 vs. ≤120 mmHg: 1.65 (1.37-1.98)].

CONCLUSION

BP measurement during rest, exercise and recovery phases of EST provides incremental prognostic information regarding long-term risk for cardiovascular events and the probability for developing hypertension.