The interplay of exercise heart rate and blood pressure as a predictor of coronary artery disease and arterial hypertension.

Delayed blood pressure (BP) and heart rate (HR) decline at recovery post-exercise are independent predictors of incident coronary artery disease (CAD). Delayed BP recovery and exaggerated BP response to exercise are independent predictors of future arterial hypertension (AH). This study sought to examine whether the combination of two exercise parameters provides additional prognostic value than each variable alone. A total of 830 non-CAD patients (374 normotensive) were followed for new-onset CAD and/or AH for 5 years after diagnostic exercise testing (ET). At the end of follow-up, patients without overt CAD underwent a second ET. Stress imaging modalities and coronary angiography, where appropriate, ruled out CAD. New-onset CAD was detected in 110 participants (13.3%) whereas AH was detected in 41 former normotensives (11.0%). The adjusted (for confounders) relative risk (RR) of CAD in abnormal BP and HR recovery patients was 1.95 (95% confidence interval [CI], 1.28-2.98; P=.011) compared with delayed BP and normal HR recovery patients and 1.71 (95% CI, 1.08-2.75; P=.014) compared with normal BP and delayed HR recovery patients. The adjusted RR of AH in normotensives with abnormal BP recovery and response was 2.18 (95% CI, 1.03-4.72; P=.047) compared with delayed BP recovery and normal BP response patients and 2.48 (95% CI, 1.14-4.97; P=.038) compared with normal BP recovery and exaggerated BP response individuals. In conclusion, the combination of two independent exercise predictors is an even stronger CAD/AH predictor than its components.

The effects of angiotensin receptor blockers vs. calcium channel blockers on the acute exercise-induced inflammatory and thrombotic response.

Arterial hypertension is an established risk factor for acute coronary syndromes, and physical exertion may trigger the onset of such an event. The mechanisms involved include the rupture of a small, inflamed, coronary plaque and the activation of thrombogenic factors. Blood pressure (BP)-lowering treatment has been associated with beneficial effects on subclinical inflammation and thrombosis at rest and during exercise. This prospective study sought to compare the effect of different antihypertensive drugs on the inflammatory and thrombotic response during exercise. A total of 60 never-treated hypertensive patients were randomized to an angiotensin receptor blocker (ARB)- or non-dihydropyridine calcium channel blocker (CCB)-based regimen. Patients with inflammatory or coronary artery disease were excluded. Six months after pharmaceutical BP normalization, the patients underwent a maximal treadmill exercise testing. High-sensitivity C-reactive protein (hsCRP), serum amyloid A (SAA), white blood cells (WBC), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), total fibrinogen (TF) and von Willebrand factor (vWF) levels, as well as plasminogen activator inhibitor-1 (PAI-1) activity were measured in blood samples taken while the patients were at rest and during peak exercise. All of these biomarkers increased with exercise, except PAI-1, which decreased (P<0.05 for the difference between resting and peak exercise for all biomarkers). The ARB group had less marked (P<0.05) exercise-induced changes than the CCB group in hsCRP (5.8% vs. 7.7%), SAA (4.2% vs. 7.2%), WBC (46.8% vs. 52.6%), TNF-α (16.3% vs. 24.3%), TF (9.5% vs. 16.9%) and PAI-1 (-9.5% vs. -12.3%) but a similar (P=NS) change in IL-6 (39.4% vs. 38.6%) and vWF (29.2% vs. 28.6%). In conclusion, ARBs are most likely more effective than CCBs at suppressing the exercise-induced acute phase response. Potential protection against exercise-related coronary events remains to be elucidated.

Nocturnal hypertension: poor correlation with office blood pressure but strong prognostic factor for target organ damage.

INTRODUCTION: We investigated the correlation between systolic and diastolic nocturnal blood pressure (BP) values and office BP values, as well as parameters of 24-hour ambulatory BP monitoring, in patients with hypertension. In addition, we compared nocturnal hypertensives with nocturnal normotensives regarding their demographic, clinical, and laboratory characteristics, as well as other data from 24-hour BP monitoring. METHODS: The study included 182 consecutive patients who had newly diagnosed, never treated, uncomplicated arterial hypertension. Blood samples were obtained from all patients for the determination of glycaemic and lipidaemic profiles. All underwent a complete echocardiographic examination, including tissue Doppler imaging, measurement of carotid intima-media thickness, measurement of carotid-femoral pulse wave velocity, and determination of the augmentation index of reflected waves (Aix@75), as well as 24-hour ambulatory BP monitoring. The population was divided into nocturnal normotensives (NN, n=77) and nocturnal hypertensives (NH, n=105, nocturnal BP >120/70 mmHg). RESULTS: Although the NH did not differ from the NN as regards the classical cardiovascular risk factors, they showed an excessive inotropic response to exercise (61.9% vs. 22.7%, p=0.028), higher levels of serum uric acid (5.5 ± 1.56 mg/dl vs. 4.7 ± 1.36 mg/dl, p=0.003), as well as greater arterial stiffness, as expressed by a higher carotid-femoral pulse wave velocity (8.6 ± 1.6 m/s vs. 7.9 ± 1.4 m/s, p=0.009), and a greater carotid intima-media thickness (0.74 ± 0.17 mm vs. 0.68 ± 0.15 mm, p=0.007). In addition, although the two groups did not differ significantly as regards office BP values and did not show strong correlations between nocturnal and office BP, both nocturnal diastolic and, especially, systolic BP showed strong correlations with levels of serum uric acid and with subclinical lesions in the heart, central aorta, peripheral vessels, and renal vasculature. CONCLUSIONS: Nocturnal BP is poorly correlated with office BP values. However, the presence of nocturnal hypertension is associated with morphological and functional disturbances of the cardiovascular net. 24-hour ambulatory BP monitoring is an essential tool for revealing this subgroup of hypertensive patients who are at increased cardiovascular risk.

A 31 year old woman with essential hypertension grade III and branch retinal vein occlusion with homozygous C677T MTHFR hyperhomocysteinemia and high Lp(a) levels.

We report a 31-year old woman with essential hypertension grade III and history of branch retinal vein occlusion in the setting of hyperhomocysteinemia due to homozygous MTHFR gene mutation and elevated Lp(a). The patient was treated successfully with antihypertensive treatment, acetylsalicylic acid and multivitamin complex supplementation.

Correlation of modification of heart rate recovery with adaptation to myocardial ischemia in a model of sequential exercise testings.

BACKGROUND: Heart rate recovery (HRR) has been identified as a reliable predictor of cardiac mortality, correlated with autonomic tone. In a model of sequential exercise testings, we investigated the reproducibility of HRR and the association between HRR modification and myocardial adaptation to ischemia. METHODS: We studied 128 patients (mean age 62 +/- 9 years, 83% males) with angiographically documented coronary artery disease (CAD) and a first positive exercise testing, who agreed to undergo a second exercise testing after 24 hours. RESULTS: HRR was increased from 25 +/- 10 beats/min at the first exercise testing to 30 +/- 13 beats/min at the second exercise testing (P < 0.001). Thereafter, participants were divided into two groups: Group I comprised 88 patients who presented augmentation of the HRR in the first compared to the second exercise testing, while group II comprised 40 patients who presented unchanged or reduced HRR. The rate-pressure product (RPP) at 1 mm ST-segment depression (ischemic threshold) at the second compared to the first exercise testing were significantly improved in group I patients (2345 +/- 3429 mmHg/min), while it was worsened in group II patients (-630 +/- 2510 mmHg/min) (P < 0.001). CONCLUSIONS: In a model of sequential exercise testings, myocardial adaptation to exercise-induced ischemia was associated with favorable modification of HRR.

QRS score improves diagnostic ability of treadmill exercise testing in women.

OBJECTIVE: The accuracy of treadmill exercise testing to detect coronary artery disease is limited in women. This study was undertaken to evaluate whether QRS score can improve the accuracy of treadmill exercise testing in women. METHODS: The study population consisted of 114 women with angina-like symptoms, who underwent both treadmill exercise testing and coronary angiography. The impact of QRS score on the standard ST-segment based diagnostic ability of treadmill exercise testing to detect coronary artery disease was studied. RESULTS: Incorporation of QRS score in standard ST-segment diagnostic criteria significantly enhanced sensitivity (from 59 to 80%), specificity (from 40 to 94%) and diagnostic accuracy (from 50 to 87%) of treadmill exercise testing. The QRS score was shown to reduce significantly the false-positive results from 60 to 6%. Furthermore, QRS score accuracy was correlated with the extent of coronary artery disease. The diagnostic ability of QRS score was greater both among patients with normal and impaired systolic function of the left ventricle. CONCLUSIONS: QRS score can improve the limited diagnostic accuracy of treadmill exercise testing in women, by predominantly decreasing the high prevalence of false-positive results.