Hypertensive response to exercise: does it have prognostic implications?

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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "246" "paginaFinal" => "247" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "L. Vigil Medina, R. Garcia Carretero" "autores" => array:2 [ 0 => array:4 [ "nombre" => "L." "apellidos" => "Vigil Medina" "email" => array:1 [ 0 => "lvigil.hmtl@salud.madrid.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Garcia Carretero" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Hipertension Arterial, Servicio de Medicina Interna, Hospital Universitario de Mostoles (Madrid), Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Respuesta hipertensiva al ejercicio: ¿tiene implicaciones pronósticas?" ] ] "textoCompleto" => "Stress testing is a standard procedure in clinical practice for detecting myocardial ischemia and exercise-induced arrhythmia and to assess a patient’s functional capacity. Blood pressure (BP), measured routinely during stress testing, increases progressively in a physiological manner as the exercise load increases in response to the muscles’ metabolic needs. Abnormal BP behavior during stress testing is a relatively common phenomenon and can unmask cardiovascular abnormalities that are not identifiable in a BP examination at rest.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> An insufficient increase or even a reduction in BP during exercise confers a poor cardiovascular prognosis and is an indication to stop the stress test.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> However, there is some controversy as to the meaning of the hypertensive response to exercise (HRE) and the BP thresholds that define it. Typically, HRE is defined (at the maximum effort peak) as a BP greater than the 90 percentile for each age and sex, which generally corresponds to a systolic blood pressure (SBP) ≥210/110mm Hg for men and ≥190/110mm Hg for women.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> An association has also been reported between an SBP ≥150mm Hg in the submaximum effort (5–7 metabolic equivalents of task [METs]) with the future development of arterial hypertension (AHT<a class="elsevierStyleCrossRef" href="#bib0020">4</a> and with the presence of left ventricular hypertension (LVH).<a class="elsevierStyleCrossRef" href="#bib0025">5</a> In other studies, the SBP thresholds with submaximum exercise associated with an increase in cardiovascular risk (CVR) have been set in the range of 160–180mmHg.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>The prevalence of HRE depends on the type of study population and ranges from 3% to 4% in young populations with normal BP<a class="elsevierStyleCrossRef" href="#bib0035">7</a> and up to 58% for masked AHT (normal BP in the doctor's office and high in the outpatient blood pressure monitoring [OBPM]).<a class="elsevierStyleCrossRef" href="#bib0040">8</a> HRE can be indicative of a preclinical phase of AHT, prior to its future development. Thus, HRE during stress testing in patients with normal BP helps predict the onset of AHT within 5 years.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> These findings establish a clinical overlap between HRE and the so-called arterial prehypertension.In this issue of the journal, Bouzas-Mosquera et al.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> report on a retrospective study that included women referred for exercise echocardiography due to known or suspected coronary artery disease, analyzing the association between an exaggerated increase in SBP with exercise (defined as an increase >70mmHg with respect to baseline SBP) and overall mortality and the development of cardiovascular disease (CVD). In their cohort, this increase was not a predictor for any of these variables. As the authors stated, previous studies conducted mainly with men without coronary artery disease found that HRE with moderate or intense exercise predicted the onset of CVD, as well as cardiovascular and overall mortality, regardless of resting BP.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> However, these studies suffered from a lack of uniformity in their methodology in terms of the HRE definition and the exercise load (moderate or intense).To solve these methodological limitations, Schult et al. conducted a meta-analysis that included 12 studies and 46,314 healthy patients with a mean follow-up of 15 years. Regardless of age, sex, baseline BP and other associated cardiovascular risk factors, the authors found a 36% increase in CVD and overall mortality rates in the individuals with HRE. Every 10mmHg increase in SBP with moderate exercise intensity was associated with a 4% annual increase in CVD.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> These results suggest that only the increase in SBP achieved with a moderate exercise load (such as that achieved in the first or second stage of a stress test, with greater reliability in its measurement and similar to the intensity experienced during the daily outpatient activities) was prognostic for healthy individuals. In fact, when the studies that recorded an HRE with maximum intensity effort were grouped, the association with CVD and/or overall mortality was no longer significant. This finding could be partly related to the greater variation and difficulty in measuring SBP during maximum exercise due to the movement artifact associated with intense effort. Although the results of this meta-analysis are potentially of clinical relevance for individuals who have a normal resting BP and no history of CVD, other prospective studies on individuals with underlying CVD or coronary artery disease have shown that HRE is not correlated with higher mortality rates.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> On the contrary, HRE can be considered protective in these high-risk patient cohorts, possibly because this response is indicative of the maintenance of adequate myocardial function, as reported by Bouza-Mosquera in their study.It is unclear why moderate-intensity HRE increases the CVR, but it could be due in part to the presence of undiagnosed or insufficiently treated AHT in resting conditions, as is the case for masked AHT. The added predictive value of OBPM could support this hypothesis, as it includes physical activity in actual living conditions and is therefore more representative of the long-term BP load compared with the outpatient BP, in resting conditions.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> In this respect, patients with prehypertension and HRE in the doctor's office have higher BP values in OBPM than those without HRE.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>In summary, HRE should serve as an alarm signal for possibly increased cardiovascular risk. However, further studies are needed to determine the specific exercise intensity and to define BP thresholds, taking into account the patient’s sex, age and physical training level. This information can serve as guidance for BPs indicative of a high cardiovascular risk and/or a poor outpatient BP control. For the time being, however, the latest 2018 hypertension guidelines of the European Society of Cardiology and the European Society of Hypertension<a class="elsevierStyleCrossRef" href="#bib0080">16</a> do not recommend stress testing for the systematic assessment of AHT due to its limitations, which include a lack of standardization in the methodology and definitions. However, the guidelines emphasize that, except for cases with very high BP levels (grade 3 AHT), patients and athletes with treated or untreated AHT should not be advised against physical exercise (especially aerobic), because exercise is considered beneficial as part of the lifestyle changes for reducing BP. We also need to determine whether therapy to normalize HRE will result in a better prognosis for the patient." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Vigil Medina L, et al. 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