Exaggerated blood pressure response to exercise is not associated with masked hypertension in patients with high normal blood pressure levels

Masked Hypertension and Exaggerated Blood Pressure Response to Exercise: A Review and Meta-Analysis

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.

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.

Elevated peak systolic blood pressure in endurance-trained athletes: Physiology or pathology?

Blood pressure is a function of cardiac output and peripheral vascular resistance. During graded exercise testing (GXT), systolic blood pressure (SBP) is expected to increase gradually along with work rate, oxygen consumption, heart rate, and cardiac output. Individuals exposed to chronic endurance training attain a greater exercise SBP than in their untrained state and sedentary counterparts, but it is currently unknown what is considered a safe upper limit. This review discusses key studies examining blood pressure response in sedentary individuals and athletes. We highlight the physiological characteristics of highly fit individuals in terms of cardiovascular physiology and exercise blood pressure and review the state of the current literature regarding the safety of high SBP during exercise in this particular subgroup. Findings from this review indicate that a consensus on what is a normal SBP response to exercise in highly fit subjects and direct causation linking high GXT SBP to pathology is lacking. Consequently, applying GXT SBP guidelines developed for a "normal" population to endurance-trained individuals appears unsupported at this time. Lack of evidence for poor outcomes leads us to infer that elevated peak SBP in this subgroup could more likely reflect an adaptive response to training, rather than a pathological outcome. Future studies should track clinical outcomes of those achieving elevated SBP and develop athlete-specific guidelines.

The Relationship between Left Ventricular Function Indices in Tissue Doppler Imaging and Exaggerated Blood Pressure Response During the Exercise Stress Test

Background:

Studies have indicated that exaggerated hypertension during activity and stress can be a good predictor of the incidence of hypertension. This study tries to evaluate left ventricular (LV) function by tissue Doppler to assess early changes in ventricular compliance before the onset of Hypertension (HTN) in patients with exaggerated blood pressure response during the exercise test.

Materials and Methods:

In this case-control study, 40 patients without a history of hypertension with systolic blood pressure less than 140/90 which referred for exercise test, were included. The exercise test was performed for all patients. Patients who had exaggerated blood pressure during the stress test were considered as cases and the controls with normal blood pressure responses. Then standard echocardiography and Tissue Doppler imaging performed and indices of LV systolic and diastolic were recorded.

Results:

The LV mass in cases and controls were 174.9±50.78 and 152.9±33.59, respectively (P=0.114), and LV mass index in cases and controls were 127.4±13.5 and 79.8±15.75, respectively (P=0.023). Moreover, the LV Myocardial Performance Index were 0.68±0.11 and 0.48±0.06 in cases and controls, respectively (P<0.001). The heart rate, E/A, EE, E Velocity and S velocity were measuremented. Except E/A (P=0.009), there was no significant difference between the other variables measured between the cases and controls (P>0.05).

Conclusion:

The results of this study showed that using 2D conventional echocardiography as a noninvasive method if performed in prestigious centers can evaluate systolic and diastolic function Tissue Doppler parameters very well in the early stages of heart disease caused by HTN.

An exaggerated increase in blood pressure with exercise does not predict mortality or severe cardiovascular events in women referred for exercise echocardiography for clinical reasons

BACKGROUND AND OBJECTIVES

The association between an exaggerated systolic blood pressure increase with exercise (EBPIE) and the probability of cardiovascular events is controversial and poorly studied in the female population. Our aim was to determine the possible association between EBPIE on one hand and mortality and cardiovascular events on the other in women referred for exercise echocardiography due to known or suspected coronary artery disease.

PATIENTS AND METHODS

A total of 3942 women with known or suspected coronary artery disease underwent exercise echocardiography. We defined EBPIE as a ≥70mm Hg increase in systolic blood pressure with exercise. The study endpoints were overall and cardiac mortality, acute myocardial infarction (MI), stroke and coronary revascularisation procedures.

RESULTS

A total of 332 women developed EBPIE during the test. During the follow-up, 458 deaths (162 of cardiac origin), 212 MIs, 89 strokes and 345 coronary revascularisation procedures were recorded. The annual rates of overall and cardiac mortality were lower in the patient subgroup with EBPIE (0.15% vs. 2.3%, P=.02 and 0.01% vs. 0.2%, P=.015, respectively). There were no significant differences in the rates of MI, stroke and the need for coronary revascularisation procedures, which occurred in 1.1%, 0.43% and 2.24% of the patients with EBPIE, respectively, and occurred in 0.09%, 0.05% and 0.13% of the women without EBPIE (P=.66; P=.57; P=.19, respectively). After a multivariate adjustment, EBPIE was not a predictor of mortality or cardiovascular events.

CONCLUSIONS

EBPIE is not associated with mortality or severe cardiovascular events in women with known or suspected coronary artery disease.

Exercise blood pressure and the risk for future hypertension among normotensive middle-aged adults

Background

The aim of the present study was to examine whether exercise blood pressure can be used to predict the development of hypertension in normotensive middle‐aged adults.

Methods and Results

We investigated 7082 normotensive subjects who were annually screened in a tertiary medical center and completed maximal treadmill exercise tests at each visit. After the initial 3 years, subjects were divided into approximate quartiles according to their average exercise systolic and diastolic blood pressure responses (≤158; 158 to 170; 170 to 183; ≥183 mm Hg for systolic blood pressure and ≤73; 73 to 77; 77 to 82; ≥82 mm Hg for diastolic blood pressure). Mean age of the study population was 48±9 years and 73% were men. Average baseline resting blood pressure was 120/77±12/7 mm Hg. During a follow‐up of 5±3 years, 1036 (14.6%) subjects developed hypertension. The cumulative probability of new‐onset hypertension at 5 years was significantly increased with increasing quartiles of exercise systolic blood pressure (5%, 9%, 17%, and 35%, respectively; P<0.001), with a similar association shown for diastolic blood pressure. After adjustment for baseline resting blood pressure and clinical parameters, each 5‐mm Hg increments in exercise either systolic or diastolic blood pressures were independently associated with respective 11% (P<0.001) and 30% (P<0.001) increased risk for the development of hypertension.

Conclusions

In normotensive middle‐aged individuals, blood pressure response to exercise is associated with future development of hypertension.