Type-2 Diabetes and the Clinical Importance of Exaggerated Exercise Blood Pressure

Risk Factors Associated With Exaggerated Blood Pressure Response at the Time of Exercise Treadmill Stress Test

BACKGROUND

Exaggerated blood pressure response (EBPR) to exercise stress testing (EST) may be a marker of future hypertension and carry valuable information for the prediction of cardiovascular events. We sought to evaluate the clinical and resting EST parameters associated with an increased likelihood of EBPR.

METHODS

The records of 14,073 patients (mean age: 55 ± 11 years) without known cardiovascular disease who underwent a treadmill EST were analyzed.

RESULTS

The overall prevalence of arterial hypertension was 44%. A considerable proportion (24%) of patients exhibited EBPR. Multivariate analysis of the entire study population showed that middle-aged individuals (40-60 years old), resting systolic BP > 130 mmHg and/or diastolic BP > 80 mmHg, known arterial hypertension, current cigarette smoking, and family history of premature coronary artery disease are all independent risk factors for EBPR (all P < 0.001). Although the presence of arterial hypertension increased the likelihood of EBPR in the analysis of the entire population, the relevant association in subjects above 60 years old is statistically nonsignificant (P = 0.120). Notably, the pre-test systolic BP > 130 mmHg and/or diastolic BP > 80 mmHg level increased significantly the likelihood of manifesting EBPR in all age categories (<40, 40-60, and >60 years old) independent of hypertension presence and in all hypertensive patients independently of antihypertensive treatment intake (all P < 0.001).

CONCLUSIONS

Considering the diagnostic and prognostic utility of EBPR during treadmill EST the clinical and resting hemodynamic parameters that increase the likelihood of EBPR are targets for interventions and preventive measures to modify lifestyle risk behaviors and reduce hypertension and cardiovascular risk factors in the early stages.

The cardiovascular changes underlying a low cardiac output with exercise in patients with type 2 diabetes mellitus

The significant morbidity and premature mortality of type 2 diabetes mellitus (T2DM) is largely associated with its cardiovascular consequences. Focus has long been on the arterial atheromatosis of DM giving rise to early stroke and myocardial infarctions, whereas less attention has been given to its non-ischemic cardiovascular consequences. Irrespective of ischemic changes, T2DM is associated with heart failure (HF) most commonly with preserved ejection fraction (HFpEF). Largely due to increasing population ages, hypertension, obesity and T2DM, HFpEF is becoming the most prevalent form of heart failure. Unfortunately, randomized controlled trials of HFpEF have largely been futile, and it now seems logical to address the important different phenotypes of HFpEF to understand their underlying pathophysiology. In the early phases, HFpEF is associated with a significantly impaired ability to increase cardiac output with exercise. The lowered cardiac output with exercise results from both cardiac and peripheral causes. T2DM is associated with left ventricular (LV) diastolic dysfunction based on LV hypertrophy with myocardial disperse fibrosis and significantly impaired ability for myocardial blood flow increments with exercise. T2DM is also associated with impaired ability for skeletal muscle vasodilation during exercise, and as is the case in the myocardium, such changes may be related to vascular rarefaction. The present review discusses the underlying phenotypical changes of the heart and peripheral vascular system and their importance for an adequate increase in cardiac output. Since many of the described cardiovascular changes with T2DM must be considered difficult to change if fully developed, it is suggested that patients with T2DM are early evaluated with respect to their cardiovascular compromise.

Targeting Hypertensive Response to Exercise and the Association of Masked Hypertension With Subclinical Organ Damage: A Mini-Review and Meta-Analysis

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.