Detecting Exaggerated Blood Pressure Response to Exercise
What is the impact of exaggerated blood pressure response to exercise (Ex-BP) seen in patients with hypertension undergoing antihypertensive therapy on the regression of left ventricular hypertrophy (LVH)?
The study included 124 never-treated patients with hypertension with LVH on echo-Doppler (LV mass corrected by body surface area [LVM index] >115 g/m2 for men and >95 g/m2 for women. After a pretreatment evaluation, antihypertensive treatment was started and exercise test was performed in all patients. Exclusion criteria included cardiac diseases, diabetes mellitus, chronic kidney disease, pulmonary or hepatic diseases, and inadequate echocardiographic image quality. Treadmill exercise was performed with the Bruce protocol with endpoints of excessive fatigue, leg weakness, shortness of breath, achievement of the target heart rate, and severe hypertension (systolic BP >240 mm Hg or diastolic BP >110 mm Hg). Ex-BP was defined by a maximum systolic/diastolic BP during exercise of ≥210/105 mm Hg in men and ≥190/105 mm Hg in women. Patients with Ex-BP were divided into the Ex-BP (+) group and those without were divided into the Ex-BP (−) group. Regression of LVH (reduction of LVM index by at least 10% compared to baseline) over the follow-up period was compared between the groups.
At baseline, there was no difference in mean age of 62 years, mean body mass index 26.5 kg/m2, mean interventricular septal thickness 13.2 mm and posterior wall thickness 12 mm, mean LVM index 126 g/m2, and LV ejection fraction 65%. The follow-up duration was approximately 12 months in both the groups. Mean values of BP at rest during the follow-up period were similar between the groups. There was no difference between groups for treatment using angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers, calcium channel blockers, or beta-blockers or the number of agents. Reduction of LVH was seen in both the groups. There was no difference between groups for exercise duration (7 minutes), max metabolic equivalents (8.0), or peak heart rate. Ex-BP (+) mean increment of systolic BP was 80 mm Hg and with Ex-BP (–) 38 mm Hg with only a 1 mm Hg greater diastolic BP in Ex-BP (+). Changes in the LVM index were significantly lower in the Ex-BP (+) group compared with the Ex-BP (−) group (8.4 g/m2 vs. 17.1 g/m2; p < 0.001). Regression of LVH was much less frequently seen in the Ex-BP (+) group compared with the Ex-BP (−) group. Multiple regression analysis determined that on-treatment Ex-BP was an independent negative determinant of antihypertensive treatment-induced reduction of LVH.
This study suggests that on-treatment Ex-BP is associated with reduced regression of LVH in patients with hypertension with antihypertensive treatment. If Ex-BP is detected despite receiving antihypertensive agents, improvement of Ex-BP may be necessary to achieve an effective reduction of LVH. Active search of Ex-BP is recommended in patients with hypertension with antihypertensive treatment.
In patients with hypertension, regression of LVH is associated with improved prognosis. The clinical implications and degree to which LVH regression is decreased due to failure to block exercise hypertension in hypertensive subjects on effective antihypertensive therapy needs to assessed in large clinical trials.
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