Decreased exercise capacity in mild essential hypertension: non-invasive indicators of limiting factors.

Available data suggest that exercise capacity is limited in hypertension. The mechanism of this reduced maximal exercise capacity has not been fully elucidated. In this study 22 patients with mild essential hypertension (162 +/- 22 mmHg systolic and 95 +/- 8 mmHg diastolic) and 36 normotensive control subjects (128 +/- 13 mmHg systolic and 80 +/- 7 mmHg diastolic) (P less than 0.01) performed an ergometer test till exhaustion. Body mass index in the two groups did not differ. The maximal oxygen consumption VO2 was lower in the hypertensive group (18 +/- 7 versus 23 +/- 8 ml/kg/min; P less than 0.02) as was the maximal workload (141 +/- 52 vs. 185 +/- 70 Watt; P less than 0.01). Rate pressure product rose only 2.7 fold in hypertensive patients versus 3.5 fold in the control group (P less than 0.001). In hypertensive patients maximal workload decreased with increasing resting systolic blood pressure (P less than 0.05) while in the normotensive subjects maximal workload rose with increasing resting systolic blood pressure (P less than 0.05). In conclusion both high and low blood pressure was associated with a decreased maximal voluntary exercise capacity. Even mild hypertension was accompanied by lower maximal exercise capacity. Hypertensive patients also had a lower maximal VO2 and lower maximal rate pressure product than did normotensive subjects.     

Increased central body fat deposition precedes a significant rise in resting blood pressure in male offspring of essential hypertensive parents: a 5 year follow-up study.

OBJECTIVES: As long as offspring of essential hypertensive parents (OHyp) are lean, their blood pressure usually remains within normal limits. The mechanism(s) transforming this 'genetically dysregulated normotension' into hypertension are unclear. We hypothesized that OHyp are not only genetically prone to develop hypertension, but may also have a particular propensity to accumulate central body fat. DESIGN: A 5-year follow-up cohort study. SETTING: University Hospital in Switzerland. PARTICIPANTS: Seventeen young (25 +/- 1 years, mean +/- SD), lean healthy normotensive male OHyp and 17 age- and sex-matched offspring of normotensive parents (ONorm) paired for baseline blood pressure with the OHyp. MAIN OUTCOME MEASURES: Resting and exercise blood pressure, body weight, body mass index (BMI) and waist-to-hip ratio were assessed at baseline and after 5 years. RESULTS: At baseline, body weight, BMI, waist-to-hip ratio and blood pressure did not differ significantly between OHyp and ONorm. At follow-up, body weight was increased in both groups (from 73.9 +/- 6.0 to 77.7 +/- 8.1 kg in OHyp, P = 0.008, and from 71.5 +/- 6.9 to 73.5 +/- 6.6 kg in ONorm, P = 0.03). BMI followed a similar pattern. In contrast, waist-to-hip ratio increased in OHyp (from 0.84 +/- 0.03 to 0.87 +/- 0.03, P = 0.012), but not in ONorm (from 0.84 +/- 0.03 to 0.84 +/- 0.04, P = 0.79) and was therefore higher in OHyp at follow-up (P = 0.011, OHyp versus ONorm). Peak systolic blood pressure during dynamic exercise also rose at 5 years in the OHyp (from 182 +/- 10 to 214 +/- 17 mmHg, P = 0.0001) while resting systolic blood pressure only tended to do so (from 121 +/- 7 to 128 +/- 12 mmHg, P = 0.07). In ONorm, resting and peak dynamic exercise systolic blood pressure remained unchanged (119 +/- 11 versus 121 +/- 9 mmHg, baseline versus follow-up, P = 0.40, and 186 +/- 12 versus 196 +/- 22 mmHg, P = 0.10, respectively). Thus, systolic peak exercise blood pressure was significantly (P = 0.014) elevated at follow-up in OHyp compared to ONorm, while resting systolic blood pressure only tended (P = 0.06) to do so. CONCLUSIONS: Initially lean normotensive OHyp have a disparate long-term course of central body fat as compared to ONorm. Thus, OHyp are not only genetically prone to develop hypertension, but they also have a particular propensity to accumulate central body fat, even before a distinct rise in resting blood pressure occurs. The exaggerated blood pressure response to exercise observed at follow-up in the OHyp represents another marker that confers them a greater risk of developing future hypertension.     

Relation between exercise-induced hypertension and sustained hypertension in adult patients after successful repair of aortic coarctation

OBJECTIVES: To investigate whether exercise-induced hypertension in successfully repaired adult post-coarctectomy patients is associated with hypertension on 24-h blood pressure measurement and increased left ventricular mass. METHODS: One hundred and forty-four consecutive post-coarctectomy patients (mean age 31.5 years, range 17-74 years; mean age at repair 7.9 years, range 0-45 years) from three tertiary referral centres were studied using ambulatory blood pressure monitoring, treadmill exercise testing and echocardiography. RESULTS: Of the 144 patients, 27 (19%) were known to have sustained hypertension, based on their history, and all were on antihypertensive medication. However, 32 (27%) of the remaining 117 patients showed elevated mean daytime systolic blood pressure readings at 24-h ambulatory blood pressure monitoring (systolic blood pressure > or = 140 mmHg). Of the remaining 85 patients with normal mean daytime systolic blood pressure, 18 patients (21%) had exercise-induced hypertension (maximal exercise systolic blood pressure > 200 mmHg). Mean daytime systolic blood pressure was higher in the exercise-induced hypertensive patients compared to the normotensive patients with normal exercise blood pressure (134 +/- 5 versus 129 +/- 7 mmHg, P = 0.008). By multivariate analysis, both maximal exercise systolic blood pressure (P = 0.007) and resting systolic blood pressure (P < 0.0001) were independently associated with mean daytime systolic blood pressure. Maximal exercise systolic blood pressure had no independent predictive value for left ventricular mass (P = 0.132). CONCLUSIONS: In adult post-coarctectomy patients, maximal exercise systolic blood pressure is independently associated with mean daytime systolic blood pressure at ambulatory blood pressure monitoring. In this study no independent predictive value of maximal exercise systolic blood pressure for left ventricular mass could be demonstrated.     

Exaggerated hypertensive response to exercise in patients with diastolic heart failure

Systolic load elevation during exercise prolongs left ventricular (LV) relaxation, compromises filling, and raises end-diastolic pressure, leading to reduced exercise tolerance. The aim of this study was to test the hypothesis that the hypertensive response to exercise is exaggerated in patients with diastolic heart failure (DHF). Echocardiograms and treadmill testing were performed in patients with DHF (n=20) and age-matched hypertension with LV hypertrophy (HTN; n=20). The Minnesota Living with Heart Failure Questionnaire was used to estimate quality of life (QOL). There were no differences in resting blood pressure or echocardiographic parameters between the groups. The maximum exercise time was significantly shorter in the DHF group than in the HTN group (6.0+/-3.0 vs. 12.5+/-2.5 min), and the peak systolic blood pressure during exercise was significantly higher in the DHF group (212+/-18 vs. 189+/-16 mmHg, p<0.05). After 4 weeks of treatment with candesartan, an angiotensin II receptor blocker (8 mg/d), peak systolic blood pressure during exercise decreased to 191+/-13 mmHg, maximum exercise time increased (10.4+/-3.0 min; p<0.05), and QOL improved in patients with DHF, while there was no change in patients with HTN, despite the similar resting blood pressure. In patients with DHF, systolic blood pressure markedly increased during exercise, and this was accompanied by impaired exercise tolerance and a decreased QOL, both of which were partly suppressed by blocking angiotensin II.     

Patients with a hypertensive response to exercise have impaired left ventricular diastolic function

An exaggerated increase in systolic blood pressure prolongs myocardial relaxation and increases left ventricular (LV) chamber stiffness, resulting in an increase in LV filling pressure. We hypothesize that patients with a marked hypertensive response to exercise (HRE) have LV diastolic dysfunction leading to exercise intolerance, even in the absence of resting hypertension. We recruited 129 subjects (age 63+/-9 years, 64% male) with a preserved ejection fraction and a negative stress test. HRE was evaluated at the end of a 6-min exercise test using the modified Bruce protocol. Patients were categorized into three groups: a group without HRE and without resting hypertension (control group; n=30), a group with HRE but without resting hypertension (HRE group; n=25), and a group with both HRE and resting hypertension (HTN group; n=74). Conventional Doppler and tissue Doppler imaging were performed at rest. After 6-min exercise tests, systolic blood pressure increased in the HRE and HTN groups, compared with the control group (226+/-17 mmHg, 226+/-17 mmHg, and 180+/-15 mmHg, respectively, p<0.001). There were no significant differences in LV ejection fraction, LV end-diastolic diameter, and early mitral inflow velocity among the three groups. However, early diastolic mitral annular velocity (E') was significantly lower and the ratio of early diastolic mitral inflow velocity (E) to E' (E/E') was significantly higher in patients of the HRE and HTN groups compared to controls (E': 5.9+/-1.6 cm/s, 5.9+/-1.7 cm/s, 8.0+/-1.9 cm/s, respectively, p<0.05). In conclusion, irrespective of the presence of resting hypertension, patients with hypertensive response to exercise had impaired LV longitudinal diastolic function and exercise intolerance.     

Absence of post exercise hypotension and sympathoinhibition in normal subjects: additional evidence for increased sympathetic outflow in borderline hypertension

OBJECTIVE: In young men (mean age 25 years) with borderline hypertension the authors have documented a reduction in systolic blood pressure and muscle sympathetic nerve activity 60 mins after 45 mins of submaximal treadmill exercise. The aim of this study was to determine if post exercise hypotension occurs in normotensive young men, and if so, if it is accompanied by a decrease in sympathetic nerve activity. DESIGN: Replicating a previous protocol, the authors recorded blood pressure, heart rate, plasma noradrenaline and muscle sympathetic nerve activity (microneurography; peroneal nerve) before and 60 mins after submaximal treadmill exercise. SUBJECTS: Ten healthy male volunteers (mean age 28 +/- 5 years). INTERVENTION: Forty-five minutes of treadmill exercise at 70% of resting heart rate reserve. MAIN RESULTS: In contrast to borderline hypertensive subjects, prior exercise had no effect on either systolic or diastolic blood pressure or muscle sympathetic nerve activity in healthy volunteers. Plasma noradrenaline concentrations were similar before and after exercise. Resting heart rate (56 +/- 3 versus 70 +/- 3 beats/min; P less than 0.002), and sympathetic burst frequency (10 +/- 4 versus 20 +/- 2 bursts/min; P = 0.026) were lower in normal than in borderline hypertensive men. CONCLUSIONS: At rest, discharge to muscle sympathetic nerves is increased in young borderline hypertensive men; and blood pressure and sympathetic nerve activity are decreased after exercise in borderline hypertensive but not normotensive men. These observations suggest that the depressor response to prolonged rhythmic exercise in young men with borderline hypertension may be due in part to transient suppression of augmented central sympathetic outflow.     

Haemodynamic contributions to post-exercise hypotension in young adults with hypertension and rapid resting heart rates.

The haemodynamic effects of 45 min of treadmill exercise (at 70% of resting heart rate reserve) were determined in 5 young adults with hypertension and rapid resting heart rates (greater than 90 beats/min in clinic) and were compared with those of 5 age-matched normotensive subjects. Blood pressure was lower after exercise in the hypertensive, but not the normotensive subjects. Mean cardiac output before exercise was similar in the two groups, and fell from 6.8 +/- 0.6 before to 5.4 +/- 0.6 l/min 60 min after exercise in the hypertensive group (P less than 0.01). Total peripheral resistance tended to be higher at this time. Neither variable was affected by prior exercise in the normotensive group. The depressor effects of prior exercise on mean arterial pressure (-8.6 +/- 1.0 vs. -1.4 +/- 2.5 mmHg; P less than 0.04) and cardiac output (-1.4 +/- 0.3 vs. -0.1 +/- 0.1 l/min; P less than 0.005) and the increase in total peripheral resistance (+3.0 +/- 1.2 vs. 0.0 +/- 1.0 Units; P less than 0.05) were greater in the hypertensive group. Thus, the post-exercise hypotension in this selected group of young hypertensive subjects with rapid resting heart rates was mediated by a decrease in cardiac output and stroke volume disproportionate to the fall in blood pressure, suggesting sustained compromise of their cardiac performance after acute exercise.     

Stress echocardiography in the evaluation of exercise physiology in patients with severe arterial pulmonary hypertension. New methodology.

INTRODUCTION: Doppler echocardiography is usually performed when assessing a patient with severe pulmonary hypertension (PHT), since it enables accurate determination of the severity of the hypertension through evaluation of several morphologic and hemodynamic variables. Echocardiograms are usually performed in left lateral decubitus (LLD). However, symptoms often arise only in a standing position and particularly during exercise. OBJECTIVE: To evaluate a group of patients with severe PHT using Doppler echocardiography during treadmill exercise testing. METHODS: We studied 8 patients (group A), mean age 43.88 +/- 14 years, 7 women; three had idiopathic pulmonary hypertension, 2 pulmonary thromboembolic disease, 2 Eisenmenger syndrome, and one pulmonary hypertension associated with celiac disease. We also studied an 8-patient control group (group B) with similar demographic characteristics, who had tricuspid regurgitation but no known cardiac disease, including pulmonary hypertension (excluded by echocardiogram). In addition to the ergometric variables of stress test duration using the modified Bruce protocol, resting heart rate, peak heart rate (PHR), resting systolic blood pressure (RSBP) and peak systolic blood pressure (PSBP), we evaluated the following echocardiographic variables: pressure gradient between right ventricle and right atrium (RV/RAg) and systolic volume (SV) in left lateral decubitus, in a standing position (SP) and at peak workload (PW). Stress testing was stopped in cases of fatigue and/or dyspnea. RESULTS: In group A, the RV/RAg in LLD was 100 +/- 20 mmHg, 98 +/- 20 mmHg in SP (p = NS) and 129 +/- 27 mmHg at PW (p = 0.003 vs. SP). In group B, the RV/RAg in LLD was 19.8 +/- 3.5 mmHg, 14.6 +/- 2.1 mmHg in SP (p = 0.0005) and 29.5 +/- 3.3 mmHg at PW (p < 0.0001 vs. SP). In group A, SV was 38 +/- 11 ml in LLD, 35 +/- 10 ml in SP and 32 +/- 9 ml at PW (p = NS); in group B, it was 63 +/- 5 ml in LLD, 55 +/- 5 ml in SP and 64 +/- 7 ml at PW (p < 0.0001). PHR was 114 +/- 10 bpm in group A and 145 +/- 8 (p < 0.0001) in group B. RSBP was 113 +/- 13 mmHg and PSBP 112 +/- 21 mmHg (p = NS) in group A, and 116 +/- 18 mmHg and 161 +/- 25 mmHg respectively (p < 0.0001) in group B. In four patients from group A, symptomatic falls in systolic blood pressure and SV occurred at PW. During a mean follow-up of 27 months (between 6 and 44 months), two of these four patients died and one is awaiting lung transplantation. CONCLUSIONS: 1. RV/RAg did not diminish in the standing position and rose significantly with orthostatic isotonic exercise during exercise testing in patients with severe PHT, with pulmonary artery systolic pressure reaching suprasystemic values. 2. Systolic volume and systolic blood pressure did not rise during exercise in patients with severe PHT, and patients with a decrease in systolic volume had worse clinical evolution. 3. Patients with severe PHT appeared to have chronotropic incompetence during exercise compared to the control group.     

Prognostic significance of exercise-induced systemic hypertension in healthy subjects

Exercise hypertension has been suggested to predict future resting hypertension, but its significance in terms of cardiovascular risk has not been defined. To assess the prognostic significance of exercise hypertension, 150 healthy, asymptomatic subjects with normal resting blood pressures and exercise systolic blood pressures > or =214 mm Hg (i.e., >90th percentile) on Bruce treadmill tests were identified retrospectively and age- and gender-matched with subjects with exercise systolic blood pressures of 170 to 192 mm Hg (40th to 70th percentiles). Subjects were contacted by survey a mean of 7.7+/-2.9 years after the index treadmill test. The survey response rate was 93%. There were 12 deaths, including 8 in the exercise hypertension group. A major cardiovascular event, defined as cardiovascular death, myocardial infarction, stroke, coronary angioplasty, or coronary bypass graft surgery occurred in 5 controls and 10 subjects with exercise hypertension. At follow-up, 13 controls and 37 subjects with exercise hypertension were now diagnosed as having resting hypertension. In multivariate analysis, exercise hypertension was not a significant predictor for death or any individual cardiovascular event, but was for total cardiovascular events and new resting hypertension. The multivariate risk ratio for exercise hypertension was 3.62 (p = 0.03) in predicting a major cardiovascular event. Other significant predictors included body mass index and age. For predicting new resting hypertension, the multivariate odds ratio for exercise hypertension was 2.41 (p = 0.02). These data suggest that exercise hypertension carries a small but significant risk for major cardiovascular events in healthy, asymptomatic persons with normal resting blood pressures.     

Relationship between ambulatory blood pressure monitoring and response of blood pressure in male hypertensive adolescents to exercise

BACKGROUND: High blood pressure in the young has been related to the development of hypertension in adults; hence the importance of identifying adolescents with the risk of developing it.OBJECTIVE: To investigate the relationship between 24 h ambulatory blood pressure monitoring and the response of blood pressure in adolescents to exercise. DESIGN: A prospective and cross-sectional study. METHODS: We classified 101 men aged 13-18 years as obese hypertensive, lean hypertensive, obese normotensive, and lean normotensive. Mean blood pressure and variability were measured with ambulatory blood pressure monitoring, and expressed as 24 h, awake, and sleeping periods. Treadmill tests were also performed. RESULTS: Hypertensives and obese normotensives had higher ambulatory blood pressure monitoring values (P< 0.0001). Systolic blood pressure during sleep in obese subjects was significantly higher than that in lean usbjects (119.9 +/- 9 versus 113.6 +/- 8 mmHg, P < 0.001, obese hypertensives versus lean hypertensives; and 113.6 +/- 2 versus 103.0 +/- 2 mmHg, P < 0.002, obese normotensives versus lean normotensives) and nocturnal drop of systolic blood pressure was lower in obese subjects. We found a significant correlation between systolic blood pressure during ambulatory blood pressure monitoring and systolic blood pressure during moderate and maximal exercise for all periods (P < 0.0001). Blood pressure variability during awake period was higher in subjects with maximum exercise systolic blood pressure >/= 200 mmHg (7.4 +/- 2 versus 6.4 +/- 2%, P < 0.01).CONCLUSION: Systolic blood pressure measured by ambulatory blood pressure monitoring is related to response of systolic blood pressure to exercise and ambulatory blood pressure monitoring can identify groups of subjects at greater than normal risk through their higher blood pressure during sleep. Greater than normal blood pressure variability in adolescents is an indicator of the risk of reaching abnormal exercise values of systolic blood pressure. Higher casual blood pressure than ambulatory blood pressure monitoring values for adolescents should be considered abnormal.     

The association between exercise blood pressure and the prevalence of ECG abnormalities

The relationship between atrial and ventricular electrocardiographic abnormalities and exercise systolic blood pressure was studied in 246 male and 183 female subjects, of whom 199 males and 158 females were normotensive (resting blood pressure below 140/90 mmHg) and 47 males and 25 females were borderline hypertensive (resting systolic blood pressure 140 to 159 and/or diastolic blood pressure 90 to 99 mmHg). Subjects were classified into three groups according to systolic blood pressure during treadmill exercise (less than or equal to 180 mmHg, 180 to 199 mmHg and greater than or equal to 200 mmHg). With respect to atrial electrocardiographic abnormalities, the prevalence of abnormal values of the P-terminal force in lead V1 increased significantly with increased levels of resting exercise systolic blood pressure in males and females. The prevalence of electrocardiographic left ventricular hypertrophy, as reflected in abnormal values of one or more RS voltage indices, increased significantly with exercise systolic blood pressure in males but not in females. Males did not show a trend of increasing electrocardiographic left ventricular hypertrophy with increased resting systolic blood pressure means. In females, the significant difference between resting systolic blood pressure means and electrocardiographic left ventricular hypertrophy did not reflect a linear progression across resting systolic blood pressure categories. The significant association of the P-terminal force in lead V1 with exercise systolic blood pressure has not previously been reported. Although an association between left ventricular hypertrophy and exercise systolic blood pressure in hypertensives has been reported by others, the association seen in normotensive and borderline hypertensive males has not been reported previously.(ABSTRACT TRUNCATED AT 250 WORDS)     

Exercise hypertension: its measurement and evaluation

Blood pressure, the central parameter in the diagnosis of arterial hypertension, is subject to a high degree of variability. The dilemma for the evaluating physician is that he has no true value for the resting blood pressure that is both comparable and reproducible. Reproducibility, however, is an essential requirement for all diagnostic procedures in medicine. A standardized ergometric procedure (at workloads of 50 to 100 watts [W]; incremented 10 watts/min; cuff blood pressure measurements) is suitable to obtain comparable, reproducible monitoring of the blood pressure response in both pressure response in both normotensive subjects and hypertensive patients. The blood pressure behavior during and after ergometric exercise was investigated in 552 males in order to clarify if this standardized procedure is suitable for differentiating between normotensive subjects and hypertensive patients. The following normal upper limits for blood pressure values in men and women between the ages of 20 and 50 years of 200/100 mmHg (mean + 1 SD) at a workload of 100 W as well as 140/90 mmHg in the fifth minute of the recovery phase were obtained. Patients suffering from mild hypertension showed significantly (p less than 0.001) higher blood pressures (213 +/- 22/116 +/- 11 mmHg) at 100 W and after exercise than age-matched normotensives (188 +/- 14/92 +/- 9 mmHg) but significantly (p less than 0.001) lower values than hypertensives with stable hypertension (225 +/- 22/126 +/- 11 mmHg). Moreover, the systolic pressure response to ergometric work was significantly (p less than 0.05 to p less than 0.01) influenced by age. Using the normal upper limits for blood pressure during and after ergometry, the ergometric procedure revealed that 50% of the patients with borderline hypertension at rest could be classified as hypertensives. Their blood pressure response at 100 W (216 +/- 21/113 +/- 8 mmHg) did not significantly differ from the patients with mild hypertension. In contrast, in the 50% who reacted negatively to ergometric testing, the systolic blood pressure response at 100 W (204 +/- 18 mmHg) was significantly (p less than 0.01) lower than that of those who demonstrated a positive reaction, revealing exactly the same diastolic blood pressure value of 92 mmHg as the normotensives. Follow-up examinations several years (average 3.8 years) subsequently showed that 97% of the ergometric-positive borderline hypertensives developed established hypertension. Thus an early diagnosis of arterial hypertension was achieved years before its established manifestation.(ABSTRACT TRUNCATED AT 400 WORDS)     

Left ventricular systolic response to exercise in patients with systemic hypertension without left ventricular hypertrophy

Supine exercise radionuclide angiography was performed in 367 men to assess left ventricular (LV) systolic response to exercise; 58 had systemic hypertension without LV hypertrophy on a resting electrocardiogram and 309 were normotensive. All patients met the following criteria defining a low pretest likelihood of coronary artery disease: age less than 50 years; normal electrocardiographic response to exercise; absence of typical or atypical chest pain; and exercise heart rate greater than 120 beats/min. Patients taking beta-receptor blockers were excluded. There were no significant differences between hypertensive and normotensive groups in peak exercise heart rate, workload or exercise duration. However, hypertensive patients had significantly higher peak exercise systolic blood pressures and peak exercise rate-pressure products. There were no differences between patients with and without hypertension in resting ejection fraction, peak exercise ejection fraction (hypertensive patients 0.71 +/- 0.01, normotensive patients 0.70 +/- 0.05) or change in ejection fraction at peak exercise (hypertensive patients 0.07 +/- 0.01, normotensive patients 0.07 +/- 0.04). Diastolic and systolic ventricular volumes tended to be smaller in the hypertensive patients, but the difference was not statistically significant. The change in systolic volume with exercise was similar in the 2 groups (hypertensive -10 +/- 3 ml/m2, normotensive -10 +/- 1 ml/m2). In the absence of electrocardiographic evidence of LV hypertrophy, systemic hypertension does not influence LV systolic response to exercise.     

Usefulness of exertion tests in the evaluation of the effectiveness of antihypertensive therapy

Aim of this study was to assess the reliability of blood pressure (BP) response to exercise compared with the occasional BP measurements in evaluating the efficacy of an antihypertensive therapy. We have studied 40 subjects (22 M, 18 F mean age 33.3 +/- 6.6) with essential hypertension (19 with mild hypertension, 8 with moderate hypertension, 13 with severe hypertension). Every patient underwent a maximum graded exercise test in the supine position on a bicycle ergometer before starting the antihypertensive treatment. An exercise test was repeated with the same procedure after resting BP had been normalized for at least six months. Both systolic and diastolic BP at peak exercise were significantly reduced (systolic BP from 212.13 +/- 25.79 mmHg to 194.38 +/- 21.58 mmHg; diastolic BP from 128.00 +/- 16.52 to 114.1 +/- 11.02 mmHg) during the second test. An excessive BP increase (above the 95% confidence limits of the BP response to exercise in a group of normotensives) was observed in 32 subjects during the first test. A "hypertensive" response to stress persisted in 13 subjects during the second test even if the resting BP values were normalized. Our data support the value of stress testing in both the evaluation of the hypertensive patient and the assessment of the individual response to treatment.     

Is there a relationship between exercise systolic blood pressure response and left ventricular mass? The Framingham Heart Study.

OBJECTIVE: To assess the association between an exaggerated exercise systolic blood pressure response and the occurrence of left ventricular hypertrophy in healthy, normotensive individuals. DESIGN: Cross-sectional survey using M-mode echocardiography to measure left ventricular mass and to detect left ventricular hypertrophy. SETTING: The Framingham Heart Study. SUBJECTS: Eight-hundred sixty men and 1118 women were studied who were free of cardiovascular or pulmonary disease, who were not taking any antihypertensive or cardiovascular medications, and who successfully achieved at least 90% of their age-predicted maximum heart rate during a monitored exercise treadmill test. All subjects had normal baseline and exercise electrocardiograms. MEASUREMENTS AND MAIN RESULTS: Men with a peak exercise systolic blood pressure of 210 or more and women with a peak exercise systolic blood pressure of 190 or more were considered to have an "exaggerated" blood pressure response; 122 men and 67 women met these criteria. Subjects with an exaggerated exercise systolic blood pressure response had 10% higher left ventricular mass than those with a normal exercise systolic blood pressure response (in men: 115 +/- 25 compared with 105 +/- 24 g/m, P less than 0.001; in women: 86 +/- 22 compared with 73 +/- 16 g/m, P less than 0.001); they also had a higher prevalence of left ventricular hypertrophy (in men: odds ratio, 1.34, 95% CI, 1.00 to 1.80; in women: odds ratio, 2.12, CI, 1.48 to 3.03). After adjusting for age, resting systolic blood pressure, and body mass index, however, subjects with an exaggerated exercise systolic blood pressure response had only 5% higher left ventricular mass (in men: 111 +/- 2.1 compared with 106 +/- 0.8 g/m, P = 0.02; in women: 80 +/- 1.8 compared with 74 +/- 0.4 g/m, P = 0.002), and they no longer had a statistically increased prevalence of left ventricular hypertrophy (in men: odds ratio, 1.21, CI, 0.87 to 1.67; in women: odds ratio, 1.30, CI, 0.84 to 2.01). CONCLUSIONS: The apparent relation between exercise systolic blood pressure response and left ventricular mass is confounded by age, resting systolic blood pressure, and body mass; the degree of confounding is such that the biologic significance of this relationship should be questioned.     

Normal exercise blood pressure response in African-American women with parental history of hypertension

BACKGROUND: Genetic and environmental hypotheses may explain why normotensive persons at high risk of developing hypertension often exhibit greater cardiovascular reactivity to stressors than those at low risk. METHODS: Pearson's correlation was used to evaluate reproducibility and independent t test to compare the cardiovascular responses to 30 W of exercise of normotensive young adult African-American women with positive and negative parental histories (PH) of hypertension (PH, n = 23; PH, n = 20). RESULTS: Correlations were significant for duplicate measurements. The effects of PH on blood pressure measured at rest and during exercise were not statistically significant (P > 0.1). A nearly significant trend for greater resting (.-)VO(2) (P = 0.08) was detected in the PH than in the PH group (3.67 +/- 0.18 versus 3.26 +/- 0.14 mL/kg/min). CONCLUSION: A hyper-reactive blood pressure response to exercise, characteristic of the evolution of hypertension, may not be present among the normotensive female offspring of hypertensive African Americans. The significance of an 11% intergroup difference in the mean resting (.-)VO(2) observed in this study is unclear.     

Prevalence of sustained hypertension and obesity in urban and rural school going children in Ludhiana

BACKGROUND: Increasing trend of hypertension is a worldwide phenomenon. The data on sustained hypertension in school going children is scanty in India. The present study was conducted to evaluate the prevalence of sustained hypertension and obesity in apparently healthy school children in rural and urban areas of Ludhiana using standard criteria. METHODS AND RESULTS: A total of 2467 apparently healthy adolescent school children aged between 11-17 years from urban area and 859 students from rural area were taken as subjects. Out of total 3326 students, 189 were found to have sustained hypertension; in urban areas prevalence of sustained hypertension was 6.69% (n=165) and in rural area it was 2.56% (n=24). Males outnumbered females in both rural and urban areas. The mean systolic and diastolic blood pressure of hypertensive population in both urban and rural population was significantly higher than systolic and diastolic blood pressure in their normotensive counterparts (urban normotensive systolic blood pressure:115.48+/-22.74 mmHg, urban hypertensive systolic blood pressure: 137.59+/-11.91 mmHg, rural normotensive systolic blood pressure: 106.31+/-19.86 mmHg, rural hypertensive systolic blood pressure: 131.63+/-10.13 mmHg, urban normotensive diastolic blood pressure: 74.18+/-17.41 mmHg, urban hypertensive diastolic blood pressure: 84.58+/-8.14 mmHg, rural normotensive diastolic blood pressure: 68.84+/-16.96 mmHg, rural hypertensive diastolic blood pressure: 79.15+/-7.41 mmHg). Overweight populationwas significantly higher in urban area. There were 287 (11.63%) overweight students and 58 (2.35%) were obese. In rural population overweight and obese students were 44 (4.7%) and 34 (3.63%) respectively. There was significant increase in prevalence of hypertension in both rural and urban population with increased body mass index in urban students; those with normal body mass index had prevalence of hypertension of 4.52% (n=96), in overweight it was 15.33% (n=44) and in obese it was 43.10% (n=25). In rural area, the overweight students showed prevalence of sustained hypertension in 6.82% (n=3) and in obese group it was 61.76% (n=21). None of the student with normal body mass index in rural area was found to be hypertensive. The mean body mass index of hypertensive population in both rural and urban areas was significantly higher than respective normotensive population (mean body mass index in urban normotensive group: 20.34+/-3.72 kg/m2, hypertensive group: 24.91+/-4.92 kg/m2; mean body mass index in rural normotensive group: 18.41+/-3.41 kg/m2, hypertensive group: 21.37+/-3.71 kg/m2, p<0.01). CONCLUSIONS: Prevalence of sustained hypertension is on the rise in urban area even in younger age groups. Blood pressure is frequently elevated in obese children as compared to lean subjects. This is possibly related to their sedentary lifestyle, altered eating habits, increased fat content of diet and decreased physical activities.     

Augmented norepinephrine and renin output in response to maximal exercise in hypertensive coarctectomy patients.

To evaluate a possible neural or renal contribution to the hypertension that occurs in some patients following coarctation of aorta repair, 35 patients underwent graded bicycle exercise with serial measurements of plasma norepinephrine concentrations and plasma renin activity. Sixteen patients with coarctectomy who had systolic or diastolic hypertension at peak exercise were compared with 19 normotensive patients with coarctectomy. The average time interval between coarctation repair and study was significantly longer (p less than 0.05) in the hypertensive group than in the normotensive patients (12.8 +/- 4.8 versus 8.7 +/- 2.2 years). The heart rate response to exercise was similar for both patient groups. The systolic blood pressure in the hypertensive group was higher than in the normotensive group at rest in the supine and upright positions and at 5 minutes of recovery, in addition to peak exercise, and the diastolic blood pressure was increased at peak exercise. Plasma norepinephrine concentrations were significantly higher at peak exercise and during recovery in the hypertensive group than in the normotensive patients. Plasma renin activity was also significantly higher in the hypertensive group at peak exercise. These data suggest that patients with coarctectomy who have a hypertensive response to exercise have an augmented sympathetic nervous system output and increased plasma renin activity that may lead to peripheral vasoconstriction at peak exercise and that may contribute to the development of their hypertension.     

Exaggerated blood pressure response to exercise is associated with carotid atherosclerosis in apparently healthy men

OBJECTIVE: Although an exaggerated systolic blood pressure (SBP) response to exercise is a predictor of future hypertension and cardiovascular mortality, the underlying mechanisms are not fully understood. We tested the hypothesis that an exaggerated SBP response is associated with carotid atherosclerosis in a cross-sectional study of 9073 healthy men (aged 47.8 +/- 8.8 years). METHODS: Exaggerated SBP response was defined as an SBP of 210 mmHg or greater during a maximal treadmill test. Carotid atherosclerosis was defined as stenosis greater than 25% or intima-media thickness greater than 1.2 mm using B-mode ultrasonography. RESULTS: An exaggerated SBP response was present in 375 men (4.1%). The proportion of individuals with carotid atherosclerosis in the group with an exaggerated SBP response to exercise was higher than in the group with a normal SBP response (14.4 versus 5.3%, P < 0.001). In a multivariable logistic regression model, individuals with an exaggerated SBP (>or= 210 mmHg) response to exercise had a 2.02 times [95% confidence interval (CI) 1.33-3.05] increased risk of carotid atherosclerosis compared with individuals with an SBP response of less than 210 mmHg. The highest quartile (> 61 mmHg) group of relative exercise-induced increases in SBP showed a 1.57 (95% CI 1.18-2.08) greater risk of carotid atherosclerosis compared with individuals in the lowest quartile (< 38 mmHg) in the adjusted model. CONCLUSIONS: These results suggest that an exaggerated SBP response to exercise is strongly associated with carotid atherosclerosis, independent of established risk factors in healthy men. It may be an important factor in evaluating hypertension related to target-organ damage.     

Endothelial dysfunction in patients with exaggerated blood pressure response during treadmill test

BACKGROUND: The diagnostic and prognostic importance of exaggerated blood pressure response to exercise is controversial. Endothelial dysfunction has been demonstrated in patients with atherosclerosis and risk factors for coronary artery disease, but there is a paucity of information on patients with exercise-induced hypertension. HYPOTHESIS: We designed the study to evaluate endothelial function in patients with exaggerated blood pressure response during exercise. METHODS: Exercise-induced hypertension was defined as systolic blood pressure > or = 210 mmHg in men and > or = 190 mmHg in women during the treadmill test. Using a high-resolution ultrasound technique, endothelial function of the brachial artery in patients with exercise-induced hypertension (n = 25) and control subjects (n = 25) was investigated. RESULTS: Endothelium-dependent vasodilation was impaired in patients with exercise-induced hypertension compared with controls (7.77 +/- 5.14 vs. 2.81 +/- 2.29%, p < 0.05). On univariate analysis, the extent of vasodilation correlated negatively with age (r = -0.43, p < 0.05) and delta systolic blood pressure (r = -0.39, p < 0.05). Even after adjustment for factors known to affect endothelial function, endothelium-dependent vasodilation was decreased in patients with exercise-induced hypertension (beta = 5.375, p = 0.02). CONCLUSION: Patients with exercise-induced hypertension have impaired endothelium-dependent vasodilation. This study also supports the concept that endothelial dysfunction may play an important role in exercise-induced hypertension.