1 / 80

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.

julie
Download Presentation

Clinical Significance of an Exaggerated Blood Pressure Response During Exercise

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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.

More Related