Transcript EXERCISE EXAGGERATED BP RESPONSE

Clinical Significance of an
Exaggerated Blood Pressure
Response During Exercise
ANDREAS PITTARAS MD
Patient A
Patient B
67
58
Rest BP
120/80
120/78
BP @ 5 METs
160/80
220/90
Peak BP
190/80
230/100
Age
QUESTIONS
•
The Clinical Significance?
•
What to do about it?
Definition
•
Peak Exercise SBP >210 mm Hg for
men and 190 mm Hg for
women
respectively (Framingham)
•
SBP >200 mm Hg at Exercise
Workload of about 6-7 METs
Exaggerated BP Response to
Exercise and Associations
•
Future Development of HTN
•
Cardiovascular Mortality and
Cardiovascular events
•
Left Ventricular Hypertrophy
Clinical Significance
Jong-Won Ha, et al. JACC 2002:112:161-66
False-positive results were twice
as likely in patients with
hypertensive response to
exercise echocardiography
(22% vs 12%).
Exaggerated BP and
Future Development of
Hypertension
New-onset of HTN and Exercise BP in Men (n=1026)
The Framingham Heart Study
Singh JP, et al. Circulation 1999;99:1831-36
Odds Ratio
SBP
*
DBP
4.16
4
*
2.17
2
1.36
1
0
Women
Men
Exaggerated BP Response to Exercise
and Risk for Developing HTN (n=1,033)
Miyai, et al. Hypertension 2002;39:761-6
Relative Risk
8
SBP
DBP
6.62
4.7 yrs F/U
6
4.91
3.7
4
2.89
2
1
1
0
Multiple Adjusted
Age-Adjusted
Exaggerated BP Response to Exercise
and Risk for Developing HTN
Relative Risk
4
Miyai, et al. Hypertension 2002;39:761-6
3.82
3.17
3
2
1.08
1.05
1
0
Exag-BP
Resting HTN
BMI
Age
Exaggerated Exercise BP and Future
HTN (Conclusion)
• Overall, an exaggerated BP response to
exercise is likely to lead to future HTN
• Confounding factors such as age,
gender, and physical fitness have not
always been considered
• Pre-hypertension ?
Patients with Pre-hypertension are
at twice the risk to develop
hypertension compared to those
with lower BP values.
Vasan RS, et al. The Framingham Study. JAMA
2002;287:1003-1010
Exaggerated BP and CV
Events and CV Mortality
Exercise BP and CV Mortality
in Middle-aged Men (n=1999)
Mundal et al. Hypertension 1994;24:56-62
%
18
F/U: 16 yrs
16.1
* RR=2.0
NS
8.1
9
5.6
6
<140 / >200
mm Hg
<140 / <200
mm Hg
0
>140 / <200
mm Hg
>140 / >200
mm Hg
Exercise BP and Risk of Developing MI
in Middle-aged Men (n=1999)
Mundal et al. 1996; Hypertension;27:324-29
%
20
18.8
*
15.7
>140 / >200
mm Hg
15
11.4
9.5
10
<140 / >200
mm Hg
<140 / <200
mm Hg
5
>140 / <200
mm Hg
Conclusion
SBP >200 mm Hg at exercise intensity
of about 6 METs is a stronger
predictor of CV and MI morbidity and
mortality than resting BP In pts with
resting HTN.
Mundal R. et al., Hypertension 1996;27(1):324-29
Exaggerated BP Response
and
Left Ventricular
Hypertrophy
Resting BP is weakly related to LVH
(r=0.26) and can only partially
explain its development
and progression.
Exaggerated BP & LVH in
Normotensive Men
An exaggerated blood pressure (SBP
>210) at peak exercise is associated
with left ventricular hypertrophy
(LVH). The association is much
stronger than that between resting BP
and LVH.
Gottdiener JS., et al. Annals of Internal Medicine 1990; 112:116-66
Peak Exercise SBP and LV MASS
Polonia J, et al. Eur Heart Journal 1992; 13(A):30-36
g/m2
230
224
HTN with SBP >210 mm Hg
222
>210 mm Hg
<210 mm Hg
200
180
170
155
143
140
124
110
Peak SBP
LVMI
Peak Exercise BP and LV MASS
Molina L, et al. Am J Cardiol 1999; 84:890-93
230
220
<210 mm Hg
>210 mm Hg
200
176
170
140
124
103
110
80
Peak SBP
LVMI
Peak Exercise BP (SBP>210 mm Hg) and
LVH in Men & Women
Lauer et al. Annals Intern Med 1992;116;203-10
g/m2
120
<210 mm Hg
111
>210 mm Hg
106
100
80
80
74
60
Men
Women
Conclusion
Lauer et al. Annals Intern Med 1992;116;203-10
The relationship between Peak
exercise BP and LVM is
confounded by a number of
baseline variables so that its
biological significance must be
questioned.
Peak vs Sub-maximal Exercise BP
Peak Exercise BP
Exer. BP (5-7 METs)
–Relatively difficult
–Easier to assess
to assess
–Practical (reflects
–Impractical
daily activities)
–Based on a relative –Wider clinical
workload
application
–Based on absolute
workloads
Exercise SBP and Fitness in
Normotensive Men (n=1,025)
Low-Fit
mm Hg
185
High-Fit
Moderate
182
* p<0.01
178
*
173
165
*
*
166
161
153
145
149
140
125
SBP @ 5 METs
SBP@ 7-METs
Peak Exercise
179
Patients with Pre-hypertension
(SBP 120-139 mm Hg or DBP 80-89
mm Hg), are at twice the risk to
develop hypertension compared to
those with lower BP values.
Vasan RS, et al. The Framingham Study. JAMA
2002;287:1003-1010
LVMI Predictors for Pre-HTNsive
Men (Multiple Regression)
M (n=269)
W (n=243)
R2
R2
• SBP @ 7 METs
0.62
0.50
• Age
0.64
0.51
• T-Time
0.65
0.53
LVMI & Exercise SBP Association
in Pre-Hypertensive Women
Kokkinos P, Pittaras A et al. Circulation 2004
200
180
160
140
120
100
80
SBP>169 mm Hg
60
120
140
160
180
SBP at 7 METs
200
220
240
LVMI & Exercise SBP Association
in Pre-Hypertensive Men
Kokkinos P., Pittaras A et al. Circulation 2004
200
180
160
140
120
100
80
SBP>164 mm Hg
60
120
140
160
180
SBP at 7 METs
200
220
LVMI & Exercise SBP in
Pre-hypertensive Men and Women
Kokkinos P., Pittaras A et al. Circulation 2004
g/m2
135
133
* p<0.01
EX-HTN
Normal
125
120
115
*
105
*
96
92
95
85
75
Women
Men
Prevalence of LVH in Pre-HTN
Men
–EX-HTN (+):
–EX-HTN (-) :
%
59
4.5
OR
30.2
CI
p-value
13.8-66.2 0.00
–RR= 5.9 times higher likelihood of LVH/10 mm
Hg Increase in SBP@ 6 min. of exercise
Women
–EX-HTN (+):
86 21.6
12.3-38.2 0.00
–EX-HTN (-) :
22
–RR= 2.9 times higher likelihood of LVH/10 mm
Hg increase in SBP@ 6 min. of exercise
Conclusions
•
Systolic BP at about 6-7 METs is the
strongest predictor of LV mass in Prehypertensive men and women.
•
The threshold for LVH is SBP >164 mm
Hg for men and >169mm Hg for Women.
•
The likelihood of having LVH increases
by 6-fold in men and 3-fold in women for
every 10 mm Hg increase in SBP above
these thresholds.
What to Do for Patients with
Exaggerated BP Response
to Exercise ?
•
Antihypertensive Agents
•
Exercise Training
Exercise BP and Antihypertensive Meds (n=1,977)
mm Hg
195
BB-Based
192
* p<0.01
Others
*
*
182
175
*
170
164
167
151
145
SBP@ 5 MET
SBP@ 7 METS
SBP @ Peak
*
Exercise BP and Antihypertensive Agents (n=1,977)
mm Hg
185
BB-Based
CCB
ACE
181
Diuretics
182
180
* p<0.01
170
166
164
166
164
155
152
140
SBP@ 5 MET
SBP@ 7 METS
Clinical Significance
Beta-blockade may be a prudent
approach to protect against excessive
and repetitive elevations in BP likely
to occur during vigorous activities
such snow-shoveling basketball,
tennis, etc., that require repetitive
burst of effort to maximal or near
maximal levels.
What to Do for Patients with
Exaggerated BP Response
to Exercise ?
•
Antihypertensive Meds
•
Exercise Training
Exercise Indices for Fit and Unfit Women
Kokkinos P. Pittaras A et al, J Cardiopulmonary Rehab 2002;22:178-183
Normotensive
SBP- 6 min
Fit (n= 557)
145±18
Unfit (n=463)
156±20*
152±17*
HR- 6 min
136±15
Hypertensive
Fit (n= 99)
SBP- 6 min
172±21
184±21*
HR- 6 min
141±15
156±15*
Unfit (n=186)
* p =0.000
Exercise BP, Fitness & LVMI in Men
Pittaras A, et al. Circulation 2003
186
Low-Fit
184
Moderate
*
High-Fit
* p<0.01
175
166
165
146
135
*
126
125
117
106
SBP @ 7 METs
LVMI
Exercise BP, Fitness & LVMI in Women
Pittaras A, et al. Circulation 2003
190
Low-Fit
* p<0.01
187
Moderate
High-Fit
177
*
167
160
140
130
127
*
117
100
EX-BP
LVMI
SBP Following Aerobic Training
Kokkinos P. et al, Am J Cardiol. 1997
mm Hg
220
*p<0.01
219
219
*
200
*
198
187
*
180
199
171
160
*
140
138
131
120
Rest
6-Min
9-Min
Peak
Wall Thickness at Baseline and 16 wks
Kokkinos, Pittaras A et al. New Engl J Med 1995;333:1462-7
mm
15
* p<0.05
*
14
13
*
12
PW
IVS
LVMI at Baseline and 16 Wks of Exercise
Kokkinos, Pittaras A et al. New Engl J Med 1995;333:14627
g/m2
* p<0.05
163
165
*
150
143
Baseline
135
16 weeks
Antihypertensive Agents
and Exercise
Exercise SBP and Fitness in Hypertensive
Men on B-Blockers (n=453)
Low-Fit
mm Hg
180
High-Fit
Moderate
* p<0.01
173
*
174
170
171
160
*
163
*
156
140
155
146
136
120
SBP @ 5 METs
SBP@ 7-METs
Peak Exercise
Exercise SBP and Fitness in Hypertensive
Men on Meds (n=455)
Low-Fit
mm Hg
200
High-Fit
Moderate
* p<0.01
196
*
193
193
*
180
*
179
181
170
160
163
155
140
SBP @ 5 METs
SBP@ 7-METs
Peak Exercise
192
Does exercise BP at 5-7 METs
reflect daytime Ambulatory BP?
Exercise BP & ABP in Fit & Unfit Men
159
160
151
147
EX-BP
144
145
ABPM
ABPM
130
126
EX-BP
LVMI
115
111
LVMI
100
Unfit
Fit
Exercise BP & ABP in Fit & Unfit Women
164
165
153
EX-BP
148
150
143
ABPM
133
135
ABPM
EX-BP
120
113
LVMI
105
LVMI
90
Unfit
Fit
Summary and Conlusions
• Fit individuals have Lower:
• BP at intensities of 5-7 METs
• Lower ABPM
• Lower LVMI
Than Unfit.
• Physical activity lowers the daily
hymodymanic load, leading to lower
LV Mass.
Mitigates the
hemodynamic load
During Daily Activities
Prevents or Attenuates
Increases
in LV Mass
How Much Physical Activity?
• Some is Better than None!
•
•
•
•
•
•
•
Choose an activity you enjoy
Start Low & Progress Slowly
Start as low as 10 min/week
Split duration (AM/PM) if needed
Increase duration by 1-2 min/wk
Goal: 100-200 minutes/week
Be Consistent (2-6 times/week)
How Much Physical Activity ?
Think F.I.T
F- Frequency: 2-6 days/Wk
I – Intensity : 60-80% of HRR
T- Time
: 100-200 min/week
• The daily hemodynamic load is
likely the impetus for the
development and progression of
LVH.
• SBP at 5-7 METs of exercise
reflects the hemodynamic load
during daily activities.
Therefore, attenuating
an abnormal rise in BP
during daily physical
exertion may prevent the
development and/or
maintenance of LVH.
Conclusion 1
High fit Women had:
• Lower LVMI
• BP @ 6 min of Exercise
•
The metabolic demand of about
6-7 METs at 6 min of exercise
(Bruce protocol) is equivalent to
that of most daily activities.
Thus, the 6-minute exercise BP
may reflect the hemodynamic
load during daily activities.
•
Furthermore, the maintenance and
progression of LVH may be
mediated by this daily hemodynamic
load. Thus, attenuating an abnormal
rise in BP during daily physical
exertion may prevent the
development and/or maintenance
of LVH.
Correlation of 6-minute Exercise SBP,
LVMI and Daytime ABP in Men
r=0.73
SBP@
6-min
ABPM
r=0.68
r=0.81
LVMI
Correlation of 6-minute Exercise SBP,
LVMI and Daytime ABP in Women
SBP@
6-min
r=0.79
ABPM
r=0.67
r=0.71
LVMI
Peak Exercise DBP Before and After
Exercise Training in Women
Seals et al, Am J Cardiol ‘97
mm Hg
100
P<0.05
97
94
93
89
90
80
Baseline
4 wks
8 wks
12 wks
Peak Exercise SBP Before and After
Exercise Training in Women
Seals et al, Am J Cardiol ‘97
mm Hg
P<0.05
190
183
176
171
170
162
150
Baseline
4 wks
8 wks
12 wks
Exercise RPP at Pre & Post Training
Kokkinos P. et al, Am J Cardiol. 1997
35
*p<0.05
*
30
*
25
*
20
15
6 min
9 min
Peak
Exaggerated BP & False-Positive
Exercise Test Results
Jong-Won Ha, et al. JACC 2002:112:161-66
•
•
•
132 pts with Peak Exercise SBP>220 mm
Hg for Men; > 190 mm Hg for Women
108 had positive exercise Echo finding
24/108 (22%) had no significant CAD
•
•
•
416 pts with Normal Exercise BP
320 had Positive Exercise Echo Findings
39/320 (12%) had no significant CAD
Exercise Response for Pts on BetaBlockers vs Other Antihypertensive Meds
Variables
SBP @ 3 min
SBP @ 6 min
Peak SBP
HR @ 3 min
HR @ 6 Min
Peak HR
Ex. Time (sec)
Others (n=1254)
167±27
182±27
192±28
119±17
133±16
148±17
412±166
BB (n=561) Δ
151±26
164±25
175±30
106±17
119±18
31±21
419±160
16
18
17
13
14
17
7
P<0.001
BP Response to HR During Exercise Test
and Risk of Future Hypertension
Miyai N, et al. Hypertension 2002;39761-66
•
•
•
•
•
N=1033 Men, No HTN, DM or CVD
Cycle Ergometer; Automated BP
monitoring device.
Age: 42.9 ±8.5 yrs; range: 20-59 yrs
726 pts with complete data;
4.7 yrs F/U
Exercise BP Predicts CV Mortality
in Middle-aged Men
Mundal et al. 1994; Hypertension;24:56-62
•
•
•
N=1999 healthy men
F/U: 16 yrs
Exercise BP at 600 kg-m/min (~100
watts; approximately 6 METs)
Peak Exercise SBP and LV MASS
g/m2
Polonia J, et al. Eur Heart Journal 1992; 13(A):30-36
200
190
180
160
<210 mm Hg
>210 mm Hg
HTN with
SBP >210 mm Hg
174
155
152
143
140
124
120
100
BP @ 3 min
LVMI
• SBP at sub-maximal exercise reflects
the daily hemodynamic load.
• Therefore, it may be a stronger
predictor of HTN and LVH.
• Sub-maximal exercise BP may also
have a wider clinical application than
maximal exercise BP.
• Left ventricular hypertrophy (LVH) is a
powerful and independent predictor of
cardiovascular events in patients with and
without obstructive coronary disease.
• The risk for CV morbid events, including
sudden cardiac death, increases-three fold
in patients with LVH.
Levy D., et al. N Engl J Med 1990;332:1561-66
Ghali JK et al., 1992; Ann Intern Med 1992;117:831-36
Koren MJ et al., 1991; Ann Intern Med 1991;114:345-52
Casale PN, et al., Ann Intern Med 1986;105:173-78
Clinical Characteristics
N
Age
RHR
RSBP
RDBP
BMI
* p =0.008
Men
269
49±10
78 ± 8
129 ±6
76±7
27±2.6
Women
243
54±10
82 ±14
132 ±7
79 ±8
27±2.4
Exercise SBP and Fitness in Hypertensive
Men (n=908)
mm Hg
B-Blockers
Other Meds
195
190
185
173
*
170
171
164
150
151
130
SBP @ 5 METs
SBP@ 7-METs
Peak Exercise
LVMI in Normotensive and Hypertensive
Women
Kokkinos , Pittaras A et al. Circulation ‘98
g/m2
* p<0.01
Low-Fit
Moderate
143
High-Fit
135
128
*
117
110
*
110
105
99
85
HTN (+)
HTN (-)
Exercise BP, Fitness & LVMI in Men
Pittaras A, et al. Circulation 2003
190
EX-BP
* p<0.01
184
ABPM
LVMI
*
160
165
152
144
130
135
*
117
100
Low-Fit
High-Fit
SBP at 7 METs and LVMI in Fit & Unfit
Normotensive Women
Kokkinos P. Pittaras A et al. JACC ‘99
* p<0.02
165
*
160
*
140
148
*
126
115
103
SBP
LVMI
SBP
LVMI
90
Low-Fit
High-Fit
SBP at 7 METs and LVMI in Fit & Unfit
Hypertensive Women
Kokkinos P. Pittaras A et al. JACC ‘99
190
189
* p<0.02
*
172
160
143
*
130
117
Low-Fit
High-Fit
Low-Fit
High-Fit
100
SBP
LVMI
Exaggerated BP & LVH in
Normotensive Men
• Normotensive Men (N=39)
• Age: 44.6±8.5
• LVH (LVMI >134 g/m2 ) found in
63% (14/22) of those with Peak
Exercise SBP >210 mm Hg.
Gottdiener J. et al. Annals Intern Med 1990:112:161-66
Correlations (r) of Sub-maximal
Exercise SBP and ABP (n=892)
Daytime
Nighttime
24-hours
5-MET
r
0.71
0.69
0.70
7-MET
r
0.78
0.77
0.77
LVMI & Exercise SBP @ 7-METs in
Pre-Hypertensive Women
187
185
Ex-HTN
* p<0.01
Normal BP
*
157
160
133
135
110
*
96
85
SBP
LVMI
LVMI & Exercise SBP @ 7 METs in
Pre-Hypertensive Men
Ex-HTN
Normal BP
180
* p<0.01
*
155
130
*
105
80
SBP
LVMI