Cardiovascular risk profiles and stress echocardiography results in patients with hypertensive response to exercise

Aim. To compare markers of high cardiovascular risk and stress echocardiography results depending on the type of blood pressure (BP) response to exercise in patients without obstructive coronary artery disease.

Material and methods. Our single-center cross-sectional study included 96 patients without hemodynamically significant coronary artery stenosis according to coronary angiography or multislice computed tomography angiography. All patients underwent physical examination, cardiovascular risk stratification, electrocardiography, extracranial cerebrovascular ultrasound, echocardiography, treadmill exercise stress echocardiography.

Results. According to the test results, the patients were divided into groups with a hypertensive response (n=41) and a normal response to exercise (n=55). Patients with hypertensive response to exercise had significantly higher values of left ventricular mass index (100,0 (90,0; 107,0) g/m² vs 76,0 (68,0; 91,0) g/m², p<0,0000001) and left atrial volume index (36,7 (32,0; 46,0) ml/m² vs 29,7 (26,3; 32,0) ml/m², p=0,000003). There was also a higher level of cardiovascular SCORE risk (5,0 (2,0; 6,0) vs 2,0 (1,0; 3,0), p=0,004); patients more often had associated clinical conditions (36,6% vs 12,7%, χ²=7,57, p=0,006) and left ventricular diastolic dysfunction (39,02% vs 78,18%, χ²=15,21, p=0,0001). Pathological BP increase during stress echocardiography was associated with worse exercise tolerance (7,4 (5,6; 10,0) METs vs 10,2 (8,4; 11,95) METs, p=0,000041) and more frequent transient regional contractility impairment (46,34% vs 1,8%, p<0,00001), mainly of the lateral and inferior left ventricular walls.

Conclusion. Despite the absence of coronary artery stenosis, patients with hypertensive response to exercise are significantly more likely to have markers of high cardiovascular risk and require more careful monitoring of risk factors. Also, the hypertensive response to exercise is associated with more frequent regional contractility impairment even without coronary artery stenosis.

1. Mazic S, Suzic Lazic J, Dekleva M, et al. The impact of elevated blood pressure on exercise capacity in elite athletes. Int J Cardiol. 2015;180:171‐7. doi:10.1016/j.ijcard.2014.11.125.

2. Le VV, Mitiku T, Sungar G, et al. The blood pressure response to dynamic exercise testing: a systematic review. Prog Cardiovasc Dis. 2008;51(2):135‐60. doi:10.1016/j.pcad.2008.07.001.

3. Sharman JE, Hare JL, Thomas S, et al. Association of masked hypertension and left ventricular remodeling with the hypertensive response to exercise. Am J Hypertens. 2011;24(8):898‐903. doi:10.1038/ajh.2011.75.

4. Lauer MS, Levy D, Anderson KM, Plehn JF. Is there a relationship between exercise systolic blood pressure response and left ventricular mass? The Framingham Heart Study. Ann Intern Med. 1992;116(3):203-10. doi:10.7326/0003-4819-116-3-203.

5. Weiss SA, Blumenthal RS, Sharrett AR, et al. Exercise blood pressure and future cardiovascular death in asymptomatic individuals. Circulation. 2010;121(19):2109-16. doi:10.1161/CIRCULATIONAHA.109.895292.

6. Kim D, Ha JW. Hypertensive response to exercise: mechanisms and clinical implication. Clin Hypertens. 2016;22(17). doi:10.1186/s40885-016-0052-y.

7. Jurrens TL, From AM, Kane GC, et al. An exaggerated blood pressure response to treadmill exercise does not increase the likelihood that exercise echocardiograms are abnormal in men or women. J Am Soc Echocardiogr. 2012;25(10):1113-9. doi:10.1016/j.echo.2012.07.001.

8. Prada-Delgado O. Prognostic Value of Exercise-induced Left Ventricular Systolic Dysfunction In Hypertensive Patients Without Coronary Artery Disease. Rev Esp Cardiol. 2015;68(2):107-14. doi:10.1016/j.rec.2014.03.023.

9. Olesen KKW, Madsen M, Gyldenkerne C, et al. Absence of Coronary Artery Disease by Coronary Angiography is Associated With a Lower Risk of Myocardial Infarction Than in the General Population. Circulation. 2019;140:A12767.

10. Sarma S, Howden E, Carrick-Ranson G, et al. Elevated exercise blood pressure in middleaged women is associated with altered left ventricular and vascular stiffness. Journal of Applied Physiology. 2020;128(5):1123-9. doi:10.1152/japplphysiol.00458.2019.

11. Spartano NL, Lyass A, Larson MG, et al. Submaximal Exercise Systolic Blood Pressure and Heart Rate at 20 Years of Follow-up: Correlates in the Framingham Heart Study. J Am Heart Assoc. 2016;5(6):e002821. doi:10.1161/JAHA.115.002821.

12. Schultz MG, Sharman JE. Exercise Hypertension. Pulse (Basel). 2014;1(3-4):161-76. doi:10.1159/000360975.

13. Tuka V, Rosa J, Dědinová M, Matoulek M. The determinants of blood pressure response to exercise. Cor et vasa. 2015;57(3):e163-e167. doi:10.1016/j.crvasa.2015.03.010.

14. Mizuno R, Fujimoto S, Saito Y, Yamazaki M. Clinical importance of detecting exaggerated blood pressure response to exercise on antihypertensive therapy. Heart. 2016;102(11):849-54. doi:10.1136/heartjnl-2015-308805.

15. Pellikka PA, Arruda-Olson A, Chaudhry FA, et al. Guidelines for Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease: From the American Society of Echocardiography. J Am Soc Echocardiogr. 2020;33(1):1-41. e8. doi:10.1016/j.echo.2019.07.001.