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Clinical Significance of an Exaggerated Blood Pressure Response During Exercise

Clinical Significance of an Exaggerated Blood Pressure Response During Exercise. ANDREAS PITTARAS MD. Patient A Patient B Age 67 58 Rest BP 120/80 120/78 BP @ 5 METs 160/80 220/90 Peak BP 190/80 230/100. QUESTIONS.

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Clinical Significance of an Exaggerated Blood Pressure Response During Exercise

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  1. Clinical Significance of an Exaggerated Blood Pressure Response During Exercise ANDREAS PITTARAS MD

  2. Patient A Patient B Age 67 58 Rest BP 120/80 120/78 BP @ 5 METs 160/80 220/90 Peak BP 190/80 230/100

  3. QUESTIONS The Clinical Significance? What to do about it?

  4. Definition Peak Exercise SBP >210 mm Hg for men and 190 mm Hg for women respectively (Framingham) SBP >200 mm Hg at Exercise Workload of about 6-7 METs

  5. Exaggerated BP Response toExercise and Associations • Future Development of HTN • Cardiovascular Mortality and Cardiovascular events • Left Ventricular Hypertrophy

  6. Clinical Significance Jong-Won Ha, et al. JACC 2002:112:161-66 False-positive results were twice as likely in patients with hypertensive response to exercise echocardiography (22% vs 12%).

  7. Exaggerated BP and Future Development of Hypertension

  8. New-onset of HTN and Exercise BP in Men (n=1026) The Framingham Heart Study Singh JP, et al. Circulation 1999;99:1831-36 Odds Ratio SBP * DBP *

  9. Exaggerated BP Response to Exercise and Risk for Developing HTN (n=1,033) Miyai, et al. Hypertension 2002;39:761-6 Relative Risk SBP DBP 4.7 yrs F/U

  10. Exaggerated BP Response to Exercise and Risk for Developing HTN Miyai, et al. Hypertension 2002;39:761-6 Relative Risk

  11. Exaggerated Exercise BP and Future HTN (Conclusion) • Overall, an exaggerated BP response to exercise is likely to lead to future HTN • Confounding factors such as age, gender, and physical fitness have not always been considered • Pre-hypertension ?

  12. Patients with Pre-hypertension are at twice the risk to develop hypertension compared to those with lower BP values.Vasan RS, et al. The Framingham Study. JAMA 2002;287:1003-1010

  13. Exaggerated BP and CV Events and CV Mortality

  14. Exercise BP and CV Mortality in Middle-aged Men (n=1999) Mundal et al. Hypertension 1994;24:56-62 % F/U: 16 yrs * RR=2.0 >140 / >200 mm Hg NS <140 / >200 mm Hg <140 / <200 mm Hg >140 / <200 mm Hg

  15. Exercise BP and Risk of Developing MI in Middle-aged Men (n=1999) Mundal et al. 1996; Hypertension;27:324-29 % * >140 / >200 mm Hg >140 / <200 mm Hg <140 / >200 mm Hg <140 / <200 mm Hg

  16. Conclusion SBP >200 mm Hg at exercise intensity of about 6 METs is a stronger predictor of CV and MI morbidity and mortality than resting BP In pts with resting HTN. Mundal R. et al., Hypertension 1996;27(1):324-29

  17. Exaggerated BP Response and Left Ventricular Hypertrophy

  18. Resting BP is weakly related to LVH (r=0.26) and can only partially explain its development and progression.

  19. Exaggerated BP & LVH in Normotensive Men An exaggerated blood pressure (SBP >210) at peak exercise is associated with left ventricular hypertrophy (LVH). The association is much stronger than that between resting BP and LVH. Gottdiener JS., et al. Annals of Internal Medicine 1990; 112:116-66

  20. Peak Exercise SBP and LV MASS Polonia J, et al. Eur Heart Journal 1992; 13(A):30-36 g/m2 HTN with SBP >210 mm Hg >210 mm Hg <210 mm Hg

  21. Peak Exercise BP and LV MASS Molina L, et al. Am J Cardiol 1999; 84:890-93 <210 mm Hg >210 mm Hg

  22. Peak Exercise BP (SBP>210 mm Hg) and LVH in Men & Women Lauer et al. Annals Intern Med 1992;116;203-10 g/m2 <210 mm Hg >210 mm Hg

  23. Conclusion Lauer et al. Annals Intern Med 1992;116;203-10 The relationship between Peak exercise BP and LVM is confounded by a number of baseline variables so that its biological significance must be questioned.

  24. Peak Exercise BP Relatively difficult to assess Impractical Based on a relative workload Exer. BP (5-7 METs) Easier to assess Practical (reflects daily activities) Wider clinical application Based on absolute workloads Peak vs Sub-maximal Exercise BP

  25. Exercise SBP and Fitness in Normotensive Men (n=1,025) Low-Fit Moderate High-Fit mm Hg * p<0.01 * * *

  26. Patients with Pre-hypertension (SBP 120-139 mm Hg or DBP 80-89 mm Hg), are at twice the risk to develop hypertension compared to those with lower BP values.Vasan RS, et al. The Framingham Study. JAMA 2002;287:1003-1010

  27. LVMI Predictors for Pre-HTNsiveMen (Multiple Regression) M (n=269)W (n=243) R2 R2 SBP @ 7 METs 0.62 0.50 Age 0.64 0.51 T-Time 0.65 0.53

  28. LVMI & Exercise SBP Association in Pre-Hypertensive WomenKokkinos P, Pittaras A et al. Circulation 2004 SBP>169 mm Hg

  29. LVMI & Exercise SBP Association in Pre-Hypertensive MenKokkinos P., Pittaras A et al. Circulation 2004 SBP>164 mm Hg

  30. LVMI & Exercise SBP in Pre-hypertensive Men and Women Kokkinos P., Pittaras A et al. Circulation 2004 g/m2 * p<0.01 EX-HTN Normal * *

  31. Prevalence of LVH in Pre-HTN Men % OR CI p-value EX-HTN (+): 59 30.2 13.8-66.2 0.00 EX-HTN (-) : 4.5 RR= 5.9 times higher likelihood of LVH/10 mm Hg Increase in SBP@ 6 min. of exercise Women EX-HTN (+): 86 21.6 12.3-38.2 0.00 EX-HTN (-) : 22 RR= 2.9 times higher likelihood of LVH/10 mm Hg increase in SBP@ 6 min. of exercise

  32. Conclusions Systolic BP at about 6-7 METs is the strongest predictor of LV mass in Pre- hypertensive men and women. The threshold for LVH is SBP >164 mm Hg for men and >169mm Hg for Women. The likelihood of having LVH increases by 6-fold in men and 3-fold in women for every 10 mm Hg increase in SBP above these thresholds.

  33. What to Do for Patients with Exaggerated BP Response to Exercise ? Antihypertensive Agents Exercise Training

  34. Exercise BP and Antihypertensive Meds (n=1,977) mm Hg * BB-Based * p<0.01 Others * * *

  35. Exercise BP and Antihypertensive Agents (n=1,977) mm Hg BB-Based CCB ACE Diuretics * p<0.01

  36. Clinical Significance Beta-blockade may be a prudent approach to protect against excessive and repetitive elevations in BP likely to occur during vigorous activities such snow-shoveling basketball, tennis, etc., that require repetitive burst of effort to maximal or near maximal levels.

  37. What to Do for Patients with Exaggerated BP Response to Exercise ? Antihypertensive Meds Exercise Training

  38. Exercise Indices for Fit and Unfit Women Kokkinos P. Pittaras A et al, J Cardiopulmonary Rehab 2002;22:178-183 Normotensive Fit (n= 557) Unfit (n=463) SBP- 6 min 145±18 156±20* HR- 6 min 136±15 152±17* Hypertensive Fit (n= 99) Unfit (n=186) SBP- 6 min 172±21 184±21* HR- 6 min 141±15 156±15* • * p =0.000

  39. Exercise BP, Fitness & LVMI in Men Pittaras A, et al. Circulation 2003 Low-Fit Moderate * * p<0.01 High-Fit *

  40. Exercise BP, Fitness & LVMI in Women Pittaras A, et al. Circulation 2003 Low-Fit * p<0.01 Moderate High-Fit * *

  41. SBP Following Aerobic Training Kokkinos P. et al, Am J Cardiol. 1997 mm Hg *p<0.01 * * * *

  42. Wall Thickness at Baseline and 16 wks Kokkinos, Pittaras A et al. New Engl J Med 1995;333:1462-7 mm * p<0.05 * *

  43. LVMI at Baseline and 16 Wks of Exercise Kokkinos, Pittaras A et al. New Engl J Med 1995;333:1462-7 * p<0.05 g/m2 * Baseline 16 weeks

  44. Antihypertensive Agents and Exercise

  45. Exercise SBP and Fitness in Hypertensive Men on B-Blockers (n=453) Low-Fit Moderate High-Fit mm Hg * p<0.01 * * *

  46. Exercise SBP and Fitness in Hypertensive Men on Meds (n=455) Low-Fit Moderate High-Fit mm Hg * p<0.01 * * *

  47. Does exercise BP at 5-7 METs reflect daytime Ambulatory BP?

  48. Exercise BP & ABP in Fit & Unfit Men EX-BP ABPM ABPM EX-BP LVMI LVMI

  49. Exercise BP & ABP in Fit & Unfit Women EX-BP ABPM ABPM EX-BP LVMI LVMI

  50. Summary and Conlusions • Fit individuals have Lower: • BP at intensities of 5-7 METs • Lower ABPM • Lower LVMI Than Unfit. • Physical activity lowers the daily hymodymanic load, leading to lower LV Mass.

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