Predictors of exaggerated exercise-induced systolic blood pressures in young patients after coarctation repair

The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States of America.
Cardiology in the Young (Impact Factor: 0.84). 09/2012; 23(3):1-7. DOI: 10.1017/S1047951112001114
Source: PubMed


In normotensive subjects, an exaggerated blood pressure response to exercise is associated with the development of resting hypertension. We sought to determine the prevalence of elevated blood pressures during exercise in post-operative coarctation patients with normal resting blood pressure, and investigate associations with exercise-induced hypertension in this population.

A total of 38 patients were enrolled after end-to-end anastomosis repair and resting normotension. All patients underwent anthropometric and blood pressure measurements, echocardiographic evaluation of function, arterial stiffness assessment by pulse wave velocity, and a graded exercise test. An abnormal response was defined as a maximum systolic blood pressure greater than the 95th percentile of published normal values. Correlation analyses and stepwise regression analyses were performed.

The mean age was 12.7 years, including 79% male patients. The mean resting systolic blood pressure was 111.3 millimetres of mercury and the mean exercise systolic blood pressure was 178.1 millimetres of mercury. The prevalence of a systolic blood pressure greater than the 95th percentile was 16.7%. In multivariate analysis, the exercise systolic blood pressure index was associated with body mass index, age, aortic valve annulus, shortening fraction, and pulse wave velocity (R2 equal to 0.79, p equal to 0.0009). Estimates of ventricular filling and indexed left ventricular mass were elevated.

There is a risk of elevated systolic blood pressure during exercise in normotensive patients after coarctation repair. Resting blood pressures are useful but not sufficient. Echocardiography demonstrated abnormalities suggestive of a chronic cardiac burden despite resting normotension. Regular imaging may be necessary to improve long-term outcomes. New paradigms for the continued follow-up of these patients are necessary.

7 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: Opinion statement: While congenital heart defects are typically diagnosed in early childhood, depending on the severity of the lesion, they may not be recognized until later childhood or in adulthood. Left heart pressure loading lesions, including mitral valve stenosis, subaortic stenosis, valvular aortic stenosis, supravalvular aortic stenosis, and coarctation of the aorta, may be found as an isolated lesion or as a constellation together known as Shone syndrome. This review will highlight the literature published regarding the diagnosis, intervention, and long-term management of left heart pressure loading lesions.
    No preview · Article · Aug 2013 · Current Treatment Options in Cardiovascular Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Coarctation of the aorta represents more than a simple obstructive lesion, as there is often evidence of hypertension and vascular dysfunction despite successful surgery at an early age. There are ample data showing that a large proportion of patients develop arterial hypertension, and this appears to increase with age. Our understanding of the pathogenesis of late hypertension is incomplete, and there is limited information on which drugs are most appropriate. Increased arterial rigidity is now well described in this patient group, although it is not known how this should influence therapy. The increase in afterload associated with this increased rigidity has been found to have an impact on the left ventricle at an early stage, and the interaction between the vascular dysfunction and the ventricle is an area of interest and active research. This article reviews some recent studies and highlights areas where research questions remain.
    No preview · Article · Mar 2014 · Current Hypertension Reports
  • [Show abstract] [Hide abstract]
    ABSTRACT: Alteration of right ventricular (RV) function has been found in patients with pressure-loaded left ventricles due to systemic hypertension and aortic stenosis. We tested the hypothesis that RV mechanics are altered in adolescents and adults with repaired coarctation of the aorta (CoA). Twenty-eight (15 male) patients, aged 23.7 ± 6.5 years, and 28 (14 male) controls were studied. M-mode, tissue Doppler imaging, and speckle tracking echocardiography were performed to assess, respectively, LV mass and RV wall thickness, RV myocardial tissue velocities, and deformation. Systolic (P = 0.14) and diastolic (P = 0.32) blood pressures were similar between patients and controls. Compared with controls, patients had significantly greater LV mass (P = 0.016) and RV anterior wall thickness (P = 0.012). Tricuspid annular systolic (P < 0.001) and early diastolic (P < 0.001) velocities, isovolumic acceleration (P = 0.004), global RV systolic longitudinal strain (P = 0.03), systolic strain rate (P = 0.012), and early (P = 0.021) and late (P = 0.012) diastolic strain rates were significantly lower in patients than controls. Patients with an associated ventricular septal defect (n = 6) requiring closure compared to those without had even lower tricuspid annular systolic (P = 0.01) and early diastolic (P = 0.041) velocities. Left ventricular mass correlated negatively with RV systolic strain rate (r = -0.27, P = 0.045) and tricuspid annular early diastolic velocity (r = -0.40, P = 0.002), while RV anterior wall thickness correlated negatively with tricuspid annular systolic (r = -0.42, P = 0.002) and late diastolic (r = -0.40, P = 0.003) velocities, and positively with e/a ratio (r = 0.31, P = 0.024). RV systolic and diastolic mechanics are impaired in patients late after repair of CoA and related to increased LV mass and RV thickness. © 2014, Wiley Periodicals, Inc.
    No preview · Article · Dec 2014 · Echocardiography
Show more