Hypertensive response to exercise in adult patients with repaired aortic coarctation.
Meijs TA, Muller SA, Minderhoud SCS, de Winter RJ, Mulder BJM, van Melle JP, Hoendermis ES, van Dijk APJ, Zuithoff NPA, Krings GJ, Doevendans PA, Spiering W, Witsenburg M, Roos-Hesselink JW, van den Bosch AE, Bouma BJ, Voskuil M.Heart. 2022 Jun 24;108(14):1121-1128. doi: 10.1136/heartjnl-2021-320333.PMID: 34987066
Take Home Points:
- Study involved use of Dutch registry CONCOR
- Exercise induced hypertension occurred in 44% of patients in this cohort of 675 patients
- Increased peak exercise systolic blood pressures (> 210 mmHg systolic) was found more often in males, and those with higher resting blood pressures
- Increased peak exercise systolic blood pressures were found less frequently in patients with bicuspid aortic valve and those following coarctation stenting
- Increased peak systolic blood pressures predicted higher resting systolic blood pressures in follow up, regardless of resting systolic blood pressure at rest baseline
- There was no correlation between the occurrence of later cardiovascular events (coronary artery disease, stroke, aortic complications, death) and peak exercise systolic blood pressure
Commentary from Dr. Thomas Zellers (Dallas, USA), section editor of Congenital Heart Disease Interventions and ACHD Journal Watch:
The authors sought to determine the prevalence of hypertensive response to exercise, identify factors associated with exercise induced hypertension and examine the association between peak exercise systolic blood pressure and resting systolic blood pressure and cardiovascular events at follow up.
The authors used the Dutch national congenital corvitia (CONCOR) registry and examine 920 patients with repaired coarctation. Of these, 675 patients (median age 24 years with range of 16-72 years) underwent exercise testing and follow up at a mean of 10.1 years. Variables examined included resting and stress blood pressure response to exercise, 24 hour ambulatory blood pressure monitoring, echo evaluation for LV hypertrophy and mass, and history of cardiovascular events.
Of the 675 patients, 44% showed a hypertensive response to exercise (systolic BP of > 210 mmHg for men and > 190 mmHg for women). Of the 299 patients with normal resting blood pressure, 35% (n = 104) had hypertensive response to exercise; 50% of those had hypertension at later follow up visits. Of the 376 with resting hypertension, 52% had a hypertensive response to exercise.
In evaluating factors associated with peak exercise systolic blood pressure (SBP), in multivariable analysis, increased resting SBP at baseline was positively correlated with increased peak exercise SBP. Males were also more likely to have elevated peak exercise SBP. Bicuspid aortic valve and coarctation stenting were negatively correlated with peak exercise SBP.
Peak exercise SBP positively predicted office SBP at follow up visit and increased ambulatory blood pressure measurements at follow up; this was independent of resting SBP at baseline. Resting SBP at baseline and the use of antihypertensive medications were also positive predictors of office resting SBP at follow up. When considering only normotensive patients at baseline, peak exercise SBP was also predictive of SBP at office follow up. Given that 35% of normotensive patients, at baseline, had exercise induced hypertension, and that 50% of those had resting hypertension at follow up, it appears that exercise testing, even in normotensive patients, can help predict systolic hypertension at follow up. This is a population that may require an increased frequency in follow up visits to address new onset of hypertension. However, of particular interest, hypertensive response to exercise did not correlate with adverse cardiovascular events.
One must realize that this is a multicenter study using a registry and thus there may be differences in who gets tested, which exercise protocols are used, the use of antihypertensive medications, and the follow up duration. This was a young cohort and thus, the incidence of cardiovascular adverse events may not yet have been realized at follow up.