Exercise blood pressure relative to fitness and cardiovascular outcomes: the EXERTION study.

Exercise Blood Pressure and the Risk of Incident Cardiovascular Disease (from the Framingham Heart Study)

Assessing blood pressure response to exercise: methodological issues and clinical relevance.

Prognosis in Relation to Blood Pressure Variability

The term white coat hypertension (WCH) was initially introduced in 19841 to describe patients who had hypertension in the office but were normotensive with ambulatory blood pressure monitoring (ABPM). At the time, WCH was simply a phenomenon with nothing known about its possible effect on the development of cardiovascular (CV) disease. Three decades later, it is apparent that hypertension in the office is a relatively poor predictor of CV risk in the individual, with ABPM now considered to be the best determinant of future CV events. Many patients diagnosed with WCH are not hypertensive on ABPM which leads one to ask: Why call a patient hypertensive when the final diagnosis will frequently be normal blood pressure (BP)? Despite numerous clinical studies, there is still no consensus on whether WCH is a benign condition or a risk factor for the development of sustained hypertension and CV disease.2 WCH is generally diagnosed when a patient’s office BP is high and out-of-office (ABPM or home BP) is normal. A typical study examining WCH as a CV risk factor consists of a patient population classified at baseline into categories of normotension or white coat, masked and sustained hypertension on the basis of office and out-of-office BP, with follow-up of several years for the occurrence of CV events. Patients are sometimes subdivided into groups who at baseline are either untreated or on antihypertensive drug therapy. Treatment during follow-up has not been taken into account in most of the studies because of lack of data or difficulty of modeling survival analysis. The results of individual studies on WCH and CV risk are somewhat inconsistent. In many instances, the investigators had difficulty matching a control (normotensive) group with the WCH patients for factors affecting future CV risk. The most easily recognized difference is the baseline …

Exaggerated exercise blood pressure (EEBP) during clinical exercise testing is associated with poor blood pressure (BP) control and cardiovascular disease (CVD). Type-2 diabetes (T2DM) is thought to be associated with increased prevalence of EEBP, but this has never been definitively determined and was the aim of this study. Clinical exercise test records were analyzed from 13 268 people (aged 53±13 years, 59% male) who completed the Bruce treadmill protocol (stages 1-4, and peak) at 4 Australian public hospitals. Records (including BP) were linked to administrative health datasets (hospital and emergency admissions) to define clinical characteristics and classify T2DM (n=1199) versus no T2DM (n=12 069). EEBP was defined as systolic BP ≥90th percentile at each test stage. Exercise BP was regressed on T2DM history and adjusted for CVD and risk factors. Prevalence of EEBP (age, sex, preexercise BP, hypertension history, CVD history and aerobic capacity adjusted) was 12% to 51% greater in T2DM versus no T2DM (prevalence ratio [95% CI], stage 1, 1.12 [1.02-1.24]; stage 2, 1.51 [1.41-1.61]; stage 3, 1.25 [1.10-1.42]; peak, 1.18 [1.09-1.29]). At stages 1 to 3, 8.6% to 15.8% (4.8%-9.7% T2DM versus 3.5% to 6.1% no-T2DM) of people with 'normal' preexercise BP (<140/90 mm Hg) were identified with EEBP. Exercise systolic BP relative to aerobic capacity (stages 1-4 and peak) was higher in T2DM with adjustment for all CVD risk factors. People with T2DM have higher prevalence of EEBP and exercise systolic BP independent of CVD and many of its known risk factors. Clinicians supervising exercise testing should be alerted to increased likelihood of EEBP and thus poor BP control warranting follow-up care in people with T2DM.

Poster presentations

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Masked hypertension is associated with increased cardiovascular risk but is undetectable by clinic blood pressure (BP). Elevated systolic BP responses to submaximal exercise reveal the presence of masked hypertension in adults, but it is unknown whether this is the case during adolescence. We aimed to determine if exercise BP was raised in adolescents with masked hypertension, and its association with cardiovascular risk markers. A total of 657 adolescents (aged 17.7±0.3years; 41.9% male) from the Avon longitudinal study of parents and children (ALSPAC) completed a step-exercise test with pre-, post-, and recovery-exercise BP, clinic BP and 24-hour ambulatory BP. Masked hypertension was defined as clinic BP <140/90mmHg and 24-hour ambulatory BP ≥130/80mmHg. Assessment of left-ventricular (LV) mass index and carotid-femoral pulse wave velocity (aortic PWV) was also undertaken. Thresholds of clinic, pre-, post-, and recovery-exercise systolic BP were explored from ROC analysis to identify masked hypertension. Fifty participants (7.8%) were classified with masked hypertension. Clinic, pre-, post-, and recovery-exercise systolic BP were associated with masked hypertension (AUC≥0.69 for all, respectively), with the clinic systolic BP threshold of 115mmHg having high sensitivity and specificity and exercise BP thresholds of 126, 150, and 130mmHg, respectively, having high specificity and negative predictive value (individually or when combined) for ruling out the presence of masked hypertension. Additionally, this exercise systolic BP above the thresholds was associated with greater left-ventricular mass index and aortic PWV. Submaximal exercise systolic BP is associated with masked hypertension and adverse cardiovascular structure in adolescents. Exercise BP may be useful in addition to clinic BP for screening of high BP and cardiovascular risk in adolescents.

This clinical advisory statement from the Coordinating Committee of the National High Blood Pressure Education Program is intended to advance and clarify the recommendations of the Sixth Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI, 1997).1 The advisory addresses several interrelated issues about blood pressure (BP) that affect people approaching the later decades of life. On the basis of the wealth of currently available evidence, the committee now recommends a major paradigm shift in urging that systolic BP become the major criterion for diagnosis, staging, and therapeutic management of hypertension, particularly in middle-aged and older Americans. Several lines of strong evidence support the initiative to emphasize systolic BP. Pathophysiologically, there are strong associations among aging, increased stiffness of large arteries, increased systolic BP, increased pulse pressure, and the prevalence of cardiac and vascular disease. Epidemiologically, isolated systolic hypertension is the most common form of hypertension and is present in approximately two thirds of hypertensive individuals >60 years of age. Diagnostically, classification and staging of hypertension are more precise when systolic rather than diastolic BP is used as the principal criterion. Risk stratification for major complications of hypertension (stroke, myocardial infarction, heart failure, and kidney failure) is actually confounded by the use of diastolic BP; in older people with systolic hypertension, diastolic BP is inversely related to cardiovascular risk. Clinical benefits of treatment of isolated systolic hypertension include reductions in stroke, myocardial infarction, heart failure, kidney failure, and overall cardiovascular disease morbidity and mortality. Currently, only 1 in 4 Americans with hypertension falls below JNC VI–recommended values of 140/90 mm Hg in uncomplicated hypertension or 130/85 mm Hg in individuals with kidney disease or diabetes. Hypertension control rates are poorest in older people, primarily as a result of inadequate …

Exercise blood pressure (BP) is an important marker of left ventricular hypertrophy, incident hypertension, and future cardiovascular events. Although impaired vascular function is hypothesized to influence the BP response during exercise, limited data exist on the association of vascular function with exercise BP in the community. Framingham Offspring cohort participants (n=2115, 53% women, mean age 59 years) underwent a submaximal exercise test (first 2 stages of the Bruce protocol), applanation tonometry, and brachial artery flow-mediated dilation testing. We related exercise systolic and diastolic BP at second stage of the Bruce protocol to standard cardiovascular risk factors and to vascular function measures. In multivariable linear regression models, exercise systolic BP was positively related to age, standing BP, standing heart rate, smoking, body mass index, and the total cholesterol-to-high-density cholesterol ratio (P≤0.01 for all). Similar associations were observed for exercise diastolic BP. Carotid-femoral pulse wave velocity (P=0.02), central pulse pressure (P<0.0001), mean arterial pressure (P=0.04), and baseline brachial flow (P=0.002) were positively associated with exercise systolic BP, whereas flow-mediated dilation was negatively associated (P<0.001). For exercise diastolic BP, forward pressure wave amplitude was negatively related (P<0.0001), whereas mean arterial pressure was positively related (P<0.0001). Increased arterial stiffness and impaired endothelial function are significant correlates of a higher exercise systolic BP response. Our findings suggest that impaired vascular function may contribute to exaggerated BP responses during daily living, resulting in repetitive increments in load on the heart and vessels and increased cardiovascular disease risk.

In adults, blood pressure (BP) during exercise has prognostic advantages compared to resting BP, whereas its relevance for children has not been revealed as clearly. Because exercise BP among young subjects might be of clinical importance, we sought to determine reference values in adolescents. BP recordings at rest and during a cycle ergometer test (1.5W/kg) were assessed in 492 teenagers (12-17 years) in the Kiel EX.PRESS. Study (EXercise and PRESSure). The resting systolic BP (SBP) values at the 90th and 95th percentile of the German reference population were applied on our resting SBP distribution. The resulting resting SBP percentiles were then used to propose exercise SBP limits. Of our group, 12.4% exhibited a resting SBP ≥ 90th reference percentile, with 7.9% ≥ 95th percentile. The corresponding age group- and sex-specific percentiles were assigned to the exercise SBP distribution resulting in reference values for high normal and elevated SBP (upper limit, girls/boys, mm Hg): 172/172 for 12-13 years, 174.7/177.3 for 14-15 years, 178.5/201.3 for 16-17 years). Using these limits, exercise SBP values were elevated in 8.1%, 5.5% were within the high normal range. Normal resting SBP but at least high normal exercise SBP was found in 7.7%. In contrast, 7.4% were high normal or hypertensive at rest but normotensive during exercise. Exercise BP is expected to be of additional use for the evaluation of BP in younger age groups. As long as prognostic data for exercise BP in adolescents are not available, the limits proposed might be considered in clinical practice.

Exaggerated exercise blood pressure (BP) is independently associated with cardiovascular disease (CVD) outcomes. However, it is unknown how individual CVD risk factors may interact with one another to influence exercise BP. The aim of this study was to quantify direct and indirect associations between CVD risk factors and exercise BP, to determine what CVD risk factor/s most-strongly relate to exercise BP. In a cross-sectional design, 660 participants (44 ± 2.6 years, 54% male) from the population-based Childhood Determinants of Adult Health Study had BP measured during low-intensity fixed-workload cycling. CVD risk factors were measured, including body composition, clinic (rest) BP, blood biomarkers, and cardiorespiratory fitness. Associations between CVD risk factors and exercise BP were assessed using linear regression, with direct and indirect pathways of association assessed via structural equation model. Sex, waist-to-hip ratio, fitness, and clinic BP were independently associated with exercise systolic BP (SBP), and along with age, had direct associations with exercise SBP (p < 0.05 all). Most CVD risk factors were indirectly associated with exercise SBP via a relation with clinic BP (p < 0.05 all). Clinic BP, waist-to-hip ratio, and fitness were most-strongly associated (direct and indirect association) with exercise SBP (β[95% CI]: 9.35 [8.04, 10.67], 4.91 [2.56, 7.26], and -2.88 [-4.25, -1.51] mm Hg/SD, respectively). Many CVD risk factors are associated with exercise BP, mostly with indirect effects via clinic BP. Clinic BP, body composition, and fitness were most-strongly associated with exercise BP. These results may elucidate how lifestyle modification could be a primary strategy to decrease exaggerated exercise BP-related CVD risk.

Objective: Exaggerated exercise blood pressure (EEBP) during clinical exercise testing is associated with elevated cardiovascular disease (CVD) risk. Type-2 diabetes (T2DM) is thought to be associated with higher prevalence of EEBP, but this has never been determined in a large clinical population, which was the aim of this study. Design and method: Clinical exercise test records were analysed from 15,994 people (mean age 53 ± 13 years, 59% male) referred for the Bruce treadmill protocol (stages 1–4 + peak) at 4 Australian public hospitals. Exercise records including blood pressure (BP) were linked to administrative datasets (hospital and emergency admissions) to define clinical characteristics and classify prior history of T2DM (n = 1,345) vs. no-T2DM (n = 14,649). EEBP was defined &gt; 90th centile for each exercise stage. Exercise BP was regressed on T2DM history, adjusted to consider CVD risk factors. Results: EEBP prevalence (stage-1: + 4.1%; stage-2: + 4.4%; stage-3: + 4.9%; stage-4: + 4.8%; peak: + 1.9%, P &lt; 0.05 respectively) and exercise systolic BP (stage-1: + 4.25, stage-2: + 4.52, stage-3: + 4.43, stage-4: + 3.08, peak: + 0.75 mmHg, P &lt; 0.05 respectively) were higher across all exercise stages in T2DM vs. no-T2DM. However, all differences were abolished by adjustment for either: age, sex, peak workload, CVD history, or pre-exercise BP. Restricting analyses to those with normal pre-exercise BP (&lt;140/90 or &lt; 130/90 mmHg) revealed no differences in exercise BP or EEBP prevalence between T2DM and no-T2DM. Conclusions: This is the first study to confirm higher prevalence of EEBP in T2DM, but this is explained by accompanying CVD risk factors. Identification of EEBP should prompt aggressive CVD risk factor modification in T2DM.

Ambulatory Blood Pressure Phenotypes in Children and Adolescents

Cardiovascular Protection in People With Diabetes.