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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Stress testing is a standard procedure in clinical practice for detecting myocardial ischemia and exercise-induced arrhythmia and to assess a patient&#8217;s functional capacity&#46; Blood pressure &#40;BP&#41;&#44; measured routinely during stress testing&#44; increases progressively in a physiological manner as the exercise load increases in response to the muscles&#8217; metabolic needs&#46; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></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&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However&#44; there is some controversy as to the meaning of the hypertensive response to exercise &#40;HRE&#41; and the BP thresholds that define it&#46; Typically&#44; HRE is defined &#40;at the maximum effort peak&#41; as a BP greater than the 90 percentile for each age and sex&#44; which generally corresponds to a systolic blood pressure &#40;SBP&#41; &#8805;210&#47;110<span class="elsevierStyleHsp" style=""></span>mm Hg for men and &#8805;190&#47;110<span class="elsevierStyleHsp" style=""></span>mm Hg for women&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> An association has also been reported between an SBP &#8805;150<span class="elsevierStyleHsp" style=""></span>mm Hg in the submaximum effort &#40;5&#8211;7 metabolic equivalents of task &#91;METs&#93;&#41; with the future development of arterial hypertension &#40;AHT<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and with the presence of left ventricular hypertension &#40;LVH&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In other studies&#44; the SBP thresholds with submaximum exercise associated with an increase in cardiovascular risk &#40;CVR&#41; have been set in the range of 160&#8211;180<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The prevalence of HRE depends on the type of study population and ranges from 3&#37; to 4&#37; in young populations with normal BP<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and up to 58&#37; for masked AHT &#40;normal BP in the doctor&#39;s office and high in the outpatient blood pressure monitoring &#91;OBPM&#93;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> HRE can be indicative of a preclinical phase of AHT&#44; prior to its future development&#46; Thus&#44; HRE during stress testing in patients with normal BP helps predict the onset of AHT within 5 years&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> These findings establish a clinical overlap between HRE and the so-called arterial prehypertension&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In this issue of the journal&#44; Bouzas-Mosquera et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> report on a retrospective study that included women referred for exercise echocardiography due to known or suspected coronary artery disease&#44; analyzing the association between an exaggerated increase in SBP with exercise &#40;defined as an increase &#62;70<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg with respect to baseline SBP&#41; and overall mortality and the development of cardiovascular disease &#40;CVD&#41;&#46; In their cohort&#44; this increase was not a predictor for any of these variables&#46; As the authors stated&#44; previous studies conducted mainly with men without coronary artery disease found that HRE with moderate or intense exercise predicted the onset of CVD&#44; as well as cardiovascular and overall mortality&#44; regardless of resting BP&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> However&#44; these studies suffered from a lack of uniformity in their methodology in terms of the HRE definition and the exercise load &#40;moderate or intense&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">To solve these methodological limitations&#44; Schult et al&#46; conducted a meta-analysis that included 12 studies and 46&#44;314 healthy patients with a mean follow-up of 15 years&#46; Regardless of age&#44; sex&#44; baseline BP and other associated cardiovascular risk factors&#44; the authors found a 36&#37; increase in CVD and overall mortality rates in the individuals with HRE&#46; Every 10<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg increase in SBP with moderate exercise intensity was associated with a 4&#37; annual increase in CVD&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> These results suggest that only the increase in SBP achieved with a moderate exercise load &#40;such as that achieved in the first or second stage of a stress test&#44; with greater reliability in its measurement and similar to the intensity experienced during the daily outpatient activities&#41; was prognostic for healthy individuals&#46; In fact&#44; when the studies that recorded an HRE with maximum intensity effort were grouped&#44; the association with CVD and&#47;or overall mortality was no longer significant&#46; 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&#46; 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&#44; other prospective studies on individuals with underlying CVD or coronary artery disease have shown that HRE is not correlated with higher mortality rates&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> On the contrary&#44; HRE can be considered protective in these high-risk patient cohorts&#44; possibly because this response is indicative of the maintenance of adequate myocardial function&#44; as reported by Bouza-Mosquera in their study&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">It is unclear why moderate-intensity HRE increases the CVR&#44; but it could be due in part to the presence of undiagnosed or insufficiently treated AHT in resting conditions&#44; as is the case for masked AHT&#46; The added predictive value of OBPM could support this hypothesis&#44; 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&#44; in resting conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> In this respect&#44; patients with prehypertension and HRE in the doctor&#39;s office have higher BP values in OBPM than those without HRE&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In summary&#44; HRE should serve as an alarm signal for possibly increased cardiovascular risk&#46; However&#44; further studies are needed to determine the specific exercise intensity and to define BP thresholds&#44; taking into account the patient&#8217;s sex&#44; age and physical training level&#46; This information can serve as guidance for BPs indicative of a high cardiovascular risk and&#47;or a poor outpatient BP control&#46; For the time being&#44; however&#44; the latest 2018 hypertension guidelines of the European Society of Cardiology and the European Society of Hypertension<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> do not recommend stress testing for the systematic assessment of AHT due to its limitations&#44; which include a lack of standardization in the methodology and definitions&#46; However&#44; the guidelines emphasize that&#44; except for cases with very high BP levels &#40;grade 3 AHT&#41;&#44; patients and athletes with treated or untreated AHT should not be advised against physical exercise &#40;especially aerobic&#41;&#44; because exercise is considered beneficial as part of the lifestyle changes for reducing BP&#46; We also need to determine whether therapy to normalize HRE will result in a better prognosis for the patient&#46;</p></span>"
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May 2020 Hypertensive response to exercise: does it have prognostic implications?
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Vol. 220. Issue 4.
Pages 246-247 (May 2020)
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Vol. 220. Issue 4.
Pages 246-247 (May 2020)
Editorial
DOI: 10.1016/j.rceng.2019.07.006
Hypertensive response to exercise: does it have prognostic implications?
Respuesta hipertensiva al ejercicio: ¿tiene implicaciones pronósticas?
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L. Vigil Medina
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lvigil.hmtl@salud.madrid.org

Corresponding author.
, R. Garcia Carretero
Unidad de Hipertension Arterial, Servicio de Medicina Interna, Hospital Universitario de Mostoles (Madrid), Spain
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