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Original Article • Arq. Bras. Cardiol. 120 (11) • Nov 2023 • https://doi.org/10.36660/abc.20230047 linkcopy

Exaggerated Systolic Blood Pressure Increase with Exercise and Myocardial Ischemia on Exercise Stress Echocardiography

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background The association between exaggerated systolic blood pressure response to exercise (ESBPRE) and myocardial ischemia is controversial and little studied in patients with established or suspected chronic coronary syndrome.

Objective To verify the relationship between myocardial ischemia and ESBPRE in patients undergoing exercise stress echocardiography (ESE).

Methods This is a cross-sectional study with 14,367 patients undergoing ESE, from January 2000 to January 2022, divided into the following 2 groups: G1, composed of patients whose peak systolic pressure increased ≥ 90 mmHg (value corresponding to the 95th percentile of the study population), and G2, patients who did not demonstrate an exaggerated hypertensive response. The groups were compared using Student’s t and chi-square tests. P values < 0.05 were considered significant. Logistic regression was also performed to identify independent risk factors for myocardial ischemia, ESBPRE, complaints of typical chest pain prior to the exam, and angina during the test.

Results Of the 14,367 patients, 1,500 (10.4%) developed ESBPRE, and 7,471 (52.0%) were female. The percentages of previous complaints of typical chest pain, angina during the test, and myocardial ischemia in patients with ESBPRE were 5.8%, 2.4% and 18.1%, compared to 7.4%, 3.9%, and 24.2%, in patients without ESBPRE, respectively (p = 0.021,p = 0.004, p < 0.001). In multivariate analysis, ESBPRE was independently associated with a lower probability of myocardial ischemia (odds ratio: 0.73; 95% confidence interval: 0.58 to 0.93; p = 0.009).

Conclusion Exaggerated increase in systolic blood pressure during ESE may be a marker for excluding myocardial ischemia.

Arterial Pressure; Stress Echocardiography; Exercise Test; Coronary Artery Disease; Myocardial Ischemia

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Central Illustration
: Exaggerated Systolic Blood Pressure Increase with Exercise and Myocardial Ischemia on Exercise Stress Echocardiography

Variables	ESBPRE n=1500 (10.4%)	Without ESBPRE n=12,867 (89.6%)	p ^*
Male sex	1008(67.2%)	5888(45.8%)	<0.001
Age (mean, years)	54.6±10.3	58.1±11.4	<0.001
Systemic arterial hypertension	972(65.5%)	7459(58.7%)	<0.001
Diabetes mellitus	202(13.6%)	1651(13.0%)	0.516
Dyslipidemia	819(55.2%)	7353(57.9%)	0.041
Smoking	88(5.9%)	631(5.0%)	0.110
Sedentary lifestyle	602(53.2%)	4783(52.7%)	0.726
Obesity	489(32.8%)	2859(22.3%)	<0.001
Family history of CCS	831(56.0%)	7283(57.4%)	0.323
Personal history of CCS	188(19.7%)	1738(21.4%)	0.242
Clinical treatment for CCS ^†	83(44.1%)	795(45.7%)	0.677
Angioplasty + stent ^†	78(41.5%)	680(39.1%)	0.529
Surgical revascularization ^†	32(17.5%)	344(20.1%)	0.397
Old infarction (> 60 days)	76(5.3%)	680(5.5%)	0.730
Recent infarction (< 60 days)	0(0.0%)	48(0.4%)	0.018
Symptoms ^‡
– Asymptomatic	648(45.0%)	5209(42.0%)	0.028
– Typical chest pain prior to the test	83(5.8%)	922(7.4%)	0.021
– Atypical chest pain prior to the test	644(44.7%)	5630(45.4%)	0.642
– Dyspnea prior to the test	69(4.8%)	731(5.9%)	0.091
Left bundle branch block	42(2.8%)	534(4.2%)	0.012
Use of antihypertensive medication	723(49.4%)	6020(47.8%)	0.271
– Diuretics	17(3.7%)	200(4.1%)	0.657
– ACEI	159(10.9%)	1159(9.2%)	0.040
– ARB	346(23.7%)	2672(21.3%)	0.034
– Calcium channel blocker	121(8.3%)	918(7.3%)	0.178
– Beta blocker	303(20.7%)	2887(23.0%)	0.052
– Nitrate	40(2.7%)	357(2.8%)	0.814
Clinical indications for ESE ^§
– Investigation of chest pain	727(50.5%)	6552(52.8%)	0.097
– Preoperative assessment for non-cardiac surgery	58(6.2%)	585(7.4%)	0.170
– SET in patients with low risk of coronary syndromes	221(23.6%)	1675(21.2%)	0.099
– SET in patients with intermediate or high risk of coronary syndromes	41(4.4%)	436(5.6%)	0.133
– NET in patients with intermediate or high risk of coronary syndromes	12(1.3%)	112(1.4%)	0.730
– Arrhythmias during ET	1(0.1%)	48(0.6%)	0.051
– CCS risk stratification	188(19.7%)	1738(21.4%)	0.242

Variables	ESBPRE n=1500 (10.4%)	Without ESBPRE n=12,867 (89.6%)	p ^*
Results of segmental motion ^†
– Normal	1227(81.9%)	9751(75.8%)	<0.001
– Induced ischemia	127(8.5%)	1563(12.2%)	<0.001
– Fixed ischemia	121(8.1%)	1151(9.0%)	<0.001
– Fixed and induced ischemia	24(1.6%)	391(3.0%)	0.002
Resting SBP (mmHg)	123.6±12.1	128.6±12.7	<0.001
Peak SBP (mmHg)	219.3±16.3	189.1±16.6	<0.001
SBP after exercise (mmHg)	156.5±25.8	145.0±20.7	<0.001
Resting HR (bpm)	76.9±13.1	77.9±14.0	0.005
Peak HR (bpm)	159.8±16.8	154.1±19.2	<0.001
HR after exercise (bpm)	101.7±15.3	98.0±18.3	<0.001
Resting DP (×103 mmHg.bpm)	9.5±2.0	10.0±2.2	<0.001
Peak DP (×103 mmHg.bpm)	35.0±4.0	29.2±4.7	<0.001
DP after exercise (×103 mmHg.bpm)	15.9±3.7	14.2±3.5	<0.001
% of theoretical maximum HR	96.7±8.3	95.2±9.7	<0.001
HR reached on the test ^‡
– Below submaximal	119(7.9%)	1657(12.9%)	<0.001
– Submaximal	619(41.3%)	5138(40.0%)	0.329
– Maximum	211(14.1%)	1392(10.8%)	<0.001
– Above maximum	551(36.7%)	4670(36.3%)	0.754
Angina during the test	36(2.4%)	500(3.9%)	0.004
Dyspnea during the test	164(11.0%)	1421(11.1%)	0.951
ST depression	883(59.3%)	6824(53.8%)	<0.001
– Ascending ^§	325(36.8%)	2661(39.0%)	0.209
– Horizontal ^§	318(36.0%)	2669(39.1%)	0.075
– Descending ^§	241(27.3%)	1499(22.0%)	<0.001
Atrioventricular block	3(0.9%)	18(0.5%)	0.304
Coronary spasm	0(0.0%)	1(0.0%)	0.766
Non-sustained VT	1(0.3%)	24(0.6%)	0.448
Ventricular extrasystole	75(21.6%)	1012(25.8%)	0.088
Atrial fibrillation or flutter	0(0.0%)	8(0.2%)	0.399
Non-sustained SVT	5(1.4%)	59(1.5%)	0.925
Supraventricular extrasystole	30(8.7%)	406(10.4%)	0.313
Treadmill time (minutes)	8.2±2.6	7.1±2.6	<0.001
Functional capacity (METs)	10.5±3.1	9.7±3.0	<0.001
Predicted VO ₂ max (mL.kg ^-1 .min ^-1 )	26.3±6.0	24.5±6.2	<0.001
VO ₂ max achieved (mL.kg ^-1 .min ^-1 )	36.7±10.7	34.1±10.5	<0.001
Ratio between predicted and achieved VO ₂ max (%)	143.2±38.9	143.2±42.8	0.986
LV ejection fraction (%)	67.1±6.4	67.1±6.7	0.808
LV mass index (g/m ² )	88.6±22.1	84.9±22.9	<0.001
Left atrial volume (mL/m ² )	28.8±13.1	29.3±14.2	0.400
Resting LVWMSI	1.02±0.1	1.03±0.1	0.001
LVWMSI during exercise	1.03±0.1	1.04±0.1	<0.001
Diastolic function ^//
– Normal	230(20.4%)	1998(22.2%)	0.163
– Grade I dysfunction	618(54.7%)	5016(55.7%)	0.531
– Grade II dysfunction	277(24.5%)	1950(21.7%)	0.028
– Grade III dysfunction	4(0.4%)	38(0.4%)	0.738

Variables	Odds ratio	95% CI	p
Myocardial ischemia	0.72	0.59-0.87	0.001
Male sex	2.38	2.05-2.77	<0.001
Age	0.98	0.97-0.99	<0.001
Systemic arterial hypertension	1.42	1.21-1.65	<0.001
Chronic coronary syndrome	0.85	0.70-1.03	0.103
Obesity	1.54	1.32-1.79	<0.001
Typical angina prior to the test	0.83	0.61-1.13	0.229
Typical pain during the test	0.81	0.52-1.27	0.367

Variables	Odds ratio	95% CI	p
ESBPRE	0.73	0.58-0.93	0.009
Male sex	1.33	1.15-1.55	<0.001
Age	1.00	1.00-1.01	0.361
Systemic arterial hypertension	1.10	0.94-1.28	0.241
Diabetes mellitus	1.32	1.10-1.58	0.003
Dyslipidemia	1.39	1.21-1.61	<0.001
CCS	3.69	3.16-4.30	<0.001
Tobacco use	1.44	1.08-1.91	0.012
Family history of CCS	1.38	1.19-1.59	<0.001
Typical angina prior to the test	2.38	1.87-3.02	<0.001
Angina during the test	11.03	7.60-16.01	<0.001
ST depression	1.53	1.33-1.76	<0.001
Functional capacity (METs)	0.94	0.91-0.97	<0.001
LV ejection fraction (%)	0.94	0.93-0.95	<0.001

Variables	Odds ratio	95% CI	p
ESBPRE	0.80	0.56-1.14	0.218
Echocardiographic myocardial ischemia	2.37	1.88-3.00	<0.001
Male sex	1.05	0.84-1.31	0.676
Age	0.99	0.98-0.995	0.003
Systemic arterial hypertension	1.06	0.85-1.33	0.602
Diabetes mellitus	1.10	0.84-1.44	0.501
Dyslipidemia	1.32	1.06-1.64	0.013
Chronic coronary syndrome	1.01	0.78-1.30	0.964
Tobacco use	1.81	1.24-2.64	0.002
Angina during the test	6.52	4.73-8.99	<0.001
ST depression	0.89	0.72-1.09	0.256
Functional capacity (METs)	0.95	0.91-0.99	0.008

Variables	Odds ratio	95% CI	p
ESBPRE	1.12	0.68-1.85	0.651
Myocardial ischemia	10.37	7.21-14.91	<0.001
Male sex	1.63	1.17-2.26	0.004
Age	0.98	0.96-0.99	0.003
Systemic arterial hypertension	1.01	0.72-1.42	0.950
Diabetes mellitus	1.04	0.71-1.51	0.856
Dyslipidemia	0.89	0.65-1.22	0.471
Chronic coronary syndrome	1.02	0.73-1.43	0.892
Typical angina prior to the test	6.51	4.72-8.97	<0.001
ST depression	1.70	1.25-2.32	0.001
Functional capacity (METs)	0.83	0.78-0.88	<0.001

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