ArticlePDF Available

Significance of an Increase in Diastolic Blood Pressure During a Stress Test in Terms of Comorbidities and Long-Term Total and CV Mortality

Authors:

Abstract and Figures

Background: A decrease in diastolic blood pressure (DBP) with exercise is considered normal, but the significance of an increase in DBP has not been validated. Our aim was to determine the relationship of DBP increasing on a stress test regarding comorbidities and mortality. Methods: Our database was reviewed from 1993-2010 using the first stress test of a patient. Non-Minnesota residence, baseline CV disease, rest DBP <60 or >100 mmHg, and age <30 or ≥80 were exclusion criteria. DBP response was classified Normal if peak DBP-rest DBP <0, Borderline 0-9, Abnormal ≥10mmHg. Mortality was determined from Mayo Clinic records and Minnesota Death Index. Logistic regression was used to determine the relationship of DBP response to presence of comorbidities. Cox regression was used to determine total and CV mortality risk by DBP response. All analyses were adjusted for age, sex and resting DBP. Results: 20760 patients were included (51±11 years, female n=7314). Rest/peak averaged DBP 82±8/69 ±15 mmHg in normal vs 79±9/82±9 mmHg in borderline vs 76±9/92±11 mmHg in abnormal DBP response. There were 1582 deaths (8%) with 557 (3%) CV deaths over 12±5 years of follow-up. In patients with borderline and abnormal DBP response, odds ratios for obesity, hypertension, diabetes and current smoking were significant, while hazard ratios for total and CV death were not significant compared to patients with normal DBP response. Conclusions: DBP response to exercise is significantly associated with important comorbidities at the time of the stress test but does not add to the prognostic yield of stress test.
Content may be subject to copyright.
976 American Journal of Hypertension 31(9) September 2018
Brief communication
It is important for both good patient care and health care
economics to gain the most information possible from each
test performed. is is true for the exercise test which pro-
vides both diagnostic and prognostic information.1 is
means not only looking at the ST segment response but also
accurately reporting and identifying the signicance of other
exercise parameters including blood pressure(BP).
A gradual decrease in diastolic blood pressure (DBP)
with exercise has long been considered a normal response.2,3
While various studies have shown that hypertensive BP
response to exercise may be an independent predictor of le
ventricular hypertrophy,4 development of hypertension,5,6
and total and cardiovascular (CV) mortality in a low-risk
population,7,8 these studies were focused on systolic blood
pressure (SBP) responses to exercise.9,10 e signicance of
an increase in DBP with exercise in a low-risk population
has not been validated yet, either in terms of association
with comorbidities such as diabetes, hypertension, obesity,
and smoking that increase CV risk or in terms of the hard
endpoints of death and CVdeath.
Our aim was to determine the signicance of an increase
in DBP on an exercise test in terms of comorbidities and
long-term total and CV mortality.
METHODS
is was a retrospective study approved by Mayo Clinic
Rochester IRB. Patients not consenting to have their data
used in this research under Minnesota Statute (§144.335)
were excluded.11 e Mayo Integrated Stress Center data-
base was reviewed between 21 September 1993 and 20
December2010.
Study population
In this study, we included Minnesota residents who had
nonimaging, symptom-limited treadmill exercise tests on
the Bruce protocol between ages 30 and 79years. Where mul-
tiple qualifying tests were available for a given patient, the
Signicance of an Increase in Diastolic Blood Pressure
During a Stress Test in Terms of Comorbidities and
Long-Term Total and CV Mortality
NóraSydó,1,2,* TiborSydó,3,* Karina A.Gonzalez Carta,1 NasirHussain,1 BélaMerkely,2
Joseph G.Murphy,1 Ray W.Squires,1 FranciscoLopez-Jimenez,1 and Thomas G.Allison1
BACKGROUND
A decrease in diastolic blood pressure (DBP) with exercise is considered
normal, but the signicance of an increase in DBP has not been vali-
dated. Our aim was to determine the relationship of DBP increasing on
a stress test regarding comorbidities and mortality.
METHODS
Our database was reviewed from 1993 to 2010 using the rst stress test
of a patient. Non-Minnesota residence, baseline cardiovascular (CV) dis-
ease, rest DBP <60 or >100mm Hg, and age <30 or ≥80 were exclusion
criteria. DBP response was classied: normal if peak DBP–rest DBP < 0,
borderline 0–9, and abnormal ≥10mm Hg. Mortality was determined
from Mayo Clinic records and Minnesota Death Index. Logistic regres-
sion was used to determine the relationship of DBP response to the
presence of comorbidities. Cox regression was used to determine total
and CV mortality risk by DBP response. All analyses were adjusted for
age, sex, and resting DBP.
RESULTS
Twenty thousand seven hundred sixty patients were included (51±11years,
female n=7,314). Rest/peak averaged DBP 82±8/69±15mm Hg in normal
vs. 79±9/82±9mm Hg in borderline vs. 76±9/92±11mm Hg in abnor-
mal DBP response. There were 1,582 deaths (8%) with 557 (3%) CV deaths
over 12± 5 years of follow-up. In patients with borderline and abnormal
DBP response, odds ratios for obesity, hypertension, diabetes, and current
smoking were signicant, while hazard ratios for total and CV death were
not signicant compared with patients with normal DBP response.
CONCLUSIONS
DBP response to exercise is signicantly associated with important
comorbidities at the time of the stress test but does not add to the
prognostic yield of stress test.
Keywords: blood pressure; exercise; hypertension; mortality.
doi:10.1093/ajh/hpy080
Correspondence: Thomas G.Allison (allison.thomas@mayo.edu).
Initially submitted February 1, 2018; date of rst revision April 2, 2018;
accepted for publication May 11, 2018; online publication May 15, 2018.
© American Journal of Hypertension, Ltd 2018. All rights reserved.
For Permissions, please email: journals.permissions@oup.com
1Department of Cardiovascular Medicine, Mayo Clinic, Rochester,
Minnesota, USA; 2Heart and Vascular Center, Semmelweis University,
Budapest, Hungary; 3Csolnoky Ferenc Hospital, Veszprém, Hungary.
*These authors contributed equally to this work.
2018
September
Downloaded from https://academic.oup.com/ajh/article-abstract/31/9/976/4996225 by guest on 07 December 2018
American Journal of Hypertension 31(9) September 2018 977
Diastolic Blood Pressure Response to Exercise
rst test chronologically was chosen to maximize follow-up.
Patients were excluded if they1 had documented history of
CV disease—including ischemic heart diseases, heart failure,
cardiac surgery, structural or valvular heart diseases, major
arrhythmias, debrillator or pacemaker, congenital heart
diseases, cerebrovascular diseases, and peripheral vascular
diseases2; pre-exercise DBP was <60 or >100mm Hg.
Clinicaldata
We collected demographic and clinical data prospect-
ively at the time of the exercise test. Heart rate (HR), BP,
and other exercise parameters were uploaded electronic-
ally to our database from the GE CASE stress testing sys-
tems (Milwaukee, WI). Patient characteristics—including
age, sex, and anthropometric data—and comorbidities were
collected at the time of the stress test from patient medical
charts and patient interview. We specically looked comor-
bidities including diabetes and hypertension (dened by the
previous diagnosis or receiving antihypertension medica-
tion), obesity (dened as body mass index 30kg/m2), cur-
rent smoking, and use of an HR-lowering drug (beta-blocker
or nondihydropyridine calcium channel blocker).
Exercise test protocol and variables
Symptom-limited treadmill exercise testing was per-
formed on usual medications using the standard Bruce
protocol according to ACC/AHA guidelines.12,13 Patients
were not allowed to grip the treadmill handrails tightly.
Resting HR and BP measurements were obtained in the
standing position immediately before the test. BP was meas-
ured by auscultation with a stethoscope placed over the bra-
chial artery while the cu was inated and deated manually
according to standard methods. DBP was taken as the h
Korotko phase (disappearance of all sound).14 Symptoms,
BP, HR, rating of perceived exertion, and workload were
electronically entered into the database during the nal
minute of each stage of exercise, peak exercise, 1 and 3 min-
utes of active recovery at 1.7 MPH/0% grade, and 6 minutes
postpeak exercise in seated recovery.
Exercise test interpretation data including the reason
for termination, symptoms, abnormal signs, and exercise
electrocardiographic (ECG) analysis were added to the
database immediately aer the test. DBP response was clas-
sied as normal if peak DBP–rest DBP was <0, borderline if
0–9, and abnormal if 10mm Hg. Functional aerobic cap-
acity was expressed as 100% × actual performance time/
predicted performance time based on previous publica-
tions from our laboratory.10 Peak HR was also expressed as
percent predicted peak HR.15 HR recovery was calculated
as peak exercise HR minus HR at 1 minute of active re-
covery at 1.7 MPH/0% grade. An abnormal exercise ECG
was dened as any ST depression or elevation >1.0mm ir-
respective of the resting ECG, while an abnormal exercise
ECG was considered positive only if the resting ECG did
not present with signicant ST-T abnormalities, the patient
was not taking digitalis, and rate-related le bundle branch
block did not occur.
Mortality outcomes
Outcomes were taken from Mayo Clinic patient records
and the Minnesota Death Index which was reviewed in
March 2016. Adeath was considered to be CV-related if a CV
condition was included among the rst three listed causes in
the Minnesota Death Index. Mortality data were classied
using ICD 9 (391, 391.9, 394–398, 402, 404, 410–414, 415–
417, 420–429, 430–438, 440–448, 451–454, 456–459) and
ICD 10 (I101, I05–I09, I11, I13, I20–I25, I26–I28, I30–I52,
I60–I69, I70–I79, I80–I89) codes.
Statistical analysis
Statistical analyses were performed using SAS 9.4
(Raleigh, NC). Patient characteristics, outcomes, and exer-
cise data were analyzed by BP groups. Logistic regression
was used to determine the relationship of DBP response to
the presence of obesity (body mass index 30kg/m2), cur-
rent smoking, hypertension, and diabetes. Cox regression
was used to determine long-term total and CV mortality risk
according to DBP response. All analyses were adjusted for
age, sex, and resting DBP. We also performed fully adjusted
Cox regression analyses using hypertension, diabetes, cur-
rent smoking, and use of an HR-lowering drug as covariates,
along with other exercise variables including low functional
aerobic capacity (<80% predicted), abnormal HR recovery,
and abnormal exercise ECG. P<0.05 was considered signi-
cant for all analyses.
RESULTS
Study population
A total of 20,760 patients (age 51±11years) were avail-
able for analysis. ere were 7,314 females (35%). eir
demographic and clinical data stratied by DBP response,
along with the long-term outcome data are shown in
Table1.
Exercise test results
Exercise test data by DBP response are provided in part
A of the Table 1. Because of the large sample size, even
minor dierences, such as in resting HR or highest rating
of perceived exertion reached statistical signicance, though
some age trends were pronounced. In general, patients with
normal DBP response (N= 11,254, 54%) have the overall
best results, though dierences among the groups are gen-
erally small. Functional aerobic capacity was the same in
normal and borderline DBP groups, but lower in patients
with abnormal DBP response. Rest DBP/peak DBP averaged
82±8/69±15mm Hg in normal vs. 79±9/82±9mm Hg
in borderline vs. 76± 9/92±11mm Hg in abnormal DBP
response. Resting DBP was lower in patients with abnormal
DBP response, while their peak DBP was higher. Resting
SBP was not dierent between borderline and abnormal
DBP groups, but the SBP of abnormal response group was
higher with a lower peak HR.
Downloaded from https://academic.oup.com/ajh/article-abstract/31/9/976/4996225 by guest on 07 December 2018
978 American Journal of Hypertension 31(9) September 2018
Sydó etal.
Comorbidities
Table 1 part B shows the rates of obesity, hypertension,
diabetes, and current smoking along with odds ratios (95%
condence intervals) for borderline and abnormal vs. normal
DBP response. Patients with borderline and abnormal DBP
response had more obesity, hypertension, diabetes and were
more likely to be current smokers compared with patients
with normal DBP response.
Outcomes
ere were a total of 1,582 deaths (7.6%) over an aver-
age follow-up of 12.4 ± 5.0 years. Consistent with the
exclusion of baseline CV disease and residence in a state
(Minnesota) with low CV mortality, the overall and CV
death rates (557, 2.7%) were low. In the Table 1 part C
hazard ratios (95% condence intervals) for death and CV
death are shown. Although there was a trend of increas-
ing total and CV death rates with borderline and abnor-
mal DBP response, hazard ratios were not signicant aer
minimal adjustment for age, sex, and pre-exercise DBP
or aer full adjustment for clinical risk factors and other
exercise test abnormalities. Substitution of peak DBP or
delta DBP as a continuous variable for the categorical vari-
ables normal, borderline, and abnormal DBP response did
not identify a signicant impact of DBP on CV or total
death (data not shown).
Table1. Results according to diastolic blood pressure response
A.Exercise test results by diastolic blood pressure response
Normal DBP response,
N=11,254 (54%)
Borderline DBP response,
N=6,042 (29%)
Abnormal DBP response,
N=3,463 (17%)
Mean ± SD Mean ± SD Mean ± SD
Age (years) 50.4±10.5 52.2±10.6a54.0±10.7a,b
Female (n, %) 3,978, 35.4% 2,159, 35.7% 1,177, 34.0%
FAC (%) 93.9±21.6 93.4±22.7 92.3±23.6a
Resting HR (bpm) 77.2±13.2 76.5±12.7a75.9±12.7a
Peak HR (bpm) 164.9±19.6 162.0±19.6a160.8±18.7a,b
HR-lowering drug 1,321 (11.7%) 823 (13.6%)a465 (13.4%)a
Resting SBP (mm Hg) 124.7±16.4 123.3±16.6a123.4±17.4a
Resting DBP (mm Hg) 82.5±8.8 79.2±8.5a76.1±8.8a,b
Peak SBP (mm Hg) 173.9±24.1 177.8±23.9a186.4±25.3a,b
Peak DBP (mm Hg) 68.8±15.1 82.4±8.7a91.5±10.5a,b
Delta DBP (mm Hg) −13.6±13.0 +3.1±2.9a+15.4±6.3a,b
B.Comorbidities by diastolic blood pressure response
Rate, Referent Rate, OR [95% CI] Rate, OR [95% CI]
Obesity 36%, Referent 39%, 1.33 [1.24–1.42]a41%, 1.63 [1.50–1.77]a
Hypertension 22%, Referent 24%, 1.20 [1.11–1.30]a27%, 1.48 [1.34–1.63]a
Diabetes 5%, Referent 7%, 1.19 [1.04–1.36]a8%, 1.33 [1.13–1.55]a
Current smoking 10%, Referent 12%, 1.30 [1.17–1.44]a13%, 1.42 [1.25–1.61]a
C. Mortality by diastolic blood pressure response
Rate, Referent Rate, HR [95% CI] Rate, HR [95% CI]
Age, sex, rest DBP adjusted model
Death 6%, Referent 9%, 1.01 [0.89–1.13] 11%, 1.07 [0.94–1.22]
CV death 2%, Referent 3%, 1.14 [0.94–1.39] 4%, 1.16 [0.93–1.45]
Fully adjusted model
Death 6%, Referent 9%, 1.01 [0.90–1.14] 11%, 1.07 [0.93–1.22]
CV death 2%, Referent 3%, 1.21 [0.99–1.49] 4%, 1.15 [0.91–1.45]
Continuous variables expressed as mean ± SD; discrete variables N (%). Abbreviations: DBP, diastolic blood pressure; SBP, systolic blood
pressure; CV, cardiovascular; FAC, functional aerobic capacity; HR, heart rate; bpm, beats per minute; OR, odds ratio; CI, confidence interval;
HR, hazard ratio.
aDifferent than normal DBP at P < .05.
bBorderline DBP different than abnormal DBP at P < .05.
Downloaded from https://academic.oup.com/ajh/article-abstract/31/9/976/4996225 by guest on 07 December 2018
American Journal of Hypertension 31(9) September 2018 979
Diastolic Blood Pressure Response to Exercise
DISCUSSION
We conrm that a decrease in DBP is the normal re-
sponse to exercise seen in more than 50% of exercise tests.
DBP response to exercise is signicantly associated with
the prevalence of obesity, hypertension, diabetes, and cur-
rent smoking at the time of the stress test, though the ac-
tual dierences in rates of these comorbidities among DBP
groups are small. Aborderline (increase of <10mm Hg) or
abnormal (increase of >10 mm Hg) was not signicantly
associated in an independent manner with long-term death
or CV death. DBP response to exercise is not strongly related
to functional aerobic capacity, which has been shown to be
the strongest prognostic factor on the exercise test.16
e physiological basis of the observed interaction between
resting DBP and change in DBP with exercise is not clear, but
resting DBP was not signicant in any of the Cox regression
models. is may represent simple regression to themean.
In a meta-analysis which investigated exercise BP and
long-term CV events and mortality—including 12 longitu-
dinal studies with more than 46,000 patients and 15years
follow up—it was determined that hypertensive BP response
(systolic BP 210mm Hg for males and 190mm Hg for
females) at moderate exercise intensity during exercise stress
testing is an independent risk factor for CV events and mor-
tality, but they only examined the SBP response.8
One other large study of 12,000 patients investigated the
relationship of hemodynamic response and cardiometa-
bolic risk factors in patients—including patients with cor-
onary artery disease (CAD)—undergoing treadmill exercise
testing. Patients with obesity, hypertension, and smokers
showed higher values of peak SBP and DBP, while in diabetic
patients they did not nd any dierence in DBP. In contrast
to their ndings, we found more abnormal DBP response in
patients having these comorbidities. e dierence may be
explained by the dierent study populations.17
In Myers etal.18 study—which focused on exercise cap-
acity and mortality, both in healthy men and patients with
CAD—peak SBP was lower in those who died, while DBP
was not dierent. ey stated that exercise capacity is a
more powerful predictor of mortality than other exercise
test parameters or even risk factors for CV disease. We
would also like to emphasize that DBP responses—even
with the presence of comorbidities—are not associated with
long-term total or CV mortality; therefore focus should be
turned to other variables including exercise capacity and HR
recovery.19,20
In terms of potential mechanisms, an increase in DBP
with exercise may be a result of increased arterial stiness or
endothelial dysfunction, which are considered early signs of
atherosclerotic vascular disease.21,22 On the other hand, the
fact that coronary arteries ll during diastole might suggest
that an increase in DBP during exercise could be protective
in patients with coronary artery disease, and this has been at
least somewhat conrmed in the settling of myocardial per-
fusion imaging.23 High DBP during exercise may also cause
enhanced external counterpulsation, increasing the develop-
ment of collateral channels.24
us, although we can speculate that increased DBP with
exercise signals higher peripheral arteriolar resistance and
impaired exercise-induced vasodilation through various
mechanisms which increase myocardial oxygen demand
during exercise by increasing aerload, higher exercise DBP
conversely has the potential to decrease exercise-induced
myocardial ischemia by increasing of myocardial bloodow.
Strengths and limitations
e strengths of our study include a large consecutive cohort
with complete mortality follow-up over a long time period.
Exercise test data were robust and complete, and important
data on comorbidities and pharmacotherapies were available.
In terms of limitations, our study reected the limited racial
diversity seen in Minnesota, so our results may not be applic-
able to more diverse racial or ethnic groups, especially African
Americans who have high rates of hypertension in comparison
to white Americans. Overall mortality was low, reecting the
status of Minnesota as a state with low total and CV mortality.
Measuring BP on an exercise test is not always easy at a
high HR given noise of the treadmill and patient motion. We
relied solely on unconrmed DBP assessment by ausculta-
tion with a manually inated cu; invasive measures of BP
were not performed. Exercise tests were not systematically
repeated to determine if the response of DBP to exercise was
consistent.
Exercise tests were conducted in a clinical environment,
and patients were instructed to exercise to subjective fa-
tigue. Gas exchange was not measured to conrm the level
of metabolic eort by the respiratory exchangeratio.
For our nonimaging noncardiopulmonary stress tests,
we generally used the Bruce protocol (>90% of tests where
gas exchange is not measured), so we did not have a suf-
cient number of patients of cycle ergometer or treadmill
tests on other protocols to perform similar analyses of DBP
responses.
ACKNOWLEDGMENTS
e authors would like to acknowledge the critical assist-
ance of Laurie Barr for her help in extracting these data from
the Mayo Integrated Stress Center database. No specic
funding was required for this work.
DISCLOSURE
e authors declared no conict of interest.
REFERENCES
1. Kligeld P, Lauer MS. Exercise electrocardiogram testing: beyond the
ST segment. Circulation 2006; 114:2070–2082.
2. Bruce RA, Gey GO Jr, Cooper MN, Fisher LD, Peterson DR. Seattle
heart watch: initial clinical, circulatory and electrocardiographic
responses to maximal exercise. Am J Cardiol 1974; 33:459–469.
3. Wolthuis RA, Froelicher VF Jr, Fischer J, Triebwasser JH. e response
of healthy men to treadmill exercise. Circulation 1977; 55:153–157.
Downloaded from https://academic.oup.com/ajh/article-abstract/31/9/976/4996225 by guest on 07 December 2018
980 American Journal of Hypertension 31(9) September 2018
Sydó etal.
4. Lauer MS, Levy D, Anderson KM, Plehn JF. Is there a relationship between
exercise systolic blood pressure response and le ventricular mass? e
Framingham Heart Study. Ann Intern Med 1992; 116:203–210.
5. Manolio TA, Burke GL, Savage PJ, Sidney S, Gardin JM, Oberman A.
Exercise blood pressure response and 5-year risk of elevated blood pres-
sure in a cohort of young adults: the CARDIA study. Am J Hypertens
1994; 7:234–241.
6. Berger A, Grossman E, Katz M, Kivity S, Klempfner R, Segev S,
Goldenberg I, Sidi Y, Maor E. Exercise blood pressure and the risk for
future hypertension among normotensive middle-aged adults. J Am
Heart Assoc 2015; 4:e001710.
7. Filipovský J, Ducimetière P, Safar ME. Prognostic signicance of exer-
cise blood pressure and heart rate in middle-aged men. Hypertension
1992; 20:333–339.
8. Schultz MG, Otahal P, Cleland VJ, Blizzard L, Marwick TH, Sharman
JE. Exercise-induced hypertension, cardiovascular events, and mortal-
ity in patients undergoing exercise stress testing: a systematic review
and meta-analysis. Am J Hypertens 2013; 26:357–366.
9. Schultz MG, La Gerche A, Sharman JE. Blood pressure response to
exercise and cardiovascular disease. Curr Hypertens Rep 2017; 19:89.
10. Daida H, Allison TG, Squires RW, Miller TD, Gau GT. Peak exercise
blood pressure stratied by age and gender in apparently healthy sub-
jects. Mayo Clin Proc 1996; 71:445–452.
11. Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, iene G. Trends in
sudden cardiovascular death in young competitive athletes aer implemen-
tation of a preparticipation screening program. JAMA 2006; 296:1593–1601.
12. Gibbons RJ, Balady GJ, Beasley JW, Bricker JT, Duvernoy WF,
Froelicher VF, Mark DB, Marwick TH, McCallister BD, ompson PD
Jr, Winters WL, Yanowitz FG, Ritchie JL, Gibbons RJ, Cheitlin MD,
Eagle KA, Gardner TJ, Garson A Jr, Lewis RP, O’Rourke RA, Ryan TJ.
ACC/AHA guidelines for exercise testing. Areport of the American
College of Cardiology/American Heart Association task force on prac-
tice guidelines (Committee on Exercise Testing). J Am Coll Cardiol
1997; 30:260–311.
13. Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher
VF, Mark DB, McCallister BD, Mooss AN, O’Reilly MG, Winters WL,
Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos
G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC; American College
of Cardiology/American Heart Association Task Force on Practice
Guidelines. Committee to Update the 1997 Exercise Testing Guidelines.
ACC/AHA 2002 guideline update for exercise testing: summary art-
icle. Areport of the American College of Cardiology/American Heart
Association task force on practice guidelines (Committee to update the
1997 exercise testing guidelines). J Am Coll Cardiol 2002; 40:1531–1540.
14. Alpert B, McCrindle B, Daniels S, Dennison B, Hayman L, Jacobson
M, Mahoney L, Rocchini A, Steinberger J, Urbina E, Williams R.
Recommendations for blood pressure measurement in human and
experimental animals; part 1: blood pressure measurement in humans.
Hypertension 2006; 48:e3; author reply e5.
15. Sydo N, Abdelmoneim SS, Mulvagh SL, Merkely B, Gulati M, Allison
TG. Relationship between exercise heart rate and age in men vs women.
Mayo Clin Proc 2014; 89:1664–1672.
16. Myers J, McAuley P, Lavie CJ, Despres JP, Arena R, Kokkinos P. Physical
activity and cardiorespiratory tness as major markers of cardiovascu-
lar risk: their independent and interwoven importance to health status.
Prog Cardiovasc Dis 2015; 57:306–314.
17. Chrysohoou C, Skoumas J, Georgiopoulos G, Liontou C, Vogiatzi G,
Tsious K, Lerakis S, Soulis D, Pitsavos C, Tousoulis D. Exercise cap-
acity and haemodynamic response among 12,327 individuals with
cardio-metabolic risk factors undergoing treadmill exercise. Eur J Prev
Cardiol 2017; 24:1627–1636.
18. Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE.
Exercise capacity and mortality among men referred for exercise test-
ing. N Engl J Med 2002; 346:793–801.
19. Cole CR, Blackstone EH, Pashkow FJ, Snader CE, Lauer MS. Heart-rate
recovery immediately aer exercise as a predictor of mortality. N Engl J
Med 1999; 341:1351–1357.
20. Dhoble A, Lahr BD, Allison TG, Kopecky SL. Cardiopulmonary tness
and heart rate recovery as predictors of mortality in a referral popula-
tion. J Am Heart Assoc 2014; 3:e000559.
21. Lambiase MJ, Dorn J, urston RC, Roemmich JN. Flow-mediated
dilation and exercise blood pressure in healthy adolescents. J Sci Med
Sport 2014; 17:425–429.
22. anassoulis G, Lyass A, Benjamin EJ, Larson MG, Vita JA, Levy D,
Hamburg NM, Widlansky ME, O’Donnell CJ, Mitchell GF, Vasan RS.
Relations of exercise blood pressure response to cardiovascular risk fac-
tors and vascular function in the Framingham Heart Study. Circulation
2012; 125:2836–2843.
23. Yamagishi H, Yoshiyama M, Shirai N, Akioka K, Takeuchi K, Yoshikawa
J. Protective eect of high diastolic blood pressure during exercise
against exercise-induced myocardial ischemia. Am Heart J 2005;
150:790–795.
24. Masuda D, Nohara R, Hirai T, Kataoka K, Chen LG, Hosokawa R,
Inubushi M, Tadamura E, Fujita M, Sasayama S. Enhanced exter-
nal counterpulsation improved myocardial perfusion and coron-
ary ow reserve in patients with chronic stable angina; evaluation
by(13)N-ammonia positron emission tomography. Eur Heart J 2001;
22:1451–1458.
Downloaded from https://academic.oup.com/ajh/article-abstract/31/9/976/4996225 by guest on 07 December 2018
... Potential mechanisms associated with the hypertensive response of post-Bruce DBP can be explained by the excessive elevation of the double product that can result in global subendocardial ischemia due to an inability to maintain myocardial oxygen supply and demand (Ha et al., 2002). On the other hand, Sydó et al. (2018) point out that the etiology of an increase in DBP after physical exercise is not fully elucidated in the literature; possible risk factors or cardiovascular disease may not be associated with increased DBP. The same authors suggest that the central focus of analysis should be on cardiorespiratory capacity and recovery heart rate, although the present study did not identify a difference in HR during the 15 min of measurement. ...
Article
Full-text available
The present study aimed to evaluate the body composition and cardiorespiratory fitness of overweight or obese people after COVID-19. 171 volunteers of both sexes (men, n = 93 and women, n = 78) between 19 and 65 years old were allocated into three groups according to the severity of their symptoms of COVID-19: non-hospitalized people/mild symptoms (n = 61), hospitalized (n = 58), and hospitalized in an intensive care unit-ICU (n = 52). Two laboratory visits were carried out 24 h apart. First, a medical consultation was carried out, with subsequent measurement of body weight and height (calculation of body mass index) and body composition assessment via electrical bioimpedance. After 24 h, a cardiorespiratory test was performed using the Bruce protocol, with a direct gas exchange analysis. Hospitalized individuals had significantly higher values for fat mass and body fat percentage than non-hospitalized individuals (p < 0.05). Significantly higher values were found for heart rate (HR) and peak oxygen consumption (VO2peak) for individuals who were not hospitalized when compared to those hospitalized in the ICU (p < 0.05). Significantly higher values for distance, ventilation, and the relationship between respiratory quotient were found for non-hospitalized individuals compared to hospitalized individuals and those in the ICU (p < 0.05). After the cardiorespiratory test, higher values for peripheral oxygen saturation (SpO2) were observed for non-hospitalized individuals than for all hospitalized individuals (p < 0.05). Diastolic blood pressure was significantly higher at the tenth and fifteenth minute post-Bruce test in hospitalized than in non-hospitalized participants (p < 0.05). Based on these results, proposals for cardiopulmonary rehabilitation are indispensable for hospitalized groups considering the responses of blood pressure. Monitoring HR, SpO2, and blood pressure are necessary during rehabilitation to avoid possible physical complications. Volume and intensity of exercise prescription should respect the physiologic adaptation. Given lower physical conditioning among all the groups, proposals for recovering from health conditions are urgent and indispensable for COVID-19 survivors.
... However, other studies investigating the prognostic value of abnormal DBP responses to exercise did not demonstrate any significant association with mortality. For example, Sydó et al. (35) studied 20,000 patients with no previous history of cardiovascular diseases and found no association between DBP . ...
Article
Full-text available
Background: The identification of variables obtained in the exercise test (ET) associated with increased risk of death is clinically relevant and would provide additional information for the management of Chagas disease (CD). The objective of the present study was to evaluate the association of ET variables with mortality in patients with chronic CD. Methods: This retrospective longitudinal observational study included 232 patients (median age 46.0 years; 50% women) with CD that were followed at the Evandro Chagas National Institute of Infectious Diseases (Rio de Janeiro, Brazil) and performed an ET between 1989 and 2000. The outcome of interest was all-cause mortality. Results: There were 103 deaths (44.4%) during a median follow-up of 21.5 years (IQR 25–75% 8.0–27.8), resulting in 24.5 per 1,000 patients/year incidence rate. The ET variables associated with mortality after adjustments for potential confounders were increased maximal (HR 1.02; 95% CI 1.00–1.03 per mmHg) and change (HR 1.03; 95% CI 1.01–1.06 per mmHg) of diastolic blood pressure (DBP) during ET, ventricular tachycardia at rest (HR 3.95; 95% CI 1.14–13.74), during exercise (HR 2.73; 95% CI 1.44–5.20), and recovery (HR 2.60; 95% CI 1.14–5.91), and premature ventricular complexes during recovery (HR 2.06; 1.33–3.21). Conclusion: Our findings suggest that ET provides important prognostic value for mortality risk assessment in patients with CD, with hemodynamic (increased DBP during exercise) and electrocardiographic (presence of ventricular arrhythmias) variables independently associated with an increased mortality risk in patients with CD. The identification of individuals at higher mortality risk can facilitate the development of intervention strategies (e.g., close follow-up) that may potentially have an impact on the longevity of patients with CD.
... However, other studies investigating the prognostic value of abnormal DBP responses to exercise did not demonstrate any significant association with mortality. For example, Sydó et al. (35) studied 20,000 patients with no previous history of cardiovascular diseases and found no association between DBP . ...
Preprint
Full-text available
Background The identification of variables obtained in the exercise test (ET) associated with increased risk of death is clinically relevant and would provide additional information for the management of Chagas disease (CD). The objective of the present study was to evaluate the association of ET variables with mortality in patients with chronic CD. Methods This retrospective longitudinal observational study included 232 patients (median age 46.0 years; 50% women) with CD that were followed at the Evandro Chagas National Institute of Infectious Diseases (Rio de Janeiro, Brazil) and performed an ET between 1989 and 2000. The outcome of interest was all-cause mortality. Results There were 103 deaths (44.4%) during a median follow-up of 21.5 years (IQR 25–75% 8.0–27.8), resulting in 24.5 per 1,000 patients/year incidence rate. The ET variables associated with mortality after adjustments for potential confounders were increased maximal (HR 1.02; 95% CI 1.00–1.03 per mmHg) and change (HR 1.03; 95% CI 1.01–1.06 per mmHg) of diastolic blood pressure (DBP) during ET, ventricular tachycardia at rest (HR 3.95; 95% CI 1.14–13.74), during exercise (HR 2.73; 95% CI 1.44–5.20), and recovery (HR 2.60; 95% CI 1.14–5.91), and premature ventricular complexes during recovery (HR 2.06; 1.33–3.21). Conclusion Our findings suggest that ET provides important prognostic value for mortality risk assessment in patients with CD, with hemodynamic (increased DBP during exercise) and electrocardiographic (presence of ventricular arrhythmias) variables independently associated with an increased mortality risk in patients with CD. The identification of individuals at higher mortality risk can facilitate the development of intervention strategies (e.g., close follow-up) that may potentially have an impact on the longevity of patients with CD.
... This finding is concordant to a larger study conducted in 20,726 patients, in which subjects with an abnormal DBP response during exercise have a lower functional aerobic capacity and cardiorespiratory fitness compared to those with normal and borderline DBP [41]. Therefore, elevated peak DBP is a consequence of impaired peripheral vascular resistances, which also cause a reduction in peripheral oxygen extraction and in peak oxygen uptake, according to Fick law [42]. ...
Article
Full-text available
AimTo evaluate the incidence and clinical significance of impaired cardiorespiratory fitness (CRF) and the association with baseline blood pressure (BP) levels and hypertensive response to exercise (HRE).MethodsA cross-sectional study was conducted on a total sample of 2058 individuals with a mean age of 38 ± 9 years, enrolled for the first time at the Ferrari corporate wellness program “Formula Benessere”, including a maximal exercise stress testing (EST). BP and heart rate (HR) values were obtained from EST at rest, during exercise and recovery time. CRF was arbitrarily classified according to estimated VO2 max in optimal, normal, mildly and moderately reduced.ResultsOne-hundred and thirty-nine individuals of 2058 (6.7%) showed a moderate CRF reduction assessed by EST. Subjects with elevated resting and/or exercise BP showed a worse CRF than those with normal BP levels, also after the adjustment for age, sex, body mass index, smoking habits, peak SBP and DBP. Seventy-seven individuals (3.7%) showed an HRE during EST, with normal baseline BP levels.Conclusion About 7% of a corporate population showed a significantly reduced CRF, assessed by EST. Individuals with lower levels of CRF have higher resting and/or peak exercising BP values after adjusting for co-variables. This study expands the role of EST outside of traditional ischemic CVD evaluation, towards the assessment of reduced CRF and HRE in the general population, as a possible not evaluated CV risk factor.
... Patients with severe lung damage, such as chronic obstructive pulmonary disease, exhibit a higher heart rate after exercise (6-min walk test) when wearing an N95 respirator compared to without, which could be interpreted as a compensatory mechanism for impaired lung capacity [29]. Since a gradual decrease in diastolic blood pressure with exercise is considered normal in healthy individuals and adds no prognostic value of stress tests [30,31], our focus was on systolic blood pressure. In line with previous studies, masks were not associated with changes in systolic blood pressure at exhaustion [7,9]. ...
Article
Full-text available
Background During the COVID-19 pandemic, compulsory masks became an integral part of outdoor sports such as jogging in crowded areas (e.g. city parks) as well as indoor sports in gyms and sports centers. This study, therefore, aimed to investigate the effects of medical face masks on performance and cardiorespiratory parameters in athletes. Methods In a randomized, cross-over design, 16 well-trained athletes (age 27 ± 7 years, peak oxygen consumption 56.2 ± 5.6 ml kg ⁻¹ min ⁻¹ , maximum performance 5.1 ± 0.5 Watt kg ⁻¹ ) underwent three stepwise incremental exercise tests to exhaustion without mask (NM), with surgical mask (SM) and FFP2 mask (FFP2). Cardiorespiratory and metabolic responses were monitored by spiroergometry and blood lactate (BLa) testing throughout the tests. Results There was a large effect of masks on performance with a significant reduction of maximum performance with SM (355 ± 41 Watt) and FFP2 (364 ± 43 Watt) compared to NM (377 ± 40 Watt), respectively ( p < 0.001; ηp ² = 0.50). A large interaction effect with a reduction of both oxygen consumption ( p < 0.001; ηp ² = 0.34) and minute ventilation ( p < 0.001; ηp ² = 0.39) was observed. At the termination of the test with SM 11 of 16 subjects reported acute dyspnea from the suction of the wet and deformed mask. No difference in performance was observed at the individual anaerobic threshold ( p = 0.90). Conclusion Both SM and to a lesser extent FFP2 were associated with reduced maximum performance, minute ventilation, and oxygen consumption. For strenuous anaerobic exercise, an FFP2 mask may be preferred over an SM.
... We did not address exercise diastolic BP, as our prior report indicates a lack of association with outcomes. 32 Strengths of our study include a large cohort and long-term follow-up with 100% mortality ascertainment and tested in a single facility, which reduces technical variabilities. Furthermore, several important baseline characteristics and comorbidities, use of antihypertensives and statins, and other exercise responses, including CRF, exercise HR, and exercise ECG abnormalities, were adjusted for in Cox regression models. ...
Article
We sought to update norms for peak systolic blood pressure (SBP) on the graded exercise test and examine its prognostic value in patients without baseline cardiovascular disease. Mayo graded exercise test data (1993–2010) were reviewed for nonimaging tests using Bruce protocol, selecting Minnesota residents 30 to 79 years without baseline cardiovascular disease. We formed a pure cohort of patients without factors significantly affecting peak SBP to determine peak SBP percentile norms by age and sex. Then we divided the full cohort of patients into 5 groups based on peak SBP percentiles: low (<10th), borderline low (10th–25th), referent (25th–75th), borderline high (75th–90th), and high (>90th). The relationship between peak SBP and mortality was tested using Cox regression adjusting for age, sex, and comorbidities affecting peak SBP or mortality. We identified 20 760 eligible patients with 7313 females (35%) and mean age 51.5±10.7 years. Our pure cohort included 7810 patients. Over 12.5±5.0 years follow-up, there were 1582 deaths, including 541 cardiovascular deaths. In the fully adjusted model, low-peak SBP was associated with increased total mortality (heart rate, 1.41 [1.19–1.66], P <0.0001) and cardiovascular mortality (heart rate, 1.54 [1.16–2.03], P =0.001), while borderline low-peak SBP was associated with increased cardiovascular mortality only (heart rate, 1.36 [1.02–1.81], P =0.027). High peak SBP was associated with increased total mortality only in the age-sex adjusted model (heart rate, 1.18 [1.02–1.36], P =0.026), not after full adjustment. We conclude that low exercise peak SBP is an independent predictor of higher total and cardiovascular mortality.
Article
Full-text available
Purpose of review: This review aimed to provide a clinical update on exercise blood pressure (BP) and its relationship to cardiovascular disease (CVD), outlining key determinants of abnormal exercise BP responses. We also highlight current evidence gaps that need addressing in order to optimise the relevance of exercise BP as clinical CVD risk factor. Recent findings: Abnormal exercise BP manifests as either exercise hypotension (low BP response) or as exaggerated exercise BP (high BP response). Exercise hypotension is an established sign of existing and likely severe CVD, but exaggerated exercise BP also carries elevated CVD risk due to its association with sub-clinical hypertension. Although exaggerated exercise BP is related to heightened CVD risk at any exercise intensity, recent data suggest that the BP response to submaximal intensity exercise holds greater prognostic and clinical significance than BP achieved at peak/maximal intensity exercise. Cardiorespiratory fitness is a strong modifier of the exercise BP response, and should be taken into consideration when assessing the association with CVD. Both exercise hypotension and exaggerated exercise BP serve as markers that should prompt evaluation for potential underlying CVD. However, the clinical utility of these markers is currently inhibited by the lack of consensus informing the definitions and thresholds for abnormalities in exercise BP.
Article
Full-text available
Background The aim of the present study was to examine whether exercise blood pressure can be used to predict the development of hypertension in normotensive middle‐aged adults. Methods and Results We investigated 7082 normotensive subjects who were annually screened in a tertiary medical center and completed maximal treadmill exercise tests at each visit. After the initial 3 years, subjects were divided into approximate quartiles according to their average exercise systolic and diastolic blood pressure responses (≤158; 158 to 170; 170 to 183; ≥183 mm Hg for systolic blood pressure and ≤73; 73 to 77; 77 to 82; ≥82 mm Hg for diastolic blood pressure). Mean age of the study population was 48±9 years and 73% were men. Average baseline resting blood pressure was 120/77±12/7 mm Hg. During a follow‐up of 5±3 years, 1036 (14.6%) subjects developed hypertension. The cumulative probability of new‐onset hypertension at 5 years was significantly increased with increasing quartiles of exercise systolic blood pressure (5%, 9%, 17%, and 35%, respectively; P<0.001), with a similar association shown for diastolic blood pressure. After adjustment for baseline resting blood pressure and clinical parameters, each 5‐mm Hg increments in exercise either systolic or diastolic blood pressures were independently associated with respective 11% (P<0.001) and 30% (P<0.001) increased risk for the development of hypertension. Conclusions In normotensive middle‐aged individuals, blood pressure response to exercise is associated with future development of hypertension.
Article
Full-text available
Exercise testing provides valuable information in addition to ST-segment changes. The present study evaluated the associations among exercise test parameters and all-cause mortality in a referral population. We examined conventional cardiovascular risk factors and exercise test parameters in 6546 individuals (mean age 49 years, 58% men) with no known cardiovascular disease who were referred to our clinic for exercise stress testing between 1993 and 2003. The association of exercise parameters with mortality was assessed during a follow-up of 8.1±3.7 years. A total of 285 patients died during the follow-up period. Adjusting for age and sex, the variables associated with mortality were: smoking, diabetes, functional aerobic capacity (FAC), heart rate recovery (HRR), chronotropic incompetence, and angina during the exercise. Adjusting for cardiovascular risk factors (diabetes, smoking, body mass index, blood pressure, serum total, HDL, LDL cholesterol, and triglycerides) and other exercise variables in a multivariable model, the only exercise parameters independently associated with mortality were lower FAC (adjusted hazard ratio [HR] per 10% decrease in FAC, 1.21; 95% confidence interval [CI], 1.13 to 1.29; P<0.001), and abnormal HRR, defined as failure to decrease heart rate by 12 beats at 1 minute recovery (adjusted HR per 1-beat decrease, 1.05; 95% CI, 1.03 to 1.07; P<0.001). The additive effects of FAC and HRR on mortality were also highly significant when considered as categorical variables. In this cohort of patients with no known cardiovascular disease who were referred for exercise electrocardiography, FAC and HRR were independently associated with all-cause mortality.
Article
Haemodynamic parameters during and after exercise test seem to have a role in predicting cardiovascular events. We sought to evaluate the potential different responses in exercise capacity, heart rate and blood pressure levels in relation to major cardiovascular disease risk factors, among individuals undergoing exercise tolerance testing.
Article
To analyze a large cohort of patients who underwent exercise testing and also report sex differences in other exercise heart rate (HR) parameters to determine whether separate sex-based equations to predict peak HR are indicated. Patients aged 40 to 89 years who performed treadmill exercise tests (Bruce protocol) from September 21, 1993, to December 20, 2010, were included. Patients with cardiovascular disease or taking HR-attenuating drugs were excluded. After analyses on preliminary cohort, peak HR-modifying factors were eliminated to obtain a pure data set. Analysis of variance was used to test difference in HR responses by sex with age adjustment. A total of 37,010 patients (67.3% men) were included in the preliminary cohort. Men had higher peak HR (166±17 vs 163±16 beats/min [bpm]; P<.001), HR reserve (90±19 vs 84±17 bpm; P<.001), and HR recovery (19±8 vs 18±9 bpm; P<.03). Poor exercise capacity, current smoking, diabetes, and obesity had significant peak HR-lowering effects (all P<.001). In a pure cohort of 19,013 patients (51.3% of full cohort) without these factors, regression lines approximated more closely the traditional line of 220 - age. For men, the regression line in our final cohort was peak HR = 220 - 0.95 × age. For women, both slope (0.79 bpm/y) and intercept (210 bpm) were still substantially different from those obtained with the traditional formula. The HR responses to exercise are different in men and women. The HR response of men was close to that obtained with the traditional formula, but peak HR in women had a lower intercept and decreased more slowly with age. A separate formula for peak HR in women appears to be appropriate. Copyright © 2014 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
Article
The evolution from hunting and gathering to agriculture, followed by industrialization, has had a profound effect on human physical activity (PA) patterns. Current PA patterns are undoubtedly the lowest they have been in human history, with particularly marked declines in recent generations, and future projections indicate further declines around the globe. Non-communicable health problems that afflict current societies are fundamentally attributable to the fact that PA patterns are markedly different than those for which humans were genetically adapted. The advent of modern statistics and epidemiological methods has made it possible to quantify the independent effects of cardiorespiratory fitness (CRF) and PA on health outcomes. Based on more than five decades of epidemiological studies, it is now widely accepted that higher PA patterns and levels of CRF are associated with better health outcomes. This review will discuss the evidence supporting the premise that PA and CRF are independent risk factors for cardiovascular disease (CVD) as well as the interplay between both PA and CRF and other CVD risk factors. A particular focus will be given to the interplay between CRF, metabolic risk and obesity.
Article
Exercise blood pressure is a robust predictor of cardiovascular disease risk. Endothelial dysfunction occurs early in development of cardiovascular disease and is associated with greater exercise blood pressure in adults. However, it is not yet clear whether endothelial function is associated with exercise blood pressure in youth. The purpose of this study was to examine the relationship between endothelial function, indexed by brachial artery flow-mediated dilation, and submaximal exercise blood pressure in healthy adolescents. Cross-sectional study. Adolescents (N=45) completed a graded submaximal treadmill test. Blood pressure was measured during rest and each exercise stage. Ultrasound measurement of brachial artery flow-mediated dilation was completed on a separate visit. Pearson correlations and multiple regression were used to assess the unadjusted and multivariate adjusted associations between flow-mediated dilation and exercise blood pressure, respectively. Lower flow-mediated dilation was associated with lower diastolic blood pressure (r=0.37, p=0.01) and greater pulse pressure (r=-0.38, p=0.01) during exercise. The significance did not change when adjusting for age, gender, fitness, or resting blood pressure. Exploratory analyses suggest that flow-mediated dilation was associated with exercise diastolic blood pressure primarily among adolescents with low resting diastolic blood pressure. Studies in youth are important to understand the early pathogenesis of cardiovascular disease. Findings from this study suggest that endothelial function may play a role in regulating blood pressure responses during submaximal exercise in healthy adolescents.