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Wiech P, Würzburger L, Rossi VA, Caselli S, Schmied CM, Niederseer D. Hypertensive response to exercise, hypertension and heart failure with preserved ejection fraction (HFpEF)-a continuum of disease? Wien Klin Wochenschr 2023; 135:685-695. [PMID: 37069407 PMCID: PMC10713678 DOI: 10.1007/s00508-023-02195-3] [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: 04/19/2022] [Accepted: 03/05/2023] [Indexed: 04/19/2023]
Abstract
INTRODUCTION Heart failure with preserved ejection fraction (HFpEF) has been shown to be a long-term consequence of uncontrolled arterial hypertension (aHT). Other than that, hypertensive response to exercise (HRE) precedes aHT. We aim to evaluate the available evidence for a continuum of HRE, aHT and HFpEF. METHODS A literature search on PubMed was conducted to assembly the most recent data on the topic. After collecting the data, a qualitative analysis was instrumented. RESULTS 10 studies including 16,165 subjects were analyzed with respect to the association between HRE and the future risk of developing aHT. With the exception of one study, all reported on a positive association between HRE and the future development of aHT despite methodological issues related to different definitions for HRE. Furthermore, HRE was associated with an increased risk of coronary artery disease. Moreover, we analysed 6 studies including overall 1366 subjects investigating the association between HRE and HFpEF. In these studies, increased left atrial volume index (LAVI), elevated E/e' (as surrogate parameters of increased LV end-diastolic filling pressure and of diastolic dysfunction) and higher LV mass index have been proposed as independent predictor of HRE in patients with no known HFpEF diagnosis. DISCUSSION AND CONCLUSION The literature search revealed suggestive data on a connection of HRE, aHT and HFpEF. HRE seems to be an independent risk factor for aHT and aHT in turn is one of the main risk factors for HFpEF. However, further research is needed to improve our knowledge of a possible continuum of disease.
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Affiliation(s)
- Patrick Wiech
- Department of Cardiology, University Hospital Zurich, University Heart Center Zurich, University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Laura Würzburger
- Department of Cardiology, University Hospital Zurich, University Heart Center Zurich, University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Valentina A Rossi
- Department of Cardiology, University Hospital Zurich, University Heart Center Zurich, University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Stefano Caselli
- Hirslanden, Klinik im Park, Cardiovascular Center Zurich, Zurich, Switzerland
| | - Christian M Schmied
- Department of Cardiology, University Hospital Zurich, University Heart Center Zurich, University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - David Niederseer
- Department of Cardiology, University Hospital Zurich, University Heart Center Zurich, University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
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Jin S, Heo JH, Kim BJ. Effects of White-coat Hypertension on Heart Rate Recovery and Blood Pressure Response during Exercise Test. KOSIN MEDICAL JOURNAL 2020. [DOI: 10.7180/kmj.2020.35.2.89] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Baker-Smith CM, Pietris N, Jinadu L. Recommendations for exercise and screening for safe athletic participation in hypertensive youth. Pediatr Nephrol 2020; 35:743-752. [PMID: 31025109 DOI: 10.1007/s00467-019-04258-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 03/28/2019] [Accepted: 04/01/2019] [Indexed: 01/19/2023]
Abstract
Physical activity is an important component of ideal cardiovascular health. Current guidelines recommend that youth with hypertension participate in competitive sports once hypertensive target organ effects and risks have been assessed and that children with hypertension receive treatment to lower BP below stage 2 thresholds (e.g., < 140/90 mmHg or < 95th percentile + 12 mmHg) before participating in competitive sports. Despite these recommendations, pediatricians and pediatric subspecialists continue to struggle with how best to counsel their patients regarding appropriate forms of physical activity, the impact of exercise on blood pressure, and how best to screen for cardiovascular conditions that place youth at risk for sudden cardiac death. This review provides a summary of our current knowledge regarding the safety and utility of exercise in the management of high blood pressure in youth. We review determinants of blood pressure during exercise, the impact of blood pressure on cardiovascular health and structure, mechanisms for assessing cardiometabolic fitness (e.g., exercise stress test), contraindications to athletic participation, and how best to plan for athletic participation among hypertensive youth. Greater knowledge in these areas may offer clarity to providers faced with the challenge of prescribing exercise recommendations for hypertensive youth.
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Affiliation(s)
- Carissa M Baker-Smith
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
| | - Nicholas Pietris
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Laide Jinadu
- Department of Pediatrics, Valley Children's Medical Center, Madera, CA, USA
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Currie KD, Floras JS, La Gerche A, Goodman JM. Exercise Blood Pressure Guidelines: Time to Re-evaluate What is Normal and Exaggerated? Sports Med 2018; 48:1763-1771. [PMID: 29574665 DOI: 10.1007/s40279-018-0900-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Blood pressure responses to graded exercise testing can provide important diagnostic and prognostic information. While published guidelines outline what constitutes a "normal" and "abnormal" (i.e., exaggerated) blood pressure response to exercise testing, the widespread use of exaggerated blood pressure responses as a clinical tool is limited due to sparse and inconsistent data. A review of the original sources from these guidelines reveals an overall lack of empirical evidence to support both the normal blood pressure responses and their upper limits. In this current opinion, we critically evaluate the current exercise blood pressure guidelines including (1) the normal blood pressure responses to graded exercise testing; (2) the upper limits of this normal response; (3) the blood pressure criteria for test termination; and (4) the thresholds for exaggerated blood pressure responses. We provide evidence that exercise blood pressure responses vary according to subject characteristics, and subsequently a re-evaluation of what constitutes normal and abnormal responses is necessary to strengthen the clinical utility of this assessment.
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Affiliation(s)
- Katharine D Currie
- Faculty of Kinesiology and Physical Education, University of Toronto, 55 Harbord Street, Toronto, ON, M5S 2W6, Canada
| | - John S Floras
- University Health Network and Mount Sinai Hospital Division of Cardiology, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.,Department of Medicine, University of Toronto, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Andre La Gerche
- Sports Cardiology and Cardiac Magnetic Resonance Imaging Lab, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC, 3004, Australia.,Cardiology Department, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Jack M Goodman
- Faculty of Kinesiology and Physical Education, University of Toronto, 55 Harbord Street, Toronto, ON, M5S 2W6, Canada. .,University Health Network and Mount Sinai Hospital Division of Cardiology, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
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Keller K, Stelzer K, Ostad MA, Post F. Impact of exaggerated blood pressure response in normotensive individuals on future hypertension and prognosis: Systematic review according to PRISMA guideline. Adv Med Sci 2017; 62:317-329. [PMID: 28511070 DOI: 10.1016/j.advms.2016.11.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 09/09/2016] [Accepted: 11/29/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE Arterial hypertension (aHT) is the leading risk factor for morbidity and mortality worldwide. Blood pressure (BP) deviation at rest is well defined and accompanies risk for cardiovascular events and cardiovascular mortality. A growing body of evidence emphasises that an exaggerated blood pressure response (EBPR) in cardiopulmonary exercise testing (CPET) could help to identify seemingly cardiovascular healthy and normotensive subjects, who have an increased risk of developing aHT and cardiovascular events in the future. MATERIALS AND METHODS The PubMed online database was searched for published studies reporting exercise-related BP and both the risk of aHT and cardiovascular events in the future. RESULTS We identified 18 original studies about EBPR in CPET, which included a total of 35,151 normotensive individuals for prediction of new onset of aHT in the future and 11 original studies with 43,012 enrolled subjects with the endpoint of cardiovascular events in the future. Although an EBPR under CPET is not well defined, a large number of studies emphasise that EBPR in CPET is associated with both new-onset aHT and cardiovascular events in the future. CONCLUSIONS A growing number of studies support the hypothesis that EBPR in CPET may be a diagnostic tool to identify subjects with an elevated risk of developing aHT and cardiovascular events in the future.
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Eshraghi A, Ebdali RT, Sajjadi SS, Golnezhad R. Diagnostic Value of Electrocardiogram in Predicting Exaggerated Blood Pressure Response to Exercise Stress Testing. Electron Physician 2016; 8:2765-2771. [PMID: 27757187 PMCID: PMC5053458 DOI: 10.19082/2765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 05/18/2016] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION It is believed that an exaggerated blood pressure response (EBPR) to exercise stress test is associated with a higher risk of cardiovascular events. It is also assumed that QT dispersion (QT-d), which was originally proposed to measure the spatial dispersion of ventricular recovery times, may have a relationship to cardiovascular events. The objective of this study was to examine the difference of changes in QT-d, Maxi-QT, Mini-QT, and QT-c (corrected QT interval) of the electrocardiogram in two groups of patients with exaggerated blood pressure responses (EBPR group) and normal responses (control group) to exercise testing. Also, the diagnostic value of each of these criteria in the prediction of EBPR was studied. METHODS This cross-sectional study was conducted from May 2015 to February 2016 on patients suspected of coronary artery disease (CAD) undergoing exercise testing who had been referred to Ghaem and Imam Reza hospitals in Mashhad (Iran). All patients underwent a treadmill exercise test with the 12-lead ECG, which was optically scanned and digitized for analysis of QT-d, QT max, and QT min. Patients were divided into two groups of normal and EBPR to exercise testing. QT changes of ECG were compared between the two groups, and the diagnostic accuracy of QT variables for prediction of EBPR to exercise testing was studied. A multiple linear regression analysis (MLR), Pearson Chi-qquare, independent samples t-test, and receiver operating characteristic (ROC) curve were used as statistical methods in IBM SPSS version 19. RESULTS Sixty patients (55% male) with a mean age of 50.48 ± 10.89 years were studied in two groups of normal (n=30) and exaggerated blood pressure response (n=30) to exercise testing. Maximum QT and QT dispersion were statistically different in individuals' exaggerated blood pressure response to exercise stress test (p < 0.05). The logistic regression analysis revealed that none of our parameters predicted the EBPR. The ROC curve showed that 50 and 345 milliseconds for QT dispersion and Maxi-QT were the optimal cut-off points for the prediction of EBPR. CONCLUSION It seems that Maxi-QT and QT-d may be predictors of EBPR during exercise testing. Also, a significant difference in maxi-QT and QT-d was observed between two groups of patients with normal and EBPR during the exercise testing.
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Affiliation(s)
- Ali Eshraghi
- M.D., Assistant Professor, Department of Cardiology, Atherosclerosis Prevention Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Reyhaneh Takalloo Ebdali
- M.D., Resident of Cardiology, Department of Cardiology, Faculty of Medicine, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Sajed Sajjadi
- M.D., Resident of Cardiology, Department of Cardiology, Faculty of Medicine, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Reza Golnezhad
- M.D., Resident of Cardiology, Department of Cardiology, Faculty of Medicine, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
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Berger A, Grossman E, Katz M, Kivity S, Klempfner R, Segev S, Goldenberg I, Sidi Y, Maor E. Exercise systolic blood pressure variability is associated with increased risk for new-onset hypertension among normotensive adults. ACTA ACUST UNITED AC 2016; 10:527-535.e2. [DOI: 10.1016/j.jash.2016.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 03/26/2016] [Accepted: 04/05/2016] [Indexed: 10/21/2022]
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Berger A, Grossman E, Katz M, Kivity S, Klempfner R, Segev S, Goldenberg I, Sidi Y, Maor E. Exercise blood pressure and the risk for future hypertension among normotensive middle-aged adults. J Am Heart Assoc 2015; 4:jah3935. [PMID: 25904593 PMCID: PMC4579952 DOI: 10.1161/jaha.114.001710] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Assaf Berger
- Leviev Heart Center, Chaim Sheba Medical Center, Ramat Gan, Israel (A.B., M.K., R.K., I.G., E.M.)
| | - Ehud Grossman
- Department of Internal Medicine D, Chaim Sheba Medical Center, Ramat Gan, Israel (E.G.) Sackler School of Medicine, Tel-Aviv University, Israel (E.G., S.K., R.K., I.G., Y.S.)
| | - Moshe Katz
- Leviev Heart Center, Chaim Sheba Medical Center, Ramat Gan, Israel (A.B., M.K., R.K., I.G., E.M.)
| | - Shaye Kivity
- Department of Internal Medicine C, Chaim Sheba Medical Center, Ramat Gan, Israel (S.K., Y.S.) Sackler School of Medicine, Tel-Aviv University, Israel (E.G., S.K., R.K., I.G., Y.S.)
| | - Robert Klempfner
- Leviev Heart Center, Chaim Sheba Medical Center, Ramat Gan, Israel (A.B., M.K., R.K., I.G., E.M.) Sackler School of Medicine, Tel-Aviv University, Israel (E.G., S.K., R.K., I.G., Y.S.)
| | - Shlomo Segev
- Institute for Medical Screening, Chaim Sheba Medical Center, Ramat Gan, Israel (S.S.)
| | - Ilan Goldenberg
- Leviev Heart Center, Chaim Sheba Medical Center, Ramat Gan, Israel (A.B., M.K., R.K., I.G., E.M.) Sackler School of Medicine, Tel-Aviv University, Israel (E.G., S.K., R.K., I.G., Y.S.)
| | - Yehezkel Sidi
- Department of Internal Medicine C, Chaim Sheba Medical Center, Ramat Gan, Israel (S.K., Y.S.) Sackler School of Medicine, Tel-Aviv University, Israel (E.G., S.K., R.K., I.G., Y.S.)
| | - Elad Maor
- Leviev Heart Center, Chaim Sheba Medical Center, Ramat Gan, Israel (A.B., M.K., R.K., I.G., E.M.) Pinchas Borenstein Talpiot Medical Leadership Program, Chaim Sheba Medical Center, Ramat Gan, Israel (E.M.)
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